I. Introduction:

Once a differential diagnosis has been made, and it has been decided that further testing for a particular binocular dysfunction is necessary, the next task is to establish the patient's weaknesses and strengths in each of the four binocular skills modalities (accommodation, anti suppression, vergence and ocular motility). This is accomplished in a non-strabismic binocular vision evaluation. Information gained from this evaluation will allow the doctor (you) to "grade" the patient and place him/her into specific binocular skills levels (monocular, transitional, binocular and integrated) for each of the modalities . After the evaluation, it is necessary to construct a general plan of vision therapy. The general plan will be altered as the patient progresses, but it is important to offer the patient some initial idea of the scope length and prognosis of the therapy program. In addition, creating such a plan helps organize the doctor's ideas into a cohesive plan of action.

A. With any case, it is important to find a proper prescription for the patient.

1. A proper BVA prescription is important

2. An appropriate add is important

3. The prescription may change as therapy progresses:

a. distance prescription may change as accommodative therapy releases latent hyperopia or pseudo-myopia

b. near prescription may change (or become beneficial) as therapy increases plus acceptance

C. After completing a non-strabismic BV evaluation, a diagnosis is rendered and a general one month plan is proposed.

1. It is important to express to the patient:

a. the time course of the therapy

b. the possibility of a prescription change during therapy

c. the time commitment a successful therapy regimen requires

2. The patient must understand that they, more than anyone else, determine whether there will be a successful remediation of the binocular dysfunction.

a. express the importance of attending regularly scheduled appointments

b. express the importance of conducting a regular home vision therapy program as dictated by the doctor.

II. Binocular Vision Modalities (Non-Strabismic Cases):

A. Ocular motility: as described in lecture, the occurrence of functional oculomotor deficits is quite common. This is especially true for patients with multiple binocular vision problems.

1. Diagnosis of this condition is achieved by duction and version testing as well as the Developmental Eye Movement Test (DEM).

2. A decision is then made to start the patient at a particular level of binocular vision therapy. This decision is based on:

a. the presence and severity of the patient's (or parent's) complaint

b. difficulty with/avoidance of reading and school work

B. Anti-suppression:

2. A decision is then made to start the patient at a particular level of binocular vision therapy. This decision is based on:

a. the presence and severity of the patient's (or parent's) complaint

b. difficulty with other modalities secondary to intermittent suppression.

C. Accommodation:

1. Diagnosis of this condition is achieved by monocular and binocular accommodative facility testing as well as measuring amplitudes of accommodation. MEM (dynamic retinoscopy) and a kinetic cover test often aid diagnosis of an accommodative dysfunction.

2. A decision is then made to start the patient at a particular level of binocular vision therapy. This decision is based on:

a. the presence and severity of the patient's (or parent's) complaint

b. difficulty with/avoidance of reading and school work

c. decreased near and/or distance acuities not attributable to refractive status or ocular disease.

d. presence of suppression and/or reduced stereo acuity

D. Vergence:

1. Diagnosis of this condition is achieved by vergence testing at distance and near, prism facility testing (6-8 BO/BI) as well as Brock string and vectogram performance. Fixation disparity often aid diagnosis of a vergence dysfunction.

2. A decision is then made to start the patient at a particular level of binocular vision therapy. This decision is based on:

a. the presence and severity of the patient's (or parent's) complaint

b. difficulty with/avoidance of reading and school work

c. presence of suppression and/or reduced stereo acuity

III. Levels Of Binocular Vision Skills:

A. Monocular level:

1. Description: Monocular skills are developed and refined in this phase of therapy. It is hoped that this level of vision therapy

a. established sufficient skills in each eye

b. established equal skills between the eyes

2. See the attached flow chart for samples of therapy techniques for each modality at the monocular level:

B. Transitional level:

1. Description: at this phase of therapy, there is no occlusion (i.e. a binocular precept). The environment, however, is reduced. Many of the monocular fixation in a binocular field techniques fit in this level of binocular skills. The reduced environment presents selected targets to each eye while providing fusional locks. Binocular skills modalities are refined under these limited binocular conditions. It is hoped that this level of vision therapy:

a. establishes and extends visual skills under limited binocular conditions

b. carefully monitors for and eliminates suppression under these conditions

2. See the attached flow chart for samples of therapy techniques for each modality at the transitional level

C. Binocular level:

1. Description: at this phase of therapy, a more "true" binocular environment is present. Most targets are seen by both eyes. Stereopsis is emphasized for the first time at the binocular level. In addition, techniques at this level are designed to refine and extend a particular binocular skills modality while the other modalities are asked to remain at a steady state. It is hoped that this level of vision therapy:

a. establishes and extends individual binocular visual skills modalities under more extensive binocular conditions and demands

b. carefully monitors for and eliminates suppression under these conditions

2. See the attached flow chart for samples of therapy techniques for each modality at the binocular level

D. Integrated level:

1. Description: at this phase of therapy, a combination of binocular skills modalities are refined and extended under increasing binocular demand. Utilization of both, prism and dioptric lenses extends the patient's range of fusion and stereopsis under extreme vergence and accommodative demand. It is hoped that this level of vision therapy:

a. extends and integrates all binocular visual skills modalities under more extensive binocular conditions and demands

