10 things I wish I knew earlier about vision therapy

May 26, 2020

How to take on the challenge of providing therapy to improve vision.

Vision therapy is a varied and rewarding field in which there is always something new to learn. Looking back through nearly two decades of experience, here we explore what it’s good to know before you start.

Vision therapy is both an art and science. Even though I graduated from optometry school in 2001 and have been teaching vision therapy in an academic setting since completing my residency in 2004, I am still learning.

I learn from my colleagues, mentors, students, and, yes, my patients. While I am sure the learning process will continue until the day they pry the Brock string from my dead hands, there are so many things that I wish I knew before I started on this journey that would have saved me some hair follicles.

This list is by no means exhaustive, but I am happy to share it in the hopes of saving other ODs’ hair follicles and fingernails.

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There is no such thing as too much education
I love learning. I can’t even fathom the number of hours of education that I have taken since graduating, but it was the courses related to vision therapy and pediatrics from which I have learned the most.

I have taken, and taught at, many of the major meetings, and they have excellent 1- to 2-hour educational bites on a variety of topics to whet the beak. It is through organizations like the Optometric Extension Program Foundation (OEPF), College of Optometrists in Vision Development (COVD), and Neuro-Optometric Rehabilitation Association (NORA) that I have developed my model of vision. Each provides education in larger chunks ranging from 10 to 35 hours on a specific topic.

Learning extends past formal education as well. COVD and NORA offer fellowship processes, while OEPF publishes a multitude of books. Both OEPF (Optometry & Visual Performance) and COVD (Vision Development and Rehabilitation) publish world-class open-access journals as well, so the opportunity for life-long learning abounds.

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You won’t know everything; keep it simple
I promise that the complicated and puzzling cases will find their way to your offices, but, for the first few, stick to the easier ones. You need to prove to yourself, the office staff, other doctors in the office and community, and the patients that you know what you are doing.

Start with the basic binocular cases of the accommodative and/or vergence genres. Do not start with a 40-year-old esotrope with a history of three strabismus surgeries who has never seen stereo or an autistic child who is non-verbal.

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Start low and go high over time
Patients love all of the amazing technology they get to use at my clinic…and so do I. It is great for motivation and allows you to challenge the patient in a different manner.

The concern of course is that technology can be expensive for a new office. Start with a low-tech approach. Yes, buy Brock strings, lens flippers and vectograms…they will never steer you wrong (Figure 1). Over time, consider adding a computer program or larger-ticket item like a touch screen to enhance your therapy offerings and get that “wow” factor from the patients. There are many options, so do your research on the web, at meetings, and by talking to those in the field.

Results take time
You may have been taught that a “basic” convergence or accommodative therapy case will take 12 weeks to treat in therapy. Perhaps that is true for a handful of hard-charging patients who actually do the home activities prescribed or whose conditions are not embedded, but it is not true most of the time.

The longer I perform therapy, the more time I estimate is needed. I adjust my projection based on the findings but also on the patient demographics and parental involvement.

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A young child will inherently require more time, and perhaps breaks in the therapy process, than a teenager. A patient with amblyopia, strabismus, developmental challenges, or who has suffered a brain injury will take significantly longer.

Be honest at the start with the patient, parent, or family member-it is OK to tell them that treatment may take a year. In most cases, patients have taken a lifetime to develop their adaptations to survive; it will take more than 3 months to break them back down and build the patients back up.

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Every patient has a different ceiling
Honesty is the best policy. It is no different in the therapy room. In the consultation process, I always talk about removing vision as a barrier for the patient.

If she is in school, we are working toward school performance and attention, but we must never promise that vision therapy will improve grades-this will only lead to disappointment for all involved. We are, on the other hand, working to reduce the visual challenges to allow natural abilities to flow unimpeded.

