Preferred Practice Patterns

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On November 3, the American Academy of Ophthalmology published four Preferred Practice Patterns of particular interest.  You can access them through these hyperlinks:


Esotropia and Exotropia

Pediatric Eye Evaluations

Vision Rehabilitation

The following are a few highlights quoted from the Practice Patterns, but I encourage you to read the originals in their entirety to be aware of these issues from the perspective of organized ophthalmology.

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“Success rates of amblyopia treatment decline with increasing age.  However, an attempt at treatment should be offered to children regardless of age, including older children and teenagers. The prognosis for attaining normal vision in an amblyopic eye depends on many factors, including the age of onset; the cause, severity, and duration of amblyopia; the history of and response to previous treatment; adherence to treatment recommendations; and concomitant conditions.”  (P120)

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“Convergence insufficiency occurs in children and adults, and symptoms with near viewing (typically reading) can often be improved using vergence exercises.” (P150)


“Children with esotropia should undergo surgical correction if eyeglasses and amblyopia management are insufficient to align the eyes, and strabismus surgery should be performed only when more conservative methods have failed or are unlikely to be of benefit.”  (P159)

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“Barriers to eye care extend beyond inadequate screening and diagnosis. Screening programs vary in their ability to ensure access to eye examinations and treatment for children who fail screening. In 15 screening programs in the United States, the rate of referred children receiving a follow-up examination was over 70% in four programs but was below 50% in the other 11 programs. Barriers to care may include inadequate information, lack of access to care, limited financial means, and insurance coverage and reimbursement issues.”  (P199)

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“It should be emphasized that level of visual acuity alone does not determine who will benefit from multidisciplinary care or what services may help that patient. The various aspects of visual function loss (such as contrast sensitivity loss or visual field loss), extent of the patient’s goals and responsibilities, and the availability of other individual resources determine both the need for vision rehabilitation and the most appropriate interventions. Multidisciplinary rehabilitation is not reserved for patients who have advanced vision loss and not all services are required by all patients. Rehabilitation is often important for those with modest loss to address the various aspects of function that are impacted and ensure that patients are on a positive path at the outset. This is particularly true for individuals who face progressive vision loss. Medicare reimburses for a low vision evaluation by an ophthalmologist or optometrist and for occupational therapy.”  (P237)

One thought on “Preferred Practice Patterns

  1. Thanks Len. I look forward to at least scanning them later. The last paragraph is interesting on at least 2 levels. The last sentence which notes Medicare payment for low vision exams is incorrect or at least inaccurate. There are CPT codes for LV exams and they have not been paid at least since the late 1980’s. Many docs use 99000 codes for LV services and this must be what they are referring to.

    Interesting point that vision function findings alone does not define the need for services. Pretty remarkable. Their colleague, Gus Colenbrander, pointed out about 10 years ago, that functional vision needs to be considered when evaluating an individual. He felt that this could only be done in the person’s habitual environment and not in the doctor’s office. While he may be correct in the fact that true function can only be assessed in the community, practically, we alter environment / cognitive load / sensory integration all the time with patients in our exam and therapy rooms with patients undergoing VT. All eye care providers should consider and assess functional vision when working with individuals with low vision; especially children for whom brain based vision impairment is suspected.

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