How to Successfully Co-Manage Cases with an Orthoptist

Successfully examining and managing a patient comes with effective communication and a lot of teamwork. Although very specialized, orthoptists can be key to co-managing cases in both children and adults.

By implementing the tips in this guide, optometrists and ophthalmologists will gain insight into how to work with an orthoptist for optimal patient outcomes.

First, it is important to understand what an orthoptist is and what conditions they can treat.

What is an orthoptist?

According to the British and Irish Orthoptic Society, or BIOS, orthoptists specialize in the diagnosis and treatment of eye movement disorders and binocular vision.¹ Orthoptists are skilled in many diagnostic techniques and can comfortably work alongside ophthalmologists and optometrists to effectively diagnose and treat both children and adults.²

Of note, orthoptics is a well-established profession despite having fewer than 400 orthoptists throughout the US. Orthoptists work alongside physicians to help guide non-surgical and surgical management in a variety of patient cases. The most common conditions that orthoptists assess and treat are amblyopia, double vision, and eye alignment disorders.²

Orthoptists can run clinics independently, and see a plethora of patients, under the supervision of an ophthalmologist.

What training does an orthoptist require?

Training can vary from country to country e.g., in the United Kingdom, there are now four universities that provide orthoptic degrees which range from 3 to 4 years, depending on the place of study.

In the US, once you have an undergraduate degree, you can apply to one of the 16 approved programs for a 2-year certification. A full list of current programs in the US can be found here.

Orthoptic training is very in-depth and includes a large range of topics:³

Anatomy
Neuroanatomy
Physiology
Pharmacology
Diagnostic testing and measurement
Systemic diseases and ocular motor disorders
Principles of surgery
Basic ophthalmic exam techniques
Ophthalmic optics
Orthoptic treatment
Additional areas include: Principles of genetics, child development, learning disabilities, clinical research methods, and medical writing

We will get into these a little more when we discuss how orthoptists work well with other eyecare providers and what they bring to the table.

Common conditions and testing that orthoptists diagnose and perform

Orthoptists are the experts when it comes to eye movement disorders and binocular function. They diagnose, treat, and manage a wide range of patients with a plethora of conditions affecting vision. They commonly work with patients with neurological conditions such as stroke, multiple sclerosis, and brain tumors, amongst many others.¹

The above conditions tend to present to orthoptists with symptoms of double vision. Orthoptists can take accurate measurements and diagnose the cause and/or recommend further investigative testing whilst also providing a temporary solution—Fresnel prisms—to resolve the double vision.

Strabismus, or a misalignment of the eyes, is one of the most common diagnoses that orthoptists examine and treat. Prisms can be used to not only measure the alignment of the eyes, but to assess a patient’s control of their eye alignment. It is important to ascertain the magnitude of the deviation, of course, but how well a patient can refocus and realign their eyes is crucial to creating an appropriate treatment plan.

Measuring binocular function with stereotests

Orthoptists use a variety of different tests to obtain detailed information from both child and adult patients. Since a key part of orthoptics is binocular function, a lot of orthoptists begin their exam with a stereotest e.g., The Frisby Stereotest, TNO test, or the Wirt Fly Stereotest.

Stereotests are used to determine if and how well the eyes are working together. Whilst all these tests have their strengths and weaknesses, the only one that presents the challenge of true depth to the patient is The Frisby Stereotest.

In addition, The Frisby Stereotest has shown the ability to detect a possible presence of amblyopia in those who will not cooperate for accurate vision testing.⁴ It can also be used to monitor progress with those undergoing amblyopia treatment or following surgical intervention.

What treatment options do orthoptists use?

Depending on the diagnosis, orthoptists can prescribe various treatment options such as eye patches, eye exercises, prisms, or glasses. The age of the patient can also impact the choice of treatment.

When it comes to glasses, the orthoptist can work closely with an optometrist or ophthalmologist to provide the most accurate prescription for the patient. In some offices, the orthoptist’s role is to follow up with younger patients to assess for the presence of amblyopia. If amblyopia is present, then treatment can be initiated by the orthoptist.

Eye patching

Orthoptists commonly use eye patches for children who have a diagnosis of amblyopia, but more recent studies have shown improvement with atropine penalization and the utilization of red/green filters to improve binocularity in those without strabismus.

Occasionally, there are children who are seen for new-onset double vision (e.g., pediatric oncology patients) and, whilst occluding an eye with an eyepatch is not preferred, if this is needed, alternate patching is the go-to. Since the visual system may still be developing, it is important to avoid disruption of one eye only.⁵

Eye patches are also used in adult patients with new onset whose double vision cannot be resolved with prisms, have a large-angle strabismus and/or don’t prefer the visual symptoms that come with a stick-on prism.

Orthoptic exercises

Orthoptists regularly prescribe orthoptic exercises in cases of convergence insufficiency, including pencil push-ups, Brock string, jump convergence, stereograms, and computerized vision therapy.

