Defocus Media: Know the building blocks for vision therapy

Have you been interested in building a vision therapy or neurorehabilitation specialty clinic in your practice? This month’s guest, Joanna Carter, OD, FCOVD, shares the must-have technology she uses in her practice to diagnose and treat patients and practice management tips for making vision therapy a financially rewarding subspecialty.

Related: More from Dr. Lyerly

Dr. Carter founded her practice Insight Vision Therapy in 2016 as an independent specialty practice that provides only therapy services. She has no optical, she accepts no insurances, and she is open from 8:30 a.m. to 4:30 p.m. only Monday through Thursday. And yes, her practice is thriving.

Dr. Carter says that her interest in vision therapy dates back to early childhood when she was treated for esotropia with her first pair of hyperopic glasses at a young age. Growing up she always felt her eyes were “fixed” by the glasses that she had been prescribed, but after entering optometry school she soon realized that her eyes cosmetically looked aligned, but they had never truly worked together. She had no depth perception.

“Maybe that’s why I always avoided all sports,” she jokes.

As an optometry school student taking an early course in behavioral optometry, she was blown away when her professor at Pacific University College of Optometry educated the class that vision is a learned process.

“It had never occurred to me before that at some point in life we had to learn to see,” Dr. Carter says.

Related: Vision therapy: A top 10 must-have list

This personal experience has led to a passion in help others achieve binocular vision.

For ODs considering adding vision therapy to their practices, Dr. Carter encourages them to jump all in.

“There are 2 roads to take: You are either all in, or you refer out,” she says. “The people who try to just dabble in vision therapy, to be honest, are the ones who give VT a bad name. They are the ones where patients say, ‘Well I tried vision therapy, and it didn’t work.’”

To offer vision therapy care, Dr. Carter advises investing in intense continuing education curricula and/or residency programs before offering this service to patients. If that educational investment sounds like more than what ODs want to take on, she suggests they educate themselves on the questions to ask to know if a patient would benefit from vision therapy, and then refer out to a specialist in their area.

Identifying patients who would benefit

Dr. Carter advises doctors to listen for unusual visual complaints or for vision concerns following concussions and asking every child in the exam chair if they like to read.

“If the answer is no, there has to be a reason,” Dr. Carter says.

The problem isn’t always correctable with glasses. Dr. Carter watches for excessive head movement with pursuits and tests near point of convergence to get a quick idea of how the eyes and brain are coordinating (or not).

Related: Vision therapy: 10 more tools for your practice

In building her vision therapy practice, she focused on referrals from surrounding primary-care optometrists and ophthalmologists by ensuring that she was not seen as competition to their offices. She does not have an optical, and she does not accept managed vision care plans.

Referring doctors don’t need to be experts in what vision therapy entails. She suggests telling patients: “As a part of your exam today, we found that your eyes aren’t working well together, and I have a specialist that can teach your eyes how to do that properly so that you aren’t having to work so hard.”

In addition, providing a brochure or patient symptom list to referring doctors can be validating for a patient or a parent to recognize their child will benefit from this referral.

ODs are able to perform a few quick and easy tests rform during the course of a routine eye exam that can indicate significant concerns with the binocular vision system:

• Pursuits: Is the patient moving his head or body to follow the target?

• Near point of convergence: Look for patients backing away from the target as you bring it closer, indicating extreme discomfort.

• Saccades: Dr. Carter likes to use Wolff Wands as the target in older kids and adults. In younger children, finger puppets are a great option.

• Stereo test: Random dot stereo tests are more difficult for esotropes in Dr. Carter’s experience, but when patients can fuse and achieve stereopsis on this test it is a rewarding milestone for their therapy.

• Trial frames: Dr. Carter likes using trial frames to test balance and posture while wearing prescription lenses and for trialing different amounts of prism.

• Lens flippers: She uses flippers for trialing yoked prism and for showcasing different tints for her neurorehabilitation patients who often benefit from blue blocker lenses or FL-41 tinted lenses for light sensitivity.

Invest in technology

Dr. Carter likes to invest in interactive technology that gives patients awareness of space and their peripheral vision to help better integrate the eyes, brain, and body. Free-space objects are a must in her office so patients are using their eyes in real-world, physical spaces.

A few of her favorite investments for therapy include:

• Pitchback net and bean bags—this was one of her first purchases

• Space integrator allows patients to localize where targets are in space

• Marsden balls for tracking and ocular motor activities

• Yoked prisms with balance beams or ball activities

• Vectograms for developing stereoacuity

• Saccadic fixator—“I find that this is really helpful for our more competitive patients,” Dr. Carter says. She utilizes this with red-green glasses for an extra challenge.

• Vivid Vision—“I think it is helpful to create a situation for our patients to experience 3D vision for the first time, and then translate that to the real world,” she says. “I think sometimes patients are scared to experience 3D, so if you put them in a world that is totally novel, they are sometimes more willing to do it.”

As part of our live interview, Dr. Carter also fields a question about syntonics. She explains that for most of her career as a vision therapy specialist, she actively avoided this branch of therapy in which light is used to affect the autonomic nervous system. But colleague after colleague who she respected in the field kept sharing their experiences and encouraged her to take a second look.

“The way it makes the most sense to me is to think about our concussion patients,” Dr. Carter says about how she positions syntonics in her practice. “Their bodies and their eyes are experiencing a highly active sympathetic nervous system [which is why they are hyper reactive to light, convergence, and other stimuli]. The goal of syntonics is to reduce the hyperactivity of the sympathetic nervous system and restore better balance.”

Building the business

From the very beginning, Dr. Carter’s practice has been out of network for all insurance carriers.

“It was easy to do because most insurance doesn’t cover vision therapy,” she says. “Vision therapy is not reimbursed at all and is an exclusion on the policy, or it is reimbursed at such a phenomenally low rate that there is no way that you could make a living accepting these insurances.”

In her practice, patients pay up front, and if a patient has insurance the office will submit a claim through Office Ally as a courtesy. If the insurance pays anything, the practice reimburses the patient. Medicare and Medicaid do not allow for out-of-network billing, so those patients complete a form stating that they understand all treatment will be out of pocket.

As with all business best practices, changes to her office policy are always a possibility. After a high number of referrals for workman’s compensation claims, she is working to become a network plan member to better serve those patients. With a large increase in the number of patients that she is serving with post-stroke neuro-rehabilitative care, she is also considering becoming a Medicare provider.

Patient flow

Dr. Carter schedules vision therapy evaluation and consultations in 75-minute appointment windows, seeing roughly 5 to 6 patients a day at most. While she is conducting evaluations, her 2 trained vision therapists are performing therapy sessions for existing patients in different rooms. In her 3-room clinic, she has 2 vision therapists, herself, and one staff member working at the front desk. T

Her Monday-Thursday 8:30 a.m. to 4:30 p.m hours allow her to get home to her family. She says that while on paper evening sessions might sound appealing to patients, the truth is that doing therapy with tired eyes is just not as successful.

“How much of a difference can I make in your child’s visual system if she is tired when she comes in for our session after being at school all day?” Dr. Carter says.

Learn more

Dr. Carter encourages doctors to join VT ODs on Facebook. The group also offers a mentorship program to be paired with a more experienced doctor in this field to learn more and get specific questions answered.