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Low vision: a worthy optometric specialty, a growing need
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As a large portion of the American population ages, the need for skilled low vision practitioners is greater than ever. For those who choose this specialty, the ability to help patients maintain their vision and independence can be immensely rewarding.
However, some practitioners fear that as the need for low vision doctors increases, optometry’s emphasis on this specialty may be insufficient.
“If we don’t pay attention to a first love of optometry, which is sophisticated low vision services, and find a way to provide it in our offices, I can guarantee you that ophthalmology will,” said Jerome Legerton, OD, MS, MBA, FAAO, a Primary Care Optometry News Editorial Board member. “If we don’t find a way to provide quality low vision services, and let people know that this is an optometric specialty, then ophthalmology will dominate it.”
One way in which the profession can revitalize and strengthen its practice of low vision is to encourage optometry students and recent graduates to take up this challenging specialty.
“Having had rotation from two optometry schools, my opinion is that the direction is toward therapeutic management,” said William Park, OD, FAAO, assistant professor of ophthalmology at the Johns Hopkins School of Medicine. “Education regarding the importance of low vision rehabilitation — the fact that it can be fulfilling and rewarding — is not emphasized.”
The “optometric approach”
Dr. Legerton said he was first drawn to low vision through working with a mentor, Frank A. Brazelton, OD, MsEd. “At that time, Dr. Brazelton was making a concerted effort to shape that specialty in a sophisticated way,” Dr. Legerton told Primary Care Optometry News. “I liked the idea of helping people who had the misfortune of losing sight to maintain independent, productive lives.”
According to Dr. Legerton, the “optometric approach” to low vision focuses on maintaining the patient’s independence through spectacle-mounted aids. He distinguished the optometric approach from what he calls “lazy low vision.”
“Lazy low vision service is basically turning the patient loose in a room full of magnifiers and letting him or her choose one that works,” he said. “The optometric way is more sophisticated. Any lens that you can put in a magnifying glass, you can put in a pair of glasses and keep the hands free.”
Dr. Legerton said, whenever possible, spectacle lenses provide the patient with much more freedom than do magnifiers or hand-held telescopes. “Why have people hold a little binocular in the palm of their hands and try to read a sign,” Dr. Legerton said, “when you can put them in a pair of spectacle-mounted telescopes and have them drive a car?”
He said a commitment to optometric low vision as opposed to “lazy low vision” is an important goal for today’s practitioners. “I think the challenge for us is, do we believe in optimizing residual vision? Do we believe in what we were trained?” he said. “Or do we believe that low vision patients should go down to the local service for the blind and look at a room full of magnifying glasses?”
Experience of a new practitioner
Robert Joyce, OD, is a recent optometry school graduate who is director of low vision services for the San Diego office of Phillip Smith, OD. Dr. Joyce said he first became interested in low vision practice while working with Tom Hixson, OD, prior to entering optometry school.
“I was intrigued early on by low vision just by watching Dr. Hixson,” he said in an interview. “I continued to be very interested in it, but I did have some negative experiences with low vision in school.”
Dr. Joyce said, while in optometry school, he found that there was a general lack of organization in the approach to low vision. “Some of the clinics I was in had a lack of organization and a lack of measurable results,” he said. “That was very discouraging to me, and I found my patients were not responding well to it either.”
Dr. Joyce said that appreciable results – being able to show the patient how much he or she has improved – are very important to low vision. “I wasn’t able to show them how much better they were doing because that organization was not there,” he said. “It was a kind of a fly-by-the-seat-of-your-pants type approach, and I didn’t find it very helpful.”
Dr. Joyce said he also was not provided with guidelines regarding low vision examinations. “I wasn’t armed with the simple procedure for a low vision evaluation. What is the standard for a low vision evaluation?” he said. “I didn’t know. I had to define for myself what low vision was.”
Building a low vision practice
After graduation, Dr. Joyce initially worked for ophthalmologists, essentially putting his interest in low vision on hold. Then, Dr. Smith offered him the opportunity to build a low vision practice within his own practice.
