Vision therapy involves a range of non-surgical treatment modalities, including lenses, prisms, filters, occlusion, eye exercises, and orthoptics that are used for eye movement and fixation training. The goal of vision therapy is to correct or improve specific visual dysfunctions, such as amblyopia, strabismus, and disorders of accommodation and convergence. Vision therapy is also sometimes referred to as visual training, vision training, orthoptics, and orthoptic vision therapy.

Medically Necessary:

Vision therapy is considered medically necessary for treatment of the following conditions:

1. Amblyopia (with orthoptics and occlusion therapy)
2. Acquired esotropia prior to surgical intervention (with prism adaptation)
3. Convergence insufficiency and intermittent exotropia (with convergence training)

Other considerations: 

1. The initial evaluation must include quantifiable measurements to support the diagnosis(es). This will establish the baseline against which follow-up evaluations can be measured.
2. There must be a comprehensive plan of treatment that includes the projected period of treatment.
3. There must be reasonable expectation that vision therapy will produce measurable improvement in a reasonable period of time.
4. A measurable improvement must be demonstrated within the first two months of treatment. If there is no improvement, the vision therapy services will no longer be considered medically necessary.
5. Follow-up evaluations thereafter should be conducted at least monthly and should include quantifiable measurements and the percentage of improvement from the initial evaluation. The service will no longer be considered medically necessary once further improvement cannot be documented.
6. The provider should document all progress and any changes in the treatment plan. Those receiving treatment are expected to have a home program in addition to office visual therapy, and documentation of compliance should be included in the records.
7. Because vision therapy programs are individualized, the number of visits per week and the total number of visits varies depending upon the nature and severity of the problem being treated and the needs of the individual receiving treatment. Generally, maximum improvement will require no more than 24 treatments (one to two times weekly for 4-6 months), and may be achieved more quickly. Requests for additional visits will be considered on a case-by-case basis.

Not Medically Necessary:

Vision therapy (including the use of orthoptics) is considered not medically necessary for any of the following conditions:

1. Accommodative and vergence dysfunctions (with the exception of convergence insufficiency), such as fusional vergence dysfunction, divergence excess, convergence excess, divergence insufficiency, vertical phorias, basic exophoria, basic esophoria, accommodative insufficiency, sustained accommodation, accommodative infacility and spasm accommodation
2. Learning disabilities including Attention Deficit Hyperactivity Disorder (ADHD) and dyslexia
3. Low vision
4. Myopia
5. Nystagmus
6. Presbyopia
7. Strabismus except as noted above 

Maintenance programs are considered not medically necessary as they begin when the therapeutic goals of a treatment plan have been achieved or when no further significant functional progress is apparent or expected to occur.

Duration: One to two times weekly for up to 6 months (24 visits maximum) with additional home exercises done for reinforcement

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Vision therapy is the non-surgical clinical approach for treating functional visual deficiencies and includes a broad spectrum of treatment modalities such as wearing tinted or colored lenses, prisms, occlusion, eye exercises, flashing light response exercises, specialized instruments, computer programs, sensory, motor and perceptual activities. However, there is no clear consensus on an exact definition of vision therapy. Vision therapy is performed in an optometrist's or ophthalmologist's office 1-2 times weekly for a number of months with additional home exercises done for reinforcement.

Orthoptic or pleoptic training is the teaching and training process for the improvement of visual perception or coordination of the two eyes for efficient and comfortable binocular vision. It is not used to strengthen eye muscles, but rather to improve the coordination, efficiency and functioning of the vision system.

Vision therapy is often requested for individuals with the following visual dysfunctions:

• Accommodative disorders – focusing disorders
• Amblyopia – lazy eye
• Ocular motility dysfunction – eye movement disorders
• Strabismus – misalignment of the eyes
• Treatment of learning disabilities – particularly reading disorders including attention deficient disorder, dyslexia, dysphasia or other reading disorders
• Vergence dysfunction – inefficiency in using both eyes together
• Visual rehabilitation after traumatic brain injury or stroke

It has been hypothesized that anomalies of binocular vision, including problems with coordinated eye movement, can cause reading difficulties. However, there is controversy regarding this hypothesis and the available evidence does not demonstrate that visual anomalies cause learning disabilities or are more common among persons who have learning disabilities.

