Optometrists today have many unique and different career paths available to them. In this article series, we’ll be engaging with optometrists from various common (and not-so-common) practice modalities to get a firsthand perspective on what optometry is like in their setting.
Today, we’re interviewing three optometrists who share their professional experiences of practicing in various low vision settings: Emily Hable, OD, MaryCarol Graby, OD, and Arie Wong, OD. Dr. Hable is an assistant clinical professor at Indiana University School of Optometry, and practices low vision with 4th-year students at the Indianapolis Eye Care Center. Dr. Graby works with the Association for the Blind and Visually Impaired in Rochester, New York, and Dr. Wong works with the Society for the Blind in Sacramento, California.
What advice would you offer to optometrists considering a career path in low vision?
Dr. Hable: Shadow a low vision optometrist in multiple settings and ask lots of questions. Just like with primary care, contact lenses, or pediatrics, low vision can look vastly different depending on the environment you are in, such as an academic setting, Veteran’s Affairs, OMD, corporate, or private practice. Each setting offers a variety of benefits and limitations. It is important to find the method that works best with your style.
Acknowledge that a low vision exam isn’t the same as a primary care exam. You need to be a problem solver and think on your feet to help the patient achieve their goals, while having a large amount of patience for the type of patients you encounter in a low vision setting. It isn’t just about making things bigger or adding light. And it’s not all “slow vision.” Each patient brings a rewarding learning experience.
Dr. Graby: I would highly suggest doing a Residency! In my opinion, we do not receive enough training in our schooling alone to practice low vision at the highest level. For instance, being comfortable prescribing spectacle-mounted telescopes, telemicroscopes, bioptic devices that patients can be trained to wear while driving, knowing the vast spectrum of CCTVs that are available etc.
Dr. Wong: Low vision is more than just glasses and magnifiers; it’s about helping your patients rediscover their independence. Vision is such an important sense and to lose it is akin to losing a loved one. Patients will have concerns that perhaps you, the optometrist, may not be able to address and that’s okay. If this happens though, you need to know who on your low vision rehabilitation team can address those specific issues. These may include occupational therapy, assistive technology, adaptive living skills, O/M instructor, psychologists, and independent living skills instructors. You have to be able to identify who else in your community is able to provide the services you can’t. If you don’t have a team at your hospital or clinic, research that information and have it readily available for your patients.
Is further training required for optometrists to successfully work in a low vision setting?
Dr. Hable: There are primary, secondary, and tertiary levels of low vision care.
No additional training is needed to do primary or secondary as long as you feel competent in the area upon graduation. You may need additional brushing up on the basics of low vision.
When it comes to tertiary low vision services, I would suggest a residency, additional training in CE courses, or partaking in low vision conferences to better understand the device options, services and resources available, as well as reviewing the optics needed to suggest the most appropriate devices for a particular patient’s needs. One device does not fit all.
Reach out to your local optometric chapters to seek out who provides low vision services and local ocular disease clinics to better understand the low vision needs of your local demographic.
Dr. Graby: With my previous response being said, I do feel that primary care optometrists have the skills to be able to practice basic low vision care, such as prescribing high adds, hand held magnifiers, and stand magnifiers. Even providing this level of care to those we see regularly with visual impairment can go a long way to improve a patient’s quality of life!
Dr. Wong: Experience matters the most with these patients. I don’t think you will not get enough exposure to these patients consistently without a residency. A residency streamlines these patients to you so you learn more efficiently and you will feel much more comfortable seeing these patients and addressing their concerns. 3rd and 4th year rotations vary a lot and many will not get enough low vision specific rotations to get you to that comfort level.
What is the most rewarding aspect of providing low vision services to patients?
Dr. Hable: I love being able to return a patient to an activity they previously thought had been lost to them. I love seeing a patient’s face light up when they realize with a particular device they can do what they love again. Being a part of that experience is so rewarding and it gives me hope that the hard work I am doing worth it for my patients.
Another immensely rewarding aspect of low vision services, is the ability to work closely with many other types of providers to help facilitate a patient’s needs.
Dr. Graby: Patients who struggle to perform their activities of daily living or hobbies they enjoy are so very grateful to those who take the time to listen to their difficulties and find ways to improve upon them and aid in maintaining their independence. I love to be able to help those who have heard from other providers that nothing can be done, they are always so appreciative and will come back again and again!
Dr. Wong: The most rewarding thing would be the feeling you get when you know you have made a difference. Some patients will give you this enormous smile when something works out beyond their expectations. So many individuals with low vision feel like they are on their own. Even if magnification devices and glasses don’t help, they are still so appreciative of other resources. You can feel the weight being lifted off their shoulders, even if all you do is point them in the right direction towards other members of your low vision rehab team. I had a recent patient tell us our clinic was “heaven” and we air hugged from 6 feet away (due to COVID).
What is the biggest challenge in low vision care?
Dr. Hable: Vision rehabilitation can be especially challenging when having to tell a patient a poor vision prognosis, such that it limits their job opportunities or driving status and independence. However the worst is when a patient cannot afford or doesn’t have the services to cover the cost of a particular device that could be life changing. When this occurs sometimes there are local services or grants available to help cover the cost of a device, but that is all on a case by case basis and at the discretion of that service.
Dr. Graby: One of the biggest challenges particularly in the setting in which I practice where we serve many who are financially challenged, is finding a way to get patients devices that are affordable. CCTV’s in particular can be extremely expensive, upwards of $2000 for desktop units, which at times may be the only device that can allow a patient to read fluently. It is necessary to be creative at times to find something that can be affordable. Encouraging people to donate devices that they or their loved ones no longer use can be very helpful to those in need who cannot afford new ones!
Dr. Wong: The biggest challenge is when patients are referred too late. Once their vision loss has advanced to the level of legally blind and/or functionally blind, it is hard to manage their expectations and their needs. After suffering with their vision loss alone for years or decades, they may become resistant to change regardless of how useful your recommendations may be. They tend to ask for those magic glasses that do not exist. This definitely makes for a very difficult first low vision exam.
Typically, it is easier to introduce concepts to patients earlier when they have some vision left, are still doing relatively well, and are still open to small changes in their life. In these situations, a little advice goes a long way (a little magnification, lighting tips, home modification tips, accessibility features on phones/computer, techniques on adaptive living skills, non-optical aids, etc). A lot of times, patients may not realize what they need until you show it to them or bring it up with them. This is especially true for those with mild vision loss who say they “get by okay.” I find patients much more receptive when you see them early to provide magnification and advice gradually as their vision issues progress.
How is your clinic time allocated during the week? Can you briefly walk us through a “day in the life” of your typical work routine?
Dr. Hable: I work in an academic setting where my time allocation is divided between requirements of clinic, teaching, and service. I am actively in clinic 3 days a week teaching students in a clinical setting. My other 2 days are allocated to administration duties and service to the community, students, school, and catching up on additional paperwork that often comes with the vision rehabilitation service. I work with both low vision patients and vision rehabilitation patients serving at our outpatient school’s satellite clinic and at a rehabilitation inpatient hospital serving patients with strokes and traumatic brain injury.
I see patients from 5 years old and up with the majority of my patient base in the 60 to 100 year old range. The majority of my patients have low vision from macular degeneration or glaucoma, or vision loss from a stroke or traumatic brain injury. However we frequently see patients with congenital vision conditions that result in vision loss. On a daily basis I help individuals with bioptic driving services to help them maintain driving status.
Vision rehabilitation isn’t so much about “fixing” the vision issues as it is about utilizing the patients’ vision they still have to the best of their ability. We isolate a patient’s goals to best define their low vision device needs. We begin by finding the most appropriate starting point with a thorough trial frame refraction. Treatment options include a wide range of optical and electronic devices from hand held magnification to spectacle mounted magnification. These can range from a basic hand held magnifier to the top of the line artificial intelligence or augmented reality devices.
Dr. Graby: At our clinic at the Association for the Blind and Visually impaired, we see the complete spectrum of patient ages and demographics, from toddlers to those over 100. However, the majority tend to be elderly, and the most common diseases include age-related macular degeneration, glaucoma, stroke (homonymous hemianopia), Ocular albinism, and nystagmus. Each patient is seen by a low vision social worker first for approximately 45 minutes, the optometrist for 1 hour, and then the optician to be dispensed optical aids and pick out eyewear at the end. They can also be referred on to other specialists such as Orientation and Mobility, OT, and low vision rehab therapists. I like that patients have access to several specialties as I feel this gives a more well-rounded approach to patient care and touches on the many aspects of life that may affect those with a visual impairment.
Dr. Wong: Pre-COVID, I would average 3-4 patients a day, 3 days a week. Each patient would have 60-90 minutes per exam and sometimes they do run long. On the 4th day, I would have 2 patients and a half day of administrative time where I also book follow-ups as needed.
During COVID, I typically see 3 patients a day with end of the day administrative time. To reduce exposure time (and for patients who are able), we have also implemented two-part exams where part 1 is a 30-45 minute telehealth visit and part 2 is (ideally) a 30-45 minute low vision device demonstration. Extra testing like visual fields are performed at a separate visit.
I have seen patients ranging from 2 to 102 years old. There isn’t really an average age for patients. It’s probably more of a bimodal curve: 20-40 years old (congenital/hereditary conditions/diabetes) and 65-85 year old (AMD/glaucoma). The main conditions I see are retinitis pigmentosa, macular degeneration, glaucoma, and diabetic retinopathy. I also see patients who have visual field losses from strokes.
Device recommendations are goal-oriented and vary on a patient-to-patient basis. These include hand-held magnifiers, stand magnifiers, hand-held telescopes, glasses mounted telescopes, bioptic telescopes, tints, lamps/flashlights, portable CCTVs, desktop CCTVs, and text-to-speech devices like ORCAM.
I also tend to discuss free resources such as audio books, DMV handicap placards, paratransit, large print phones, money reader, etc. I also dabble in the other disciplines of the low vision rehabilitation team, but only just enough to give patients’ a taste and refer to the appropriate experts. I can show them basic accessibility features on iphones/Androids/computers and I try to keep up to date with useful phone apps. I know enough to discuss, but not teach to the level of my colleagues, computer software for low vision, home modifications recommendations, cane techniques, sighted guide techniques, etc. It’s good to research these things on your own as patients may ask you.
Conclusion
Low vision practice is a unique niche within the optometric profession. Optometrists practicing in this setting provide much-needed care to patients who have typically exhausted all other treatment options. These patients typically have end-stage ocular disease and may have given up on basic life tasks or specific hobbies due to their visual impairment. Low vision therapy can help restore some of these activities and can provide a life-changing experience for patients.
Optometrists interested in pursuing a career path in low vision have the option of starting while still a student. Many 4th year externship rotations are available throughout the country, allowing students to gain better insight into whether or not this practice modality is right for them. New grads can also opt to pursue one of the many unique low vision residency programs available as well.
Be sure to also speak with other colleagues, faculty and professional mentors to see if a career path in low vision is right for you.
