“At Issue” asked a panel: A 79-year-old in an assisted living environment complains of an inability to read and do puzzles. Her BCVA is OD 20/100 and OS 20/80 due to dry AMD. How do you manage her from a primary care low vision standpoint?
Refract with trial frame, not phoropter
Lynne Noon, OD, FAAO: This patient should have a refraction to ensure
the best distance correction. Because of the decreased central acuity, the
refraction is best done in a trial frame so the patient will be able to use
eccentric vision. The phoropter forces macular degeneration patients to look
through their central scotoma and may not yield reliable results.
For reading small newspaper type print, this patient may need a reading
add of approximately +4 D to +6 D. The power of the add depends on the amount
and position of the macular distortion.
The patient should be counseled on the correct use of task lighting and
the working distance of the near add. Quite often the difference between
success and failure when reading depends on the patient understanding the
correct use of task lighting and understanding where to place reading material.
The patient should have no problem working crossword puzzles when correctly
using the glasses and lighting. Large print versions of many types of puzzles
are available in book stores.
If making jigsaw puzzles is a goal, this patient should again be
counseled on the correct use of task lighting. Because many puzzles have high
gloss surfaces that can cause glare, the lighting must be positioned correctly
to achieve the needed illumination while eliminating glare.
A lamp with a movable arm containing a magnifying lens will help the
patient see the small details of the puzzle pieces at all working distances. An
illuminated 2X hand magnifier will also help with this task. A good choice for
the patient would be puzzles that have pictures with a great deal of contrast.
All doctors should be aware of the many services that are available for
the visually impaired in their state. A primary care optometrist may not have
the staff needed for in-home follow-up care. However, there are often low
vision rehabilitation professionals who can visit the patient in the assisted
living facility to ensure that the patient is properly using the prescribed
glasses, lighting and magnification devices.
For more information:
- Lynne Noon, OD, FAAO, can be reached at ViewFinder, Low Vision
Resource Centers, Sun City, Yuma and Mesa, Ariz.; (866) 924-8755; e-mail:
Determine etiology, provide functional vision
Katie Gilbert Spear, OD, MPH: This patient places two distinctly
different responsibilities on me as the primary care/low vision specialist. My
first responsibility is to accurately determine the etiology of the decreased
visual acuity and ensure that we prevent further reduction. In this case, where
the reduction is a result of dry AMD, my primary concern is to closely monitor
this patient to detect the slightest change that indicates conversion to the
wet form of the disease.
I would see this patient at a minimum of once a quarter for functional
and anatomical evaluation of macular status. Much is written on using optical
coherence tomography to monitor conversion. I have found that the use of
preferential hyperacuity perimetry is a useful adjunct in detecting early
changes that can indicate wet AMD.
Katie Gilbert Spear
My second responsibility is in providing the most functional vision
possible to allow the patient to maintain independence and allow her to do
specific tasks important to her lifestyle. This requires the patient to
complete a lifestyle and visual needs questionnaire to determine her visual
goals, in this case reading and doing puzzles. This, along with a comprehensive
examination, trial frame refraction and mapping of any scotomas will help me
determine what glasses or devices would be most beneficial to the patient.
From a device standpoint, my first option would be a pair of high plus
or microscopic glasses. This may be adequate to assist with reading; however,
she would have a short working distance.
If this is not acceptable, I would introduce a stand magnifier (usually
lighted) or a telemicroscope to lengthen her working distance. Other more
sophisticated devices that could be beneficial for this patient include
portable video magnifiers and CCTVs. Also remember that providing resources for
large print books and puzzles is extremely helpful.
No matter what device or aids are used, follow-up with home or onsite
visits and training by the optometrist or a vision rehabilitation specialist is
critical to a successful outcome. Without proper training and follow-up no
device will allow the patient to achieve his or her full visual potential.
For more information:
- Katie Gilbert Spear, OD, MPH, is director of Low Vision Services
for Panhandle Vision Institute. She can be reached at Baptist Medical Towers,
1717 North “E” Street, Tower 3, Suite 334, Pensacola, FL 32501; (850)
438-1277; fax: (850) 438-1278; e-mail: firstname.lastname@example.org.