The field of optometry supports vision therapy for the treatment of individuals with learning disabilities including dyslexia. According to the American Academy of Optometry and the American Optometric Association (1997), although vision therapy will not treat the disorder directly, it may improve visual efficiency and visual processing thus allowing the individual to be more able to respond to educational instruction and should therefore be part of a multidisciplinary approach to learning disabilities.

A joint statement released by the American Academy of Pediatrics, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and the American Association of Certified Orthoptists (2009) concerning pediatric learning disabilities, dyslexia and vision, found no scientific evidence to support the concept that subtle eye or visual problems cause learning disabilities. The statement concluded: "the evidence does not support the concept that vision therapy or tinted lenses or filters are effective, directly or indirectly, in the treatment of learning disabilities."

For the treatment of refractive disorders, the AAO (2004) stated:

No evidence was found that visual training has any effect on the progression of myopia. No evidence was found that visual training improves visual function for patients with hyperopia or astigmatism. No evidence was found that visual training improves vision lost through disease processes such as age-related macular degeneration, glaucoma, or diabetic retinopathy.

A pilot study of young adults age 19 to 30 (n = 46) found vision therapy/orthoptics was the only treatment that produced clinically significant improvements in the near point of convergence and positive fusional vergence (Scheiman et al., 2005). However, although their symptoms were significantly reduced, over half of the subjects in this group (58%) were still symptomatic at the end of treatment. A second pilot study of children age 9 to 18 (n=47) (Scheiman and colleagues, 2005) found vision therapy/orthoptics was more effective in reducing symptoms and improving signs of convergence insufficiency in children 9 to 18 years of age.

The Convergence Insufficiency Treatment Trial Study Group (2010) reported on a randomized clinical trial, comparing four treatment programs consisting of home-based pencil push-ups (HBPP), home-based computer vergence/accommodative therapy and pencil push-ups (HBCVAT+), office-based vergence/accommodative therapy with home reinforcement (OBVAT), and office-based placebo therapy with home reinforcement (OBPT) as treatments for symptomatic convergence insufficiency (CI). A total of 221 children between the ages of 9 to 17 years with symptomatic CI were randomly assigned to one of the four treatments. The authors concluded after 12 weeks of treatment, OBVAT resulted in greater improvement of the signs and symptoms associated with CI , as well as a larger number of children classified as successful or improved as compared to HBPP, HBCVAT+, or OBPT. It was also noted that less than 12 weeks of treatment would lead to lower overall treatment effectiveness.

Scheiman and colleagues (2011) evaluated evidence obtained from randomized controlled trials on the effectiveness of non-surgical interventions for convergence insufficiency. Six trials (three in adults, three in children) with a total of 475 participants were included in the review. Four trials with a low risk of bias were assessed. The authors concluded that current research suggests that outpatient vision therapy/orthoptics is more effective than home-based convergence exercises or home based computer vision therapy/orthoptics for children. In adults, the evidence of the effectiveness of various non-surgical interventions was less consistent.

There is a broad range of vision therapy techniques and methods among practitioners making the practice of vision therapy difficult to standardize and evaluate. Much of the literature evaluating the efficacy of vision therapy has been based more on author opinion than on quality scientific evidence. Large, well-designed studies comparing vision therapy with other treatment modalities, standardization of outcome measurements, and criteria for defining selection criteria are needed to further evaluate vision therapy for the treatment of visual dysfunctions.

Accommodation: The ability of the eye to focus on near objects.

Accommodative insufficiency: A lack of appropriate accommodation for near focus.

Accommodative spasm: A greater accommodative response than normal for a given stimulus; the inability to easily change focus from near to distant objects.

Acquired esotropia: Esotropia that is not present at birth.

Amblyopia: Sometimes called lazy eye, is poor vision in an eye that did not develop normal sight during early childhood, so that one eye develops good vision while the other does not; dimness of vision not due to organic defect or refractive errors.

Attention Deficit Hyperactivity Disorder (ADHD): A disorder of childhood and adolescence manifested at home, in school, and in social situations by developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity.

Convergence: Refers to the medial movement of the two eyes so that they both are directed toward the object as it is brought closer into view. 

Convergence excess: A condition in which an esophoria or esotropia is more marked for near vision than for far vision.

