I

Ibinocular vision

Iden ify inocular Millions of children and adults suffer

unnecessarily from binocular vision

disorders because theyre

underdiagnosed Rectify this by

following these four steps

n comparison to glaushycoma cataract age-reshylated macular degeneration diabetic retinopathy and dry eye

syndrome binocular vision (BV) disorders areeven more freshyquently encountered than these diseases and have significant negshyative effects on ones quality of life In fact one study revea led that the prevalence of accomshymodative and BV (strabismic and

o non-strabismic) disorders is 97 times greater than the prevalence of ocular disease in children ages six months to five years old and its 85 times greter than the preva lence of ocular disease in

o

children ages SL( to 18 years old 1

In addition a study of 1679 pashytients between the ages of 18 and 38 showed that 562 presented with symptoms associated with BV dysfunction 2 Although these are alarming statistics a disconshynect exists betyeen the high prevalence of BV disorders in the general population and the BV patients reported being evaluated

by primary care optometric prac shytices

To improve the lives of these often overlooked patients while augmenting the financial health of your practice follow these four steps

Ask BV-related questions Make sure your patient hisshy

tory form includes appropriate questions so you dont miss any possible BV disorders To the best of my knowledge no orgashy o nization has developed a stanshydard form primary care optometrists should use to assess the presence of BV disorders Inshystead most ODs adapt their

DOMINICK M MAINO OD MED FAAO FCOVD-A Harwood Heights III

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I Vismiddoton Disorders

forms accordshying to those currently used by BV specialists to meet their practices individual needs

For instance in my practice I provide several forms modified from the ones we use at the Illishynois Eye Institute These include the Illinois Eye Institute Eye and Medical History form for chilshydren the Convergence Insuffishyciency Symptom Survey (httpwwwminnesotavisionther apycomlUserFileslFilerroni20shy20Convergence20Insufficie ncy20Symptom20Survey pdf) and the College of Opshytometrists in Vision Development (COVD) Quality of Life Survey I may also give my adult patients the COVD Quality of Life Surshyvey along with an adult case nisshytory form that coven BV disorder symptoms

The Illinois Eye Insti tu te Eye and Medical History form for children inquires about double vision squintshying and eye tracking anomalies among other BV-related sympshytoms (See page 32) The Convershygence Insufficiency Symptom Survey is comprised of questions regarding the occurrence of speshycific symptoms related to reading and close work such as tired eyes while the COVD Quality of Life Survey requires the patient to rate the occurrence of various BV symptoms such as headaches and dizziness

Review the answers with the patient

Just because the patient fills out a form doesn t mean hes done so correctly In addition all too often I find one or more blanks on the fo1m(s) because

the pashytient missed the

question - a possible symptom of a BV disorder - didnt undershystand it doesnt see how its reshylated to vision (general development questions for inshystance) or wants to test me to deshytermine whether Im a thorough practitioner

As a result you should a twa ys review the answers to your BV form(s) with the patient andor his parent or caregiver and of course ask the appropriate folshylow-up questions to ensure the forms are complete and correct

For instance if a patient comshyplains of diplopia ask him about its frequency time of onset whether he notes it at distance or

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I Vismiddoton Disorders

forms accordshying to those currently used by BV specialists to meet their practices individual needs

For instance in my practice I provide several forms modified from the ones we use at the Illishynois Eye Institute These include the Illinois Eye Institute Eye and Medical History form for chilshydren the Convergence Insuffishyciency Symptom Survey (httpwwwminnesotavisionther apycomlUserFileslFilerroni20shy20Convergence20Insufficie ncy20Symptom20Survey pdf) and the College of Opshytometrists in Vision Development (COVD) Quality of Life Survey I may also give my adult patients the COVD Quality of Life Surshyvey along with an adult case nisshytory form that coven BV disorder symptoms

The Illinois Eye Insti tu te Eye and Medical History form for children inquires about double vision squintshying and eye tracking anomalies among other BV-related sympshytoms (See page 32) The Convershygence Insufficiency Symptom Survey is comprised of questions regarding the occurrence of speshycific symptoms related to reading and close work such as tired eyes while the COVD Quality of Life Survey requires the patient to rate the occurrence of various BV symptoms such as headaches and dizziness

