Article Date: 11/1/2004

low vision
Helping Patients Cope with Vision Loss
Low vision therapy remains our best bet in managing many of our visually challenged patients.
BY ELMER H. EGER, O.D., F.A.A.O., Trumansburg, N.Y.

In today's world, many ocular conditions such as cataracts, glaucoma and high myopia can be treated successfully and quickly thanks to medical and surgical advances. But for conditions such as age-related macular degeneration (AMD), diabetic retinopathy and retinitis pigmentosa, which affect millions of people, there is no such miracle cure.

It is in this area that low vision therapy becomes so valuable. It may not be the most convenient solution, but currently it is the most effective solution at our disposal. That's why knowledgeable counseling is so essential in persuading our patients to consider this option more readily.

Look no further

Low vision therapy is a highly developed, universally recognized system of applying magnification, contrast sensitivity and training (optically or electronically, and even pharmaceutically) to restore reading ability and to return partially sighted victims to the workplace -- in essence, to achieve some degree of rehabilitation. Low vision therapy is a holding therapy -- sustaining skills and function until we find a better alternative.

Expect denial

Here's a sample conversation that's probably familiar to you:

Doctor: "Mr. Smith, I have just finished examining you, and I have some bad news: You have new hemorrhages in the back of your eyes denoting wet macular degeneration. Every place that is bleeding blocks your vision and I recommend laser treatments."

Mr. Smith: "Fine, doctor. Will this give me back my sight?"

Doctor: "No, it will stop the bleeding and may keep you from getting worse. But it won't restore your sight. (You should be aware that every place the laser strikes destroys some retinal tissue and leaves a blind spot. In other words, if we laser in 20 places we create 20 blind spots. That's why we only laser those bad blood vessels but never the macula [center of sight])."

Mr. Smith: "But doctor, surely my sight will get better."

Doctor: "Probably not."

Mr. Smith: "Can you suggest another specialist who can help with this macular degeneration?"

Doctor: "Mr. Smith, listen carefully. At this time there is no recognized cure for macular or other retinal degeneration. They're working on it. Now, Miss Jones will schedule you for laser therapy."

So Mr. Smith heads home in a state of shock and utter confusion. He doesn't even remember the doctor saying, "No more driving for you." No wonder! By definition shock is defined as "a. something that jars the mind or emotions as if with a violent, unexpected blow; b. the disturbance of function, equilibrium, or mental faculties caused by such a blow; violent agitation."

Eventually, Mr. Smith has a happy but misguided thought: "This doctor must be mistaken; I know my vision's worse, but maybe he missed the diagnosis." (This is a reasonable thought because no one explained the condition to him in lay language and even if they did, he's in a state of shock -- he can't remember.)

And so off he goes on a merry-go-round of eye doctors, hoping for a more acceptable diagnosis and prognosis or miracle cure. But everywhere he goes he gets approximately the same story. Oh, one doctor suggests vitamins -- not as a cure, but to retard further damage. Perhaps another suggests low vision therapy, which he explains as "The optometrist can fit you with special lenses or give you a magnifier so you can read."

"Will I be able to drive?"

"Not usually."

Mr. Smith mulls this over, concluding, "I don't need a damn magnifier -- somewhere there must be a cure for this. Hell, they can replace a knee, a hip or even a heart. Surely someone can transplant an eye or a retina or whatever."

We know that this isn't an isolated instance; it happens hundreds, perhaps thousands of times every day in offices throughout the civilized, quick-fix world.

Running out of rope

Next, with the help of his grandson, our patient gets on the Internet and learns that there is such a condition as macular degeneration and there are vague references to a retina transplant in Sweden or the Netherlands. But further investigation shows that the transplants haven't worked either in humans or in mice. However, he, his family and even his doctor keep looking for a miracle therapy, not realizing that they've bypassed low vision therapy, a system of treatment that has restored reading ability, the ability to recognize faces and the ability to go on with occupations for hundreds of thousands of persons. In exceptional instances, low vision therapy has allowed some patients even to drive again.

A problem that's here to stay

Recent recognition by the National Eye Institute (NEI) and other agencies attest to the importance of low vision therapy in dramatically reducing the suffering and staggering costs of today's irreversible eye diseases. The NEI estimates that the cost to society in decreased productivity and the onset of other diseases with resultant clinical depression (and its physical and emotional consequences) is $68 billion annually. This burden to the U.S. economy is expected to increase dramatically, primarily because of an aging population and the growing prevalence of diseases such as diabetes that result in vision loss.

It's just human nature

In further assessing the importance of low vision therapy in the scheme of irreversible vision loss, we can't overlook people's predilection for "miracle cures." With news of advances such as lens implants and cornea transplants, the public and even their doctors have come to expect, and are waiting for, the "quick fix."

This patient mentality reinforces the necessity for incisive and compassionate counseling. It's essential that we're knowledgeable about the ever-growing number of trials and therapies. We must know as much as possible about their potential so we can best advise those desperately in need of guidance.

Be a step ahead of them

Hopefully now you see why it's vital that primary care optometrists both provide counsel to their patients about exotic cures and emphasize the value of low vision therapy -- not just for its current benefits, but for the benefits of maintaining the vitality of ocular and neurologic skills so that when the miracle cure does arrive, those functions won't have deteriorated to the point that negates treatment. "Use it or lose it" was never more relevant.

For the low vision specialist, a firm understanding of a patient's mindset is the key to success for both patient and doctor. If you can also motivate, energize and counsel patients, then the results can prove rewarding for your patients and for your practice.

 

Therapies Waiting in the Pipeline

Here's a sample of some therapies under research that may some day serve as an alternative to low vision therapy. Just let your patients know that these break-throughs are not around the corner. These therapies may be years away from becoming available.

Anti-vascular endothelium growth factor. Pegaptanib sodium injection (Macugen, Eyetech Pharmaceuticals) is a pharmaceutical approach to deterring the neovascularization in wet macular degeneration and in other maculopathies. A practitioner introduces it into the eye via intravitreal injection. Early studies show stabilization and even improvement in a large number of eyes. However, the treatment remains investigational and isn't recommended for clinical use at this time.

Steroids. These have long been known for their inhibition of inflammatory response. However, corticosteroids, including triamcinolone acetonide and anecortave acetate, have now been shown to be valuable anti-angiogenic agents.

Macular translocation. The surgical attempt to relocate the macula away from the area of subfoveal neovascularization. Several techniques are under study, but this remains an invasive, experimental procedure and to date hasn't received acceptance as an effective treatment modality.

Retinal pigment epithelium (RPE) transplantation. Attempts throughout the world to substitute healthy RPE cells for damaged RPE cells are the nearest thing to the much-dreamed-of retina transplant. Scientists have used both mature RPE and fetal cells. While the surgical techniques appear feasible, problems with this treatment modality are many. Only rarely have good levels of vision been attained following RPE transplantation and clinical acceptance hasn't been achieved.

Preventative therapies. In light of the Age-Related Eye Disease Study report, we finally have an authoritative voice validating vitamin and supplement therapy as a deterrent to deterioration in certain stages of wet macular degeneration.

 

Facing the Facts

The following facts point to the need for low vision therapy. They come from the National Alliance for Eye and Vision Research's Web site (www.eyeresearch.org).

Retinitis pigmentosa is the most common cause of inherited blindness and affects 100,000 Americans.

Diabetic retinopathy is the leading cause of blindness for Americans under 60, accounting for 12% of new cases of blindness each year (24,000 people). Diabetics are 25 times more at risk for blindness than is the general population.

Age-related macular degeneration is the most common cause of severe visual impairment in older Americans. Approximately 1.7 million have decreased vision and 100,000 are blind from the disease.

(Author's note: According to estimates in other demographic studies, this figure is a gross under-estimation. The figures range from about two million to 30 million, depending on the definition of impairment.)

Experts estimate that more than one million Americans are legally blind.

More than 12 million Americans suffer from some form of irreversible visual impairment.

 

 

Dr. Eger has been a practitioner of low vision rehabilitation, vision training and orthoptics for more than 40 years. He has been a fellow of the American Academy of Optometry since 1954 and was honored in 1996 with a Life Fellowship in that body. You can reach him at (607) 387-5028.

 



Optometric Management, Issue: November 2004