Clinical Referral Guidelines

Visual problems of your patients may manifest themselves in many forms. While no one of the following dysfunctions may signal a serious problem, many of them may result in a decline in academic or vocational performance. However, the patient typically credits the situation to something other than a visual problem.
When an individual feels he is doing the best he can yet performance continues to decline, a routine visual evaluation may not be sufficient. An in-depth study of the visual system including visual performance testing may be required.
The following outline is a partial listing of academic and job-related visual problems that relate to performance. While this list is not intended to be complete, it should serve as a guide to assist both you and us in the co-management of your patients.
Eye movement problems may present themselves in a variety of ways, typically:
  • Frequent omitting of words when reading, writing or copying.
  • Frequent skipping of words when reading, writing or copying.
  • Frequent loss of place while reading, writing, or copying.
  • Using finger or marker to follow while reading.
  • Slow and laborious reading.
  • Taking a long time to finish assignments.
  • Poor timing in sport activities.

The patient may exhibit difficulty in tracking a target, sometimes resorting to head and body movement.   Often the only sign is that the patient does not like to read.

Accommodative disorders may take many forms. In the early stages, the patient may notice intermittent distance blur particularly after doing some close work. Typical examples of difficulties in this performance area are:
  • Eye pain or fatigue at the end of the day.
  • Assignments not complete on time.
  • Decline in performance as the day progresses.
  • Intermittent or constant near blur.
  • Intermittent or constant distance blur.
  • Confusion when reading small words that are similar in appearance.
  • Loss off patience when sustained near work is required.
  • Difficulty when driving at night.
More measurable myopia and/or esophoria may be evident in the visual analysis. The NRA and PRA may both be reduced. 
In the early stages, difficulties in this area may only reveal themselves with highly loaded testing. However, the patient may exhibit a decrease in performance even at this level. Typical symptoms are:
  • Words running together when reading.
  • Words "swimming" or "floating" on page while reading.
  • Intermittent diplopia at near and/or far.
  • Eye fatigue at end of day.
  • Intermittent or constant eye turn. 
  • Intermittent blur at near and/or far.
  • Holding reading material very close. 
  • Frequent headaches after school or work but not on days off.
The near point of convergence may be greatly reduced. Stereopsis may also be lowered at near. BI and BO vergences may both be lower than expected or may be unbalanced.   Pseudo-myopia may also occur. ANY manifest strabismus--intermittent or constant, alternating or unilateral--elicited via cover test or history should also be referred. Tropias such as small angles (micro-strabismus) or an intermittent strabismus may be more difficult to observe, but represent a primary reason for referral as well. 
Amblyopia can have many etiologies and may be partially or fully reversed with appropriate treatment even in older patients, according to current research. Amblyopia can be binocular or monocular and may present with or without strabismus. Amblyopia has traditionally been defined as an asymmetry of more than two Snellen lines in visual acuity between the two eyes. Subtle vision losses are now being picked up through Contrast Sensitivity and Visual Evoked Potential analysis.   Any sight loss not correctable through refraction, particularly where no frank observable pathology exists, should be referred. No patient is too young or too old to refer for evaluation and possible treatment.
Optometric Vision Therapy is the treatment of choice for the conditions listed above. As part of the training, stress-relieving lenses may be prescribed. Optometric Vision Therapy for the treatment of a physical visual condition is sometimes covered by major medical insurance policies, subject to the deductible and co-payments of the policy. 
Any infant with a personal or family history of visually related health problems should be referred. This would include infants who were premature, who incurred trauma during labor and delivery, or who are neurologically impaired. Well baby evaluations are done as well. The well-documented Preferential Looking method of acuity assessment can be used on infants as young as one month old, as well as older, non-verbal patients. The following observations made either by you or by history are reason for further evaluation:
  • Inability to obtain visual acuity or refraction. 
  • Nystagmus. 
  • Significant and constant head tilt or head turn. 
  • Inability to view fundus.
  • Strabismus. 
  • Squinting or covering an eye. 
  • Confused tracking of visual stimuli.

It is best to call the referral source directly to make the initial appointment for your patient. Doing this at the time that the patient is in the chair with you helps to communicate to your patient just how important this additional optometric care is for them. As is done when making any other types of referrals, share with the doctor to whom you are referring and/or their staff, your understanding of the needs of the patient and your sense of the importance in that patient being see promptly.