Orthoptic exercises have proven to be very effective in the treatment of convergence insufficiency both in children and adults.^6,7,8 Routinely, we give patients a suggested number of times to perform the exercises at home with follow-up every 6 to 8 weeks.

Let’s bear in mind that some patients have concurrent accommodative issues that may cause convergence insufficiency; orthoptists can help differentiate between the two to allow for the proper treatment plan to be implemented.⁹ Whilst both can occur simultaneously, often correcting the accommodative component alone, can address patient symptoms.⁹

Prism correction

Prisms are most frequently prescribed for those experiencing double vision. Fresnel prisms have proven to be an effective treatment option for several etiologies of strabismus and double vision.¹⁰ Orthoptists are trained to cut and fit Fresnel prisms in several ways.

The primary role of Fresnel prisms is to alleviate symptoms of double vision, and whilst they are not a preferred long-term solution for children, they are very effective in adult patients. The use of Fresnel prisms in adults often leads to ground-in prisms in glasses. They are more commonly used as a diagnostic tool in children in cases of acquired non-accommodative concomitant esotropia.^11,12

This aids the ophthalmologist in determining the full angle of the esotropia, increasing the likelihood of a preferred surgical outcome.¹² Fresnel prisms can also be used effectively to extend the visual field of patients with homonymous hemianopia.¹³ Patches can also be used in cases where double vision is bothersome and cannot be resolved with the use of Fresnel prisms—this is mostly needed in adult patients with new onset double vision.

Orthoptists are able to place Fresnel prisms independently and prescribe ground-in prism glasses, under the supervision of the ophthalmologist. The ophthalmologist does not need to be present in the clinic, or physically see the patient, but does need to be accessible by phone, at minimum, in case of an issue.

How can an orthoptist help eyecare professionals?

Based on responses from a small group of optometrists and ophthalmologists, these are the top five ways orthoptists help:

Provide a detailed strabismus evaluation using various techniques, including diagnosis of torsion and synoptophore assessment, if available.
Enhance the flow of the clinic day and improve efficiency.
Independently evaluate and manage follow-up patients with amblyopia and those with stable strabismus.
Independent clinics allow a smaller practice to generate income when physicians are in the operating room or away.
Overall improved patient care.

In addition, orthoptists can perform specialized testing such as Bagolini glasses, Worth 4 dot, and the Hess chart. These all provide extensive information, particularly when it comes to complex strabismus. Orthoptists can save physicians time by screening new adult patients with double vision, fit Fresnel prisms, and determining if they need further testing or a surgical opinion.

Successfully co-managing with an orthoptist

1. See the orthoptist first.

New patients scheduled with the optometrist/ophthalmologist are most likely going to need a dilated exam. By seeing the orthoptist first, the patient can get a thorough sensorimotor exam and preliminary work-up and then be dilated so they are ready for the doctor without repeating testing.

2. Have confidence in your orthoptist.

As described earlier, orthoptists have in-depth knowledge of anatomy, neuroanatomy, genetics, child development, and so on. They utilize their skills daily and are very precise when it comes to those strabismus measurements.

Being aware of an orthoptist’s knowledge base is the first step to becoming more confident in their abilities. Optometrists and ophthalmologists working side-by-side with an orthoptist is a chance for a powerful, effective, and smoothly run clinic.

3. Realize independent clinics are lifesavers.

Since orthoptists can run a clinic on their own, why not make use of that? Optometrists and ophthalmologists can have the orthoptist follow stable strabismus cases and amblyopia follow-ups, allowing them to see more new patients and other patients who really need them.

This means patients can get in much sooner to see a doctor and they’ll still get a thorough evaluation from the orthoptist, too.

4. Know when you need a detailed assessment.

Sometimes, it is hard to admit that someone else just may be better trained at a particular piece of the puzzle. An orthoptist has been trained to focus specifically on binocularity and visual development—assessing the use of the eyes together in complex cases and diagnosing possible causes for those strange eye movements that don’t always make sense!

If something looks a little off—see what the orthoptist thinks. Headaches that just don’t make sense, double vision and paretic muscles, amblyopia in one or both eyes, and complex and basic strabismus, are all great examples of what an orthoptist can handle independently.

5. Headaches? Difficulty reading? Double vision? Send them over!

Orthoptists love a puzzle—that’s why we do what we do! Orthoptists will evaluate patients with a very detailed assessment to figure out the cause of the symptoms.

Cases of convergence insufficiency and accommodative insufficiency often go undiagnosed despite being quick to assess. The orthoptist can guide the treatment plan in these cases for a better outcome.

Key takeaways for co-managing with an orthoptist

The orthoptist is there to help and can make things easier—utilize their knowledge and skills!
Independently-run orthoptic clinics are an excellent way to streamline patients.
Your orthoptist will be your best guide to a successful post-operative outcome—don’t be afraid to take advantage their skills/knowledge base with your patients.
Orthoptists are very specialized in what they do, and they have a breadth of knowledge, too. Ensure you are making full use of them!