This article is more than 5 years old. Information may no longer be current.
Changing attitudes expand ophthalmology’s role in low vision patients’ rehabilitation
New initiatives are helping to fuel a broad multidisciplinary approach to visual rehabilitation.
Click Here to Manage Email Alerts
Changing attitudes are expanding the role ophthalmologists can play in visual rehabilitation of patients.
From treatment guidelines developed by the American Academy of Ophthalmology to increasing clinical cooperation among optometrists, ophthalmologists, occupational therapists and other low vision professionals, multidisciplinary teams are expanding their services to help patients once medications and surgical options are no longer effective.
Eleanor E. Faye, MD, FACS, has been working as a low vision specialist at the nonprofit organization Lighthouse International since 1956 and has been the organization’s medical director since 2006. According to Dr. Faye, the organization has recently received more recognition due to these changing attitudes.
“The doctors now are really responsible for keeping their patients going and not just saying that nothing can be done, so I think the changes are really attitudinal more than anything else,” she explained to Ocular Surgery News in a telephone interview.
According to Dr. Faye, the low vision service at Lighthouse International has been in existence for 53 years, but it is only recently that more people have begun to take notice, thanks to a growing need for a better informed population and an initiative from the AAO to improve access to a workable system for vision rehabilitation.
The catalyst for this awareness of options for low vision patients is the increase in the number of elderly patients who have partial vision due to macular degeneration therapies.
New therapies such as Lucentis (ranibizumab, Genentech) and Avastin (bevacizumab, Genentech) are available for the wet form of age-related AMD, but vision loss is still a major problem among these patients.
“All the advances that we are looking at are so important because what they’ve done is reduce the overall impact of low vision on the patient,” Dr. Faye said. “That’s all the more reason for all of us in ophthalmology to be aware of our patients’ needs and either get help for them or refer them to a place like Lighthouse for help.”
AAO vision rehab SmartSight initiative
A significant step toward the increased involvement of ophthalmologists in low vision care has been the SmartSight initiative begun by the AAO Vision Rehabilitation Committee.
According to committee chair Lylas Mogk, MD, the initiative began with a question put to leaders of advocacy organizations such as the American Foundation for the Blind, the National Association for the Visually Handicapped and others: If they could send any message to ophthalmologists, what would that message be? The resounding answer was to communicate to patients with vision loss that there are options for continuing to live full lives.
“Ophthalmologists are so desperate to help the person’s eye that that’s the focus. The SmartSight message is that we need to think one step beyond the patient’s eye to their life and say ‘I can’t do anything more for your eye, but much can be done for your life,’” Dr. Mogk told OSN.
The initiative works on three levels and is designed to enable ophthalmologists to help their patients who have visual acuity less than 20/40 or who have scotoma, field loss or contrast loss related to macular degeneration.
Level one is “Recognize and respond,” reiterating the primary idea that ophthalmologists need to recognize the difficulties of low vision and inform patients of rehabilitation services.
Level two details the importance of recording precise visual acuity, refracting accurately and reporting the vision loss to primary-care physicians so they can prepare for concurrent health problems such as depression.
“There is a high correlation between vision loss and depression. [However], it does not correlate to the level of vision loss, but rather to loss of function. If you can keep people doing their daily activities, that’s a huge step in preventing or alleviating depression,” Dr. Mogk said.
While the first level is aimed at all ophthalmologists and the second level at general ophthalmologists, the third level is designed to promote the creation of vision rehabilitation programs in academic ophthalmology programs or large group practices by describing the content and methods of a low vision evaluation and rehabilitation training. These include activities of daily living and environmental adaptations, according to Dr. Mogk.
“At the very least, every academic center should have such a program, and that would put at least one in every state,” she said.
The multidisciplinary model for rehabilitation
A multidisciplinary low vision practice is designed to help low vision patients maximize the remaining vision they have by first providing functional vision examinations consisting of visual acuity assessment, continuous print reading ability of various materials, contrast sensitivity and magnification needs.
Once the patients’ vision is assessed, they are trained to apply optical aids such as specially designed spectacles, hand magnifiers, telescopes and electronic devices to accomplish their desired tasks, and to use non-optical aids and resources such as accessibility software for computers or audio newspapers and books.
Conversations among multidisciplinary teams are helpful for prescribing not only low vision devices, but also the rehabilitation that accompanies the devices. Vision rehabilitation is framed by the patient’s goals.
“According to what the patient needs, we tailor a program for that patient depending on their vision and what they have left and what they are capable of and what they want to do, so the rehab is a big deal nowadays,” Dr. Faye said.
According to Dr. Mogk, this multidisciplinary model is beginning to take hold as more institutions are developing their own low vision services.
“If we look at 5 or 10 years ago and now, [there is] no question there are new programs. There’s a brand-new program at the University of Nebraska headed by ophthalmologist John Shepherd, MD, and Harvard has just rejuvenated its program under the directorship of Mary Lou Jackson, MD, who is also the new chair of the Vision Rehabilitation Committee of the [AAO]. So there are definitely new programs starting up,” she said.
Dr. Jackson has grown the vision rehabilitation service at Harvard’s Massachusetts Eye and Ear Infirmary (MEEI) by introducing tools such as a scanning laser ophthalmoscope macular perimeter, which enables both the physician and the patient to appreciate specifically hwere scotomas are, and to understand how these impact function, particularly reading. Patients may use alternate, healthy areas of retina for fixation when foveal vision is compromised.
Dr. Jackson and the MEEI Vision Rehabilitation Team — which includes three occupational therapists — specifically addresses five areas: reading, activities of daily living, safety, community participation and patient well-being in terms of depression, adjustment to vision loss and appreciation of the Charles Bonnet visual hallucinations.
These hallucinations occur in more than one third of vision rehabilitation patients.
“Those are the five parts of our model, and our job is not done until all five are addressed,” she said.
“The secret there is to keep multiple professions working together in this area even though they may be split on other things, and that we work together,” she said.
For more information:
- Eleanor E. Faye, MD, FACS, can be reached at Lighthouse International, The Sol and Lillian Goldman Building, 11 E. 59th St., New York, NY 10022-1202; 212-821-9200; fax: 212-821-9707; e-mail: efaye@lighthouse.org.
- Mary Lou Jackson, MD, can be reached at Massachusetts Eye and Ear Infirmary, 243 Charles St., Boston, MA 02114; 617-523-7900; fax: 617-523-5498; e-mail: marylou@mljackson.ca.
- Lylas Mogk, MD, can be reached at Henry Ford Visual Rehabilitation & Research Center, 29200 Schoolcraft, Livonia, MI 48150; 734-523-1070; fax: 734-523-1080; e-mail: mogk@aol.com.
- Jared Schultz is an OSN Correspondent based in Philadelphia.