By Tamara Petrosyan, OD
If you see children and young adults in your practice, a significant percentage of them will have issues with accommodative, binocular and oculomotor function optometry has been moving more and more towards a medical model, increasing our scope of practice, though perhaps at the risk of overlooking other clinical conditions. As we move forward, it is good to keep in mind that the AOA’s Clinical Practice Guideline on Care of the Patient with Accommodative and Vergence Dysfunction is included in the National Guideline Clearinghouse through the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services.
It is estimated that anywhere from 10-20% of the U.S. population have symptoms due to binocular or accommodative dysfunction. Unfortunately, only a small percentage of these individuals are identified, yet alone treated. Adding a few key questions to your history may be all it takes to help identify at risk patients, bearing in mind that young children may not express symptoms because they presume everyone else sees and feels the same way they do.
A problem focused and extensive case history can be one of your most useful tools when trying to identify accommodative, binocular, or oculomotor dysfunctions. A visual function questionnaire can be mailed to the patient or parent, be placed on your website for patients to fill out, or be handed to the patient in the waiting room before they enter the exam room. The Convergence Insufficiency Symptom Survey is a readily available standardized survey that can be used on your patients. I have put together the below questionnaire to help identify those patients at risk for accommodative, binocular, and oculomotor vision dysfunction. If the patient answers positively for 5 or more of the below 25 questions, a more in depth evaluation of visual function should be considered. Make sure that a parent understands that, if possible, they should be asking the child to answer these questions instead of filling it out for the child. Many times children will not complain of any issues because they do not realize that not everyone sees words moving on the page or gets a headache after reading.
Additional tests for accommodation, binocularity and oculomotor function are listed below. Purchasing extra equipment is not required to perform these additional tests. Although extra equipment can be purchased for more in depth evaluation, all of the testing below can be performed with equipment most optometrists have in their office. The chart below provides norms for these findings. To further evaluate oculomotor function, a practitioner may purchase a Diagnostic Eye Movement (DEM) or King Devick test.
The following tables summarize diagnostic findings for various accommodative and non strabismic vergence dysfunctions. This is not the complete list of diagnostic findings, but is a useful guide.
If a patient comes to the office complaining of difficulties noted in the questionnaire and your testing shows signs that an accommodative, binocular, or oculomotor dysfunction is present, discuss the findings with your patients and consider referring them for a vision therapy evaluation and treatment if you do not provide the treatment yourself. Doctors with a practice emphasis in vision therapy will always weigh differential diagnosis factoring in potential medical issues as well.
If you do not perform vision therapy in your practice, there are many highly trained and qualified doctors of optometry that perform vision therapy. We should be making use of these practitioners and their services for intra-optometric referral. They will work with the patient and parent to develop a treatment plan that works for them, whether that may be monitoring, glasses, prisms, in-office therapy or home-prescribed therapy. When referring a patient for an evaluation, be sure to note what specifically the patient is being referred for, when you want the patient to return to you, if you have an optical in your office, and in what form you would like a report to be sent to you.
Sometimes the therapy doctor may write a new glasses prescription, especially for a bifocal or reading glasses, as needed for the patient so be sure to inform them that you do have an optical and would like the patient to return with the prescription to purchase spectacles or contacts from your office. The consulting doctor should only perform the procedures that you request and return the patient to you for all other care.
You can access the full AOA Clinical Practice Guideline (CPG-1) on Accommodative and Vergence Dysfunction here.
Or, you can access the Quick Reference Guide (QRG-18) here.