For patients suffering a brain injury, we strive to get them back to pre-injury levels visually and cognitively. As with school-age children, we must not make promises we cannot keep; in most cases, the stopping point will be well below the desired endpoint. Our goal with all patients is to enable meaningful change and improvement to the highest level possible, but never make promises.

Meet patients where they are
Within a given activity, there are infinite levels. Be flexible with the activities and demands so that the patient has an opportunity to learn and make meaningful change. It is essentially the story of Goldilocks: you want the activities not too hard or too easy, but just right. If they are too easy, the patient does not have to work to make change; if too hard, the patient is likely to fail and there is no opportunity for learning to take place (Figure 2).

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For example, take everyone’s favorite activity, the Brock string. You can make it easier by using a string with larger beads, or you can make it harder by having the patient stand on a balance board, Bosu ball, or foam pad to add balance to the mix.

It is important to remember that age can be used as a guide to find the appropriate level, but patients are surprising in their abilities. Younger patients often advance quickly, while patients suffering a brain injury or with special needs may need to start at a much lower level than their age dictates. Finding the starting level for a given patient takes time, and even after 15 years, I am still learning.

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Vision therapy affects the Rx, and the RX can affect VT
“Eyeglasses/lenses have both positive and negative attributes. In some cases, they can enhance overall visual functioning, while in other cases they can deeply embed maladaptive behaviors. For these reasons, eyeglasses/lenses should always be prescribed judiciously.”

I could not agree more with this statement from former New England College of Optometry professor, Richard Laudon, OD, FAAO in a personal email. I have always fit into the “less is more” philosophy when it comes to prescribing, and my experiences have only strengthened in that regard.

If there is no test that I can point to that backs up a change in, or even giving, the prescription, it is not going to happen. This is especially true if I am recommending the patient for therapy or the patient is in an active therapy process.

There is no harm in waiting until therapy is completed, then reassessing the visual system to provide the prescription that best supports the patient and the gains that he has made.

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A good vision therapist makes the difference
The importance of a vision therapist who has the right training and works independently from the doctor cannot be understated. This can happen only if the doctor spends time with the therapist in the therapy room and therapy programming for the patients.

While this can impact the bottom line because it is not efficient use of the doctor’s time, this practice will reap benefits down the line. In a busy office, the therapist is seeing patients at the same time as the doctor, so setting the stage early on with good training is crucial.

A good therapist is also vital to patient outcomes. Therapists need to think outside the box and find not only what motivates each patient but also what activities patients enjoy and how to find the appropriate level of challenge.

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The proof is in the results
You will always have your fans and your haters-show them the same attention, but always take the high road. Don’t try to prove the haters wrong; show them they are wrong through your patient care.

There will always be those in the medical community who not only disregard but actively put down vision therapy as a treatment option. Don’t waste time sending them research studies-they most likely won’t read them. Instead, show them the impact through patient care outcomes. Let the patients and their families be your ambassadors to spread the news of success to those doubters and to anyone who will listen.

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Vision therapy is not for everyone
Despite your best intentions, not everyone is ready to commit to the therapy process. This hesitation can be due to parent or patient concerns. The child may not be on board because he is “too cool” for therapy or he does not see a need in the first place. There can also be family challenges, including financial or divorce. This can lead to problems with show rate and homework compliance, leading to poor outcomes.

Choosing patients and their families who are ready to make the commitment to the therapy process is just as important as the therapy itself.

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Take the leap
For those who are ready to take on the challenge of providing vision therapy, my last piece of advice is to take the leap.

Be smart; do your research. Don’t forget that you are not alone. You will find that vision therapy doctors will literally give you the plans to their offices and therapy; don’t hesitate to ask for help.

Go to a meeting, shadow an office, and join the DOC List (a listserv with over 1,000 clinicians worldwide; email me for more details) or VTODs on Facebook.

There is no need to reinvent the wheel. Vision therapy is not only fun, but it can change lives, yours and the patients’. What are you waiting for?

More by Dr. Taub: Vision therapy: A top 10 must-have list

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