Determine necessary visual acuity
Michael R. Politzer, OD, FAAO, FCOVD: Elderly patients who remain
relatively healthy and active present a unique challenge in providing
appropriate solutions to their vision care needs.
The approximate add required to do the tasks this patient wishes to
accomplish is determined by dividing the patient’s best-corrected visual
acuity by the visual acuity needed to do the task.
Michael R. Politzer
In this example, reading the newspaper will require a visual acuity of
20/30. The patient has 20/100, so 100/30 = 3.33 or +3.50 D. This amount is then
added to her current add of +2.50 D, which results in a total add power of
+6.00 D. A +6.00 D add will allow our patient to read and do puzzles at 6 to 7
inches; 40/6 = 6.66 inches or 16.6 cm (100/6 = 16.67 cm).
Once the add power is determined, the best way to manage the
patient’s response and expectations is to demonstrate how the
“new” +6.00 D add power will work. To do this, use a trial frame, set
at the near PD with the patient’s combined distance prescription and +6.00
D add in the trial rings.
Place the ophthalmic stand’s light source over the patient’s
left shoulder (left eye in this example is the BCVA eye), slightly behind the
back well of the trial frame. Hand the patient appropriate reading material and
ask her to close her eyes.
Position the reading material so it touches the patient’s nose. Ask
the patient to open her eyes and push the material away from her nose until the
type is clear. Discuss with the patient that this will be her new viewing
distance. It will take some time to adjust, but she will be able to reach and
accomplish her goals.
If the patient cannot read the material, increase the add power in
+1.00-D increments. Be sure to instruct the patient that as the add power
increases, the viewing distance decreases.
If the patient objects to the viewing distance, decrease the add power
in -1.00-D increments. Be sure to instruct the patient that as the add power
decreases, the size of the print must increase.
Key points to remember are:
- Prescribe single vision reading glasses only. Although you can
special order a +6.00 D add, patients are at a higher risk for falls when using
a bifocal with this type of prescription..
- Always instruct the patient to remove his or her reading glasses
before standing or walking.
- Use a solid 50% yellow (450 nm) tint to improve contrast and reduce
For more information:
- Michael R. Politzer, OD, FAAO, FCOVD, specializes in low vision,
vision enhancement and rehabilitative optometry. He is an adjunct professor at
the Illinois College of Optometry and Southern College of Optometry. He can be
reached at 7003 Chadwick Drive, Bristol Building One, Suite 120, Brentwood, TN
37027; (615) 604-2949; e-mail: email@example.com.
Start with expanded functional history
Katherine White, OD: A low vision specialist will take an expanded
functional history including questions about managing medications and finances,
food preparation, communication skills, leisure activities, mobility issues and
social/emotional status. The goals of reading and working puzzles may expand to
include other activities of daily living.
In addition to medical examination and management, the visual status
evaluation should include corrected distance and near acuities, peripheral and
central visual field deficits and contrast sensitivity. Because decreased
acuity with central scotomas is likely, trial frame refraction using a reduced
test distance will provide an accurate refraction. Preferred lighting and
filters may further enhance function and comfort.
With a corrected acuity of 20/80 in the better eye, magnification will
be required to read fine print. Depending on the print size desired, a +4 D to
+5 D add will be appropriate. Options such as high add reading glasses,
handheld aids, stand magnifiers on an arm, clip-on spectacle magnifiers or
electronic devices will enable the patient to read fine print. If the right eye
is dominant, it may need to be occluded for continuous text reading.
A magnifier is always practical for spot reading a telephone number or
food package directions. The hands-free options of stronger reading glasses,
clip-on spectacle magnifiers, magnifiers on an arm or a closed circuit
television will be better suited for working puzzles. Cost, portability and
appearance will all be important to the patient.
The patient will need training to use the prescribed aids with proper
task lighting. Nonoptical devices such as a large print checkbook may further
enhance independence. Psychosocial and mobility needs may be better met by
other providers. Finally, education about the disease process and available
resources will prepare the patient for future needs.
For more information:
- Katherine White, OD, is the managing director of Low Vision
Services at ABVI-Goodwill. She can be reached at 422 S. Clinton Ave.,
Rochester, NY 14620; (585) 697-5733; e-mail: