Behavioural vision care (BVC) is an often misunderstood yet fascinating field of optometry that can be used to manage patients of all ages with complex vision problems, such as deficits in oculomotor, binocular, and perceptual processing.

In this article Evan Brown, past President of the Australasian College of Behavioural Optometrists (ACBO), unwraps some of the most common myths surrounding BVC and provides evidence enabling clinicians to confidently refer patients for care, or expand their personal model of care to include behavioural vision therapy.

WRITER Evan Brown

Firstly, let’s define behavioural vision care (behavioural optometry).

Optometrists who provide behavioural vision care are licensed professionals. They have attained post graduate education and advanced competence, with emphasis on health and development, in the prevention and treatment of vision problems, and how vision impacts on an adult’s or child’s performance. Following assessment and diagnosis, behavioural vision care practitioners treat and manage adult’s and children’s vision problems by prescribing spectacles, contact lenses, prisms, filters, vision therapy, and by providing advice.

The underlying philosophy behind behavioural vision assessment and management is that vision is much more than just eyesight. Vision is a complex process of space and time, prediction and anticipation, utilising learnt behavioural patterns (schemata) that enables us to aim, focus, and move our eyes, to take in and interpret what we see. We use vision in every aspect of our lives to direct our actions as we comprehend and interact with our world. Dysfunction or slowed development of vision interrupts the accuracy, fluency, vigour, and grace with which our vision process gathers information and guides our movements and actions.

Myth 1. There’s no scientific evidence supporting behavioural vision care.

Reality. The field is supported by a growing body of research and wherever possible, behavioural vision care practitioners use the latest in research-based assessment and treatment. Vision problems that are well defined and easy to pigeonhole, like convergence insufficiency1-3and binocular vision disorders,2 have randomised controlled trials supporting diagnosis and treatment using office-based vision therapy.

Vision problems can be complex, and multifactorial, i.e., a convergence insufficiency deficit often, but not always, has an associated accommodation deficit. As a result, there are sub-types: developmental, accommodative, and acquired in aetiology. A binocular alignment problem, such as basic exophoria or esophoria, may or may not have an accommodation deficit or aetiology. An oculomotor development problem may or may not have an associated diagnosis of dyspraxia, retained primitive reflexes, or general developmental delay.4

Amblyopia can be strabismic, refractive, or of combined aetiology. When researchers fail to sub-classify a studied cohort for different problems in their inclusion/exclusion criteria, and instead bracket all types of convergence insufficiency, amblyopia or oculomotor dysfunction together, the outcomes can be less efficacious or weaker than would have been the case if the problems were better understood and treated with improved specificity. This also makes studies hard to design: we are still uncovering the complexity of these differing visual conditions and presentations as the literature expands our understanding about the afferent and efferent neurological sensorimotor interactions of vision.

Myth 2. Behavioural optometrists claim to cure dyslexia or ADHD.

Reality. Most behavioural vision care practitioners do not claim to treat dyslexia or attention-deficit/hyperactivity disorder (ADHD) directly. Instead, they focus on learning-related vision problems such as deficits in accommodation,5,6 vergence facility and binocular vision,7,8 convergence,9 saccadic and pursuit eye movement control,10-14 vision development, and visual perceptual information processing skills.15-18 Deficits in these visual abilities can co-exist with problems such as dyslexia19 or ADHD20-25 and affect visual information processing performance, concentration, and learning aptitude. For example, there is a three times greater incidence of convergence insufficiency in those diagnosed with ADHD.10

Myth 3. It’s just expensive quackery.

Reality. A behavioural vision assessment is an in-depth evaluation of a person’s vision system. While this incorporates eyesight and ocular health, the total evaluation takes far longer and probes deeper into our primary functional and perceptual processing sense of how we use vision. When vision has developed in the normal sequence, it becomes our dominant sensorimotor process to understand and act on our world.

Identified vision problems can be treated and managed with lenses, prisms, filters, or vision therapy. Vision therapy is individually delivered, to develop or rehabilitate visual abilities that help us use vision to understand and act on our world. While this time-consuming treatment and assessment can be costly, many families report positive outcomes and find value in the process, especially in children with visual processing challenges.

Myth 4. Vision problems don’t affect learning.

Reality. Vision is more than just seeing clearly. Skills like visualisation and visual memory,26 visual discrimination ability and just noticeable difference,27 fixation and eye movement control development,13,28 accommodation and eye teaming accuracy,31 and spatial awareness, play a huge role in the ease with which we learn to read and write, and the fluency and attention required in reading to learn.16,30

Behavioural vision care aims to strengthen these abilities where standardised assessment shows they have fallen outside normal variance for age, which can indirectly support academic performance.

Myth 5. Vision therapy is just exercising the eye muscles.

Reality. Vision training, also called vision therapy or perceptual learning, is an individualised program of planned sequential activities designed to enhance development, and correct, or ameliorate visual functioning. The program works on the neurological pathways to enable efficient functional and perceptual visual abilities that have been shown to be fragile during behavioural vision assessment. Examples include eye movement disorders, non-strabismic binocular dysfunctions, focussing disorders, strabismus, amblyopia, nystagmus, and visual perceptual (information processing) disorders. Vision training is designed to create awareness, challenge, and strengthen performance of the skills that comprise the process of vision, and integrate vision with other sensory and motor processes.

Myth 6. Behavioural optometrists are not qualified.

Reality. Behavioural vision care practitioners have the same undergraduate training and qualifications as all optometrists. They are optometrists registered with the Australian Health Practitioner Regulation Agency (Ahpra) or the Optometrists and Dispensing Opticians Board (ODOB) in New Zealand and have a special interest in neuro-developmental optometry; they consider broader concepts in vision. Members of ACBO have extensive postgraduate training and education, and are required to maintain continuing professional development (CPD) standards.

ACBO has invested heavily in creating an evidence-based education platform, with comprehensive training pathways. More recently, ACBO partnered with Rodenstock International to create a new science knowledge centre. These programs provide a literature-backed framework for neuro and developmental optometry, and give the public, optometrists, ophthalmologists, and allied health professionals a reliable way to see who has appropriate post-graduate qualifications.

Myth 7. Pencil push ups or prism spectacles are enough to fix convergence insufficiency.

Reality. While we were all taught at university to utilise pencil push ups as the standard of care, a large multi-centre, multi-discipline (optometry, ophthalmology and orthoptic) randomised controlled trial showed that office-based vision therapy is the gold standard treatment for convergence insufficiency, and that pencil push-ups, computer orthoptics, and home based therapy were no better than placebo therapy.1

Myth 8. Vision therapy will fix a child’s learning disability.

Reality. While some children do struggle with learning because they have a vision problem, many have the double deficit of an auditory processing problem.31 Others have dyslexia or attention deficit, some have background problems with health, diet, education, and/or opportunity exposure that limit academic and learning potential.32 Vision therapy programs do not claim to ameliorate learning disabilities. Vision therapy addresses vision problems that contribute to a learning disability, by developing a child’s visual potential to maximise their ability to engage and attend to visual information in their environment.

Myth 9. A concussion or mild acquired brain injury will resolve without the need for vision therapy.

Reality. While 70–80% of patients reporting visual symptoms following concussion injury recover spontaneously within the first month, 20–30% of patients experience persisting symptoms at three months, and a further subset of 20–30% remain symptomatic at 12 months.33 The incidence of functional vision problems, such as oculomotor deficits, convergence insufficiency, accommodation dysfunction, vestibular-ocular reflex deficits, pattern glare, and light sensitivity mean return to work or learning is impacted.34-36 Behavioural vision care practitioners who have completed accreditation in neurooptometric care are well placed to care for these patients and help them return to activities of daily living more quickly.

Myth 10. Low plus lenses are of no value when prescribed to pre-presbyopic children and adults.

Reality. Refractive lenses alter the perception of space, which modifies our ambient prediction systems for action. Low plus lenses expand central space (x and y axis) while influencing our perception toward further away (z axis). This alters our afferent and efferent responses for vestibulo-ocular reflex gain, pursuit, and saccadic eye movements; our vergence responses and our accommodation responses. The resting point of accommodation (dark focus) is 1 m distal.37 For a person engaged in prolonged near activity 40 cm away, a 0.50DS lens alters the parasympathetic controlled tone in the ciliary body by one third (from a 1.5DS shift to a 1DS shift when adjusting accommodation from 1 m to 40 cm). This has a considerable impact on the balance and interaction within the autonomic nervous system and how it helixes with the vergence (cns) response. Many individuals can use these adjustments in space perception and neurology to improve visual performance with efficiency and reduced effort.

BUILDING THE EVIDENCE BASE

Our beliefs, opinions, and biases are reflected in what we value. All optometrists value eyesight, ocular health, and the evidence-based model of ophthalmic health care.

In caring for patients’ vision, behavioural optometrists choose to add value to their professional practice by extending their learning, assessment, and management into a holistic model inclusive of the functional and perceptual process of vision; specifically, how vision assists us to comprehend and interact with our world. An example here is to consider what is a phoria? While some practitioners believe it is a measure of the oculomotor imbalance of binocular alignment, others will argue it is a reflection of the space volume a patient has learnt to prefer to attend and act in; an exophoria reflects a large volume of space operation and an esophoria a more condensed or compressed volume. The correct view here is a matter of belief, opinion and bias; there is no evidence-based model (EBM) that will help solve this; simply literature and viewpoint that fits what we see in our interaction and experience with patients.

While a point of controversy, behavioural vision care practitioners choose to accept that not all vision problems can be researched to meet the desirable Level 1 and 2 EBM criteria for gold standard practice, but there is an ever-growing, large body of Level 3 and 4 literature that supports their practice.38 As such, behavioural vision care practitioners commit themselves to post graduate education to acquire advanced competence in:

• Eye health, encompassing nutrition, general health, and the effects of psychological and physiological stress, with particular emphasis on the autonomic nervous systems role in vision dysfunction; referring to relevant professionals as indicated.

• Focus, eye coordination flexibility, and stamina problems that can affect visual attention, comfort, and performance when reading, writing, using computers, transferring information, or in sport.

• Development of eye movement abilities for reading concentration, fluency, and activities of daily living.

• Visual dysfunctions, including eyestrain due to focussing problems, and convergence weakness associated with excessive reading or near visual work on computers and digital handheld devices.

• Myopia and its association with repeated excessive and prolonged near visual work, and reduced time spent outdoors.

• Amblyopia and strabismus, and the increasing literature to support the management of binocularity and dichoptic training as the standard of care, prescribing spectacles or contact lenses to maximise binocular potential and apply vision therapy (perceptual learning), which may include virtual reality therapy or other dichoptic methods, to improve binocular potential.

• Visual perception abilities for spatial visual processing, just noticeable difference and discrimination, imagery, and visual recall.

• Visual consequences of neurological conditions, such as stroke and head injury, Parkinson’s disease, concussion, and whiplash (neuro-optometric rehabilitation).

ADDING VALUE TO OPHTHALMIC CARE

Vision is much more than just sight, it is a complex process of aiming, focussing and moving our eyes to take in and interpret what we see. We use vision in every aspect of our lives to interact with our world and direct action. Optometrists in general practice have an opportunity to refer patients to behavioural optometrists when they present with unmet vision problems that cannot be solved by compensation of refractive error, or management of ocular health problems.

For information on evidence-based courses in behavioural vision care provided by ACBO, visit acbo.org.au.

Evan Brown is in private practice in Auckland, New Zealand. He is a Fellow of the Australasian College of Behavioural Optometrists (ACBO) and the Optometric Vision Development and Rehabilitation Association, and the former President of ACBO. Mr Brown authored and lectures Part 1 of the ACBO accreditation in neuro-optometric care module; and is an editor and lecturer for the ACBO Practical Vision Therapy Program.

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