Review the answers with the patient

Just because the patient fills out a form doesn t mean hes done so correctly In addition all too often I find one or more blanks on the fo1m(s) because

the pashytient missed the

question - a possible symptom of a BV disorder - didnt undershystand it doesnt see how its reshylated to vision (general development questions for inshystance) or wants to test me to deshytermine whether Im a thorough practitioner

As a result you should a twa ys review the answers to your BV form(s) with the patient andor his parent or caregiver and of course ask the appropriate folshylow-up questions to ensure the forms are complete and correct

For instance if a patient comshyplains of diplopia ask him about its frequency time of onset whether he notes it at distance or

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Ibinocular vision

near vvhether it occurs during a particular time of day during the performance of a particular task or tasks and whether its consisshytent or intermittent

Perform appropriate testing

If the patients complete and correct patient history data re-

answer is a more in-depth assessshyment of oculomotor dysfunction sensory and motor fusion vershygences and accommodation

The saccadic function assessshyment often includes the Developshymental Eye Movement (DEM) test (Bernell) while the cover-unshycover test assesses motor fusion These tests determine problems

Explain that the typical comprehensive examinations dont always yield enough information for you to determine the presence of a specific BV disorder

veal that he may have a BV disshyorder explain to him that youre going to conduct a comprehenshysive examination that includes appropriate tests so you can deshycide whether he needs additional testing Be sure to mention to the patient however that the typical comprehensive examinations don t always yield enough inforshymation for you to determine the presence of a specific BV disorshyder or for that matter the most appropriate diagnosis to decide on the best course of action

For the patients I see I usually conduct a comprehensive examishynation that includes enough tests so that I can determine whether additional testing is required while meeting all the requireshyments of various health insurshy

D ance companies I then re-appoint them for a visual effishyciency evaluation if needed I exshyplain to my patients that some or all of the specialized testing may require that they payout of pocket In other words I tell them not to necessarily expect inshysurance to pick up the costs

So what comprises this vishysual efficiency evaluation The

with accuracy of reading eye movements as well as the presshyence of strabismus (As a brief aside you can often diagnose poor pursuit and saccadic skills subjectively using a + 1 to +4 scale with +1 indicating very poor performance and +4 the very best [the DEM test provides a more objective evaluation])

The sensory fusion assessment is often comprised of four tests The Worth 4 Dot Random Dot Wirt Dot and Stereo Fly tests These tests help to determine the presence of suppression which often accompanies a BV disorder

The motor fusionvergence asshysessment is comprised of the near point of convergence (NPC) test as well tests that determine whether a large heterophoria and reduced vergences at far and near are present You may conduct these tests using Risley prisms (Veatch Ophthalmic Instrushyments) in the phoropter or by usshying the handheld prism bar out of the phoropter The results of these tests help you diagnose the major vergence dysfunctions asshysociated with convergence and divergence

Finally the assessment of acshycommodation consists of amplishytudes negative relative accommodation positive relative accommodation accommoda tive facility determination of the Acshycommodative ConvershygenceAccommodation (AClA) ratio and an assessment of the lag of accommodation The amshyplitudes of accommodation tests reveal how much accommodashytion is present (eg accommodashytive insufficiency or excess) You can assess the amplitude of acshycommodation using several difshyferent methods including a minus lens push up and pull away techshyniques accommodative facility and the +-200 flipper test The positive relative and negative relshyative accommodative tests show how accommodation works unshyder binocular conditions Acshycommodative facility tests determine how easily focusing can change from distance to near and back again You can assess positive relative and negative relshyative accommodation using +shy200 flippers and an appropriate near target The ACIA ratio reshyveals how the accommodative stimulus and response are related (eg if a little accommodation reshysults in a great deal of convershygence) And you can assess the lag of accommodation via the Monocular Estimation Method (MEM) (See Specific BV Disorshyders page 30)