Convergence insufficiency: A condition in which an exophoria or exotropia is more marked for near vision than for far vision.

Divergence excess: A condition in which an exophoria or exotropia is more marked for far vision than for near vision.

Divergence insufficiency: A condition in which an esophoria or esotropia is more marked for far vision than for near vision.

Dyslexia: An impaired reading ability with a competence level below that expected based on the individual's level of intelligence, and in the presence of normal vision and letter recognition and normal recognition of the meaning of pictures and objects.

Esophoria (basic): A tendency for the eye(s) to turn inward.

Esotropia: A constant turning of the eye(s) inward.

Exophoria (basic): A tendency for the eye(s) to turn outward.

Exotropia: A constant turning of the (eyes) outward.

Fusional vergence dysfunction: The inability of reflex movement that moves the visual axes to the object of fixation so that stereoscopic vision is possible. Vergence is a disjunctive movement of the eyes in which the fixation axes are not parallel.

Hyperopia: Also known as "farsighted".

Low vision: Also called partial sight; sight that cannot be satisfactorily corrected with glasses, contacts, or surgery.

Myopia: Also known as "nearsighted".

Nystagmus: An involuntary rhythmic oscillation of the eyeballs, either pendular or with a slow and fast component.

Pencil push-up therapy: A specific type of eye exercise used to treat convergence insufficiency in which an individual is required to practice converging on a pencil tip by turning his or her eyes inward.

Presbyopia: A physiologic loss of accommodation in the eyes in advancing age.

Spasm of accommodation: An excessive contraction of the ciliary muscle (the intrinsic smooth muscle of the ciliary body of the eyeball) By contracting its diameter the muscle is reduced thus reducing stretching forces on lens allowing the lens to thicken for near vision.

Strabismus: A condition in which the two eyes are directed to different points when looking at an object in space. Crossed eyes (esotropia) are one type of strabismus; "wall-eyes" (exotropia) is another.

Vertical phorias: A form of strabismus in which the visual axis of one eye deviates upward or downward.

Peer Reviewed Publications:

1. Adler P. Efficacy of treatment for convergence insufficiency using vision therapy. Ophthalmic & Physiological Optics: the Journal of the British College of Ophthalmic Opticians. 2002; 22(6):565-571.
2. Barber Starr N. Vision therapy for learning disabilities and dyslexia. Journal of Pediatric Health Care. 2000. 14(1):32-33.
3. Ciuffreda K. The scientific basis for and efficacy of optometric vision therapy in non strabismic accommodative and vergence disorders. Optometry. 2002; 73(12):735-762.
4. Ciuffreda KJ, Ordonex X. Vision therapy to reduce abnormal nearwork-induced transient myopia. Optometry & Vision Science. 1998; 75(5):311-315.
5. Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol. 2008; 126(10):1336-1349.
6. Convergence Insufficiency Treatment Trial (CITT) Study Group. The convergence insufficiency treatment trial: design, methods, and baseline data. Ophthalmic Epidemiol. 2008; 15(1):24-36.
7. Figueira EC, Hing S.  Intermittent exotropia: comparison of treatments.Clin Experiment Ophthalmol. 2006; 34(3):245-251.
8. Fitzgerald K, Krumholtz I. Maintenance of improvement gains in refractive amblyopia: a comparison of treatment modalities. Optometry. 2002; 73(3):153-159.
9. Gallaway M. Optometric vision therapy. Binocular Vision & Strabismus Quarterly. 2002; 17(2):82.
10. Holmes JM, Beck RW, Repka MX. Amblyopia current clinical studies. Ophthalmology Clinics of North America. 2001; 14(3):393-398.
11. Hutchinson AK. Intermittent exotropia. Ophthalmology Clinics of North America. 2001; 14(3):399-406.
12. Kushner B, Doolittle J, Doolittle H. Vision therapy for amblyopia? Postgraduate Medicine. 2002; 112(4):16.
13. Lightstone A, Evans BJW. A new protocol for the optometric management of patients with reading difficulties. Ophthal. Physiol. Opt. 1995; 15(5):507-512.
14. London R, Wick B, Kirschen D. Post-traumatic pseudomyopia. Optometry. 2003; 74(2):111-120.
15. Maples W. Bither M. Efficacy of vision therapy as assessed by the COVD quality of life checklist. Optometry. 2002: 73(8):492-498.
16. Olitsky SE. Reading disorders in children. Pediatr Clin North Am. 2003. 50(1): 213-224.
17. Press LJ. The interface between ophthalmology and optometric vision therapy. Binocular Vision & Strabismus Quarterly. 2002; 17(1):6-11.
18. Romano P. Optometric vision therapy & training for learning disabilities and dyslexia; DVD surgery: curing complications of strabismus surgery. Binocular Vision & Strabismus Quarterly. 2002; 17(1):12-14.
19. Scheiman M, Cooper J, et al. A survey of treatment modalities for convergence insufficiency. Optometry and Vision Science. 2002; 79(3):151-157.
20. Scheiman M, Kulp MT, Cotter S, et al. Convergence Insufficiency Treatment Trial Study Group. Vision therapy/orthoptics for symptomatic convergence insufficiency in children: treatment kinetics. Optom Vis Sci. 2010; 87(8):593-603.
21. Scheiman M, Mitchell GL, Cotter S, et al. Convergence Insufficiency Treatment Trial Study Group. A randomized clinical trial of treatments for convergence insufficiency in children. Arch Ophthalmol. 2005; 123(1):14-24.
22. Scheiman M, Mitchell GL, Cotter S, et al. A randomized clinical trial of vision therapy/orthoptics versus pencil pushups for the treatment of convergence insufficiency in young adults. Optom Vis Sci. 2005; 82(7):583-595.
23. Taylor M, Schmidt P. Effect of oculomotor and other visual skills on reading performance: a literature review. Optometry and Vision Science; Official Publication of the American Academy of Optometry. 1996; 73(4):283-292.
24. Unknown Author. Vision therapy co-management. Optometry. 2002; 73(1):64-65.
25. Unknown Author. Vision therapy only. Optometry. 2002; 73(1):61-63.
26. Verma A, Singh D. Active vision therapy for pseudophakic amblyopia. Journal of Cataract and Refractive Surgery. 1997; 23(7):1089-1094.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Academy of Ophthalmology Complementary Therapy Task Force. Complementary therapy assessment. Visual training for refractive errors. 2004. For additional information visit the AAO website: http://one.aao.org/CE/PracticeGuidelines/Therapy.aspx. Accessed on June 24, 2011.
2. American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Preferred Practice Pattern^® Guidelines. Esotropia and Exotropia. 2007. For additional information visit the AAO website: http://www.aao.org/ppp. Accessed on June 24, 2011.
3. American Academy of Optometry. Vision, learning and dyslexia. A joint organizational policy statement of the American Academy of Optometry and the American Optometric Association. 1997. For additional information visit the AAO website: http://www.aaopt.org/about/position/index.asp. Accessed on June 24, 2011.
4. American Academy of Optometry. Vision Therapy: A joint organizational policy statement of the American Academy of Optometry and the American Optometric Association. 1999. For additional information visit the AAO website: http://www.aaopt.org/about/position/index.asp. Accessed on June 24, 2011.
5. American Academy of Pediatrics, Section on Ophthalmology, Council on Children with Disabilities; American Academy of Ophthalmology; American Association for Pediatric Ophthalmology and Strabismus; American Association of Certified Orthoptists. Joint statement--Learning disabilities, dyslexia, and vision. Pediatrics. 2009; 124(2):837-844.
6. Hatt, S, Antonio-Santos A, Powell C, Vedula S. Interventions for stimulus deprivation amblyopia. Cochrane Database Syst Rev.2006; (3): CD005136.
7. National Eye Institute. Convergence Insufficiency Treatment Trial. NLM Identifier: NCT00338611. Last updated March 24, 2010. Available at: http://www.clinicaltrials.gov/ct/show/NCT00338611?order=1. Accessed on June 23, 2011.
8. Richardson S, Gnanaraj L. Interventions for intermittent distance exotropia. The Cochrane Library Eyes and Vision Group. Volume (3); 2003; (2):CD003737.
9. Scheiman M, Gwiazda J, Li T. Non-surgical interventions for convergence insufficiency. Cochrane Database Syst Rev. 2011; (3):CD006768.

Orthoptics
Orthoptic Vision Therapy
Vision Therapy
Vision Training
Visual Training