David Armstrong, OD, prescribes a variety of low vision lenses to his patients: Teresa Barber wears bioptic telescopic glasses, 3X full diameter; Arthur Stewart wears 2.2X bioptics; Joan Painter with E Scoop glasses. Laura Cunningham wears a 3X wide angle telescopic lens for her left eye; Brian McMillan wears bioptic 2.2X wide angle telescopic glasses
Photographs Courtesy of David Armstrong, OD, low vision optometry/virginialowvision.com
By David Armstrong, OD
Later the patient said, “The loss of independence is huge. You don’t realize how confined you are when you can’t drive, and you have to depend on somebody else. It’s quite depressing frankly. It’s wonderful to have that life back.”
Another patient told me “I wish I’d known about you and these glasses 15 years ago.” He had been losing vision for years from Stargardt Disease. When he was in his early 40s, he was no longer able to pass the DMV vision test and lost his license. Without a driver’s license, he had to retire from his work. Using the bioptic glasses that I prescribed has given him some independence back. He has been driving safely for three years.
A third patient, an 80-year-old widow, hires a driver each year to take her 60 miles to my office so I can certify that her vision still meets DMV requirements for a bioptic driver’s license. She feels fortunate to be able to drive a few miles close to home and worries that one day her vision will decrease, and she will lose that freedom.
For patients like these, the loss of independence can be devastating. Losing the ability to drive or read can result in isolation and depression. A Clinical Ophthalmology report from 2015 linking anxiety, depression and age-related macular degeneration stated that clinically significant depression can be found in one-third of visually impaired older adults. That’s twice as high as in normally sighted older adults.
Low vision affects a significant portion of the U.S. population. As The Vision Council’s 2015 Low Vision Report states, “Approximately one in 28 Americans age 40 and older are robbed of their sight by low vision, defined as visual impairments that are not correctable through surgery, pharmaceuticals, glasses or contact lenses.”
As the Baby Boomers age, low vision is rising sharply. The U.S. Centers for Disease Control and Prevention estimates that 1.8 million Americans age 50 and older are affected by age-related macular degeneration, and that number is expected to increase to 3 million by 2020.
According to the Clinical Ophthalmology report, “Traditional low vision rehabilitation (which includes care provided by low vision optometrists, occupational therapists, low vision specialists and other professionals with training in low vision rehabilitation) presents the best current treatment option to address these mental health problems in a rehabilitation context.”
Tonya Davison enjoys reading a Stephen King novel with her Clear Image microscopic glasses.
All optometrists should become familiar with low vision rehabilitation and either establish a referral relationship with a low vision optometrist or include low vision in the services that they provide. In addition to better serving the patient’s needs, low vision care can add an additional revenue source to a practice and create the opportunity for other doctors to refer their low vision patients.
The most common goals of low vision patients are to be able to continue reading and driving. Many also request help with viewing television screens, using a computer or recognizing the faces of family and friends. Low vision optometrists are prepared to help patients with these activities.
When planning to add low vision care to a practice, a doctor should consider the following factors.
Become up to date on what devices are available and learn how to prescribe them. This can be done by attending continuing education courses at optometric meetings or by taking courses online or in journals such as 20/20. You can contact the speakers and authors to inquire if they offer training and consulting to optometrists who wish to add low vision to their practices. “The Lighthouse Guild Clinician’s Guide to Low Vision Practice,” available from the Lighthouse Guild is a helpful resource.
Manufacturers of low vision glasses, magnifiers and electronic devices are a resource. They are very happy to provide information and training in the use of their products. Another option for low vision training is to seek out a low vision colleague who is willing to serve as a mentor.
LOW VISION TRIAL SET
A trial lens set including several low vision devices should be available for testing patients. A beginning set might include the following:
•Trial frame and trial lens set.
•Bioptic telescopes in trial rings.
•Full diameter telescope in trial rings.
•Plus lenses mounted in caps to fit the
full diameter telescope, modifying the
telescope for near vision.
•Microscopic lenses in trial rings.
•Several different powers of prismatic glasses.
•A selection of high-quality hand magnifiers.
•A handheld electronic magnifier with the option of several different powers.
•Low vision acuity charts for distance and near.
•Examples of good lighting for near testing and to be recommended to patients.
You may wish to add a desktop video magnifier (CCTV) to your menu of devices available to your patients. I recommend getting one that is easy to use, has a large screen and is portable.
