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Today's primary care OD can provide low vision care more easily
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Devices are more readily available for patients to test on their own, allowing the optometrist to focus on managing the condition.
 Scott A. Edmonds |
Low vision care has undergone a dramatic change over the past 10 years. These changes have opened the door for more of this care to move out of the specialty low vision clinic and back into the scope of the primary care optometrist.
Low vision aids more accessible
One paradigm shift is related to the procurement of “low vision aids.” It was once the case that in order to provide low vision care, one needed a vast array of magnifiers, telescopes and electronic readers to test on these patients and then supply, repair, service and replace all of these devices.
Today, patients and their family members can review and evaluate all of these optical options on the Internet. They can often order, test and return low vision aids and even get free shipping on some. Most states do not require a doctor’s prescription to get magnifiers. In addition to the Internet, the devices are readily available from a host of local retailers at amazingly low prices. Even sophisticated electronic magnifiers are sold by an aggressive sales force, often with no formal low vision training.
To the traditional low vision provider, this might seem like an affront to the practice, but it actually removes the low vision doctor from the role of vendor and allows a better focus on specialized refraction, prism evaluation, visual function, rehabilitation, and the coordination and management of the pathology with other ophthalmic subspecialists. This also lowers the barrier of entry to the primary care optometrist to provide basic low vision care.
Medical, surgical treatment is improved
Another major change has been the successful medical and surgical treatment of ocular pathology. Today’s cataract surgery cleanly eliminates the major source of blur and glare while leaving the cornea with regular astigmatism and little trauma. The treatment of wet age-related macular degeneration with various anti-VEGF agents has vastly improved the visual outcome of patients who suffer from this and other vascular problems. These problems previously led to major vision loss only manageable by the most patient and persistent low vision clinician in a specialized clinic.
That being said, patients with AMD and other disorders that result in reduced vision still require careful and diligent optometric care. They do not respond well to the autorefractor and the latest progressive bifocal. They require a skilled evaluation with retinoscopy, manual keratometry and a trial frame refraction.
Even small central scotomas from dry AMD or surface wrinkle retinopathy can cause a change in the visual angle that renders the phoropter and the autorefractor useless. A good primary care refractionist, however, will find that most of these patients are quite responsive to manual techniques and will enjoy a marked improvement in best corrected visual acuity.
If a low vision patient can be improved to 20/60 or better, he or she is an excellent candidate for a high add in a flat top design. By testing with these lenses in a trial frame at the correct focal length and direct lighting, the optometrist will often find that these patients are able to fluently read standard size print. They do not require rehabilitation or referral for specialized services and can be managed in the primary care setting.
It is critical, however, that the optometrist evaluates the pathology and works closely with the other treating subspecialists to provide the ongoing care. The functional visual result must be shared with the other providers and re-evaluated at each visit so the treatment plan can be constantly adjusted and refined.
Challenges with elderly dry AMD patients
A unique situation is arising for patients who suffer from dry AMD, and especially choroidal sclerosis. As these patients are now routinely living well into their ninth decade, the visual deficit continues to expand, causing a large ring scotoma and small central island of vision. These patients have an inverse response to magnification and need lower magnification and lower-powered adds. They find that they can read the text of the newspaper but cannot read the headlines. They respond poorly to refractions at 10 feet but do much better at 20 feet.
One surprising element found in caring for these patients is a dramatic response to increased light. After an excellent response to distance testing even to levels of 20/40 vision, they often cannot read any characters on the near chart. Introducing various add powers are of no help and often make things worse.
However, when handed a high-intensity flashlight, they find that they can read the finest print with no add. The aid of choice is not a magnifier, but a flash light. Although this is an extreme example, the primary care optometrist must always remember to test under different lighting before designing the final treatment plan.
Patient education, counseling critical
Perhaps the most critical aspect of providing low vision care is related to patient education and counseling. In spite of the long-term treatment of ocular pathology, ophthalmic subspecialists seldom spend the time to explain the pathology in terms that the patient can understand and rarely discuss the effects of the pathology on visual outcome and day-to-day living tasks.
This is the unique strength of the optometrist. We have a vast experience of explaining the complexities of myopia, hyperopia, astigmatism and presbyopia to patients and helping them adapt to day-to-day life with these problems. It is not a big stretch for the primary care optometrist to use those same communication skills to explain AMD, provide the proper optics and teach patients how to adapt and adjust their life to these problems.
Far too many primary care optometrists feel their job is complete once they make a diagnosis of AMD or other permanent sight loss problem and then make the correct referral to a retina doctor, low vision clinic or other subspecialist. They are then quick to remove themselves from the patient’s care. More discouragingly, many redefine their role as the “local optician,” filling the eyeglass prescriptions of the subspecialist ophthalmic tech or the low vision clinic.
Instead, this is the time when you need to “step up.” Take a good look at the pathology and provide the basic low vision care as defined here or, at the very least, get involved and help counsel, advise and assist your patient in learning to cope with a difficult, life altering problem in the area of your expertise: vision.
- Scott A. Edmonds, OD, FAAO, is co-director of the Low Vision/Contact Lens Service at Wills Eye Institute in Philadelphia. He can be reached at Suite 1010 840 Walnut St., Philadelphia, PA 19107; (484) 326-9017; scottaed@aol.com. www.edmondsgroup.com.