Vision Evaluation Processes Described by Pediatric Occupational Therapists: A Qualitative Study

ABSTRACT

Vision deficits can impact areas of occupation and limit one’s ability to function academically and socially, making it essential for assessing and treating children with developmental delays and acquired brain injuries. This qualitative study describes the occupational therapist’s process when completing vision evaluations in pediatric settings such as schools and early intervention, where data was analyzed utilizing thematic analysis. Twenty-one occupational therapists with at least one year of experience in pediatrics and vision evaluations who completed structured interviews were included in the study. Purposive sampling and snowball recruitment were used. Common symptoms seen with children who display visual deficits indicated by participants include headaches, double vision, and clumsiness. Common difficulties shown by children with visual deficits indicated by participants were reading, handwriting, and difficulty copying. Two themes were created based on the data analysis: exploring how OTs benefited from the partnership with optometrists when treating visual deficits and the significance of how the visual system plays in a child’s overall functioning. Pediatric OTs can be among the first team members to note concerns impacting their occupational performance. With this knowledge, OTs can help children progress academically and become more independent.

KEYWORDS:

• Occupational therapist
• vision evaluations
• vision screening
• vision assessments
• pediatric settings

Introduction

Routine vision screenings and examinations are essential in identifying whether one has an underlying visual deficit. Less than 22% of preschool children in the United States receive some form of vision screening or evaluation by a qualified eye care specialist such as an optometrist (i.e., a general optometrist or a behavioral and developmental optometrist) or ophthalmologist (Shakarchi & Collins, 2019). Without a formal vision screening or evaluation, children can present difficulties with visual acuity, binocular vision (both eyes working together cohesively), and visual perceptual skills, which can affect their academics, activities of daily living, and social participation. Approximately 65% of children’s school day is engaged in visual-motor tasks, and an estimated 26% of children have visual deficits other than visual acuity alone (Falkenberg et al., 2019; Jang et al., 2017).

An individual can visit different types of eye care professionals to obtain a vision screening or an evaluation. An ophthalmologist assesses the structure of the eye and eye health, emphasizing treatment through medication and surgery. In contrast, an optometrist diagnoses and treats eye disease and visual deficits while looking at the relationship of vision to performance in play, school, sports, work, social participation, and navigating one’s environment (Brown & Hockey, 2013; Fessler et al., 2020). Optometrists can also rule out the visual diagnosis and prescribe yoked prisms, prisms, or lenses for effective treatment and remediation (Au & Coulter, 2014). While pediatricians conduct a basic vision screening during routine checkups, it only assesses visual acuity (i.e., the distance a child can see). A school nurse or a vision program conducted at the school level typically focuses on visual acuity and determining whether a child needs glasses. Families might not take their child to an optometrist due to barriers such as living in a low-income neighborhood, limited access to health care, lack of education, and understanding of what eye care professionals assess.

Vision evaluations or screenings provided in schools or by a qualified occupational therapist can assist with identifying visual deficits in children across pediatric settings while collaborating with qualified eye care professionals such as optometrists, including developmental and behavioral optometrists (Shin et al., 2011; Sullivan et al., 2018; Visser et al., 2017). Occupational therapists can screen informally or use evaluative tools and assessments to help identify if there are concerns with visual perceptual skills, visual motor skills, oculomotor skills, and binocular vision. Once OTs screen and evaluate, they can make referrals to a qualified eye care professional if concerns are present and rule out any potential visual diagnosis. With the knowledge and understanding of the different visual diagnosis along with collaboration from an optometrist, it can assist occupational therapists to help guide their treatment interventions (AOA Vision Rehabilitation Committee, 2023). However, families need help following up with qualified eye care professionals after completing an evaluation due to external circumstances like income, educational background, geographic location, insurance coverage, ethnicity, and language. There are similarities between the two fields as they emphasize the relationship between treating the underlying skills problems and improving the performance of daily living skills (Fessler et al., 2020).

In-depth vision screenings and evaluations are often not administered to children, especially children with underlying intellectual and learning disabilities (Abu Bakar et al., 2012; Au & Coulter, 2014; Redondo et al., 2019). Children with learning disabilities are more at risk of developing vision problems than the general population (Donaldson et al., 2019). Children with developmental delays or acquired brain injuries have difficulty communicating their symptoms, so they are often misdiagnosed or not receiving the proper treatment. Occupational therapists in school settings and early intervention can screen and refer children to appropriate eye care professionals during initial assessments and evaluations. 35% of teachers say school screens are inadequate as most do not assess convergence, visual tracking, and binocular vision (Hinkley et al., 2011; Hopkins et al., 2016).

