“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.
2/9/2019 02:50:23 pm
Great blog. I’m doing the remedial vision track with Dr. Scheiman right now. Thanks for posting!
2/9/2019 03:34:54 pm
Thanks, Dawn. It was a great program....so glad I did it! Good luck with your remaining time.
2/11/2019 10:29:19 am
I so agree with your blog. I have seen some blending of the two worlds 0T and ophthalmology so at least there is some acknowledgment of that importianf pairing. I would really like to see the OT collaboration with hearing loss and audiology. My husband has been struggling with it for years and the affect on activities of daily living is immense. Let me know if you have connections in how to move forward with these out of the box therapeutic applications.
2/11/2019 07:33:48 pm
Thanks so much, Caralyn! Although your question is in regards to your husband, I hope that a peds therapist reading this can maybe speak more to the OT audiologist connection, as I have no direct experience...but what another GREAT team idea! It makes so much sense. I will keep this in mind if I come across anything!
2/11/2019 08:57:54 pm
Wow thanks for writing this! You’re right, even some optometrists don’t get it. Hoping I can find an OT like you in my area! 🙏
2/11/2019 09:56:29 pm
Thank you so much, Dr. Lee....so glad to have started the conversation. The response to this has been amazing! Good luck finding an OT in your region....finding this teamwork is 90% of the battle!
2/13/2019 05:32:38 pm
My son has nystagmus and finds reading and writing difficult. He avoids situations where he needs to focus his vision. This can present itself with similar symptoms to ADD, ADHD, dyspraxia and many others. His bad eyesight plays a huge part in how my little boy behaves. We are lucky enough to work closely with a great OT and the best Ophthalmologist in the area.
2/13/2019 08:19:53 pm
Emma...that is such great news that you have support via your OT and eye professional! Research does suggest that sometimes visual problems can be misdiagnosed as ADHD. Great job seeking out all avenues.
2/14/2019 07:35:22 am
This is a strong area of interest for me as well as the other therapists at my clinic. Do you have any recommendations for specific courses for vision and/or vision rehab specifically relating to concussions?
2/14/2019 01:02:07 pm
7/29/2019 11:26:47 am
It's good to know that optometrists can recommend vision therapy to patients who may need it. My wife has been having some trouble seeing, and I want to make sure that she gets the help she needs. I'll pass this information along to her so that she can look further into her options for seeing an optometrist in the future.
1/19/2020 11:23:48 am
9/1/2020 10:40:40 am
Thank you for sharing this blog, it is very useful and informative. Everything is clear to me after reading this article, it is really important knowing the differences, importance and relationship of occupational therapy and optometry.
10/20/2020 04:50:20 pm
Great! So glad that you found this useful in understanding the differences in professions and who can help!
9/28/2020 01:07:19 pm
Thanks for explaining that visual integrity, efficiency, and information processing are all areas that optometrists are trained in. My cousin noticed the other day that her three-year-old little girl seems to have some problems seeing things. I'll have to tell her to get her eyes examined and evaluated so that they can visit an optometrist to figure out what the vision problem she has is and how to fix it so that she won't have any troubles when she starts school in a few years.
10/20/2020 04:51:45 pm
I think that sounds like a great idea! Did you know that we should start having our eyes checked at 6 months?!?!?! I hope that if she needs anything, she can find the services she needs. Best of luck!
5/21/2021 12:40:38 pm
Thanks for clarifying how optometrists are the experts in vision that I should look for. Maybe I can find one with a ton of experience. Then I know for sure they can take care of my eyes.
9/14/2021 09:06:58 am
I am glad to see that optometrists are experts in vision. I couldn't remember the name of the type of doctors that deal with vision. Now I can try and find one near me to set up an appointment with.
4/7/2022 11:06:23 pm
Great post! I found all the content in this post quite valuable for my daily life - loved it! I want to share a clinic that specializes in eye healthcare. "Eye Connection". https://www.eyeconnection.com.au They have quality optometrists and offer the widest range of glasses. Thanks again!
7/20/2022 04:22:36 am
By examining professions and activities, occupational therapy distinguishes itself from other disciplines. To guarantee that clients are autonomous, professionals in this sector consider clients' occupations, environments, performance, and other factors. Children examine the causes of their inability to play and take action when necessary. Adults who are unable to work once again engage in comparable activities. They take into account the expertise required for that specific work and make up, modify, or repair the missing item. They excel at what they do because it is their profession.
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