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Low vision can be treated in a primary care setting
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The world’s population 60 years of age and older is estimated at 291 million, according to United Nations data, and this number is projected to increase by 100 million in 20 years. These statistics suggest primary care optometrists can expect to see more low vision patients in their practices.
“Many low vision patients could probably have their needs prescribed for in a primary care setting,” said Douglas R. Williams, OD, FAAO, associate professor of low vision rehabilitation at the Southern California College of Optometry. “Many low vision specialists see patients who have simple needs for improvement and function.”
Optometrists seeking to augment this part of their practices should be aware of the possibilities and limitations of low vision treatment in a primary care setting. “The most important point is that low vision services are not as difficult to add to your primary care practice as they may seem,” said Al Morier, OD, a low vision specialist based in Albany, N.Y. “Simple common sense and a few basic principles will allow primary care optometrists to help their patients continue functioning as best they can.”
Central field loss “easiest” to work with
It is the responsibility of the primary care optometrist to carefully assess whether or not a patient’s low vision condition would be better served at the primary care level or should be referred to a low vision specialist.
“Primary care providers can easily satisfy most of their patient’s needs without consultation with a low vision specialist,” Dr. Morier said. “But when a person of any age has goals that are extensive and complicated, a low vision specialist should be consulted.”
Roy G. Cole, OD, FAAO, a low vision specialist at the Jewish Guild for the Blind in New York, divides low vision conditions into categories: “There are three basic types of impairments: central field loss, overall blur and peripheral field loss. Of those three, central field loss would probably be easiest to work with optically. This would include macular degeneration, the most commonly encountered problem causing low vision.”
Dr. Morier said patients with age-related macular degeneration (AMD) can and should be treated by the family eye doctor they have been seeing for years. “Psychologically, this is less disturbing for the patient,” he said. “In most cases, the elderly patient’s goals are fairly simple. Reading mail, bills, recipes, etc., are standard requests. As AMD is a central vision loss, it usually responds well to magnification.”
According to Dr. Williams, ocular diseases in their early stages are the most amenable to treatment on a primary care level. “The beginning stages of most ocular diseases still leave the patient with some visual function,” he said. “Stable congenital conditions are more favorable for rehabilitation than sudden visual loss of recent onset.”
Overall blur, Dr. Cole said, would pertain to ocular diseases such as cataracts. “We can definitely work with the overall blur category,” he said, “but it becomes more an issue of lighting and filters to control glare.”
The peripheral field loss category is perhaps the most difficult for the primary care optometrist to treat, Dr. Cole said. “There is not a lot we can do with this optically,” he said. “That becomes more of a mobility training issue.”
Dr. Williams said conditions affecting the peripheral field, such as retinitis pigmentosa, glaucoma and hemianopic loss, may require additional rehabilitative care. He added that if the condition results in a best-corrected acuity of better than 20/160 (10/80), the primary care practitioner may be able to assist the patient with either functional adds or hand magnifiers of powers of 8 D or less.
“You must not be scared off by any particular diagnosis,” Dr. Williams said. “What is more important is assessing the remaining function and the tasks for which the patient desires help. You must think in terms of rehabilitation for the patient’s needs.”
While many excellent low vision devices are currently available, practitioners are urged to provide their patients with realistic expectations.
“The most important tip on prescribing for the visually impaired patient is to define for them realistic goals and expectations for any low vision device,” Dr. Morier said. “They are not magical tools that bring people back to normal vision. They are simply aids that help them function to the best of their abilities.”
Dr. Cole said his most valued low vision tools are spectacles and hand-held and stand magnifiers. “The basic assumption is that you’ve maximized patients’ general vision with the best possible pair of glasses,” he said, “and you’ve maximized their general near vision with what I call a standard add, for eating and things like that.”
Dr. Cole also cited the value of equipment such as telescopes and filters for patients with glare. “Telescopes are not used very much, but they should be considered,” he said.
Dr. Morier said his favorite low vision device is the Eschenbach 6× stand magnifier (Eschenbach Optik of America, Ridgefield, Conn.). “It is automatically focused when it is flat on the page and self-illuminated,” he said. “It works for the 20/100 to 20/300 range quite nicely.”