Schneck’s (2020) research reported that 40% of sensory processing is used for visual motor skills, as one has to sense, interpret, plan, and react (Schneck, 2020). Houwen et al. (2022) states, “… children with visual impairments (VI) are not able to use vision as the primary sense for learning, they need to rely more on their other senses, such as touch and hearing, to stay in touch with their physical and social environment” (p. 2). Dunn’s Four Quadrant Model focuses on sensory modulation and the interaction between self-regulation and neural sensitivity (Dunn, 1997; Houwen et al., 2022). The four quadrants that make up Dunn’s model includes (1) low registration with a high threshold and passive response, (2) sensory sensitivity with a low threshold and passive response, (3) sensation seeking with a high threshold and active response, and (4) sensation avoiding with a low threshold and active response (Dunn, 1997; Houwen et al., 2022). Every child has a different threshold for processing sensory stimulation, which can impact behaviors that indicate a child may have difficulty with vision.

Current research signifies the need to explore pediatric occupational therapists’ understanding of completing vision evaluations due to the high prevalence of vision dysfunctions referred to occupational therapists (Fessler et al., 2020). Literature states statistically significant results on improving convergence which leads to increased reading endurance, decreased work avoidance, and increased concentration and attention (Borsting et al., 2012; Dudovitz et al., 2016; Falkenberg et al., 2019; Scheiman et al., 2011; Shin et al., 2011). This study aims to explore pediatric occupational therapists’ experiences completing vision evaluations to expand knowledge and inform occupational therapists on relevant assessments and evaluative approaches due to the high prevalence of children having learning disabilities.

Aim of the Study

The purpose of the study is to describe the process of vision evaluations completed by pediatric occupational therapists, including those who work in schools and early intervention. The authors define pediatric occupational therapists who work with children in settings such as outpatient, school-based, early intervention, and pediatric hospitals for at least one year or more who have completed vision evaluations. This study will explore the research question, “How do pediatric occupational therapists describe their process of conducting vision evaluations?”

Methodology

Study Design

This descriptive qualitative research study utilized a series of 13 structured, open-ended interview questions via Zoom with eligible occupational therapist participants. Institutional Review Board (IRB) approval was received from an accredited university in December 2022.

Participants

Participants were included in this study if they met the following criteria: (1) licensed and registered as an occupational therapist in the state they are currently practicing within a pediatric population; (2) at least one year of experience working in a pediatric setting; (3) at least one year of experience conducting vision evaluations; and (4) residents of the United States. Participants who did not meet the inclusion criteria were excluded from the research. Purposeful sampling was utilized to recruit participants who are occupational therapists with a known background and knowledge of vision rehabilitation, and a mass e-mail correspondence to occupational therapists employed by the New York City Department of Education by one of the investigator’s supervisors. Snowball sampling was also used by having participants provide investigators with potential participants’ contact information.

A total of 2380 occupational therapists were contacted via e-mail with a flyer to ask if they would be willing to participate. The recruitment period occurred between January and February 2023. Participants provided informed consent prior to the interview and were free to refuse to answer or end the interview at any point. Participants stated their interest in participation contacted the investigators via e-mail or phone call. Of the 2380 participants contacted, 42 responded via e-mail/phone call to indicate interest in participating. Those 42 participants emailed a Google Form document to complete about their preferred dates and times to schedule an interview. Investigators followed up with 42 individuals who stated interest via e-mail again after one and two weeks to see if they were willing to continue participating. After week three of no responses from 20 individuals, investigators stopped communicating with them. A total of 22 participants were interviewed between mid-January 2023 to the beginning of March 2023. One individual was excluded from the study due to failing to meet the inclusion criteria since they did not conduct vision evaluations. Most individuals contacted for the study were employees of the New York City Department of Education (n = 2300).

Informed Consent

Participants were asked to read, sign, and acknowledge an electronic informed consent form that stated the research study’s purpose, risks, benefits, and contact information at the beginning of the interview. Participating in an interview indicated consent to participate in the research study and being recorded for data purposes. If the participants felt uncomfortable with questions or their participation, they could withdraw their consent by exiting the interview.