Determine the best course of action

Once additional testing yields a diagnosis you must decide whether you feel comfortable treating the condition Keep in mind that this comfort level should be in tune with your abilshyity to provide the patient with the best treatment plan (See Managing Common BV Disorshyders page 28)

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Ibinocular vision

For instance many primaryshycare optometrists may feel comshyfortable treating intermittent strabismus but not constant unishylateral alternating or vertical strabismus as this is something typically overseen by an opshytometrist who specializes in opshytometric vision therapy As a result the best course of action is often either to refer the patient to a colleague whom you know is an expert in treating the condishytion or to provide the patient with a list of names of specialists from which he can choose You can find referral sources by conshytacting the American Optometric Association (wwwaoaorg) Colshylege of Optometrists in Vision Development (wwwcovdorg) the American Academy of Opshy

tometry (wwwaaoptorg) the Optometric Extension Program (vrwwoeppoundorgl) and your state optometrIc assoCIatIOn

I realize that several practishytioners are reluctant to refer pashytients to another optometrist or perhaps ophthalmologist for fear of losing the patient to this individuaL The ramifications of not doing so however can be devastating In fact during the crafting of this article Ive been a legal consultant in a case in which a colleague may have failed to treat or refer a child who has functional amblyopia appropriately Do you really want to be in this situation If not then you need to approprishyately diagnose treat or refer these patients

Through my experience Ive found that practitioners who speshycialize in vision therapy return a majority of these patients to the referring doctors care once the patient has completed the thershyapy or these patients return on their own The latter often ocshy bull curs if you explain to the patient that this particular condition falls out of the realm of your expertise and that you want to make sure he gets the best possible treatshyment The patient often apprecishyates your honesty and commitment to his wellbeing so much that hes sure to return to you for the other excellent eyeshycare services you provide

Remember We must treat and refer appropriately for all funcshytional vision disorders or endure

Managing Common BV Disorders

bull Amblyopia The best initial treatment for all types of amblyopia is a pair of spectacles as glasses alone can significantly improve visual acuity If after wearing glasses for a couple of months the patients improveshyment in vision isnt what youd like start a patching regshyimen consisting of two hours of daily patching that includes one hour of near visual activities

If the patient is noncompliant with patching have him or his caregiver instill atropine ophthalmic drops in the better-seeing eye over a weekend (one drop on Satshyurday another on Sunday) The result of doing so closely approximates that of patching

The one hour of near activities suggested above as a part of the treatment plan should include monocular (by patching or blurringpenalization) oculomotor handshyeye (ie filling in Os in a newspaper) and accommoshy- dation activities (i e Hart Chart Accommodative Rock Chart [wwwnovaeduhpdotmmbavtIVTACC03 HTM]) Also you may want to prescribe one of the many optometriC vision therapy computer programs available for amblyopia These include those from Home Therapy Solutions Vision Builder and Computer Aided Vision Therapy

If after a reasonable time period - typically three months ~ your treatment outcomes have reached a

plateau or youre unsure of the next step refer your pashytient for a more aggressive in-office optometric vision therapy program

As a brief aside be aware that the treatment of amshyblyopia isnt just appropriate for children but also for adults In fact current research in neuro- and cortical plasticity strongly suggests that an active therapy proshygram (vision scientists refer to this as perceptual learnshying) can show significant improvement in the visual acuity of the adult patient At the recent COVD meeting Dennis Levi 00 PhD dean of the school of optomeshytry at the University of California Berkeley and reshyspected vision scientist noted that perceptual learning (vision therapy) can be both effective and efficient if inshytervention is intensive active and challenging His reshysearch showed that 50 hours of perceptual learning shywhich is equivalent to 25 days of two hours of patching with one hour of near vision therapy activities - boosts brain processing efficiency decreases cortical image distortion and is appropriate for both the child and adult who has amblyopia

bull CI The recent Convergence Insufficiency Treatshyment Trial (CITT) revealed that the best and most efficashycious treatment for CI is office-based vision therapyorthoptics along with home-based therapy

