LOW VISION
Questions: reader queries show increasing interest in low vision
By William H. Croft, Jr.

If the rise in recent reader questions are an indication, low vision may finally be able to shed its "Rodney Dangerfield" image of no respect, and look for a much more upbeat metaphor. Following are representative of the most commonly asked questions.

WHAT ABOUT REIMBURSEMENT?

"Like many of my colleagues, I am starting to see more elderly patients and many of them present vision problems that need more than spectacles or contact lenses. These same patients, when prescribed simple devices, expect their insurance to pay for them. In the absence of reimbursement, the patients either reject the devices outright (believing they can't be any good if the government doesn't pay for them) or expect to be able to borrow the device. Is there any chance that low vision devices will become reimbursable?"

--Allentown, Pa.

Entitlement can be a very pervasive force. Doctors have all seen patients reject a device that will significantly improve their lifestyle, not because they didn't have the funds but because they expected it to be given to them. Others have seen patients, who were children of the Depression, defer help and continue to deny their own needs. Some patients never try a device that is loaned to them because of a lack of commitment; plus we all know the perceived value, or lack thereof, of something that doesn't have a cost associated with it. Worse, loaning a device tends to result in the minimum result since practitioners are reluctant to loan expensive technology, and the patient isn't prone to suddenly move up to something else if the first device "worked" for him--however marginal the results may have been. The patient who needed one thing gets another, and so on. Economics prevails.

In the opinion of many, low vision patients deserve at least basic assistance in gaining the prosthetic help they need, yet reimbursement continues to be a challenge.

One low vision patient, Anthony Chinn, took matters into his own hands and has enlisted the support of an influential California state legislator who is sponsoring legislation to ask the state to reimburse a person for necessary, prescribed low vision devices. The legislation states that to deny patients these necessary prosthetic devices is, according to the Americans with Disabilities Act (ADA), a violation of the law. Mr. Chinn, who serves as a volunteer at the low vision clinic of Jules Stein Eye Institute at UCLA, says the bill should get to the legislature floor later this year.

NON-USE OF DEVICES

"I've been told that studies show a large number of low vision devices don't get used by the patient after several months. Obvious-ly, that's not a positive outcome. I wonder if anything has been done to determine why this happens. Is this poor product, a poor treatment plan, or just par for the course? This phenomena is the single biggest reason we haven't started to offer basic low vision devices to our patients, although we are asked frequently (to do so)."

--Albuquerque, N.M.

There are a lot of reasons why historically a large number of low vision devices have ended up on the closet shelf within six months of dispensing. Perhaps the patient wasn't properly motivated, the patient's condition worsened, or the device didn't meet the patient's expectations. Regardless, the one common denominator in an unsuccessful outcome is the lack of rehabilitation training following dispensing. And it's not because of a failed protocol but because of economics--the practitioner cannot afford to offer training because there is no reimbursement. Not-for-profit clinics have proven the best to date in executing the low vision rehabilitation model, but patients often experience extremely long waiting times, sometimes months, for an appointment.

To help initiate change, in November 1998, the National Eye Institute (NEI), the American Academy of Ophthalmology (AAO), and the American Optometric Association (AOA) agreed on a joint resolution to submit to HCFA (the Medicare overlords). It defines low vision rehabilitation and requests that both O.D.s and M.D.s be considered "physicians" for obtaining reimbursement for low vision rehabilitation. Until this point. only M.D.s could prescribe the training, and then only under very specific circumstances.

The acceptance of this initiative--and it is thought to have a good chance of approval--will not only provide the much needed training for patients in the system, but increase the number of doctors who will be willing to provide the service because it will then make economic sense to do so.

WHAT'S NEW WITH TECHNOLOGY

"There is no question that in the absence of a cure, low vision patients are going to become more and more prevalent in every optometric practice. What's new in technology and/or research that will cause a paradigm shift?"

--Eugene, Ore.

There are a number of initiatives underway that may lead to significant improvements and changes in care including an artificial eye, nutrition, transplants, drug therapy, etc. Most of these, plus more than a dozen more projects, are all in the clinical evaluation stage or earlier. Right now, there is nothing to suggest that traditional low vision rehabilitation will change in the next few years. Very long term, however, some experts feel that genetic engineering will eventually provide the answer.

In fact, there isn't that much money being spent today on low vision advancements except for companies that see economic gain in nutritional or therapeutic products. Even then the investment level pales when compared to other health problems. For example, the NEI spends tens of millions of dollars to support research into the causes of certain types of blindness, but only one percent of its budget is designated for low vision, and all of that goes into the area of consumer awareness.

Looking ahead, as companies see potential profits from a growing demand for low vision services, there is the hope that more funds will be directed toward research and development in low vision.

There are already positive signs. Manufacturers are already seeing more and more eyecare professionals asking for help in establishing low vision services because they see an increasing demand from their patient base. There are finally meaningful initiatives to seek reimbursement. It will be an interesting next few years for low vision--the sub-specialty that is suddenly getting well-deserved attention and respect. EB