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Vision rehabilitation crucial for diabetic patients
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At a recent low vision support group meeting at our Eye Institute, a retinal specialist commented to my occupational therapist that "I probably only refer to you 5% of the patients that I should."
Diabetes is the leading cause of new legal blindness in those between the ages of 24 and 70 years of age in the United States. Each year, 5,800 Americans lose their sight to diabetes.
With optometrists as the gatekeepers in eye care, it is absolutely essential that the practitioner thoroughly evaluate, diagnose and educate his or her diabetic patients.
In our hospital-based, diabetic management education series, I lecture monthly to the newly diagnosed diabetic patients within the hospital system. When I lecture to the audience, I emphasize ocular anatomy, functional implications of central and peripheral pathology, systemic implications affecting diabetic retinopathy, nonproliferative and proliferative stages of retinopathy, and examination and testing (what they should look for and why tests are performed). I stress the importance of a dilated fundus examination, laser photocoagulation (the reason it is performed and the side effects that result), the existence of vision rehabilitation for the visually impaired and the importance of patient/practitioner communication for appropriate care delivery.
Referrals lacking
---This patient with nonproliferative diabetic retinopathy is being instructed on the use of an Eschenbach hand-held magnifier to identify food ingredients and assist with preparation instructions.
Timely and pertinent referral of all diabetic patients would greatly increase the number of patients with diabetic retinopathy being seen by vision rehabilitation physicians. Globally, this referral pattern for comanagement of the diabetic patient does not occur.
The questions then become: When should a diabetic patient be referred, to whom and why? Because it is known that diabetic retinopathy is progressive, early referral is critical. Too often, I see a patient after significant pan-retinal and focal laser photocoagulation, severe central visual acuity loss, restricted visual fields (as a result of treatment), poor systemic health (complicated by poor ocular health) and his or her despondency caused by the seemingly hopeless predicament.
My preference as a vision rehabilitation practitioner is to see any patient with functional complaints or any patient with central visual acuity of 20/50 or worse with a known progressive disease. This referral is absolutely essential with an employed individual, as minimal plus, hand or stand magnification along with nonoptical aids (illumination and contrast enhancement) may resolve occupational difficulties. This may also be the time to consider referral to an agency for rehabilitative resources including financial concerns. All of these services could be delivered by a primary care practitioner, if comfortable in doing so.
Interdisciplinary approach
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| A patient experienced difficulty with driving, reading, insulin management and the visual demands of her social worker job. The color fundus (left) depicts her pan-retinal and focal laser photocoagulation. The correlative visual field (right) shows relative mid-peripheral central scotomas as a result of treatment. She was eventually fit with a spectacle-mounted telescope. | |
In the severely impaired or legally blind diabetic patient, care delivery becomes more complicated and requires an interdisciplinary team approach. Again, the primary care practitioner should care for this patient and refer for comanagement when indicated.
The diabetic patient who has had cystoid macular edema (central pathology) and treatment will most likely have central visual acuity loss resulting in reduced distance, intermediate and near visual acuity. Contrast sensitivity, depth perception and color perception will also be compromised. This may adversely affect occupational demands, driving, insulin management and activities of daily living.
Pan-retinal photocoagulation (mid-peripheral and peripheral pathology) will result in restricted visual fields (relative or absolute blind spots), nyctalopia and poor light and dark adaptation, potentially creating serious driving issues, difficulty with orientation and mobility and safe independent travel.
Either entity alone - central pathology (cystoid macular edema) or peripheral pathology (secondary to treating diabetic retinopathy with laser photocoagulation) - would adversely affect functional capabilities of that individual, and both combined may be totally overwhelming and unsafe without vision rehabilitation and patient education.
If the patient has decreased visual acuity that cannot be corrected conventionally (20/200 or worse) or has restricted visual fields (less than 20°), the patient can be considered legally blind and referred to the proper state agency. The agency would provide vocational, financial and rehabilitative resources. Rehabilitation could involve cane instruction, orientation and mobility, activities of daily living, vocational training, insulin management, self-care and blind rehabilitation. This referral should be initiated as soon as possible and is critical if the prognosis is guarded to poor.
Effects on field of vision
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| An occupational therapist is conducting a Pelli-Robson contrast sensitivity test on a patient with nonproliferative diabetic retinopathy (left). The patient was fit with a Design for Vision bioptic telescope (right) to help him improve his functional activities of daily living and continue driving. | |
A 32-year-old mother of two children came to our institute as a result of referral by a friend. She chiefly complained of difficulty with driving, reading, insulin management and visual demands of her avocation as a social worker, which also involved significant traveling. Her color fundus photographs of the right eye and the resultant visual field demonstrating the effect of pan-retinal and focal laser photocoagulation on the field of vision are shown.
She has been insulin dependent since 4 years of age, with visual impairment by 13 years of age. She had undergone pan-retinal and focal laser photocoagulation and vitrectomies in both eyes.
The patient had never before been referred for visual rehabilitation, and if it were not for a friend who was an orientation and mobility specialist she would never have been aware of the field of visual rehabilitation.
At the conclusion of the initial examination the patient was informed that because her visual acuity was best corrected to OD 20/160 and OS 20/125, she could not legally drive. She was eventually fit with a spectacle-mounted telescope to improve vision for all tasks (primarily driving) and to maintain employment.
She was seen over the next 6 months for education on using the telescope along with other visual devices for activities of daily living and was enrolled in our driving program for training in driving with a telescopic system. This was successfully completed.
Because she has maintained her mobility and independence, she has since been promoted in her job. Providing care to enable her to reach her goal involved the vision rehabilitation team of: optometry, nursing, orientation and mobility, occupational therapy, social work and a certified driving instructor. This was a circumstance of care that almost did not happen.
Nonproliferative diabetic retinopathy
A 49-year-old man who had a diagnosis of nonproliferative diabetic retinopathy and had best-corrected visual acuity of 20/200 in both eyes. He was currently employed and did not desire to be on disability because of his visual impairment.
The patient was eventually fit with a 3X spiral Galilean Design for Vision (Ronkonkoma, N.Y.), bioptic spectacle-mounted telescopic system to help him improve his functional activities of daily living and continue driving. Enrollment in the driving program eventually led to a successful licensing of the patient with a telescopic restriction. He is still employed and is doing well.
Another case involves a 78-year-old woman with diabetic retinopathy and primary concerns of difficulty with kitchen-related activities and safe travel. As an adjunct to improving vision for daily demands with visual devices, occupational therapy provided patient education in kitchen-related activities within our center for her primary complaint. Orientation and mobility instruction was given within our center, the medical complex and the outside environment for safe travel.
Think of patient benefits
All three cases were not referred specifically by any eye care practitioner, and it was only by happenstance that they became patients who received vision rehabilitation and benefited greatly by it.
The first two patients were referred to a state agency for financial resources and remain employed to this day. These cases also involved the ultimate goal in complexity (driving) and the extensive patient education and interdisciplinary training necessary. As a result, the savings economically and emotionally to the government, society and the individual cannot be underestimated and should not be unappreciated.
The third case involves a patient's desire to be able to continue to do the things we may take for granted everyday.
For Your Information:
- Pelli-Robson Contrast Sensitivity Chart is available from Mattingly International Inc., 938-K Andreasen Drive, Escondido, CA 92029-1920; (800) 826-4200.
- Design For Vision Inc., can be reached at 760 Koehltr Ave., Ronkonkoma, NY 11779; (800) 345-4009.
- Eschenbach Optik of America Inc., can be reached at 904 Ethan Allen Highway, Ridgefield, CT 06877; (203) 438-7471.