Do You See What I See?

Posted on January 4th, 2013 by Denise | No Comments

Do You See What I See?


Denise Koonce OTR

As a therapist, when you are treating how often do you assess or make specific observations regarding a patient’s vision?  For many of us, when the visual impairment is more obvious, such as the presence of strabismus or amblyopia, it provides us with a more prominent cue of possible visual impairment than when the lack of certain developmental skills just doesn’t add up.  I remember as a new occupational therapist (OT), asking parents about whether or not their child had received an eye exam.   Their answer many times would be” yes”,  that the school performed visual screens every year or every other year and had reported their child’s vision was fine or at least the screen was normal.  In some cases the school screening had not been normal so the child had been evaluated by an eye doctor and now wore glasses.  Since that time I have learned that the school system generally only checks for visual acuity or the clearness of vision for distance by using the Schellen eye chart.  The Schellen eye chart is the infamous chart with lines of letters decreasing in size starting with the capital letter E.  This does not, however, check for any other visual deficits that might be present.  If the child’s vision is not 20/20 then the school recommends a formal visual evaluation be completed.  The two professionals capable of performing a visual evaluation are an ophthalmologist and optometrist.  For the purpose of this text it is necessary to understand the differences between these two eye care professions.   An ophthalmologist is a medical doctor specializing in diseases of the eye and eye surgery.  Their education does not include a significant amount of information involving visual therapy.  Whereas, an optometrist is not a medical doctor but their education includes the diagnosing and treatment of eye disease and the concept of vision and its relationship to the performance of activities in daily living.  The optometrist’s education emphasizes visual therapy and its components.  After learning this, because of the variances in visual treatment, I now specifically ask parents if their child was screened only at school, evaluated by an ophthalmologist or an optometrist and if so what was recommended.

It is important to realize that a child can have healthy eyes, normal visual acuity, pass the school visual screen and still have visual deficits.  Some symptoms showing possible evidence of a visual deficit are itchy, burning or watery eyes throughout the day, headaches after reading, extra time required for reading, holding the book to close to their face, or unwillingness to read.   They can exhibit increased time required to copy items from the blackboard and/or difficulty with the task and have poor handwriting.  Activities requiring good eye hand coordination may be difficult or impaired such as scissoring, coloring, or sports.  Children may also bump into objects, fall or appear clumsy.  A child with visual deficits can have significant issues learning at school due to their visual deficits and can appear like a learning disorder such as dyslexia or attention deficit disorder.  For educational purposes, it is very essential to have a child, who is exhibiting these types of symptoms, evaluated not only by a developmental specialist but also by a developmental optometrist to rule out a visual deficit. 

There are a greater percentage of visual deficits in children with disabilities than in the general pediatric population.  According to Mitchell Scheiman, O.D., FCOVD, and the author of Understanding and Managing Vision Deficits:  A Guide for Occupational Therapists, the most common vision problems within this pediatric population are optical problems, strabismus, amblyopia, nystagmus, optic atrophy and visual processing problems.  They can also exhibit visual field cuts or visual neglect if they experienced hemorrhagic bleeds or brain damage at birth or after birth due to trauma.  If a child with a disability is receiving occupational, physical or speech therapy, and has a visual deficit it could interfere with the child’s ability to make progress.  Therefore, if the child has not been evaluated by a developmental optometrist then it is imperative that an evaluation be preformed.   After the evaluation is complete and the child’s needs are assessed, a visual therapy program may be recommended.  A visual program might consist of wearing glasses, including prism glasses, wearing an eye patch, adapting the child’s environment and/or specific visual therapy procedures.  It is important for the therapist to follow up and coordinate with the parent and developmental optometrist regarding the recommendations of a visual therapy program so compliance will occur during their therapy sessions.  The compliance might include having the child wear their glasses during treatment, encouraging the wearing of glasses at home/school or arranging the therapy environment to optimize visual output.  If an OT is involved in the patient’s care and has training and experience in visual therapy components, the OT can also include those components in treatment.   

If you have a child or a patient who needs to be evaluated by a developmental optometrist you can find one in your area by contacting The College of Optometrists in Vision Development at or calling 1-888-268-3770.  Please share with us any experience you may have regarding visual therapy and join us next week as we continue with the OT’s role in visual therapy.

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