Interview

Interviews consisted of three parts: (1) informed consent, (2) demographic questions, and (3) experiential questions. Demographic questions obtained information about practice settings (i.e., school, hospital, outpatient), age, location, educational background, years of practice, and years implementing vision-based practices. The experiential questions were developed by the investigators based on suggestions and feedback from doctoral research capstone mentors. The questions were then reviewed by a content expert, Dr. Mitchell Scheiman, OD, Ph.D., FAAO, and the Institutional Review Board (IRB) for rigor and quality assurance. Experiential questions were asked about their experiences with vision-based evaluations, screenings, or assessments, vision-based treatment approaches, incorporation of occupational-based or client-centered treatments, and continuing education. Additional questions included: common signs or symptoms therapists observed, the duration a vision evaluation requires, how they became interested in visual-based evaluations/treatments, and if they have experience writing an Individualized Education Program (IEP) or 504 vision goals (if school-based), and what they would want other therapists to know.

Interviews were completed virtually on the Zoom platform and lasted approximately 30–60 minutes, varying by participants’ responses.

Interviews were recorded for transcription and coding purposes of qualitative data. Through the Zoom platform, an audio transcription of the interview was downloaded to text. The investigators then transcribed manually to ensure the information was transcribed accurately. All participants were asked to member-check interview transcriptions within one week to ensure accuracy. See Appendix A for a list of interview questions asked.

Data Collection

Interviews conducted by investigators were recorded and transcribed. Participants checked transcriptions after interview completion, and investigators then coded the transcribed data manually using Excel. Data was stored on password-protected devices (i.e., laptops and computers) on a private and secured network. All participants’ names and identifying information were removed to maintain confidentiality. All transcripts, audio recordings, informed consents, and any personally identifiable information investigators used for data collection will be kept in password-encrypted files (only accessible to investigators) for three years and destroyed afterward.

Data Analysis

The qualitative data were analyzed using descriptive statistics, allowing investigators to summarize and describe open-ended interview responses. Investigators completed manual coding by highlighting interview transcriptions and then tallying the common responses to identify emerging themes. Inductive coding was utilized, where the investigators developed coding after data was collected (Vears & Gillam, 2022). Reflexive and coding reliability thematic analysis were used as the codes and themes emerged from data collection and for intercoder reliability (Byrne, 2022).

The study gained credibility through member checking, peer debriefing, collection triangulation, and research triangulation (Forero et al., 2018; Guba & Lincoln, 1989; Nowell et al., 2017). Researchers utilized audit trails, field notes, and written transcripts of the interviews in order to gain dependability (Forero et al., 2018; Guba & Lincoln, 1989; Nowell et al., 2017). Tactile authenticity was gained by having participants sign a clear, informed consent form before the interviews, ensuring confidentiality by eliminating any names or identifiable information, and member checking (Amin et al., 2020; Lincoln & Guba, 1986). Educative authenticity was gained through audit trail and peer debriefing (Amin et al., 2020; Lincoln & Guba, 1986).

Results

Descriptive statistics were used to outline the participants’ demographic information (Table 1). Of 21 participants, 2 of the 21 participants worked in school and outpatient clinic settings. Only 8 participants practiced in school settings, and 9 participants worked in outpatient settings. The remainder of the participants worked in hospital-based (n = 1) and early intervention (n = 1) clinic settings. Out of the total sample of participants, the average age was 39.67 years, the average years of pediatric practice were 11.6 years, and the average years of vision-based treatment practice was 9.0 years (Table 1).

Table 1. Participant demographics (n = 21) **Multiple responses by participants.

Variable		Frequency	%
**Area of Practice	School-Based Early Intervention Outpatient Hospital Based	10 1 11 1	–
**Geographics	Florida Indiana Maryland (Washington DC) Minnesota New Jersey New York North Carolina Ohio Pennsylvania South Dakota Texas Washington	1 1 1 1 1 5 1 3 5 1 1 1	–
Years in practice setting	0–5 6–10 11–15 16–20 21+	10 5 1 2 3	47.6 23.8 4.8 9.5 14.3
Yearsincorporating vision-based treatment	0–5 6–10 11–15 16–20 21+	8 7 2 1 3	38.1 33.3 9.5 4.8 14.3
Age	25–29 30–39 40–49 50–59 60+	4 7 6 3 1	19.0 33.3 28.6 14.3 4.8
Highest Level of Degree	Bachelor’s Master’s Doctorate’s	1 11 9	4.8 52.4 42.9
**Specialty Certifications/Professional Credentials	None Remedial Vision Rehabilitation Certified Autism Specialist Interactive Metronome	10 5 2 2	–

