Focus On Low Vision
Getting started in low vision
By Barbara Kogan Anan, OD

While one out of six people age 65 and over are seriously visually impaired, less than four percent of all optometrists provide low vision care. That alone is reason enough to discuss why low vision presents a great growth opportunity and how you can get started.

The jumping-off point for this article was a course held at the AOA Congress in which a panel of low vision experts discussed the current and long-term need for more providers of low vision care.

Bruce Rosenthal, OD, chief of Low Vision Programs of Lighthouse International, examines a patient

Those panelists, who also spoke with EB about the category, are: Bruce Rosenthal, OD, chief, Low Vision Programs at the New York's Lighthouse International; Tracy Williams, OD, executive director, Deicke Clinical Associates, Wheaton, Ill., and associate professor of ophthalmology and director of low vision services at Loyola University; Paul Freeman, OD, chief of Low Vision Services in Pittsburgh's Allegheny Hospital; and Lori Grover, OD, former Southern California College of Optometry's chief of the Low Vision Rehabilitation Services.

What follows are the responses of these low vision leaders to several key questions about the low vision category.

Who is today's low vision patient?

The numbers speak for themselves. According to the National Institutes of Health's National Eye Institute (NEI), low vision affects 25 percent of adults older than 75, 17 percent of those between 65 and 74, and 15 percent between 45 and 64.

What defines a low vision patient? Rosenthal says that the best corrected visual acuity of 20/40 or 20/50 or less in the better eye, visual field constriction or moderate reduction in contrast sensitivity defines low vision.

It's important to understand that low vision doesn't just affect seniors, Williams says. "The low vision spectrum begins at birth, and many children are challenged with visual loss." Grover adds that another "offshoot as a low vision rehabilitation provider includes patients with multiple impairments."

How do you get referrals?

"Many retinal specialists also specialize in diabetes," says Rosenthal, "and an alliance with them can provide your greatest referral source." At Lighthouse, the staff does the bulk of the intake and will refer once there is recognition that low vision is rehabilitation care, rather than waiting until the patient has little or no light perception.

According to Williams, pediatric and neuro-ophthalmologists are also referral sources. Low vision rehabilitation is "becoming more of a standard to care, and it provides more referrals."

As for Freeman, "My tertiary care practice is strictly referral. Among my primary referrers are ophthalmologists, optometrists, psychologists, psychiatrists, internists, and neurologists."

To build those relationships, he recommends sending letters to referring sources and copies to practitioners who interact with low vision patients.

He also advises contacting podiatrists, diabetes specialists, pharmacists, rehabilitation groups, senior centers, and Departments of Motor Vehicles in states that permit driving using bioptic devices.

What should a doctor do to get involved in low vision?

Williams suggests: "Joining a low vision association, attending continuing education course work in low vision, and networking with mentors who are involved with these organizations will reduce your learning curve and enable you to quickly catch the low vision rehabilitation fever."

Rosenthal recommends reading about low vision and taking courses. "The Lighthouse, for example, offers an intensive three-day program, which is affiliated with the American Academy of Optometry and has ODs teaching with a team approach between the OD and MD." Learning opportunities are also available from consultants and low vision suppliers (see sidebar).

Another way to get up to speed, suggests Freeman, is to "bring a consultant into your practice who has already integrated low vision into his or her practice." And Grover adds, "By getting involved with the AOA's Low Vision Rehabilitation Section (LVRS), you can learn about both the latest technology and current prescription information."

Speaking of prescribing, what can you tell us about dispensing devices?

"Since low vision devices are not the same as eyeglasses," says Rosenthal, "the doctor should take the patient into the exam room and spend time explaining how to use the device(s). This will turn a marginal patient into a successful low vision patient." To allay any concerns, he tells patients: "If you have any questions, I am the doctor on call."

Freeman is quick to dispel the myth that dispensing low vision devices is complicated. He uses this analogy: "It is not substantially different from contact lens dispensing with some possible modification after the initial dispensing visit."

At the first dispensing session, his low vision patients receive training with equivalent powers for 45 to 60 minutes. At the second session, the patient takes the device home with instructions about how to build up use time. The patient may be told, for example, to read for 15 minutes three times a day. Freeman says it's important to do as his office does and follow up by calling the patient midway between office visits for a progress report.

Williams underscores the importance of understanding that low vision patients will require multiple visits. "This is a two-, three-, or four-office visit system. And it's important for the patient to have a coach at the dispensing visit who can then help after he or she leaves your office."

The key, says Grover, "is to look at the dispensing visit as part of continual care. Education and in-office training need to be incorporated into rehabilitation therapy."