Did you know that optometrists, as health care providers, are mandated reporters for suspected child abuse and neglect in all states?

While each state is different, this means we are legally obligated to report suspicion or evidence of neglect, physical or sexual violence towards minors, and in some states adults, as well as suspected elder abuse or neglect.

Just because optometrists don’t treat broken bones, it does not mean we don’t routinely see survivors of domestic violence. In fact, an abuse victim may be more likely to see an optometrist than other types of health care providers because their abuser may control access to other doctors but consider it “no big deal” to get new glasses or contact lenses.

According to the CDC, one in four women and one in seven men have been victims of severe physical violence by an intimate partner in their lifetime, equating to more than 10 million people being physically abused every year (Black et al.). If you see 10 to 20 patients today, there is a good chance that one or two of them have been the victim of domestic violence. Those are shocking numbers, but it is not always clear what an optometrist should do when abuse is suspected.

As someone who specializes in vision therapy and treating traumatic brain injury, it is not unusual for me to see a patient whose oculomotor dysfunction is the result of physical violence. Epidemiological studies estimate 11% of concussions are caused by an assault of some type (Langlois et al.). This is likely an underestimate, as many victims of domestic violence may be reluctant to disclose this information and may deny any history of concussion or seek medical attention. Additionally, they may not realize that repeated subconcussive blows, whiplash injury to the body (not necessarily to the head) or being choked could result in a brain injury with persistent symptoms.

When a patient presents with reading problems and other concussion symptoms, there are a few red flags I look for, including a history that doesn’t make sense. Perhaps the story about how an injury was sustained keeps changing. Perhaps the symptoms – such as recent onset of reading problems in an otherwise healthy 30-year-old woman with a few retinal hemorrhages – aren’t consistent with developmental oculomotor problems.

There are also differences in how near point of convergence (NPC) presents that may point to unreported history of brain injury and possible abuse. A developmentally abnormal NPC might be in the range of 10 cm to 15 cm, with an exophoria larger at near and reduced fusional convergence (as defined by the Convergence Insufficiency Treatment Trial, Alvarez et al.). However, an abnormal NPC resulting from trauma may present atypically with symptoms like nausea, be much more reduced (on the order of 40 cm to 50 cm) but with normal fusional vergences and aligned ocular posture. Severe asymmetry in the accommodative responses of each eye (ie, one eye being overfocused/spasm while the other is underfocused/insufficiency) is rarely developmental but not uncommon in patients with brain injury.

Suspicion of domestic violence is an uncomfortable topic for most optometrists, and it raises a host of bewildering questions: To whom should abuse be reported? What if you aren’t sure your suspicions are correct? Could reporting it make things worse for the patient? There are no easy answers, but here are five suggestions.

Find out what the laws in your state say about mandated reporting by health care providers, who to call and when to call. Be prepared.

Seek out training for yourself and your staff. The Brain Injury Association of America (biausa.org) and the National Resource Center on Domestic Violence (nrcdv.org) both have good resources for health care professionals.

Know where to refer locally if a patient asks for help (eg, women’s shelter, domestic violence help line, social worker, police).

Make posters or flyers for a domestic violence hotline and shelters available in all restrooms (male and female) at your facility. Because a bathroom stall is a very private place, this may be a safer way to offer resources to patients than directly addressing your concerns in the exam room in front of a family member. I am always surprised at how often those flyer holders are empty – people definitely take them.

Consider a note or referral to the patient’s primary care doctor documenting concerns about eye movement disorders consistent with history of head injury or trauma that the patient denies. Pediatricians and primary care physicians may also be suspicious or concerned and are well trained in the appropriate responses. Don’t be afraid to report – HIPAA allows health care providers to report suspected child abuse to a public health authority or other appropriate government authority, and most states have an immunity clause that protects reporters of child abuse who report in good faith to the best of their knowledge and concern.

Domestic violence is a tough issue to deal with, but we owe it to our patients to keep it on our radar when we see signs of abuse or unexplained oculomotor dysfunction. The eyes are currently one of the only objective biomarkers we have for concussion and mild traumatic brain injury when neuro-imaging studies are normal.

Jacqueline Theis OD, FAAO, treats patients referred with double vision, brain injury or neurological disease at her private practice, Virginia Neuro-Optometry, located at the Concussion Care Centre of Virginia, in Richmond, Va. Theis will be teaching a course on “Differentiating traumatic vs. developmental oculomotor dysfunction and its role in managing victims of domestic violence” at the 2022 NORA conference. For more information and to register, visit https://noravisionrehab.org/about-nora/annual-conferences/2022-annual-conference.

Disclaimer: The views and opinions expressed in this blog are those of the authors and do not necessarily reflect the official policy or position of the Neuro-Optometric Rehabilitation Association unless otherwise noted. This blog is for informational purposes only and is not a substitute for the professional medical advice of a physician. NORA does not recommend or endorse any specific tests, physicians, products or procedures. For more on our website and online content, click here.

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