Qualitative Findings

Five out of the twenty-one participants reported working or collaborating with optometrists throughout the treatment of children they work with whom have visual deficits. These therapists worked in school, early intervention, or outpatient settings. Several participants stated that collaboration with an optometrist enhanced their interest in expanding their knowledge, leading them to take continuing education courses and research on how to help identify and treat visual deficits among children. Four participants reported taking similar continuing education courses related to vision taught by the same occupational therapists. These continuing education courses reported by the participants being taken included Robert Constantine, OTR/L, and the Vision 101 course by Jamie Spencer, MS, OTR/L. Five participants were Salus University alumni and obtained their doctorate with a specialty certification in Remedial Vision Rehabilitation taught by Dr. Mitchell Scheiman, OD, Ph.D., FAAO.

Frequently utilized vision assessments by participants included the Beery Buktenica Developmental Test of Visual Motor Integration (Beery-VMI), Developmental Eye Movement (DEM) test, Near Point Convergence (NPC), observation, Test of Visual Perceptual Skills (TVPS-4), Wold Sentence Copy Test, and NSUCO Oculomotor Test. Most participants (n = 12) stated that vision evaluations would take approximately one hour to complete. Participants identified reading, handwriting, and difficulty copying as the most common academic difficulties during their observations of children with visual deficits in school-based settings (Table 2). Headaches, clumsiness, and double vision were signs participants saw or reported with children who have visual deficits in school-based settings (Table 2). After the occupational therapists reviewed the evaluation results, they reported guiding their treatment activities as client-centered and occupation-based. Some treatment examples provided included: convergence activities, balance, vestibular, saccades, tracking, and aperture rulers (Table 3).

Table 2. Signs & difficulties of visual deficits observed in children.

Signs & symptoms	Number of participants	%
Reading Handwriting Headaches Difficulty copying Clumsiness Double vision	13 9 7 6 5 5	61.9 42.9 33.3 28.6 23.8 23.8

Table 3. Visual based treatment activities or interventions.

Treatment activities	Number of participants	%
Convergence Balance Vestibular Saccades Aperture rule Tracking Pursuits Hart charts Swing Brock string Peripheral Ocular motor activities	6 6 6 6 6 6 5 5 5 5 5 5	28.6 28.6 28.6 28.6 28.6 28.6 23.8 23.8 23.8 23.8 23.8 23.8

As stated by Participant 1, “I want to be tying the visual system to the vestibular and proprioceptive system and put those things back together again. ‘The participants ensured that activities were related to function, play-based, and academically related. Participant 3 discussed,’ … it is still really beneficial to make them occupational-based and client-centered because then you get more desire and more willingness from the patients to participate, and they also understand why it is important for them to do the activities at home before they come see me again. ‘Participant 5 states when implementing activities that are occupation-based and client-centered, it’ … maximize their potential and engage and participate in their occupation of being a student.” When interviewing school-based therapists, their experience with Individualized Education Programs (IEPs) and 504 plans led them to create functional vision-based goals and provide accommodations in the classroom setting. They collaborated with teachers and other related service providers using response-to-intervention (RTI) strategies to make accommodations in the classroom and therapy setting.

It is essential to note the barriers and supports of implementing vision-based practices in occupational therapy. Participants encountered many barriers: insurance or finances, needing access to optometrists, location, lack of education/knowledge, parents or families, and time or availability. Participant 4 stated, “Not many functional-based optometrists understand, you know, function and occupation.” Collaboration with other team members and an optometrist were major supporting factors when implementing vision-based practices. Fessler et al. (2020) found that the ongoing collaboration between occupational therapists and optometrists supports the overall treatment of children with visual deficits who have special needs. When asked the interview question, “What would you want other pediatric occupational therapy practitioners to know about vision evaluations?,” 4 out of the 21 participants responded and suggested that vision screenings are necessary and beneficial.

The participants also stated a need for more knowledge about vision and how additional education or training would benefit all occupational therapists. In order to properly evaluate and treat patients with visual deficits, occupational therapists need to understand the entire visual system and how it is related to function (Sullivan et al., 2018). Participant 14 specified, “I hope that we’ll see a change in the next couple of years, as we continue to kind of demonstrate our value as OTs in this field, and I would love to see more education and advocacy and support for pediatric vision and the role of OT from our professional organizations.”