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Ibinocular vision

For instance many primaryshycare optometrists may feel comshyfortable treating intermittent strabismus but not constant unishylateral alternating or vertical strabismus as this is something typically overseen by an opshytometrist who specializes in opshytometric vision therapy As a result the best course of action is often either to refer the patient to a colleague whom you know is an expert in treating the condishytion or to provide the patient with a list of names of specialists from which he can choose You can find referral sources by conshytacting the American Optometric Association (wwwaoaorg) Colshylege of Optometrists in Vision Development (wwwcovdorg) the American Academy of Opshy

tometry (wwwaaoptorg) the Optometric Extension Program (vrwwoeppoundorgl) and your state optometrIc assoCIatIOn

I realize that several practishytioners are reluctant to refer pashytients to another optometrist or perhaps ophthalmologist for fear of losing the patient to this individuaL The ramifications of not doing so however can be devastating In fact during the crafting of this article Ive been a legal consultant in a case in which a colleague may have failed to treat or refer a child who has functional amblyopia appropriately Do you really want to be in this situation If not then you need to approprishyately diagnose treat or refer these patients

Through my experience Ive found that practitioners who speshycialize in vision therapy return a majority of these patients to the referring doctors care once the patient has completed the thershyapy or these patients return on their own The latter often ocshy bull curs if you explain to the patient that this particular condition falls out of the realm of your expertise and that you want to make sure he gets the best possible treatshyment The patient often apprecishyates your honesty and commitment to his wellbeing so much that hes sure to return to you for the other excellent eyeshycare services you provide

Remember We must treat and refer appropriately for all funcshytional vision disorders or endure

Managing Common BV Disorders

bull Amblyopia The best initial treatment for all types of amblyopia is a pair of spectacles as glasses alone can significantly improve visual acuity If after wearing glasses for a couple of months the patients improveshyment in vision isnt what youd like start a patching regshyimen consisting of two hours of daily patching that includes one hour of near visual activities

If the patient is noncompliant with patching have him or his caregiver instill atropine ophthalmic drops in the better-seeing eye over a weekend (one drop on Satshyurday another on Sunday) The result of doing so closely approximates that of patching

The one hour of near activities suggested above as a part of the treatment plan should include monocular (by patching or blurringpenalization) oculomotor handshyeye (ie filling in Os in a newspaper) and accommoshy- dation activities (i e Hart Chart Accommodative Rock Chart [wwwnovaeduhpdotmmbavtIVTACC03 HTM]) Also you may want to prescribe one of the many optometriC vision therapy computer programs available for amblyopia These include those from Home Therapy Solutions Vision Builder and Computer Aided Vision Therapy

If after a reasonable time period - typically three months ~ your treatment outcomes have reached a

plateau or youre unsure of the next step refer your pashytient for a more aggressive in-office optometric vision therapy program

As a brief aside be aware that the treatment of amshyblyopia isnt just appropriate for children but also for adults In fact current research in neuro- and cortical plasticity strongly suggests that an active therapy proshygram (vision scientists refer to this as perceptual learnshying) can show significant improvement in the visual acuity of the adult patient At the recent COVD meeting Dennis Levi 00 PhD dean of the school of optomeshytry at the University of California Berkeley and reshyspected vision scientist noted that perceptual learning (vision therapy) can be both effective and efficient if inshytervention is intensive active and challenging His reshysearch showed that 50 hours of perceptual learning shywhich is equivalent to 25 days of two hours of patching with one hour of near vision therapy activities - boosts brain processing efficiency decreases cortical image distortion and is appropriate for both the child and adult who has amblyopia

bull CI The recent Convergence Insufficiency Treatshyment Trial (CITT) revealed that the best and most efficashycious treatment for CI is office-based vision therapyorthoptics along with home-based therapy

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the consequences associated with patient dissatisfaction and even legal action

