EyeNet Magazine

Low Vision

Fitting Low Vision Into Your Practice
By Miriam Karmel, Contributing Writer

By the time Lylas G. Mogk, MD, met her, the patient’s vision had gradually deteriorated to the point where she could no longer read, write, pay bills or cook. Recently, Dr. Mogk, a vision rehabilitation specialist, received a letter from the suburban Detroit widow, who wrote, “I have my life back now.”

Ophthalmologists may not think they are in the business of restoring life, but the Academy—through its new SmartSight PDF initiative in vision rehabilitation—is asking them to think again.

“We need to recognize that now it’s our responsibility to look one step beyond the patients’ eyes,” said Dr. Mogk, who chairs both the Academy’s vision rehabilitation committee and the SmartSight task force.

Robert E. Kalina, MD, a member of the vision rehabilitation committee, noted that when conventional medical techniques fail, “we don’t go to the next step, which is to help patients make the most of their remaining vision.” He noted that the situation is not one-sided. “The patients are guilty of looking for a cure instead of looking for a way to maximize their existing vision. It’s your job to help them find the way,” said Dr. Kalina, professor of ophthalmology at the University of Washington, Seattle.

Continuum of Care
SmartSight wants physicians to think in terms of a spectrum of options, Dr. Kalina explained. “Ophthalmologists need to recognize visual rehabilitation as part of the continuum of care.”

Dr. Kalina doesn’t provide low vision services and thus would be at the starting point along the continuum. The SmartSight initiative recommends that he and every other ophthalmologist should recognize the signs of visual impairment—visual acuity of less than 20/40, central scotoma or loss of field or contrast sensitivity—and provide information or refer for rehabilitation. 

“It’s a new situation in ophthalmology,” said Dr. Mogk. “Until the last decade we didn’t have to be concerned about this. It wasn’t on anybody’s radar screen.” That’s because most people with low vision were young, and were identified in schools or by pediatricians.

Today’s changing demographics demand a different response. In 1999, the NEI estimated 200,000 adults lose significant vision each year from AMD alone. And Prevent Blindness America reports that as of 2000, more than 3.4 million Americans older than 40 were visually impaired (including blindness). PBA estimates that visual impairment is expected to double within the next three decades.

The senior population isn’t being screened in schools or in the workplace. “All of a sudden it’s up to us to identify people having trouble in their lives because of their vision. We end up as gatekeepers for further continued care,” Dr. Mogk said.

The challenge is to help low vision patients make the most of their remaining vision.
Caption: Diagnosis, adios? No longer: The challenge is to help
low vision patients make the most of their remaining vision.

Stepwise Approach
SmartSight realizes that not every ophthalmologist has the time or inclination to provide the kinds of services that get patients back into the flow of life. That’s why it proposes a stepwise approach to treating low vision. This approach starts with something as simple as recognizing which patients need help and moves all the way along the continuum to rehabilitation training.

Dr. Mogk’s practice is at the latter end of the continuum. Her patients are referred by other ophthalmologists who have run out of treatment options. Like them, she has no cures, but she is trained to assess the patient’s pattern of vision loss, the amount of residual vision and specific needs. She knows how to locate the scotoma, as well as the next best spot to use in place of the damaged fovea. She and her staff of occupational therapists help patients use remaining vision to the best advantage.

As Dr. Kalina put it: “We always feel so guilty when we have something that we can’t cure or treat. What SmartSight does is give us the opportunity to offer the patient something more.”   
Implications for Your Practice
Time. “The idea that [low vision] is time consuming is not always correct. There are different levels,” said Dr. Kalina. Sometimes, all a patient needs is better lighting, which can be provided by something as simple as a gooseneck lamp. Or the patient may require a stronger bifocal, he added. 
Reimbursement. In May 2002, Medicare agreed to reimburse for rehabilitation service to patients with visual impairments on the same basis as for other impairments. This addresses environmental adaptations and training in activities of daily living.

The first part of comprehensive vision rehabilitation—the low vision evaluation—is billed as a consultation, using visual impairment codes, although a handful of states still reject these codes. “It’s not a highly remunerative enterprise,” said Lee R. Duffner, MD, a comprehensive ophthalmologist who practices in Hollywood, Fla. “A lot of what you get paid is the gratitude of the patients.” 

Smart Resources

The Academy’s SmartSight Initiative in Vision Rehabilitation will help ophthalmologists help their patients with visual impairments in an easy, stepwise program PDF

As part of this, two free packets of information will be provided to all members:

Eye M.D. packet. This sets forth an easy treatment “tree,” with sources for charts and devices.

Patient packet. This is for duplication and distribution to patients. It includes tips for lighting, contrast and controlling glare; a discussion of the impact of vision loss and ways to cope; and a toll-free number that patients can call. 

Check www.aao.org for updates on SmartSight.

Simple Changes, Big Results

You don’t have to be a vision rehabilitation specialist to serve the growing low vision population. But a few simple changes in your practice can yield big results.

FIRST LEVEL. The SmartSight Initiative calls for all ophthalmologists to provide Level 1 of SmartSight services.

Recognize. The first step is to recognize the impact of vision loss and think beyond 20/200. Any patient with visual acuity less than 20/40 needs to begin using SmartSight techniques and resources. “If they’re 20/100 or worse, they’re having a lot of trouble,” said Dr. Mogk. “But even the patient whose visual acuity is less than 20/40 is having some difficulty in his or her life.”

Respond. Then respond by simply handing SmartSight resource information to patients.

SECOND LEVEL. SmartSight’s Level 2 recommendations are targeted to comprehensive ophthalmologists. These include the following “four Rs” of rehabilitation:

Record acuity. Replace “count fingers” with precise acuities. “Count fingers”  is too imprecise—instead, use special charts that tell you the difference between 20/400 and 20/2000. (Inexpensive, portable charts are available.)

Refract accurately. “It’s a little thing that’s a big thing,” said Dr. Mogk. You cannot refract low vision patients in a phoropter, which only allows you to look through the center. Begin refracting these patients the way you would an infant, by streak retinoscopy, and then use a trial frame to manifest.

Recommend reading aids. Low vision patients often benefit from higher adds, so don’t hesitate to give stronger than usual reading powers. “People do fine with four or five diopters,” Dr. Mogk said. Dr. Kalina agreed. “It’s very simple to prescribe a little more add.” 

You may want to consider selling devices in your office. “It takes a significant capital investment to go into the low vision aid business,” said Dr. Duffner. But with a minimum investment, you can supply some items, such as aspheric hand-held magnifying glasses, illuminating devices and reading glasses that have prismatic lenses already mounted in a frame. It’s important that patients go home “convinced that they have something to show for the visit,” Dr. Duffner said.

Report back. SmartSight suggests that you communicate with the patient’s internist or family physician. Topics to cover include the irreversibility of the patient’s visual loss and the resultant risk of depression, falls and Charles Bonnet syndrome.

THIRD AND FOURTH LEVELS. These involve more extensive assessment and management of visually impaired patients. At Level 3, the ophthalmologist incorporates a basic or comprehensive low vision evaluation in his or her practice and refers the patient for vision rehabilitation. Level 4 provides comprehensive rehabilitation within the ophthalmology practice.

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