After analyzing the data, two broad overarching themes emerged from the in-depth structured interviews completed by the investigators. Once examining and analyzing the pediatric occupational therapists’ experiences completing vision evaluations, the themes identified are (1) the working relationship with optometry and occupational therapy and (2) the significance of vision in relation to function. The themes provide insight into the importance of the partnership between optometry and occupational therapists in treating visual deficits and how vision relates to function.

Theme One: The Working Relationship with Optometry and Occupational Therapy

Multiple participants referred to developmental or behavioral optometry as essential to an individual’s everyday function. The skills that optometrists evaluate and treat are also areas that occupational therapists work on, such as visual motor integration, visual perceptual skills, and visual information processing. Many of these skills are integral to a child’s academic, social participation and activities of daily living. Most participants relayed that collaborative relationships between occupational therapists and optometrists are essential to treatment. Participant 4 stated, “Evaluations should really be performed by a behavioral optometrist or someone with advanced training and functional type of optometry versus a general community doctor or a general ophthalmologist, that work, structure, and less function.”

An occupational therapist and practice owner reported, “I have found at least three optometrists who are willing to have a relationship with … [OT clinic] because that helps them to treat their clients as well as helps us to have referrals‘ (Participant 19). An example of a collaborative relationship between professions was discussed by Participant 11, “… [Doctor X] would come in. He did probably 2 or 3 different in-services with us, where he taught us how to do his protocol. So, he had a convergence insufficiency protocol that he would give to occupational therapists.”

Participant 10 said, “I started to notice more of those issues, and then I started to just kind of learn more about it just to help them. And from there I actually would meet with some of the optometrists in our area. That’s kind of what led me to my current position.” With the assistance of an optometrist, participants were able to learn more about vision to be able to practice on their own. Participant 1 said, “… pediatricians do not do eye exams and that their little screener misses 30% of hyperopic kids,” so having an optometrist whom the participants were able to refer to and receive referrals from demonstrates the relationship between vision and occupational therapy treatment.

Through these interactions with optometrists, study participants reported that attending professional development courses geared toward vision rehabilitation helped them understand better how to identify and treat visual deficits with their patients. By attending continuing education workshops like by the College of Optometrists in Vision Development (COVD) or by other occupational therapists who practice in vision rehabilitation, such as Robert Constantine, OTR/L, and Jamie Spencer, MS, OTR/L, participants were able to carryover the knowledge learned into their evaluation and treatment sessions.

After better understanding vision evaluations, occupational therapists could tie in functional performance during treatment planning. Participant 7 discussed that when working with an optometrist, “We collaborate that way, but I found from his level that one of his biggest frustrations was attention. The child’s attention and participation and figuring out how to make some of these vision-related, like a vectogram, for instance, how do you make them fun and occupation-based but meaningful and client-centered and having to be really creative.”

Many participants stated that collaborating with an optometrist was a support and a barrier. Working collaboratively with an optometrist led to patients being referred to them for occupational therapy services, and obtaining feedback on their progress was beneficial to treatment sessions. As one of the participants voiced, collaborating with the optometrist to create ways to make the treatment activities client-centered is more meaningful. It was also a barrier, as participants stated that a few eye care professionals did not believe that vision fell under an occupational therapist’s scope of practice.

Theme Two: The Significance of Vision in Relation to Function

Participants reported that vision deficits affected children’s functional performance within academic setting during play, academic tasks (i.e., reading, writing, math), navigating hallways, and fine motor skills. Often, visual based issues are identified per teacher or parent reports, or therapist observation during an initial evaluation within the school setting. Participants provided insight into how they offer treatments for these disruptions in functional performance and make them relevant to children’s everyday living. Commonly reported treatment approaches included utilizing academic tasks such as: math, reading, and writing to work on visual skills like tracking, saccades, and pursuits within school settings.

Participants’ responses regarding vision evaluations indicate that children typically struggle in school, academic work, and leisure activities due to underlying visual deficits. Participant 1 stated that “… every single kid has eyes, and their vision is affecting their function.” and “We need to be aware of this because it is affecting all of our patients regardless of their age.” Not only are visual deficits impacting older children in grade school, but they can also be observed in children early on in preschool or early intervention when assessed by a qualifying professional like an occupational therapist. Oculomotor skills, tracking, saccades, pursuits, and convergence/divergence can be easily screened at any age.

