When to Refer for Developmental Optometric Evaluation

Objective Signs: Acuity

·        Any loss of visual acuity between refractions not explainable by observed corneal or media obstructions or by observed retinal pathology. (Questions about reduced acuity due to the level of cooperation in children or the feeble may be resolvable by a pinhole test to see if acuity improves.) 

·        Unexplainable acuity loss mean a judicious consultation is needed. Amblyopia is, in fact, treatable at any age.

Objective Signs: Diplopia

·         Sudden onset of diplopia at any age always deserves extra concern. More benign causes might be sinusitis, diabetes, or nutritional problems associated with acute alcoholism. 

·        The cover-uncover test, Stereopsis tests, and the Hirschberg Test can reveal a lack of binocularity. 

·        A careful history and review of childhood photos can reveal a potential prior history of strabismus which can occasionally decompensate. Referral is essential.

Subjective Signs: School Referral

·        School nurses don’t refer non-refractive cases out very often. So, when a child has been referred by the nurse or by a reading teacher and refraction reveals no clear problem, suspicions of binocular vision disorders should rise. 

·        Before concluding that the referral might have been erroneous, revealing questions should be asked: “How long can you read before you get tired?” The answer should not be less than 30 minutes, in any case, and 60-90 minutes by secondary school. Another productive question is: “What happens to your eyes when you read?”

Objective Signs: School Referral

·         Some school guidance counselors, psychologists, and (recently) occupational therapists will refer students for visual-motor problems.  Some parents, not understanding the specific reason for the referral that has occurred will approach a primary care vision doctor, or will be forced to come through HMO or PPO channels.  It would be negligent to fail to refer these individuals onward for the specialized evaluation needed.  I have records on file from a family who won a malpractice case against a large local school district for failure to address their children’s visually diagnosed perceptual problems.

Subjective Signs: Symptoms

·        Individuals whose eyes water while reading;  or,

·        rub their eyes frequently; or,

·        get closework-related headaches; or,

·        use their finger to read with; or,

·        “hate” reading; or,

·        are smart in everything but schoolwork; or,

·        whose eyes ache or fatigue rapidly with deskwork; or,

·        reverse letters or miscall words when reading, etc.

·        All these above are candidates for referral for a functional vision evaluation.

SO THEN:  What can you, the referring doctor say?  Perhaps something like: “I’ve found (or, ‘I can’t rule out’) what may be a problem with your (or your child’s) visual efficiency. You/(S)he may not be using her/his eyes as a team. I have several colleagues who treat these problems, I’m going to recommend that you be seen by one of them to settle my concern.  This needs to be addressed by a behavioral vision specialist.  I’m noting this in your/your child’s records. Do you have any questions?”