To the Editor:
The article, “Today’s primary care OD can provide low vision
care more easily” (March 2012, page 16), by Scott A. Edmonds, OD, FAAO,
brings up a number of concerns and comments that I shall address, calling on my
38 years of experience in providing low vision care.
A low vision optometrist understands how to deal with low vision
patients. These patients possess unfulfilled expectations and may experience a
shift in reality and a reduced ability to communicate.
Low vision patients want to be cured, even though they know they cannot.
All low vision practitioners know that patients with relatively good acuities
(20/40 to 20/70) are more upset and frustrated than those with profound vision
This is why I feel Dr. Edmonds is off base in suggesting that more of
this care move out of the specialty low vision clinic and back to the primary
Dr. Edmonds states that patients and their family members can evaluate
optical options on the Internet. He is totally ignoring prescription low vision
devices such as microscopes and telescopes that have the patient’s
prescription built into the system. These options are not available on the
Internet and are fabricated by a prescription laboratory. They are prescribed,
fitted and evaluated by the doctor.
Medical and surgical treatment is, indeed, improved, as Dr. Edmonds
stated. The anti-VEGF agents have increased the number of low vision patients
who can be helped. Dr. Edmonds claims, “If a low vision patient can be
improved to 20/60 or better, he or she is an excellent candidate for a high add
in a flat top design,” and “these patients are able to fluently read
standard size print.”
While that may be true, the low vision specialist understands that
patient will still be unhappy. The patient needs a doctor who comprehends his
or her emotional state and can exhibit patience and understanding while
providing guidance and counseling. Telling the patient he or she should be
happy with 20/60 vision, as I have often seen primary care providers do, is
exactly the opposite of what the patient needs.
Dr. Edmonds correctly states that optometrists “have a vast
experience of explaining the complexities of myopia, hyperopia, astigmatism and
presbyopia to patients and helping them adapt to day-to-day life with these
problems.” However, he incorrectly states: “It is not a big stretch
for the primary care optometrist to use those same communication skills to
explain AMD, provide the proper optics and teach patients how to adapt and
adjust their life to these problems.” Teaching patients how to adapt to
these problems is at the heart of being a low vision doctor.
Dr. Edmonds advises optometrists to “step up.” I agree that
optometrists need to step up and start referring patients to low vision
optometrists after all medical treatments have been exhausted.
Richard J. Shuldiner, OD, FAAO
Low Vision Diplomate, American Academy of Optometry
Founder, International Academy of Low Vision Specialists
Clinical director, Low Vision Optometry of Southern
Dr. Edmonds responds:
I want to thank Dr. Shuldiner for taking the time to respond to my
article on low vision and the primary care optometrist. Considering that we
clearly have different views, it is good to debate issues that affect our
profession in a public forum.
I, too, am a “low vision specialist” and also can call on more
than 30 years of experience providing low vision care in one of the leading
international eye institutes of the world. In my role, I also teach
optometrists and ophthalmologists, which may have led me to have a much higher
opinion of the general eye care provider, particularly the optometrist.
In reading Dr. Shuldiner’s views, I feel that he underestimates the
modern primary care optometrist. Today’s optometrist is trained to deal
with all aspects of ocular disease, even when these diseases result in
permanent vision loss. They do understand how to deal with patients who have
unfulfilled expectations and a reduced ability to communicate. This is not to
say that the primary care optometrist is equipped to deal with all low vision
patients, but I believe that they also know when to manage and when to refer.
Our low vision clinic at Wills Eye is very busy, with the advanced low
vision care using microscopes, telescopes and, in particular, the low vision
rehabilitation required to manage these clinical cases. With the baby boomers
moving into the macular degeneration age group, those of us in busy low vision
practices need to work more closely with our colleagues in primary care to
effectively manage all of these patients.
I firmly believe that primary care optometrists are ready and willing to
“step up” and work with low vision optometrists, specialty
ophthalmologists and any of the providers of the health care system to provide
the best care for their patients.
Scott A. Edmonds, OD, FAAO
Co-director, Low Vision/Contact Lens Service
Wills Eye Institute