BLOG: 7 ways to incorporate neurodevelopmental tools into optometric practice
I went into optometry to help patients with severe developmental delays who could not speak for themselves.
Over time, my practice has evolved to include rehabilitation of brain-injured patients, both adults and children. There are many similarities in these two areas of practice because, in both cases, visual skills can be profoundly affected.
Neurotypical children learn the foundational visual skills (eg, visual recall, visual analysis, hand-eye coordination, motor control, visualization) through play in a specific developmental sequence from birth through age 7 or 8 years. Developmental delays and conditions like autism or cerebral palsy may affect some or all of these skills. And adults who successfully acquired all of the appropriate visual skills in childhood can find one or more of them suddenly disrupted by a brain injury, stroke or neurodegenerative disease.
Optometrists in primary care are typically focused on ensuring the patient has a healthy cornea, lens and retina and good visual acuity, but it’s important to keep in mind that vision is also dependent on ocular alignment and tracking, peripheral vision and visual processing in the brain — all of which can be affected by brain injury or developmental disorders. Many brain-injured patients tell me they feel like they’ve gone crazy since their accident because doctors keep telling them everything is fine, but they don’t feel fine at all. Even a simple acknowledgment that the visual system has been compromised can be very helpful.
Here are seven other ways optometrists can incorporate neurodevelopmental tools into a primary care practice.
Take a little extra time. With a patient who may have brain injury or neurological challenges, plan to take a little more time with the exam. Talk to the patient (or parent) about their visual challenges or complaints. Do symptoms occur when they are in motion or stationary? Have them walk across the office to see how they move. Ask the patient to wear new glasses in the office for 30 minutes while you see the next patient, and then see how that correction is working for them.
Consider environmental modifications. Inquire about the patient’s environment. Many brain-injured patients struggle with fluorescent lighting. If the patient says they feel better at home than in the office, suggest that they turn off overhead fluorescent lighting or wear a visor/hat with a brim.
Skip the phoropter. Instead, perform a trial frame refraction or free-space retinoscopy. Vision is a bimodal system that relies on inputs from both the focal (or central) vision and peripheral vision. In a neurotypical patient without brain processing problems, blocking the peripheral vision at the phoropter helps you quickly hone in on the most effective central vision correction. But in someone with a concussion, you may only be able to discover visual deficits when the peripheral system is in use. A patient with autism may be more confident and cooperative when they can move more and use their peripheral vision.
Close the eyes. In a brain injury patient, something as simple as changing lenses can elicit symptoms. Ask the patient to close their eyes before removing or putting on glasses or before you change lenses at the phoropter.
Widen the range of tools in your toolbox. Incorporate the evaluation of eye alignment, tracking and focusing into routine exams, and consider gait and balance. I use parquetry block pattern testing developed by my mentor, Harry Wachs, OD, to explore visual thinking and visual perceptual skills, with both concussion patients and children with developmental delays. These simple colored wooden shapes can be used to test how well patients can match, recall or transpose shapes and complex patterns.
Take a course at a Neuro-Optometric Rehabilitation Association (NORA) conference. Even if you don’t want to become a neurorehabilitation optometrist, a NORA course can provide great insight into the neurological and visual challenges you might see in a typical practice population.
Don’t give up. It is all too easy for practitioners to dismiss a patient with sensory, language or muscular challenges by saying, “Well, these are just the symptoms of autism or cerebral palsy ... .” While it is true that those challenges aren’t going to entirely go away, and the patient may not achieve the goals we would expect for a neurotypical patient, there are many ways we can help improve their visual skills and quality of life.
If you feel that a patient’s challenges are beyond your abilities to accurately diagnose or treat, make a referral to a neurorehabilitation professional. You don’t have to solve everything yourself. In fact, patients are tremendously grateful when somebody finally recognizes their challenges and points them in the right direction. Your referral could be life changing for them.
For more information:
Mehrnaz D. Azimi Green, OD, FCOVD, is a neuro-developmental optometrist practicing at the Vision and Conceptual Development Center in Chevy Chase, Md. In addition to diagnosing and treating children with developmental delays, autism and other special needs, she is involved in the rehabilitation of brain injured patients who have vision-related neurological and cognitive challenges. Green is a DIR-FCD Certified Profectum Professional in Developmental Optometry and Intermediate DIR Floortime provider. She volunteers with the Special Olympics. Green will be teaching a course on “Optometry through a neurodevelopmental lens” at the 2022 NORA conference. For more information and to register, click here.
Disclaimer: The views and opinions expressed in this blog are those of the authors and do not necessarily reflect the official policy or position of NORA unless otherwise noted. This blog is for informational purposes only and is not a substitute for the professional medical advice of a physician. NORA does not recommend or endorse any specific tests, physicians, products or procedures. For more on our website and online content, click here.
Collapse