Dr. Morier also mentioned the Designs for Vision Clearimage II (Designs for Vision, Ronkonkoma, N.Y.), which is a doublet lens system offering optics from 2× to 8× power. The edge-to-edge clarity allows easier reading for the visually impaired patient.
He also uses the 7× and 5.5× Beecher head-mounted telescope (Beecher Research, Elgin, Ill.), which is lightweight and can be used with a reading cap for near and intermediate use.
Dr. Morier also said he finds video low vision devices especially effective. “I use closed-circuit televisions all the time and encourage my patients to get one despite the $2,000 price tag,” he said. “I simply explain to them that it is a life-changing device. It is much less expensive than an automobile and obviously more useful — many patients have cars in their driveways, but can’t drive them.”
Dr. Morier said for the “high-functioning” visually impaired patient, the Jordy2 from Enhanced Vision Systems (Huntington Beach, Calif.) offers a head-mounted video system that has variable magnification and color. “My younger patients love it,” he said.
Clinical pearls
Dr. Cole recommends using a trial lens set in evaluating low vision patients. “I suggest that you find out what the patient needs to see or ask the patient to perform a task using the trial lenses, which give you the power that’s needed,” he said. “And you determine whether spectacles, a hand-held magnifier or a stand magnifier would be most appropriate. Then, using the number that you used in the trial frame, you can figure out what power in that type of device is needed.”
Dr. Morier said it is important to be sure patients do not use low vision devices too far from their eyes. “Bringing the magnifiers and printed material close to their eyes increases the field of view and decreases the peripheral aberrations you get with optical lenses,” he said. “Obviously, the higher the power, the smaller the lens and the greater amount of distortions you will see.”
Another tip from Dr. Morier is control of lighting, which he said is often neglected by practitioners. “No one understands the importance of lighting better than the elderly visually impaired,” he said.
He said the bulb should not be more than 18 inches from the print and need not be more than 60 watts: “It is the proximity that gives the light its strength. There should be a shade that keeps the glare out of the patient’s eyes but directs the light onto the page.”
Dr. Williams agreed additional lighting is almost always required for low vision patients. “Do not assume that a patient understands lighting,” he said. “You need to emphasize that light should be placed on the side of the better eye and, in general, moved closer. It is not so much the wattage or type of light as it is the placement. Ask patients about their use of lighting for the tasks they want to perform.”
With regard to magnification, Dr. Williams warned against the attitude that “more is better. The caution in prescribing for the low vision patient must be the least magnification for the best performance,” he said. “Too much magnification, despite the common belief that ‘stronger is better,’ often results in closer working distances, small fields of view and more rejection from the patient.”
Low vision procedural codes
Medicare coding for low vision services is inconsistent and in some cases controversial throughout the country. “Low vision refraction has always been a non-covered service,” said Dr. Williams. “However, most of the evaluation involves testing of the patient’s function and providing rehabilitation services.”
Dr. Williams said some doctors will code these visits as 99000 series evaluation and management. Depending on the content of the medical record, the visits might even be coded as levels 4 or 5.
“For the most part, they are level 4S and 5S,” he said. “These doctors will justify this coding by advocating that the services provided are medically oriented and are centered around an ocular disease. Other doctors use other coding choices, as they feel that the 99000 codes are unjustified.”
A recently introduced bill, the Medicare Vision Rehabilitation Services Act of 2001 (HR 2484, or the Capuano Bill), along with a companion bill in the Senate (S1967) would change the provisions of low vision care under Medicare, providing coverage for low vision rehabilitation services under the same framework as other medical rehabilitation therapies. It would not, however, provide coverage for the low vision exam or devices.
For Your Information:
- Douglas R. Williams, OD, FAAO, can be reached at 6042 Warner Ave., Huntington Beach, CA 92647; (714) 847-6059.
- Al Morier, OD, can be reached at 25 Hackett Blvd., Albany, NY 12208; (518) 262-2540; fax: (518) 452-8647.
- Roy G. Cole, OD, FAAO, can be reached at 15 West 65th Street, New York, NY 10023; (212) 769-6316; fax: (212) 769-4193.
- Drs. None of the doctors have a direct financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned.