The Basics of Managing Low Vision Patients for the General Practitioner

Even while still in school, I couldn’t figure out why, when asked in class who liked low vision, I’d look around the room and be the only person raising a hand. It just didn’t make sense. But me trying to convince someone who is resolutely off-put by the idea of low vision exams is like my friend trying to convince me that I should listen to Taylor Swift: it just isn’t going to happen.

So this article isn’t necessarily meant to sway staunch non-believers into starting their own low vision specialty practice; it's meant to provide some helpful tips and resources to those who don’t want to completely ignore this growing population of patients.

If it happens to tilt some readers into pursuing this rewarding specialty further, all the better.

Even if you don’t want to specialize in low vision, you should be aware of any optometrists near you who do. Prepare yourself and your office with information about resources available to patients rather than immediately shuttling them off to a distant and possibly expensive specialist.

Sometimes just taking the time to talk to a patient and determining what it is they are having trouble with can help set you in the right direction for addressing a complaint.

I try to pin down specific tasks that are giving them difficulty.

The more specific the complaint, the better.

This can give us a big advantage if we know what the patient wants to achieve.

For example, I would approach a complaint of difficulty reading a newspaper while sitting at the kitchen table a bit differently than the complaint of trying to read a Kindle or iPad while lying in bed.

Take the patient trying to read on the tablet, for example.

Wouldn’t it be easier for you to explain in the office how they can zoom in on text or use applications to increase their functionality rather than send the patient to a potentially costly secondary exam with a specialist? Even if you don’t want to be a low vision specialist, you might be able to make a difference in someone’s life just by taking a few extra minutes to explain a device or offer tips to improve visual function.

There’s an additional advantage to taking the time to talk to your patient and define goals; you can determine whether the goals are realistic or not.

No, we can’t restore the eyes you had when you were 20 years old, but we can make it so you can still enjoy photographs of grandchildren or be able to cook for yourself in the kitchen. This also goes for patients with numerous different goals.

The patient with advanced macular degeneration who wants to be able to drive, read the stock reports in the newspaper, sign his bills, and see the television all with the same pair of glasses most likely needs some education that he may need different devices for different tasks and that it might take a few visits to sort out the different aids needed for each activity.

If you have an understanding of what is generally available on the market today, even if you yourself aren’t going to prescribe it, it can help when it comes to explaining to patients what is possible and what is to be expected.

Well, the short answer is there is a lot. But I don’t need to delve into the very specific products available such as talking watches or specialized kitchen tools. Instead, let’s focus on the products that provide the most bang for your buck and the general advantages and limitations of each.

For near-vision tasks such as reading, we have an assortment of various magnifiers, both digital and standard.

These can be generally divided into hand-held magnifiers and stand magnifiers.

Hand-held magnifiers can be great for their portability and ability to be used in nearly any environment (remember that patient earlier who liked to read in an armchair?).

However, for long-term reading, they can be tedious to continually hold, so I don’t recommend them for patients who want to spend hours reading novels or studying textbooks.

Also, any patient with a tremor or physical disability making it difficult to hold a device firmly and comfortably immediately contraindicates hand magnifiers.

Stand magnifiers can be great for those who can’t succeed with handheld magnifiers, but keep in mind that these need a flat surface, such as a desk, in order to establish the proper working distance. For that patient wanting to read in the armchair, consider recommending something like a lap desk.

So there comes a point when the amount of magnification needed for clarity may cause the material to be too large for fluid reading. Trying to read a novel one letter at a time can be quite frustrating.

Whenever I can, I try to aim for the lowest power magnifier that achieves relatively tolerable clarity and fluidity. Then I adjust other elements, such as lighting and near-vision spectacle power, in order to achieve further improvement.

For distance tasks, telescopes and binoculars are usually our most readily available devices.

Binoculars are better for stationary activities, such as watching a sporting event or television, when the user can place the device on and leave it on. Telescopes, both mounted and handheld varieties, are better for activities that require more flexibility and mobility.

One example that comes to mind is a patient wanting to order fast food and having difficulty reading the menu hanging behind the cashier. The patient can take out the telescope, use it to spot the menu, then take it away when needing to shift focus to nearer targets such as the cashier or a wallet.

Also, any time you are using a distance magnification device, you are inducing a scotoma in the area immediately surrounding the magnified target. The magnified image blocks the surrounding environment. For example, a patient wanting to use a mounted telescope for driving may spot a bicyclist crossing the road via the telescope. Still, the magnified image may block out the image of the woman jogging just behind the bicyclist.

Technology is quickly growing as a viable resource for low vision patients. More and more patients have smartphones and tablets, so if you are tech-savvy you may have an edge when it comes to recommending new apps or modifications to devices.

Apple has developed a number of features for both its iPhone and iPad, which come already loaded.

VoiceOver for iOS is a gesture-based program that allows a low vision person to navigate their Apple device even if he or she cannot see the screen. It can provide descriptions of everything on the screen, echo keyboard characters as they are typed, and work with all the built-in apps such as Safari, iTunes, and Mail. VoiceOver has many features and customizable settings that can make it a remarkably versatile resource for the visually impaired.

Speak Screen is another Apple feature that will read aloud text on the screen, such as email, texts, or even books. iOS devices also come with Dictation, which some of us may have used to compose texts while walking when we don’t have time to stop and peck out a message. For the visually impaired, this can be useful for composing emails, notes, or searching the web.

Finally, there’s Siri, Apple’s indefatigable virtual assistant, which can be used for more than telling jokes, as low vision populations can utilize it for sending messages, setting reminders, or even turning on and off other programs such as VoiceOver. Siri can also be used to Invert Colors, which for certain low vision patients, may give better contrast and a more comfortable viewing experience.

For devices running Windows, the Ease of Access menu can be used to adjust a number of computer settings for better accessibility for the visually impaired. It can be found by either selecting the button in the lower-left corner of the sign-in screen or, if already logged in, by pressing the Windows logo key+U.

Under the heading “Make the computer easier to see,” one can find many visual adjustments that can be beneficial. Under this category, one can make items on the screen bigger using a built-in magnifier, change to a high-contrast theme, enlarge text, make the cursor larger or make it blink, limit background images, turn on audio descriptions, or set up text-to-speech features.

There are a lot of options available within this menu, so for my patients, I try to figure out what they specifically want to achieve and then give them clear directions for how to adjust specific settings to optimize the display. Sometimes technology can be a bit overwhelming, even to a normally sighted individual, so I try to tailor the directions to be as concise as possible. However, once the patient has mastered the use of certain features, they might be interested in exploring other adjustments or programs that can further enhance their experience.

In addition to these pre-installed features, there are numerous apps available both for free and for purchase that have been designed specifically for those with visual impairment. Some are designed only for particular tasks, such as reading money, while others attempt to cover a broader range of use. Either way, there are resources abounding and just waiting to be found. If you have a technology-friendly patient with a precise task they are wanting to complete, consider doing a quick search of available applications to see if anything on the market might match his or her demand.