At the 2026 meeting of the American Academy of Optometry, Carlos Grandela, OD, FAAO, shared his experience as a low vision optometrist and the lessons he learned in building a low vision private practice. “I think this presentation is important for new doctors and optometry students because there is a pervasive myth that low vision cannot be a lucrative career,” he said. “But my goal is to help paint a realistic picture of low vision private practice by sharing both my triumphs and my mistakes. If aspiring optometrists can understand this, I hope more of them will become interested in low vision as a career.”

The Importance of Timing

One of the biggest lessons Dr. Grandela said he learned from his experience is the importance of timing. “When I purchased my practice in 2019, our focus was on expanding services across the state and hiring additional doctors. However, I've learned that refining our own process was much more important than expanding. By adding an exam technician, I can now see more patients alone than I did with a second full-time doctor,” he said.

Dr. Grandela added that hiring a second doctor too early led to running out of patients within the first year, losing the associate doctor, and nearly losing his practice. He said the failure to budget plan also resulted in lost sales due to lack of physical inventory.

Among the triumphs Dr. Grandela noted wasconverting the practice to newer systems, including a new electronic health record, new accounting systems, and adding texting services and an online sales platform through the practice’s website.

Spreading Awareness About Low Vision Services

Dr. Grandela said partnering with local government and nonprofit programs can provide significant revenue and support patients who cannot afford assistive technology or custom optical products out of pocket. He said his practice did this by establishing satellite clinics in surrounding regions through partnerships with local ophthalmology in Prescott, Arizona; medical optometry in Salt Lake City; state agencies with the School for the Deaf and the Blind in Tucson, Arizona; and nonprofits with the Foundation for Blind Children in Phoenix.

Creating a Financial Plan

Dr. Grandela then discussed revenue generation, expenses, and how to create a plan to start a new practice or expand an existing one.

“A savvy doctor can generate good revenue by billing higher code levels and by retail sales of devices and specialty glasses,” he explained. “I advise a slow approach to opening low vision services either cold or with an existing practice; start with 1 or 2 days a month that are dedicated to that service. It will give you an opening to start gathering referrals.”

He also advised scaling the clinic up slowly over time to match existing demand for low vision services. “Doctors need a source of financial stability while the clinic works up to full-time patient numbers,” he said. “This could be a loan for a cold start, working at a second office, or working in a second department until the low vision clinic is ready for a full schedule.”

Dr. Grandela added that doctors can start with very few staff and billing time-based exams but may want to scale up with opticians and exam technicians who are trained in low-vision devices. “This is how we can continue to grow after filling the clinic schedule,” he said. “Doctors should consider hiring additional providers like occupational therapists for continued training with devices, assistive technology evaluations, and home evaluations.”

Coding and Billing: Time vs MDM

Dr. Grandela also explained the differences between coding and billing time-based vs medical decision-making strategies (MDM). “When you code on time spent with a patient, you are maximizing revenue generated per patient encounter at the cost of fewer encounters per day,” he said. “Although many eye doctors may only bill a Level 5 New Patient exam very rarely, that can be a common occurrence in low vision. As long as the doctor spends 60 minutes working on that encounter, it's a Level 5.”

He continued, “Coding with MDM, however, can incentivize more exams in a day because technicians can perform the bulk of the eye exam testing while the provider finalizes the diagnosis, prescriptions, and the treatment plan. This means multiple exams could be billed in the same frame as a single time-based exam, but requires a higher number of staff.”

Tips for Picking the Appropriate Tools

“Finding the appropriate tool depends on the patient’s specific visual goals,” Dr. Grandela explained. “Low vision devices can be divided into categories like optical magnifiers, video magnifiers, and assistive technology like text-to-speech readers. These devices can further be divided by the visual distance of the activity, if devices must be hands-free for the activity, and if the devices are portable.”

Dr. Grandela said a good example of this is driving. “A patient who is struggling to meet their DMV vision requirements may be able to use a bioptic telescope lens system which will magnify at a distance, is mounted onto glasses to be hands-free, and is portable.”

Hurdles for Low Vision Retail

Dr. Grandela emphasized that one of the biggest hurdles for low vision retail is the public's lack of awareness about products and resources. “We are dealing mostly with vulnerable populations, such as the elderly, young children, or people on disability services,” he said. “Our patients often arrive at the clinic having purchased products and devices sold over-the-counter without having received any guidance on appropriate magnification or an opportunity to see competing products. Our role as a clinician is to provide an unbiased evaluation of vision and help the patient understand the tools and resources available—such as free services like Be My Eyes, the iOS Magnifier, or Windows screen magnification. OM