For information on how to incorporate the diagnosis and management of BV disorders into your practice look for artishycles in Optometry amp Vision Deshyvelopment (h ttpwwwcovdorgl Portals019-20Practice20 Man age ment 20 Wrightpdf) by au thors such as M ark Wright OD (wwwcovdorgl PortalslOI EvaluatingYourselpoundpdf) Jason Clopton OD FCOVD (WWvcovd orgIPorta IslOI Practice Mgmt_ChangingPara digmspdf) and PedsNT Practice tVlanagement GuruThomas Lecoq (wwwcovdorgIPortalsOI OVD 38_ 4_Practice_Managemen tpdf ) Also read the practice

management chapters in BV textshybooks by Scheiman and Wick such as Clinica l M anagement of Binocular Vision Heterophoric Accommodative and Eye Moveshyment Disorders (Lippincott WiJtiams amp Wilkins 2008) and attend the yearly COVD proshygrams

Meeting the needs of patients who have BV disorders wont only enable you to better the lives of these often-ignored pashytients but a lso grow your pracshytice This is because these pashytients tend to be so appreciative of and impressed by your diagshynostic abilities that theyll refer others w hom they believe may have BV disorders as well OM

1 Scheinum M Galaway M Coulter

R et at Preuaience of vision and ocular disease conditions in a clinical pediatric population 1 Atn Optom Assoc 1996 Apr67(4) 193-202

2 Montes-Mic6 R Prevalence of General Dysfunctions in Binocular Vimiddot sion AI1I1als ofOphthalmology 2001 Sept 33(3205 -2 08

3 Clinical Studies Database Sup-

Dr Maino

a professor of pedi shy

J rricslhinocull f viSlon

at the Illinoi Eye Insti middot

tuteIllinois College 01

Optollletry is the editor of OptOllletry

amp Vision Development and amhors the

blog MainosVIemos in which he reshy

views the latest chi ld ren s vision reshy

sCMch Also hes in private IWolCtice in

I-Luwood Heights III E-mail him at

Jmainoicoedll

(ie Pencil Push-up therapy3 Specifically the results revealed that 12 weeks post-treatment almost 75 of children ages nine through 18 who were given both forms of therapy achieved normal vision or had signifishycantly less CI symptoms Meanwhile only 43 of those patients who completed the home-based thershyapy alone 33 who used the home-based therapy in addition to computer vision therapyorthoptics and 35 who underwent placebo office-based therapy had similar outcomes

You should also keep in mind that most children ages 9 to 17 years who were asymptomatic after the 12-week treatment program of office-based vershygenceaccommodative therapy for CI maintained their improvements in symptoms and signs for at least one year post treatment (For an audiovisual presentation regarding this ground-breaking research visit http progressive uvau Itcompd1 005COV081 07player htm)

bull Intermittent strabismus The most appropriate treatment for these disorders frequently includes preshyscribing spectacles prism and initially out-of-office therapy Eventually however in-office vision therapy may be required If after three months or so your pashytient doesnt seem to be improving its time to refer to

an optometric vision therapy specialist Many primary care ODs may bel ieve that referring

patients who have a constant unilateral alternating or vertical strabismus for surgery is the best course of acshytion rather than referring these patients for vision thershyapy Studies suggest however that surgical outcomes may not be as good as most of us might believe The case ofStereo Sue (Sue BarryPhD) is a good examshyple 5

She was born with strabismus and underwent multiple surgeries to correct it While the surgeries alshymost fixed the appearance of her strabismic eyes they didn t correct the visual problem Ultimately vision therapy provided her with stereopsis and 3D vision

Further one surgical study showed that 13 years postoperatively no outcome was very good four were good 12 were satisfactory and two were poorB Very good was defined as orthophoria or orshythotropia with exophoria or esophoria of less than 5PD Good was defined as exophoria or esophoria less than 10PD or orthotropia of 5deg (microstrabismus) Satisfacshytory was defined as exophoria or esophoria greater than 1 OPD or exophoria or esotropia greater than 10PD but less than the preoperative angle Finally poor was defined as the same as the patients preoperative conshydition or worse