It is also helpful to have examples of telescopic and microscopic glasses mounted in appropriate frames so the patients can see how they will look, and you will be able to evaluate frame measurements required by the patient.
Patients with low vision may come from your general practice, by referral from other doctors or by advertising directly to the patients. The Internet is a powerful tool to get the word out that you can help people with impaired vision. A dedicated website and active Facebook page can tell your story and describe how low vision glasses can help. The visually impaired person often does not use a computer, but their friends and family probably do. These people frequently search online and may find your information. They’ll notify their loved ones that you offer help to people with visual impairments.
Newspaper advertising can be effective also. Especially in smaller communities, many people are faithful readers of the local paper. Because frequency is important, this can be expensive. However, some state press associations will place small ads very economically.
Referrals from other optometrists or ophthalmologists require marketing directly to the doctors. Contact them often either by face-to-face visits, by mail or e-mail. Always send a follow-up report to a doctor when you’ve seen one of their patients. Let the doctor know how you have helped their patient. Be sure that both doctor and patient understand that you are not taking over their care. The patient remains with their primary eye doctor for ongoing care.
A well-written pamphlet with pictures of patients you’ve helped can be sent to referring doctors and others you are marketing to. Of course, be sure that patients have a pamphlet to share with friends who have similar problems.
The use of patient photos and success stories can make your ads and pamphlets more interesting and effective. You must obtain written permission from the patient before using their personal health information for marketing.
SCHEDULING THE LOW VISION EVALUATION
Low vision evaluations require more of the doctor’s time than routine eye health exams. Don’t try to fit these patients into a busy schedule of primary eyecare. Expect to spend an hour or more with each low vision evaluation. You may want to set aside a day or half day totally dedicated to low vision.
Before beginning the actual low vision evaluation, it is important to obtain a thorough case history. Useful information can be obtained from the patient’s primary eye doctor. Most doctors will comply if you request that they send the patient’s most recent office notes. Look for diagnoses, acuities, treatments, eyeglass prescriptions and treatment recommendations.
Question the patient about their remaining vision. Visual acuity is certainly important but it is also helpful to know how the vision loss affects the person’s daily life. Question them about which activities they would most like help with. Often they’ll tell you things that they’ve enjoyed and are no longer able to do. Most commonly they want help with reading and driving. Some have hobbies or crafts that they want to continue. Be sure to try to help them return to these important activities.
FEES, BILLING AND CODING
Like all professional services, the fees are based on your time, skill and knowledge. If you are billing insurance, you must determine proper codes for the services provided and the time spent. Most medical insurance does not cover refraction as part of the evaluation. That is billed directly to the patient. Since the complexity and time spent are much greater than a spectacle refraction, the modifier GY can be added to code 92015.
Low vision glasses and other devices have higher fees than ordinary glasses. When the patient understands the complexity of these aides and sees the benefit, the fee will become less of an issue. Since insurance rarely pays for these glasses, it may be helpful to offer a payment plan. There are several companies that will finance eyeglasses with no charge to the patient. The company withholds a few percent of the fee from the amount reimbursed to the practice.
Many patients request help to continue or return to driving. It is advisable to become familiar with bioptic driving regulations in your state. Most states allow low vision patients to drive while using bioptic telescopic glasses but the requirements and restrictions vary considerably among states. The regulations may be found on the state’s DMV website or by making a call to the DMV medical review board. We optometrists have an obligation to discuss driver safety with the patient, but the decision as to whether they are approved a license is up to the DMV based on the level of remaining vision and other factors.
LOW VISION REFERRAL
If you don’t wish to add low vision care to your practice, you can establish a referral relationship with a low vision optometrist. The low vision doctor will appreciate receiving information about the patient. Send a copy of recent office notes or a letter including diagnosis, acuities, prognosis and any treatment that the person has received. Tell the doctor if the vision loss is stable or worsening.
There are a large and growing number of people with low vision who need our help. Their independence and quality of life is threatened. They have nowhere to turn but to optometry, so consider adding low vision care to your practice. You will find it personally rewarding and professionally satisfying.
Whether you provide low vision care or refer, your patients will be grateful for your efforts to help them return to favorite activities that have become impossible. They will thank you for addressing their needs and allowing them to maintain some independence. They want to continue an active, full life and will appreciate your help.■
David Armstrong, OD, is a low vision optometrist practicing in Virginia. He has offices in Roanoke, Harrisonburg and Wytheville, Va.