5 ways to offer neuro-optometric services in your practice

	Excerpted from page 46 of the January/February 2019 edition of AOA Focus

Up your game: That's the coaching from experienced doctors of optometry, including members of the AOA's Vision Rehabilitation (VR) Committee, who are urging doctors to take a more proactive approach to managing the care of patients with traumatic brain injuries (TBI). Consider these tips.

1. Manage or refer.

Offering neuro-optometric services shouldn't be a snap decision, considering the work that goes into setting them up, doctors say.

"It takes some significant preparation," says Eric Ikeda, O.D., owner-president of a California practice and an AOA VR Committee member. "Not everyone can, or is willing to do it, but everyone has a responsibility to participate in some way—whether doctors of optometry are referring patients to specialists or managing their post-concussion care themselves."

Carl Garbus, O.D., chair of the AOA VR Committee, whose California practice emphasizes the care of patients with TBI, strokes and developmental problems, adds, "Optometry has a big opportunity to work with professionals outside of our field, to create referral sources to help patients, and to be full partners on the post-concussion care team."

2. Provide the basics.

Americans show up daily at their local emergency rooms after falls, traffic accidents and assaults that deal blows to the head. All doctors should be prepared, at the very least, to identify symptoms associated with TBI, the experts say. Many practices already possess the equipment needed for this basic evaluation, including a loose prism set, Maddox rod, trial lens set, near point testing targets, rotatable prism set and special filter set for photosensitive patients. If these basic tests uncover visual symptoms associated with TBI, doctors of optometry may prescribe a pair of glasses or a change in prescription to counter the visual symptoms, as the brain heals slowly.

"A good starting point for a practice that is interested in evaluation of traumatic brain injury is to provide special lens prescriptions to help the patient to be more comfortable," Dr. Garbus says.

Follow-up will be required. Dr. Ikeda says that PM&R (physical medicine and rehabilitation) physicians represent a significant number of his referrals, both in private clinical practice and in rehabilitation clinics, as well as nurse case managers.

3. Dig deeper.

For practices considering offering neuro-optometric services, Dr. Garbus suggests doctors of optometry start by educating themselves. Attend courses at Optometry's Meeting^®. Consult other doctors. Mentoring by colleagues has been very helpful, especially early on, to assist with managing cases, Dr. Ikeda says. "An on-site visit is best," Dr. Garbus adds, to see and hear firsthand how it operates and fits in with the overall practice.

Consider whether you have the space. "It is very challenging to do rehab in an exam lane room space," says Marc Taub, O.D., chief of vision therapy and rehabilitation at The Eye Center at Southern College of Optometry, in Memphis, Tennessee. "If there is existing therapy ongoing at the practice, this is a natural extension. If not, I would not suggest this as a starting place. Find a nearby practice and build the referral relationship."

4. Equip your office.

Is your office accessible? Are the doors of your exam rooms wide enough to accommodate wheelchairs?

"The ability to control overhead lighting in the office also is a consideration," says Dr. Garbus, noting some patients with TBI typically have sensitivity to light. "If possible, have a quiet area in the office for the patient to relax," he says. "Many TBI patients get overstimulated in the busy areas."

Ideally, Dr. Ikeda says, practices that already provide therapy are uniquely equipped to transition into rehabilitation as he did in his early years. Involve your paraoptometric staff who will be responsible, if you make the transition, for scheduling patients. "The doctor of optometry providing the rehab services may need more time with these patients than with other patients," Dr. Taub says.

5. Evaluate.

Practices typically ask patients to fill out histories prior to their office visits or upon arrival. But the average forms may not include some TBI-specific questions. Some additional questions to ask:

• Were you unconscious after the blow to your head? If so, for how long?
• Did you suffer any seizures?
• Did you experience trouble navigating stairs or a crowded or busy environment? Trouble reading?
• What medications are you taking for it?
• Have you seen a neurologist or your primary care physician for your TBI? Have you had any special testing?   "I recommend mailing the patient questionnaire prior to the appointment because they are lengthy," Dr. Garbus says.

Among further tests Dr. Garbus suggests are an eye movement evaluation, near point of convergence test, cover test at distance and near, simple fusion test, the Worth's Four Dot test, stereo test and confrontation fields or standard visual fields (static or kinetic) testing. Doctors also should perform an ocular health exam including pupils, anterior segment evaluation, tonometry and dilation.

"During the testing, observe the patient to see if they are fatiguing easily and if they are developing symptoms such as a headache or eyestrain," Dr. Garbus says. "As part of the examination, it is very important to have the patient stand and walk a distance of 10 to 20 feet in order to observe a patient's overall posture, balance and gait. Special yoked prisms can often improve poor gait dynamics and posture."

He also recommends that practices provide patients with educational materials on TBI. "The literature can explain some of the vision deficits that can occur after head injuries," he says.

Access the Brain Injury Electronic Resource Manual from the AOA's VR Committee. The first section focuses on evaluation and assessment of common visual conditions associated with TBI, and the second volume focuses on treatment and management of brain-injured patients over time.