How to Provide Low Vision Services
Your Opportunity to Care for a Growing Population
When you use these steps to help patients who have low vision, chances are you will grow your practice exponentially.
NICOLE PATTERSON, O.D., F.A.A.O., FT. LAUDERDALE, FLA.
A tremendous opportunity exists for optometrists to help low vision individuals. Specifically, data show persons age 65 years or older — the population primarily affected by low vision — numbered 39.6 million in 2009, or 12.9% of the U.S. population. By 2030, about 72.1 million people age 65 and older are expected to comprise 19% of the population.1
Here, I provide specific steps on how to incorporate this specialty into your practice.
Market your services.
Make sure your community is aware of the services you provide. Start by networking with retina specialists who have many patients who can benefit from your low vision services. Give retina doctors your brochures or referral forms, and, when you see a patient, send a letter back to his/her doctor that reminds the doctor of the services you provide. This also improves patient care.
Additionally, senior and assisted living centers often have people in need of low vision services. Many are happy to have a doctor present an educational program and speak about low vision services. When contacting a center, ask to speak with the director of programs. That person is usually responsible for scheduling guest speakers.
Sample Low Vision Starter Kit
• Half-eye readers 4D, 6D*, 8D, 10D, 12D*
• Clip on adds +1.50 to +6.00
• Hand-held magnifiers (8D, 12D, 16D*, 20D, 24D*)
• Stand (8D, 12D, 16D*, 20D, 24D*)
• Dome magnifier (65mm)
• Pocket magnifiers
• Stand magnifier that permits writing*
• Monoculars (3x*, 4x, 5x*, 6x, 7x*, 8x)
• TV glasses
• Filter/sunglasses (amber/orange, yellow, grey, plum)*
*Advisable but could be omitted in initial starter kit
Request items causing visual difficulties.
For all patients who have called to schedule a low vision exam, have your receptionist tell them to bring to the appointment items that are causing them visual problems, such as crossword puzzles. (It is also advisable to have samples of these items in your office, should the patient forget).
Schedule two separate evaluations.
Keep in mind that a low vision evaluation requires more time than a primary care evaluation — likely 30 to 60 minutes. Breaking the evaluation into multiple appointments is often beneficial, as low vision patients tire easily.
Obtain the case history, trial frame refraction and ocular health history during the first appointment, and then perform a device evaluation during the second appointment (more on this below). The second appointment should also include a review of goals from the first appointment to ensure they have been accomplished.
Modify your exam for low vision patients.
The low vision evaluation is similar to a primary care exam, with a few modifications. (See “Sample Low Vision Starter Kit,” page 32.)
► History. Obtain a detailed case history to determine the activities that cause difficulty, such as paying bills, preparing meals and participating in hobbies. Case history must be obtained verbally, as these patients may not have the ability to read forms.
► Acuities. Test these patients’ acuities with a continuous text near card. (Standard near cards measure whether a patient can read black, equally spaced capital letters on a bright white background, which is likely not a good indicator of how a patient performs reading a newspaper, bill or label).
Also, utilize computerized charts that allow for the changing of optotypes and contrast. These include the ETDRS chart with a lightbox and multiple optotypes at the 20/400 level, so you can move the chart closer for patients who have reduced acuity.
Additionally, the Feinbloom chart is beneficial, as it can be moved in space to help a patient locate an eccentric viewing position. (Snellen projector charts are not ideal, as most patients are aware the first letter on the chart is a big E, and only having that one optotype at the 20/400 level and two at the 20/200 level makes it challenging to determine improvement with lenses.
► Retinoscopy. In lieu of or in addition to autorefraction, perform retinoscopy. This is done because some low vision patients have nystagmus, which may skew autorefraction results.
► Trial-frame refraction. Low vision patients often have difficulty detecting differences between lenses that are separated in power by a quarter of a diopter. If a patient has a “just noticeable difference” of two diopters, it is much easier to display a −1.00D and +1.00D loose lens than click through eight lenses in the phoropter. In addition, when a patient wears a trial frame, the lenses move with the patient, allowing you to observe the eyes. This is important, as many patients with central scotomas eccentrically view and have head turns.
► Contrast acuity testing. The MARS chart is a near contrast acuity test that can be performed quickly and easily. For this test, the patient reads a sentence, and you record how well the patient read — just like measuring distance acuity. For the distance chart, the patient reads the letters off the chart and you record what that patient reads. Other contrast tests include the Colenbrander low vision chart.
Obtain devices for demonstration.
If the patient is not able to meet his/her desired goals after completion of the trial frame refraction, low vision devices should be demonstrated.
► Clip-on additions, half-eye reading glasses and microscopes. These devices are a good place to begin, as they provide hands-free near magnification. The downside: They often require a short working distance, which is not suitable for all patients.
► Hand-held magnifiers. Both illuminated and non-illuminated are relatively affordable options. Instruct patients to wear a distance prescription when using a hand-held magnifier. If a patient looks through a bifocal, the effective power of the magnifier is decreased. Hand-held magnifiers require dexterity as well, so take that into consideration when prescribing magnifiers.
► Stand magnifiers. Like hand-held magnifiers, these are available in many shapes and sizes. When patients use stand magnifiers they must use their accommodative system or a bifocal addition.
► Electronic devices. Additionally, tablets and e-readers are beneficial for the low vision population, as font size can be easily adjusted on most devices. Also, devices such as CCTVs and portable handheld electronic devices are rapidly evolving, so create a relationship with your local representatives to keep abreast of the changes.
► Filters. Don’t overlook filters, as they often reduce glare while improving contrast and patient comfort. Yellow, orange, amber and plum are popular colors for the low vision population.
You may also wish to have an inventory of devices to dispense to patients, which can be ordered as needed. This is dependent on low vision patient volume and practice space.
As with all technology, be sure to stay informed about new low vision devices, and many optometry meetings provide this opportunity. Several of these meetings provide quality low vision continuing education, and most low vision vendors display new devices in optometry meeting exhibit halls.
Determine proper billing.
Billing and reimbursement varies from state to state, so familiarize yourself with your state’s rules. One place to obtain this information is your state optometric association. When providing low vision evaluations, you spend extra time with that patient and should be reimbursed accordingly. Many low vision practitioners bill E&M codes factoring in the time spent with each patient. Prolonged service code (99354) may also be utilized in some areas.
Additionally, many optometrists bill a higher amount for refraction (92015) on low vision patients vs. standard patients because a trial-frame refraction requires more time than a phoropter refraction.
Reap the benefits.
Not only does integrating low vision services benefit these patients, but it also grows your practice. As you help one individual with vision loss, that person may go to the senior center and tell another. For example, you may help a grandmother purchase a magnifier who also is responsible for taking her grandchildren to eye exams.
The goodwill you create by helping a patient who has a low vision need can grow your practice exponentially. OM
Dr. Patterson is an assistant professor at Nova Southeastern University College of Optometry. She also completed a Low Vision Rehabilitation Residency at Southern College of Optometry. E-mail her at firstname.lastname@example.org, or send comments to email@example.com.
Optometric Management, Volume: 48 , Issue: August 2013, page(s): 32 - 37