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Low vision care should be provided by low vision specialists
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To the Editor:
The article, “Today’s primary care OD can provide low vision care more easily” (March 2012, page 16), by Scott A. Edmonds, OD, FAAO, brings up a number of concerns and comments that I shall address, calling on my 38 years of experience in providing low vision care.
A low vision optometrist understands how to deal with low vision patients. These patients possess unfulfilled expectations and may experience a shift in reality and a reduced ability to communicate.
Low vision patients want to be cured, even though they know they cannot. All low vision practitioners know that patients with relatively good acuities (20/40 to 20/70) are more upset and frustrated than those with profound vision loss.
This is why I feel Dr. Edmonds is off base in suggesting that more of this care move out of the specialty low vision clinic and back to the primary care optometrist.
Dr. Edmonds states that patients and their family members can evaluate optical options on the Internet. He is totally ignoring prescription low vision devices such as microscopes and telescopes that have the patient’s prescription built into the system. These options are not available on the Internet and are fabricated by a prescription laboratory. They are prescribed, fitted and evaluated by the doctor.
Medical and surgical treatment is, indeed, improved, as Dr. Edmonds stated. The anti-VEGF agents have increased the number of low vision patients who can be helped. Dr. Edmonds claims, “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,” and “these patients are able to fluently read standard size print.”
While that may be true, the low vision specialist understands that patient will still be unhappy. The patient needs a doctor who comprehends his or her emotional state and can exhibit patience and understanding while providing guidance and counseling. Telling the patient he or she should be happy with 20/60 vision, as I have often seen primary care providers do, is exactly the opposite of what the patient needs.
Dr. Edmonds correctly states that optometrists “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.” However, he incorrectly states: “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.” Teaching patients how to adapt to these problems is at the heart of being a low vision doctor.
Dr. Edmonds advises optometrists to “step up.” I agree that optometrists need to step up and start referring patients to low vision optometrists after all medical treatments have been exhausted.
Richard J. Shuldiner, OD, FAAO
Low Vision Diplomate, American Academy of Optometry
Founder, International Academy of Low Vision Specialists
Clinical director, Low Vision Optometry of Southern California
Dr. Edmonds responds:
I want to thank Dr. Shuldiner for taking the time to respond to my article on low vision and the primary care optometrist. Considering that we clearly have different views, it is good to debate issues that affect our profession in a public forum.
I, too, am a “low vision specialist” and also can call on more than 30 years of experience providing low vision care in one of the leading international eye institutes of the world. In my role, I also teach optometrists and ophthalmologists, which may have led me to have a much higher opinion of the general eye care provider, particularly the optometrist.
In reading Dr. Shuldiner’s views, I feel that he underestimates the modern primary care optometrist. Today’s optometrist is trained to deal with all aspects of ocular disease, even when these diseases result in permanent vision loss. They do understand how to deal with patients who have unfulfilled expectations and a reduced ability to communicate. This is not to say that the primary care optometrist is equipped to deal with all low vision patients, but I believe that they also know when to manage and when to refer.
Our low vision clinic at Wills Eye is very busy, with the advanced low vision care using microscopes, telescopes and, in particular, the low vision rehabilitation required to manage these clinical cases. With the baby boomers moving into the macular degeneration age group, those of us in busy low vision practices need to work more closely with our colleagues in primary care to effectively manage all of these patients.
I firmly believe that primary care optometrists are ready and willing to “step up” and work with low vision optometrists, specialty ophthalmologists and any of the providers of the health care system to provide the best care for their patients.
Scott A. Edmonds, OD, FAAO
Co-director, Low Vision/Contact Lens Service
Wills Eye Institute
Philadelphia