During initial vision evaluations, multiple participants discussed how they implemented functional treatment planning after gathering an occupational profile from patients and their families. Participant 9 answered, “… the first thing I ask before we even do any testing is, what do you want to see? And I ask the parent and the child … What’s important? What do you want to make easier?” One example of a functional treatment planning goal is presented in a story participant 6 shared about a current patient planning to go to Disney in the summer. “Most times when they are being forced to come here. They are excited to work on leisure activities. And so me and mom are always like if we want to be able to go to Disney and walk around okay, and not trip and fall. So then they are so much more excited to do that rather than, like, this is going to help you read better … So you get more participation out of it that way, too.”

Others indicated in their responses that sensory and gross motor functional skills were found in vision evaluations impacting children’s occupational performance. Participant 3 mentions “… the importance vision has on the sensory system … There are more refined skills that the eyes need to develop, which are a part of one’s environment and processing.” Sensory and gross motor activities incorporated by participants following a vision evaluation include swinging, obstacle courses, proprioceptive or vestibular preparatory input, zoom ball, balance boards, and wobble cushions. Participant 14 reported, “… there is a lot of vision involved in things like climbing and jumping and running and throwing a ball that they usually do not look at from a visual standpoint. But all that can be beneficial for improving your visual abilities.”

Participants shared real-life treatment approaches and occupational therapy interventions that they have implemented to address visual deficits in children to make them client-centered and occupation-based. Several participants reported that visual-based treatments geared toward the child’s interests helped with functional performance and their willingness to participate and carry skills across environments.

Discussion

This study’s results support current research stating that vision deficits can impact areas of occupation and limit one’s ability to function academically and socially within these learning settings. Results also indicate that early vision screens and assessment followed by occupational therapy and eye care professional assessment and treatment in children are beneficial.

Occupational Therapy’s Role in Vision

Vision plays a significant role in a child’s development, as it is critical for their motor skills, reading, writing, and daily life skills. School-age students are often misdiagnosed with attention deficit hyperactivity disorder (ADHD) due to the similarity of symptoms that were reported by our study participants, such as difficulty with reading, double vision, and complaints of headaches (Sharma & Sarkar, 2021). According to Ethan and Basch (2008), about one in five American children have a visual problem. Much of the current research indicates and supports the importance of vision screenings and incorporating vision in relation to various settings and professionals (Alwhaibi et al., 2019; AOA Vision Rehabilitation Committee, 2023; Au & Coulter, 2014, Donaldson et al., 2019; Fessler et al., 2020; Hussaindeen et al., 2017; Redondo et al., 2019; Scheiman, 2011). Hinkley et al. (2011) discuss how vision diagnoses can impact children’s learning and be overlooked as learning difficulties when they are visual-based issues.

Research participants identified the importance of vision screenings and vision’s impact on functioning in schools and collaborating with an optometrist. The participants identified optometry as a barrier and support when implementing vision-based practices into occupational therapy. Depending on the location, participants identified access to an optometrist as a barrier. Some participants’ clients lived in rural areas where families had difficulty attending therapy. There was also noted to be a lack of communication between the optometrist, families, and occupational therapist regarding the treatment of symptoms due to therapists working in school settings. A few participants stated that some optometrists felt it was outside an occupational therapist’s scope of practice to provide vision-based treatment.

Significance of Collaboration Between Occupational Therapy and Optometrists

Some participants stated optometry as a strength as they collaborated with optometrists. Some would receive referrals or refer clients to the optometrist with whom they had established a relationship. A few participants worked directly with an optometrist in their current practice or were trained by an optometrist. As stated by one participant, an optometrist helped train the outpatient clinic staff to ensure that the treatment was provided accurately and to ensure carryover.

There needs to be more research pertaining to collaboration between optometrists and occupational therapists due to factors such as the scope of practice, professional organizations, and conflict among one’s profession (AOA Vision Rehabilitation Committee, 2023; Fessler et al., 2020). AOA Vision Rehabilitation Committee (2023) recently published a document on care coordination between various professions working on vision rehabilitation, which is crucial to help treat and manage visual deficits. This document explains how defining the roles of each profession on the team is critical to helping improve access and quality of care for clients with visual deficits (AOA Vision Rehabilitation Committee, 2023).

