The eyes can provide a window into domestic violence


Disclosures: Theis did not report any relevant financial information.

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

Although every state is different, this means that we are legally required to report suspicion or evidence of neglect, physical or sexual abuse of minors and, in some states, adults, as well as suspected abuse or neglect. towards the elderly.

Just because optometrists don’t treat broken bones doesn’t mean we don’t routinely see survivors of domestic violence. In fact, a victim of abuse may be more likely to see an optometrist than other types of health care providers, because their abuser may control access to other physicians, but consider themselves “not okay” to get new glasses or contact lenses.

According to the CDC, one in four women and one in seven men have experienced serious physical violence by an intimate partner in their lifetime, which equates to more than 10 million people who experience physical violence each year (Black et al .). If you see 10 to 20 patients today, chances are one or two of them have been victims of domestic violence. These are shocking numbers, but it’s not always clear what an optometrist should do when abuse is suspected.

As a specialist in vision therapy and the treatment of traumatic brain injury, it is not unusual for me to see a patient whose oculomotor dysfunction is the result of physical abuse. Epidemiological studies estimate that 11% of concussions are caused by some form of aggression (Langlois et al.). This is likely an underestimate, as many victims of domestic violence may be reluctant to disclose this information and may deny a history of concussion or seek medical attention. Additionally, they may not realize that repeated subconcussive blows, whiplashes to the body (not necessarily to the head), or choking can lead to brain injury with lingering symptoms.

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

There are also differences in proximity to point of convergence (NPC) that may indicate an unreported history of brain injury and possible abuse. A developmentally abnormal NPC may be between 10cm and 15cm tall, with a larger exophoria with close 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 such as nausea, be much smaller (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 (i.e., one eye being overfocused/spasm while the other is underfocused/insufficient) is rarely developmental but not uncommon in patients with brain damage.

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

Find out what your state laws say about mandatory reporting by health care providers, who to call and when to call. Be ready.

Seek training for you and your staff. The Brain Injury Association of America ( and the National Resource Center on Domestic Violence ( both have good resources for healthcare professionals.

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

Make posters or flyers for a domestic violence hotline and shelters available in all washrooms (men’s and women’s) in your facility. Because a bathroom stall is a very private place, it may be a safer way to offer patient resources than addressing your concerns directly in the exam room in front of a family member. I’m always surprised how often these leaflet holders are empty – people definitely take them.

Consider a note or referral to the patient’s primary care physician documenting concerns about eye movement disorders consistent with a 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 appropriate responses. Don’t be afraid to report – HIPAA allows healthcare providers to report suspected child abuse to a public health authority or other appropriate government authority, and most states have an immunity clause which protects child abuse reporters who report in good faith to the best of their knowledge and concern.

Domestic violence is a difficult issue to manage, 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 neuroimaging studies are normal.


For more information:

Jacqueline Theis OD, FAAO, treats patients with double vision, brain injury, or neurological disease in his private practice, Virginia Neuro-Optometry, located at the Virginia Concussion Care Center in Richmond, Virginia. oculomotor dysfunction and its role in caring for victims of domestic violence” at the NORA 2022 conference. For more information and to register, visit 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 stated. This blog is for informational purposes only and does not replace professional medical advice from a physician. NORA does not recommend or endorse any specific test, physician, product, or procedure. To learn more about our website and online content, click here.

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