“It was a practice builder for him, and it was a natural fit for me, because it was something I wanted to do,” he said. Dr. Joyce essentially built the low vision practice from the ground up and is still in the process of developing it to its full potential.
Dr. Legerton said there are many benefits to bringing in a new licentiate to help establish a low vision practice. “Usually, the senior practitioner is busy seeing patients and is somewhat comfortable. He or she is not going to call on ophthalmologists and take them to lunch to tell them about the practice’s low vision services,” he said. “That is how I built a low vision practice and how anyone could build one today. You need to go out and meet with established retinal ophthalmologists and let them know the services you offer.”
Dr. Legerton said the young associate plays an integral role in building the low vision practice, from producing brochures, to building an inventory of necessary aids, to establishing policies, procedures and scheduling. “Then they are ready to go out and develop referral services,” Dr. Legerton said. “Basically, the new practitioner builds a low vision practice within the established practice.”
Dr. Joyce said he has learned a great deal about low vision that has helped him in his current practice. “I have had some help through continuing education courses and through talking to doctors who are successful at it,” he said. “Eschenbach [Eschenbach Optik, Ridgefield, Conn.] is also helpful if you are a new practitioner and you want to get into low vision. Whether or not you decide to carry their products, they are very helpful in educating you and your technicians.”
Patient demographic
A low vision practitioner may see a wide variety of patients, but certain conditions are more prevalent than others.
“Sixty percent of my patients have macular degeneration, glaucoma or diabetic retinopathy,” Dr. Park said. “About 20% of them have a neurological disorder, primarily brain tumor or stroke, and 20% have congenital or hereditary eye disease. The age is from 18 months up.”
Dr. Joyce said macular degeneration represents the core of his patient base. “My youngest patients have been in their mid-20s with retinitis pigmentosa, but the mainstay is definitely macular degeneration,” he said. “Most of the patients are 70 years old and older, but I do have about a half dozen or so patients with retinitis pigmentosa who I have been following.”
Dr. Legerton said macular degeneration has traditionally been the most prevalent etiology of low vision and is predicted to increase with the greying of America. “Historically, it has been macular disease,” he said. “But diabetic retinopathy is a prevalent condition for younger people in the 30- to 50-year-old age group.”
A worthy profession
As disparate as their experiences may be, most low vision specialists seem to agree that their area of concentration is both challenging and rewarding.
“I have had patients regain their ability to read after not being able to read for 5 years,” Dr. Joyce said. “They know that it might take some hard work, and it might be different from anything they have done in the past, but it pays off.”
Dr. Legerton said he enjoyed being able to help patients of all ages to maximize their vision. “I particularly enjoyed being able to help people who were still of working age to continue in their same employment or to harness their residual vision and learn a new vocation,” he said. “And for age-related conditions, I enjoyed helping an individual who had lost sight to live independently.”
Dr. Park said, in addition to himself, his practice comprises a rehabilitation teacher and several occupational therapists, speech pathologists and social workers. “So it’s a team, and it’s actually fun,” he said. “We accomplish a great deal. We help people overcome their visual impairments and maintain their quality of life.”
For Your Information:
- Jerome Legerton, OD, MS, MBA, FAAO, is a Primary Care Optometry News Editorial Board member. He can be reached at 874 Harbor View Place, San Diego, CA 92106; (619) 758-9140; fax: (619) 758-9141; e-mail: jlegerton@aol.com.
- William Park, OD, FAAO, is an assistant professor of ophthalmology at Johns Hopkins University School of Medicine. He can be reached at 600 N. Wolfe St., B1-70 Lower Level, Baltimore, MD 21287; (410) 955-0580; fax: (410) 614-7965; e-mail: wpark@jhmi.edu.
- Robert Joyce, OD, is director of low vision rehabilitation at Total Family Eyecare in San Diego. He can be reached at 3666 Fourth Ave., San Diego, CA 92103; (619) 297-4331; fax: (619) 297-6572; e-mail: Dr.Smith@DrPhilSmith.com.