Our participants’ information and feedback include that occupational therapists are becoming more aware of how vision can be a part of occupational therapies scope of practice, obtaining the knowledge and knowing when and how to incorporate vision-based practices into their evaluation and treatment planning, as well as learning to identify the signs and symptoms of vision deficits. Investigators found two common themes after completing structured interviews and analyzing participants’ responses. These themes include (1) the working relationship with optometry and occupational therapy and (2) the significance of vision in relation to function. The first theme was created based on occupational therapists collaborating with optometrists through referrals or working directly with them in the office. Optometrists can also provide in-services and mentorship to occupational therapists to help guide treatment planning and suggest appropriate initial evaluation screening methods.

The second theme was developed because participants emphasized how function is part of occupational therapy practice and vision impacts occupational performance. A newly published study looks at how in the early ages of life, we have to master the visual function of reading and how it plays a role in academic and work success, supporting the second theme (Orduna-Hospital et al., 2023). Both of these themes help explore the process of vision evaluations completed by pediatric occupational therapists.

Limitations

Investigators identified several limitations, including low response rate, small sample size, not asking the age range of children in which the occupational therapists served in their practice setting, interview questions 5/6 and 8/9 being similar and repetitive, limited practice setting, and demographics not capturing gender identity. The number of participants in our study were limited to a specific geographical range which could be a potential biasing factor. Most participants worked on the East Coast and the Midwest. The study was restricted to therapists who worked in the United States. Roughly a quarter of the participants were Salus University alumni who had obtained the Remedial Vision Rehabilitation certificate and post-professional doctoral degree. Many of the participants worked in a school-based or outpatient setting. The questions asked about Individual Education Programs (IEPs) or 504 plans needed to be more consistent between the investigators’ interviews. Some participants were asked about IEPs or 504 plans despite not working in a school setting, while others were not asked this question.

Future Research

Using a large-scale study that will utilize a survey can help further the knowledge of what evaluative vision tools are employed in pediatric settings including in schools. Developing a standardized vision-based screening or evaluation tool that is quick to administer and looks at visual integration skills, visual perception, visual motor, binocular vision, and ocular motor skills to enhance efficiency and ensure quality patient care would be beneficial and assist therapists as well as teachers learn how to identify signs and symptoms. Additional research can be conducted by creating this tool to ensure that it is standardized, norm-referenced, valid, and reliable. With additional research and literature to support the necessity of occupational therapists’ role in vision, it will assist in the treatment and progression of our clients.

Conclusion

This study identified positive outcomes of vision rehabilitation, which were reported to benefit patients who experience visual deficits especially in schools and early intervention. According to the study participants, continuing education in vision-based evaluative methods and treatments assisted them in identifying symptoms and difficulties of visual deficits more efficiently. The findings of this study gathered that following professional development courses and ongoing collaboration with optometrists, occupational therapists could complete vision evaluations that assisted them in developing functional treatments and interventions with children. These results help expand knowledge on the types of vision evaluations commonly used across pediatric occupational therapy settings.

Author Contributions

Investigators/authors contributed to all aspects of the manuscript completion, including the research design, the undertaking of the project, data analysis, and interpretation of data.

Acknowledgements

We would like to thank Dr. Dale Coffin and Dr. Caitlyn Foy for their mentorship during the process of this doctoral capstone project. We would also like to thank Dr. Mitchell Scheiman for his feedback as a context expert.

Disclosure Statement

The author(s) reported no declarations of interest.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Appendix A

Interview Questions

A series of 13 open-ended interview questions were asked. If practitioners worked in a school-based setting, an additional question was asked regarding IEPs or 504 plans. The open-ended interview questions asked are listed below:

Questions

Table

How did you become interested in learning about vision-based evaluative methods and treatment approaches?

Tell us about your continuing education that has improved your knowledge on vision practices incorporated in occupational therapy?

Please explain how and from whom (list referring professionals) you obtain referrals for patients with visual deficits.

What are signs/symptoms you may observe from your patients?

Please describe what vision evaluations and assessments you utilize.

Please explain what a full initial vision evaluation entail.

How long does a full initial vision evaluation usually take?

Please describe the type of treatment approaches you use to address vision deficits.

After completing vision evaluations, how do you make your treatment plans occupation-based and client-centered?

What is your experience with implementing vision-based goals into IEPs and 504 plans?

What are some barriers associated with implementing vision-based practices into occupational therapy?

What are some supports associated with implementing vision-based practices into occupational therapy?

What else would you want other pediatric occupational therapy practitioners to know about vision evaluations?

Is there anything else you would like to add that I did not ask?