“Tips for Working With a Low-vision Specialist”, Retinal Physician Magazine, May 2019

Originally published in Retinal Physician Magazine.

By Rashid M. Taher, MD, and Marc Jay Gannon, OD
May 1, 2019

Referring patients begin a process of vision rehabilitation.

Forging a partnership with a low-vision specialist can benefit both retina specialists and their patients. Here we share 5 tips that have helped make our long-standing working relationship successful and one that has changed the lives of hundreds of their shared patients.

1. Value your patients’ goals

The job of the retinal physician is to treat patients’ medical condition, cure it when possible, and stabilize and retard its progression. What they must always consider is why patients would subject themselves to surgery or the trauma of getting an injection directly into their eye. The simple answer is that patients want to see. They want to participate in those activities that make them feel vital, happy, and authentically themselves. Even if the condition is cured or stabilized, without restoring sight, clinicians have missed the mark as far as patients are concerned.

2. Not all low-vision services and solutions are the same.

There are 2 main categories in low-vision rehabilitation: those services that are adaptive or compensatory, and those that are visually restorative. The difference is one method teaches people how to be blind, the other teaches them how to see.

With adaptive and compensatory strategies, the patient is trained to adapt to their vision loss and compensate with another sensory modality. An example of this would be marking the dials on an oven with bump dots. In this way, a patient could feel the dots placed on the dial and on a predetermined temperature on the oven lining up when the dots come together. This would enable them to know the oven was on and set to a specific temperature. This is a survival skill for the blind, enabling a patient who could not set the oven and cook to accomplish this activity of daily living.

In a restorative approach, patients have their vision assessed to determine where they have residual areas of vision. These would be evaluated as to size, location, and sensitivity of the individual sites. If an area is found, a telemicroscopic system may be created and a program of therapy instituted to teach the patient to view properly through the scope to regain visual function. These patients could then go into any kitchen with the telemicroscope and see the dials on the oven and visually set the temperature. They would not be limited to only using stoves that had been marked — they could use any stove, like any other sighted person.

There is a wide variety of low-vision services:

Some basic facilities may carry simple handheld magnifiers, prism readers, closed-circuit television (CCTV) reading machines, and ancillary aids like bump dots and talking watches. Patients who are higher functioning may benefit from these basic devices.
An occupational therapy group may have access to some basic devices, but most of the time they emphasize assistance in adaptive and compensatory types of low-vision survival skills.
A physician specializing in low vision is better equipped to assess those patients whose vision is so poor that they would not benefit from simple devices but who have sufficient residual sight to be able to function visually on a restorative plane. To use an analogy, if patients undergo amputation of a leg, they could get a wheelchair or have a prosthetic limb fit and undergo therapy to learn to walk again. A patient who might be able to walk or run with the proper assistance would not achieve their greatest possible quality of life if only given a wheelchair.

When choosing a low-vision specialist for your patients, look for those who have the greatest access to a wide range of devices and services. They will prove to be the best in providing your patients with the most comprehensive and functional level of vision restoration.

Low vision devices come in a wide range of design and function:

Figure 1. A patient wearing a low-vision telescopic system (Designs for Vision, Inc.). Image courtesy of Designs for Vision, Inc.

Handheld magnifiers can be used to read labels on cans or identify medications, but they are not comfortable for long-term reading or for tasks that require the use of both hands. In higher powers above 5x magnification, they have very limited fields of view and close focal ranges, and spherical and chromatic aberration affect their image quality.
Electronic magnification may come in the form of handheld magnifiers that will permit higher levels of magnification than their optical counterparts and are free of aberration.
CCTVs are better for reading, and some designs may lend themselves to tasks like writing and even viewing one’s face to shave or put on makeup.
eSight and Iris Vision offer technologies that are worn on the head and produce magnification on miniature monitors positioned in front of the eyes. These may permit some levels of hands-free magnification, enabling the patient to use both hands for some functions.
Optical telescopes (Figure 1), microscopes, and telemicroscopic systems are a superior solution. In much the same way that surgical loupes and operating microscopes work in the operating room, these enable the patient to work in real time and space. Like artificial limbs, they are custom designed to the patient’s particular needs and tend to produce the best results when properly fit and accompanied by a planned restorative therapy program.

3. There is always more that you can do

One of the greatest fears humans share is the loss of sight. Loss of sight leads to loss of the ability to perform activities and often results in dependency on others and feelings of isolation, inadequacy, depression, anger, as well as other psychological symptoms of vision loss.¹ Loss of sight can be terrifying and at times even result in loss of life, either accidently or intentionally. In 2006, a global outreach campaign to raise awareness of the little-known psychological effects of AMD was launched. The campaign aimed to demonstrate that basic support to improve AMD patients' quality of life — early access to medical expertise, diagnosis, treatment, and low-vision programs, including counseling — is vital.²^,³ When the vision team restores functional vision, there are wide-reaching positive effects in all of these areas.

Eye care clinicians might not think of these interventions as lifesaving, but often they are. When retina specialists send patients to a low-vision specialist, they provide the continuum of care that improves patients’ visual and psychological outcomes, self-esteem, safety, and confidence.

4. Refer, refer, refer

The American Academy of Ophthalmology (AAO) promotes referral to low-vision specialists and has created materials to educate ophthalmologists on vision rehabilitation.⁴ In a video created by the AAO’s vision rehabilitation committee, AAO CEO David W. Parke, MD, emphasizes the importance of referral for vision rehabilitation for patients who are starting to lose their vision. He adds that starting the process early better enables patients to involve themselves in vision rehabilitation.⁴

Many patients ask for assistance and demonstrate a desire for help. They yearn to enjoy the better quality of life, safety, and confidence that restored vision function may provide for them. Many are told, “There is nothing more that can be done.” This is not the case anymore, and it is the vision care team’s duty to provide patients with a better continuum of care.

Acuity is a potential rule of thumb for considering a patient for referral. Patients who are demonstrating acuities of less than 20/60 in their better eye are logical candidates, but patients with acuities better than this may still be having problems enjoying those activities that permit them to be fulfilled and independent. On the other end of the scale, patients who may only demonstrate hand motion centrally may have eccentric islands of vision that may have them reading 1M print, and seeing the faces of loved ones, with proper assessment, instruments, and therapy.

5. Practice humility

Ophthalmologists can feel defeated when treating patients who continue to lose vision. However, sometimes, vision cannot be saved. Retina specialists can get so caught up in the medical solutions for saving vision that they fail to remember what’s most important to patients. To the retina specialist, success is a stable eye. To patients, a stable eye is a necessary tool for their goal: seeing.

Vision rehabilitation is the standard of care for patients who have lost functional vision. Ophthalmologists have the ability and power to make a great difference in the lives of patients. Referral to a low-vision specialist empowers retina specialists to help patients improve their quality of life.

References

Cimarolli VR, Casten RJ, Rovner BW, Heyl V4, Sörensen S, Horowitz A. Anxiety and depression in patients with advanced macular degeneration: current perspectives. Clin Ophthalmol. 2015;10:55-63.
Mitchell J, Bradley C. Quality of life in age-related macular degeneration: a review of the literature. Health Qual Life Outcomes. 2006;4:97.
Macular Disease Foundation Australia. Depression, Suicide & AMD. Available at: https://www.mdfoundation.com.au/content/early-detection-amd-related-depression-and-suicidal-tendancies-critical
The American Academy of Ophthalmology. The academy’s initiative in vision rehabilitation. Available at: https://www.aao.org/low-vision-and-vision-rehab