In the 1950s, ophthalmologists Gerald Fonda, MD, and Eleanor Faye, MD, conceptualized a middle ground of vision impairment, emphasizing usable residual vision rather than blindness, and coined the term low vision. Forty years later, four major factors hav converged to prompt the rise and expansion of vision-rehabilitation services for adults: change in demographics, pathology, lifestyle and perceptions of aging; recognition of the mismatch between seniors’ needs and existing services; increased rehabilitation capability; and changes in funding.
The Changing Demographics of Those with Low Vision
Due to medical advances, protective eyewear and changes in the weapons of war, blindness among children and young adults decreased simultaneous to the escalating senior population with low vision. In 1957, 60 percent of the low-vision clients at a visual aid program in New York were ages 20-60, and 3.6 percent of clients had macular degeneration. Today, those numbers have reversed. Our concept of aging has also changed: 65-year-olds no longer automatically give up employment and activities to sit in their rocking chairs. The visual demands to perform daily activities are greater in our complex society, basic services are often distant from home and inaccessible by public transportation and adult children live far away. Seniors' survival therefore requires greater independence than in previous generations. As a result, seniors with vision loss have a desperate need to maintain their function.
Why State Services Don’t Always Serve Seniors’ Needs
All states have mandated educational services for children, vocational services for adults and “older blind” services. However, these services are mismatched to seniors' needs in six regards.
- Adult state services usually require legal blindness (20/200 or 20 degree field). However, sighted adults with gradual vision loss -- the situation of most seniors -- need intervention to preserve activities and quality of life well before they reach the point of legal blindness.
- State services, designed for small numbers of young individuals, are overwhelmed by the population of seniors in need.
- States emphasize and fund for services related to employment.
- Rehabilitation training is often conducted without a preceding low-vision evaluation. As a result, rehab personnel may overlook individual pattern of loss and usable residual vision, although they require different rehabilitation strategies.
- Comorbidities common to seniors -- balance, memory, shortness of breath or muscle weakness, for example -- affects rehabilitation strategies. However, these are beyond the scope of practice of non-medical rehabilitation professionals.
- Sighted individuals understand blind to mean no vision and do not realize that an agency for the blind means for the legally blind, nor do they wish to be identified as such.
Increased Rehabilitation Capability
Improvement in four areas has increased our ability to provide effective vision-rehabilitation services. These include visual-aid technologies, evaluation tools, training materials and strategies and professional preparation: closed circuit TVs, computers, electronic devices and GPS systems; standardized continuous print charts to accurately measure low acuities, contrast charts, and peripheral and central perimetry to map patterns of vision loss; training strategies and materials for consumers; and training for rehabilitation professionals.
Several degree programs in orientation and mobility and rehabilitation teaching have also added certification in low-vision therapy to the recently renamed vision-rehab therapy. The Occupational Therapy Department at the University of Alabama at Birmingham now offers a graduate certificate in vision rehabilitation for OTs. In addition, Western Michigan University's Occupational Therapy Department has just announced a similar certification program.
Occupational therapists are uniquely qualified for this specialty, as they are adept at problem solving functional deficits from all causes, including vision loss from strokes. With the addition of expertise in the intricacies of vision loss and rehabilitation strategies, they are exceedingly effective and efficient.
Changes in Funding
In 2002, the Centers for Medicare and Medicaid Services granted national coverage for vision rehabilitation when ordered by a physician and performed by an occupational therapist. The Academy, members of the Vision Rehabilitation Committee and others had successfully advocated for the regional policies that were in place in 28 states by that time.
However, the national policy opened the way for academic ophthalmology programs and others to offer comprehensive vision rehabilitation across the country, on the same basis as therapy for patients with functional difficulties from any other physical impairment. In many academic ophthalmology programs, ophthalmologist/optometrist/occupational therapist teams provide comprehensive vision-rehabilitation services. This increasingly happens in private non-profit agencies and even in some private practices, too. It is certainly the wave of the future.
The Vision Rehabilitation Standard of Care
The Academy’s Preferred Practice Pattern® guideline for vision rehabilitation describes three parts of comprehensive rehabilitation for adults, which studies find improve function and quality of life. First is the low-vision evaluation, including assessment of the pattern of loss, contrast sensitivity, spot and continuous print reading, writing, activities of daily living, refraction if indicated, degree and types of magnification needed, safety, psychosocial status and community participation.
Referral with recommendations to specialized occupational therapists follows. Therapists train patients to use their residual vision efficiently, apply recommended strategies and devices to desired tasks in the clinic and ideally in the patient’s home and community. They also provide guidance on how to adapt living environments; address safety issues, including medication management and basic mobility; facilitate community participation, including transportation; and consider the patient’s psychosocial condition.
The final step is referral to support groups, counseling and/or other appropriate community services. It has become the standard of care for ophthalmologists to direct patients whose best vision is 20/40 or less to further services. Ophthalmologists can easily do this by handing patients the free Academy SmartSight patient handout [PDF], available on the Academy website, in English, French and Spanish. Without this information, those with even early vision loss have a high risk for depression and injuries.
Why Do Senior Ophthalmologists Care?
Senior ophthalmologists and their siblings and spouses develop macular degeneration at the same rate as other seniors and need access to high-quality vision-rehabilitation services. Only one ophthalmologist has gone public at the Academy's annual meeting about his own vision loss from AMD. He immediately began advocating for awareness of vision rehabilitation, as he discovered its existence quite by accident. There are certainly more ophthalmologists who need to know that rehabilitation facilitates living fully with vision loss.
For senior ophthalmologists who would like to continue making a difference, part time, being the lynchpin of a vision-rehab service is terrific. One day a week of performing low-vision evaluations can keep an occupational therapist busy and billing for multiple visits, making the service financially viable. The current chair of the Vision Rehabilitation Committee is an interventional cardiologist whose myopic degeneration prompted him to retrain as a certified low vision therapist and launch a private, non-profit, vision-rehabilitation service in his home town.
A retired ophthalmologist gains much satisfaction from changing lives with vision rehabilitation a couple days a month in an East Coast non-profit. Those of us in vision rehabilitation like to say that we don’t save eyes but we save lives. Patients’ comments confirm this.
If you are interested in exploring this fulfilling option, visit any of the current programs near you or contact the Academy Vision Rehabilitation Committee via Joe Fontenot, MD, jfontenot@bellsouth.net.
Hear David W. Parke II, MD, and other prominent colleagues discuss the role of vision rehab in ophthalmology and its benefit to ophthalmologists and their practices in a six-minute video. Funded by a Reader’s Digest Partners in Sight grant to the AAO Vision Rehabilitation Committee.
For more stories from Scope, download the fall 2016 issue [PDF].