Article

MANAGING LOW VISON IN PRIVATE PRACTICE

Successful practices for serving low vision patients

You may have encountered the four myths of offering low vision services in private practice: It’s too difficult; it takes too much time; patients are never happy; there’s no business benefits.

In my experience, this hasn’t been the case. In fact, I invented The Richard Shuldiner, O.D./William Feinbloom, O.D. Philosophy & Methods for Providing Low Vision Care, and I have since developed and implemented a training program to help optometrists establish successful low-vision practices. [We also created an organization called The International Academy of Low Vision Specialists (www.IALVS.org ).]

I have found certain areas of low vision practice where optometrists could use what I have learned; here I’ll share my insights.

Dr. Shuldiner assists a patient with her low vision aid.
Photos courtesy of Dr. Richard Shuldiner

GET ON THE TELEPHONE

To serve patients, you’ll need to get the phone to ring. I found success not in referrals from other eye care professionals, but in marketing directly to the public. Specifically, I advertise my low vision services in local weekly and/or monthly newspapers and on the internet.

Once the phone rings, I think you, the doctor, should talk to the patient. Yes, you can teach a staff person how to handle the phone. But, the doctor receives the most powerful listening from the patient and the patient’s family.

The phone conversation should be less than five minutes and is all about managing the expectations of the patient. Here is the template for the call:

Get information: The medical cause of the vision loss is necessary to know.

Additionally, find out the approximate level of vision by asking questions about what the patient can and cannot see/do. For example: “Can you read newsprint?” If not, “How about large print?”

Next, identify the patient’s “wish” list. Low vision care is about doing, not seeing. Your job is to get the patient doing what he wants to do.

During the phone conversation, listen to his list, and compare it to the approximate level of vision he shared with you, and determine what is reasonable.

For example, if the patient hasn’t read anything in two years, can’t read headlines in the newspaper — even with a magnifier — you can predict the patient will probably not be reading the stock market pages after seeing you. On the other hand, if the patient says he can read newsprint with a magnifier, then yes, you probably can get him reading small print with glasses.

If I determine that I cannot help this patient reach his goals, there are a few things I try. I will sometimes say, “I understand how important it is for you to drive (read, write, etc.) but, realistically, I don’t think we are going to be successful. I know it’s very upsetting to hear, but it will be more upsetting if I give you false hope. Why don’t we consider other, more reasonable, goals. I do think I can help you see your TV better.” If I think there is no hope of low-vision tools helping, I gently suggest the patient call his department of rehabilitation or other agencies for the visually impaired. I will not offer an appointment if I don’t think I can succeed.

Give information: Now, manage expectations. Let the patient know what you think you can and can’t do. Use the information in the “Get Information” part to make your predictions.

Next, tell the patient how long the exam is and what you will and won’t do during the exam. I tell the patient this:

“The exam will take one hour. I will determine exactly how much vision you have and where it is. I will then show you low vision glasses and other low vision devices. But, you will know exactly what they do, how they will enable you to see, what they look like and how they work. There will be no surprises.”

The patient also must know potential costs. I say: “In addition to the cost of the exam, you can expect that low vision glasses and devices can cost from a few hundred to a few thousand dollars. You may need more than one device or pair of glasses, but you will decide once you see for yourself. Low vision glasses and devices are not covered by insurance.”

Then, make the appointment. Tell the patient to bring the following items:

  • All glasses
  • All magnifiers
  • A bottle of any eye vitamins being taken
  • Reading or other materials to see/work with better.

I have had patients bring art work, hand work, such as knitting/sewing, large print bibles and stock market pages, among other items.

A low vision patient paints with device assistance.

PREPARE FOR THE EXAM

Set aside a specific time in your week for low vision exams. The benefits of this: You will have all your low vision equipment out and ready to work and you will be in the appropriate mind-set. (It’s very hard to switch your mind from low vision to contact lenses to disease diagnosis, etc.) I would also recommend instructing staff that the exam length can be unpredictable and not to interrupt the appointment unless absolutely necessary. Also, you may want to have staff members observe the exam for learning purposes.

Set up your exam room for low vision. Get your medical equipment out of the way, and get all your low vision testing equipment and devices out on the counter and ready for demonstration.

Train your staff on how to handle low vision patients. Remember, these patients can’t see well! As a result, one of the items you should train staff members on is to not to ask these patients to fill out paperwork. Instead, instruct them to sit with these patients privately to complete any necessary paperwork. For privacy, this space should not be in the waiting room, perhaps in a contact lens training room. Not the exam room either because observation is critical to access the patient’s mobility and independence, body movements, peripheral awareness and any physical limitations that might be present in getting to the exam room and sitting.

ADMINISTER THE EXAM

Although many low vision experts suggest a two-hour exam, I use a 12-Step Low Vision Exam that takes one hour. The steps are as follows, but a full explanation is not possible in this article.

  1. Create relationship
  2. Opening statements
  3. Case history in less than two minutes
  4. Review the patient’s wish list
  5. Distance acuity and refraction
  6. Near acuity
  7. Stop and talk one: Discuss what is known so far
  8. Near help
  9. Distance help
  10. Intermediate distance help
  11. Stop and talk two: Summarize how you think you can help
  12. Selling help: Handle patient concerns about money, cosmetics, adaptation and the future.

USE APPROPRIATE EQUIPMENT

You need to get an accurate acuity. Therefore, I advise using a handheld number chart. This allows me to move to any distance, as well as move the chart in any direction to find the patient’s best retinal locus. Additionally, numbers are easier to read than letters, words, sentences and/or paragraphs.

Remember: We are not interested in improving the patients’ acuity on a chart. We are committed to helping the person do what he wants to do in real life.

In near testing, I’ll have these patients work with the real material they brought in. Again, I’m not so concerned about getting accurate test results; I’m concerned with real-world results.

PROVIDE LOW VISION SOLUTIONS

This is the crucial issue that makes or breaks a private practice low vision service. It must take care of the patient, and it must be financially viable.

In keeping with these necessary facts, I recommend the practice offer prescription low vision devices, as well as OTC magnifiers, electronic magnifiers and non-optical devices. Prescription low vision glasses give patients hands-free magnification, which most prefer over handheld magnifiers. However, prescription low vision glasses cannot solve every person’s vision requirements, nor can they work for every task on the patient’s wish list. Therefore, also offer handheld and stand magnifiers, as well as some electronic options available. Additionally, custom devices, such as telescopes, microscopes, filters and prismatics, in prescription form, with the best optics for the patient, differentiate your offerings from other outlets, making your practice a more attractive destination for the low vision patient.

A low vision patient drives with her device assistance.

MYTHS DEBUNKED

When managed correctly, low vision care in the private practice disproves the four myths of providing care. When using the telephone to manage expectations; when knowing that your job is to figure out how the patients can perform their real-world tasks with the vision they have; when having compassion for the vision loss patient, while giving him new hope is your goal; and when offering the highest quality, prescription-based optics, as well as other optical, electronic and non-optical devices, the result is patient satisfaction, professional satisfaction and business satisfaction. OM