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    Rethinking When to Refer Patients to Low Vision Services

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    Headshot of Ruth D. Williams, MD.

    By Ruth D. Williams, MD, Chief Medical Editor, EyeNet

    A glaucoma patient with 20/25 vision recently told me, “It’s not blurry, it’s hazy.” Understanding what a patient sees is sometimes a challenge. The patient uses words or drawings to describe a visual image, and the ophthalmologist must turn that information into a visual interpretation. It can be frustrating for the patient—and for the ophthalmologist. What’s more, Snellen chart test results provide only crude measurements that tell us little about the quality of a patient’s visual experience. The more I listen, the more I’m convinced that vision loss is nuanced and affects an individual’s quality of life in subtle and complex ways.

    It’s also easy to brush off visual complaints when we don’t have a medical explanation or when we can’t do much to ad­dress poor vision. Ophthalmologists have an ever-increasing number of patients to see. We are doers and fixers, and we like to be effective. It’s difficult to listen to a frustrated patient when their vision isn’t as good as they expect and when we don’t have a ready treatment. Perhaps we should refer patients to providers of low vision services more readily.

    I’m quick to refer patients for low vision services when they are legally blind. These patients often have macular degen­eration or conditions involving sudden and recent vision loss. But many patients with other kinds of vision loss could benefit from low vision services. Take glaucoma patients. We think of glaucoma as causing peripheral deficits, but even mild and moderate disease can affect central vision and can be associated with lower quality of life scores.1

    Lylas Mogk, medical director of the Henry Ford Visual Rehabilitation Centers, advocates for earlier referral to low vision centers for all patients who could benefit. She points out that “cataracts are routinely removed for patients with vision in the 20/40 to 20/60 range precisely because they are having functional difficulties.” Why not refer other types of patients for low vision services who have similar levels of loss, Lylas asks.

    The Academy’s Vision Rehabilitation Preferred Practice Pattern recommends that ophthalmologists provide informa­tion about rehabilitation resources to anyone with compro­mised vision because “even early or moderate vision loss can result in disability, which can affect visual performance, cause anxiety, interfere with safety and everyday activities, and diminish quality of life.”2

    Lylas points out that it’s common for health care providers to refer patients with health issues unrelated to vision—such as balance problems or back pain—to rehabilitation services. Because low vision services address quality of life issues, she suggests that low vi­sion referrals should be as accepted as, say, physical therapy. Keeping brochures with information about local, low vision centers in the exam room makes it convenient to bring up the topic.

    There’s more to offer our patients with vision loss—even those who have mild and mod­erate loss—than evidence-based care, procedures, solutions, and referrals. Simply acknowledging their vision loss is powerful. Grief counselors teach that people experiencing a great loss don’t need advice or platitudes but rather, they need someone to listen and to create a sacred space for their grief.

    I recently commented to my elderly patient with macular degeneration that vision loss can be terribly lonely. Because she appears like her “normal” self to others, and even her family members, they don’t realize how difficult it is for her. This elegant, reserved, and well-mannered woman nodded silently and quietly cried in front of her daughter. She later told me that being understood was an important part of being able to accept her limitations.

    I’m grateful to the vision rehabilitation groups in my community because they provide practical solutions for our patients and—even more important—they offer hope.


    1 Garg A et al. Am J Ophthalmol. 2018;194:88-89.

    2 Vision Rehabilitation Preferred Practice Pattern.


    READ MORE. For additional information on how to help patients with low vision, see EyeNet’s September 2023 article “Keeping an Eye on Low Vision Patients.”