Although low vision may not seem as glamorous as specialty contacts or get as much press as dry eye, it can be a great addition to any practice. Here are ten ways to get started!
1) Patient Recruitment
Internal: Forget the ideology that someone needs to be severely impaired to benefit from low vision services. Those with mild to moderate vision loss have the most options available to them.
External: I’m sure you already have a go-to retinal and glaucoma specialist and general ophthalmologist that you refer to when needed. Let these docs know that they can now refer their patients in need of low vision rehab to you.
2) Determine Fees
It is up to you to determine how much to charge for your services and decide if you will accept insurance. If you plan to bill insurance, you need to be a provider on medical panels.
3) Purchase Exam Equipment
Providing low vision services will likely require an investment in some additional equipment.
You can keep things basic. I recommend starting with:
Depending on your current setup, you may already have all or most of this equipment. Although one could argue an additional distance chart may be unnecessary with the capabilities of today’s electronic VA systems, I think a Feinbloom Chart is a nice addition. This chart allows you to measure acuities at different distances and positions.
4) Invest in Low Vision Aids
It is ideal if you can have low vision products in your office that the patient can demo and purchase. The two major players in low vision aids are Eschenbach and Optelec. Both provide high quality devices that can only be purchased through an eyecare professional.
The vendor may also carry some of the exam equipment listed above. Both offer “starter” kits that include various low vision aids. Look over pricing and decide whether or not it would be better to buy a kit or pieces individually.
These are my recommendations for a basic starter kit:
Although this kit is geared more towards mild-moderate visual impairment, you can always order these devices in higher powers once you have an established account.
5) Set Your Schedule Accordingly
While I don’t believe in the philosophy low vision=slow vision, I am very aware that an exam with an 88-year-old cannot be completed in the same time as one for an 18-year-old.
6) Brush Up on Low Vision Formulas
3 Concepts to Review:
Just Noticeable Difference (JND): The amount of lens change you need to show your patient in order for he/she to perceive a change. Convert patients' BVA at 20 ft to its 10 ft equivalent. Divide the 10 ft denominator by 100. The quotient is the patient’s JND. **Be sure to do this for each eye.
Example: BVA Distance 20/400 = 10/X | X=200 | 200/100=2 | JND=+/-2.00D
Determining Distance Magnification: Take denominator of patient’s acuity at 20 ft from better seeing eye and divide it by the goal acuity at 20 ft. The quotient is telescopic power necessary to achieve goal acuity. 20/40 is generally agreed upon as acuity necessary for seeing distance signs.
Example: BVA 20/200 Goal=20/40 | 200/40=5 | 5X Telescope needed
Determining Near Magnification: Although there are multiple ways to determine this, here is the way I think about it during my exam. Measure the patient’s near VA in M notation [numerator = working distance (cm), denominator = print size (M)]. Set up ratio to determine working distance for goal VA. Dioptric equivalent of goal working distance is the magnification needed. 1M is generally agreed upon as large print size.
Example: BVA Near .4/2M Goal=1M | .4/2M=X/1M | X=.2 | 100/20=5 | 5D Magnification needed
7) Know Legal Blindness and Driving Requirements
You will inevitably be asked about one or both of these topics; make sure you know the answer.
8) Be Aware of Community Resources
The focus of low vision rehabilitation is not only on how the patient can better use his/her vision but also on how the patient can better cope with his/her impairment. It is unlikely that you can meet all of these needs.
Be familiar with services that already exist in your community. Things to think about:
- Is there a low vision support group?
- Does your local library offer e-readers or electronic equipment for loan?
- Is there a nearby rehab facility with occupational services geared towards vision?
9) Refresh your Knowledge of Commonly Encountered Ocular Diseases
Starting up, the conditions your low vision patients are most likely to have are glaucoma and macular degeneration.
The hour you have set aside for your low vision exam is a lot more time than what was set aside for their visit at the specialist. Use this time to your advantage and educate your patient. Make sure the patient understands his condition and its impact on the eyes and visual system. Emphasize why they should continue to see their specialist even though their eyesight is impaired.
The patient will not only appreciate your efforts, but it will also help reinforce realistic expectations for the visit.
10) Set Realistic Expectations for Exam Outcomes
Although this is number 10, this is really the most important. You need to be honest with your patient about what you can achieve. I always begin my exam by telling the patient that I am working with his/her specialist in order to enhance his/her remaining sight. I stress that I cannot bring back what is lost and that there are certain limitations given the current impairment. However, this does not mean that there is no solution to the visual difficulties present, it just might not be what he/she was expecting.
This honesty builds trust and, therefore a better patient-doctor relationship.