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Ibinocular vision

ported by the Nat ional Eye Tn stitute (Accessed 11109) Symptomatic Convergence Tnsufficiency Convergence Ins ufficiency Treatment 4 Convergence Insufficiency T reatshy in Children Optom Vis Sci 2009 Sept Trial wwwneinihgovneitraisl ment Trial Study Group Long-Term Efshy 86(9 1096-11 03 viewSturly WebasJ xirl=l 07 fec tiveness of Treal111enls for 5 Sacks o A Neuro logists Note-

Specific BV Disorders bull Convergence insufficiency (CI) A patient

who has this BV disorder may have one or more of the following a receded NPC an exophoria at near reduced positive fusional vergences andor a deficit in NRA Although seeing all the above in any single patient is unusual youll almost alshyways note the presence of a poor NPC and high exophoria at near

bull Convergence excess (eEl A patient who has a near deviation of at least 3 prism diopters (PO) more esophoria than at distance and which may be associated with a high ACA has CEo

bull Divergence insufficiency (01) This rare BV disorder which may have a non-functional pathologicalorganic etiology (rule out divershygence paralysis and unilateral or bilateral sixth cranial nerve palsies) occurs when esophoria is greater at distance when compared with near Many of these patients have low fusional divershygence amplitudes at distance and reduced ACA ratios

bull Divergence excess This occurs when the patients exophoria is greater at distance than at near Many of these patients have low fusional divergence amplitudes at distance and r~duced ACA ratios Also theyre often asymptomatic but may report intermittent diplopia when going from a dark to a lighted environment (ie from a darkened movie theater into the sunlight)

bull Basic exophoria and basic esophoria These conditions show an equal amount of devishyation at distance and near You can note these BV disorders when the patients heterophorias are normal but significantly reduced vergence ranges are present These patients demonstrate a very limited zone of single clear binocular vision

bull Accommodative insufficiency When the amplitude of accommodation is low or you note a high MEM finding for the non-presbyopic pashytients age he has this BV disorder

bull III-sustained accommodation A patient with this disorder has normal accommodative amplitudes but shows rapid fatigue when you place repetitive demands upon the focusing system

bull Accommodative infacility This disorder occurs when the focusing system is slow in shiftshying from distance to near and back again or when a substantial delay occurs between the stimulus to accommodation and the response

bull Accommodative excess or spasm of acshycommodation This disorder results from overshystimulation of the parasympathetic nervous system and its frequently related to overall fashytigue The condition is also sometimes known as the spasm of the near reflex (disproportionate accommodation overconvergence and miotic pupils) Accommodative excess can result from cholinergic drug use trauma a brain tumor or myasthenia gravis

bull Strabismus The most often diagnosed forms of strabismus include exotropia and esshyotropia You may notice vertical anomalies a hyshyper or hypodeviation but you usually don t encounter these conditions as frequently as horshyizontal deviations Optometrists tend to enshycounter traumatic andor disease-caused strabismus less often than functionally induced misalignment of the eyes However this may now change with the growing interest by opshytometrists in working with acquired brain injury patients

bull Form deprivation amblyopia This type of amblyopia occurs when an obstruction along the line of sight stops the formation of a well-foshycused high-contrast image on the retina Conshygenital cataract is the most frequent etiology of this type of amblyopia Strictly speaking this isnt a true form of amblyopia since it isnt of a functional nature but rather has a pathological andor organic etiology

bull Refractive amblyopias These are comshyprised of isoametropic amblyopia which a roughly equal high magnitude uncorrected bilatshyeral refractive error causes and anisometropic amblyopia which has an etiology of demonstratshying a significant uncorrected refractive error difshyference between the two eyes

bull Strabismic amblyopia This is aSSOCiated with an early onset constant (early childhood) strabismus

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Ibinocular vision

book Stereo Sue The New Yorker 7 Press L The story behind Stereo 8 Kordic H Sturm V Landau K Sue and a world-famous neurologists June 19 2006 64-73 Long-term fo llow-up after surgery for exshy

6 Barry SR Essay Stereo views Op shy discovery of vision therapy Optom Vis odeviatiol1 Klin Monatsbl Augenheilkd tom Vis Dev 2006 Feb 37(251-4 Dev 2006 Feb (37) 255-57 2009 Apr226(4)315-20