b. carefully monitors for suppression under these conditions

2. See the attached flow chart for samples of therapy techniques for each modality at the integrated level

IV. Establishing a Framework For Your Vision Therapy Program: General Concepts

A. Scope of the vision therapy:

1. One issue that you must face is whether to limit your practice to a particular age group or B.V. anomaly type

a. pediatric cases only vs. including adults

b. non-strabismic cases only vs. including strabismics

c. traditional vision therapy vs. including vision perceptual deficits

2. Vision therapy services may take several forms:

a. offer in office therapy programs alone

b. establish home therapy regimens alone

c. utilize both

B. General Components Of a Vision Therapy Program:

1. General appearance of the vision therapy area:

a. neutral decor; flat white paint for the walls

b. well lit area; I prefer incandescent light

c.. try to keep the vision therapy area free from invasion of other areas of the practice… avoid clutter

d. size doesn't matter: therapy space my be as small as a 10 ft. by 12 ft. room

e. must have OPEN counter space:

f. must have storage space for instruments not in use:

2. General order of events to take place before vision therapy is initiated

(these will be discussed in more detail later):

a. primary care evaluation:

i. to establish proper BVA prescription

ii. to assess weaknesses in the patient's binocular vision system

b. conduct a binocular vision evaluation AT A SEPARATE VISIT FROM THE PC EXAM

i. gives you time to review your primary care tests results and make an organized plan for further binocular function testing

ii. allows you to perform specific (and time consuming) tests that would put you behind in your busy (we hope) schedule if completed during a primary care time slot

c. discuss with parent(s) their child's condition and the prognosis of therapy

i. may be of benefit to have literature (either pre-packaged by the AOA or OEP; or your own descriptions of various binocular vision buggums) for the parents

ii. present yourself accurately: that is as THE expert on binocular vision development and function

d. establish a month general plan for VT

i. it will help organize your approach to the pt.

ii. it will show reluctant parents a long term plan of improvement for their child

e. detailed plan for each office visit: monthly plans should be refined and a weekly game plan should be developed BEFORE the pt. enters your office that week

i. it should include 4-5 specific exercises to accomplish at each session

ii. it should emphasize skills in modalities where the patient needs the most work

3. Office visit schedule:

a. home therapy programs: biweekly visits-1 visit every month

b. in office therapy programs: two sessions weekly-one session weekly

4. General conduct during an office therapy session:

a. you must be able to communicate directly to (not talk down to) the pediatric patient

b. you must be able to discuss and educate the parent about their child's visual dysfunction

5. Home therapy assignments:

a. it should include details for home therapy (20-30 min/day)

b. nothing beats written instructions for each home therapy regimen you assign

c. supplies (penlights, colored filters, Brock strings, lenses, prisms etc.) should be made available to the patient

i. if you count on them to "pick something up" at Walgreen’s, it won't happen

ii. having the home therapy supplies on hand also gives you another profit possibility

6. Assessment of visual skills: a visual skills evaluation should be scheduled regularly (one every two months of therapy).

a. it documents improvements in the patient's binocular skills

b. it leads the doctor to a more accurate plan for remediation of the patient's remaining problems

7. Progress reports: it is important to report regularly (at least one every two months) prepare a report for the family that outlines their child's progress

8. Fee collection: a general rule of thumb would be to charge a dollar a minute for your professional expertise

a. charge by the session:

b. charge by the month:

c. charge for the specific diagnosis:

C. Responsibilities of your staff:

1. Greeting the patient and parent(s)

a. coloring books and magazines for children

b. a few, well constructed toys that are age and gender appropriate

i. game boys are becoming a feasible toy to distribute to a pediatric patient while waiting for an appointment

ii. bright colored blocks and puzzles for the younger children

c. the staff person is the first encounter for what is usually a frightened and apprehensive child; it must be a positive experience

d. the parent should be made to feel comfortable as well

i. make coffee available

ii. have them fill out a specifically designed general history form for pediatric patients

2. The role of the vision therapist(s): many practice management gurus have determined the economic feasibility of having specifically trained vision therapists to conduct the vision therapy sessions. This is in addition to the personnel at the front desk (listed above).

a. the doctor (i.e. you) must train the therapist(s)

i. therefore you must be able to do it successfully yourself FIRST!!!!!

ii. the therapist(s), then, report back to you after the session(s) for that week

b. the parents should know, up front, that a specialty trained therapist will conduct the therapy program YOU construct each week

c. having a therapist theoretically frees your time up to conduct primary care exams or binocular vision evaluations

d. the expense of having a part-time therapist is theoretically far outweighed by increased revenues from evaluations and therapy sessions

3. As the doctor, it is your responsibility to:

a. conduct all binocular vision evaluations

b. make all diagnoses

c. communicate openly with the parents and patient

d. keep up to date on the progress of each patient undergoing therapy and construct a specific therapy plan for each week

4. It is my opinion that you should become very comfortable (and have a few successes under your belt) before hiring (and training) a technician to conduct therapy. Additional time slots for binocular vision evaluations or primary care exams will not earn extra dollars if your patient load demand isn't near saturation. Build the practice steadily and invest in some "blue ticket" therapy instruments before training additional therapists.