P ilia es Binocular sion Service ILLINOIS EYE Phon (3 1 Z) 9-19 280

INSTITUTE Eye and Medical History Fx(31Z) Jl~76(

File jj Todays Oab _ ________

Patient Name __________ _______ Dlte ofBlnb_middot_ _ ______

Grade Level_ ___ _ Hobbies (eirc all that apply) Sports Computers Reading Ol lllr _________

Person accompanying patient _ _______________Relationshl t ~lll n t

Reason for visit ________________ _ _______ ______ ___________

Patients Ocular History Date ofJast eye exam ______ By w om

Does the patient wear glasses o No 0 Yes Has the patient had ed an eye pate D Yes Ifyes what are they used for 0 Far 0 Near 0 Other Has the patient had qe ~u erygt D Yu

Does the pltient we1r contact lenses 0 No 0 Yes HJgt the patient had any eye inj uries o Yeo Has the patient hud vision therpy 0 No 0 Yes Has the patient had any eye fn fe ruons 0 0 DYes

Please ch bullmy of the fL lIowing that apply to the patient o No probklll obsev d or report ed

o Blurry vision o Squinting o Diffiell Ity tra ng an bjt ct o Double vision o Rubs eyes o Oro ping of ey lid o Eye pain o Dry eyes o Frequ t bl k l gshyo Burning o Eyestrainfatigl ~ O Rednes-uvond eyes Ditching o Lazywandering eye o CWIrSor d oses an eye o Tearing watering o Flashes of Il h t o Discharge Crom e es o Floaters o Ugh t sensitivi ty

Family OcuJillUltitOry PIese check any of the follOwing that ap Iy to f mily mem b o Other ___ _ _ _ _ _ _ _o Wears glasses D Glaucoma

D La t y Eye o Macular Degeneration o Wandering Eye o Blindness

Patien Medical TIislO Date of last medic I exam ____ Lly whom _____

Please check any of the foil wing that apply to the patient o No prob f ms obselTltd or repOl lell

o Diabetes D fJ rt disease o Other endocr III oroblems o Allergies o Other card iovascular problems MuseI I skt h al rlt) lems o Asthma D Neurological disease o GastrointeHi l I pr blems tl Behavioral problems OMental heuth proble s o Genitomin4ry pro killS

o Attention Deficit Disorder o Hearing or ear problems D Other _______ ___ o High blood pressure o Skin problems

Ust any medication(s) the patient is currently takt ng

Is the patient currently receiving any of the following services (check all that I ply) o SpeciaJ Ed 0 Speech TIlerapy 0 Occupational Therapy 0 Physical Therapy D Tut Ii g 0 Other _ ____

Check any of the following that you have observed in the patient 0 No problems otgtserved or rltjlnted

D Trouble finishing worllt D Complains of blurred vision D Poor handVIitLng o Impulsive 0 Complains of eye pain or fatigue 0 Poor sp ling sl ill

o Frustrates easily D Avoids reading or writing D Complu Df I~ crs 11 aTOundD o Lacks confidence D Loses place while reading 0 Reverses letters whon realln or mtl g

o Difficulty sitting still 0 Skips or rereads words or letters 0 Uses fing I 10 m p pltcc Itln rlating o Difficulty paying attention 0 Reads below grade level 0 Fails to (1 111 Id e W rk em tim o Complains ofheld1ches 0 Poor reading comprehension

Has the patient received any special testing associated with school performance N D Yc i 0 [fy plcage eJopjtin

Hts the pauent had an in middotvidua[led education plan (IEP) with the school No Yes

Do (or did) any other members of the family have problems in school No 0 Yes 0 If YiS j dkar who md describe briefly the problems they experienced _____ ___________________________

Please date aua inI tial each time this cas history has been reviemiddotea

D EC l middot B E R 2 009 0 P TOM E T R I C M A N AG E MEN T bull W W Vol 0 P TOM E T RIC MAN AG E MEN T COM32