Simple refraction, coaching, may be all some low vision patients need
Low vision rehabilitation at the Moore Eye Foundation may be the closest thing to patient care in a perfect world no one is turned away regardless of the ability to pay, and the surgeon, optometrist and vision therapist spend as much time as needed with each patient.
Retina specialist Leonard H. Ginsburg, MD, said providing complete low vision services was the reason he established the foundation here in Delaware County, Pa. "I do my best to prevent disease and treat disease, but many patients end up having some visual loss, and that makes it critical to maximize their vision through rehabilitation," he said.
Multidisciplinary approach works
Dr. Ginsburg said by working closely with optometry, patients benefit from a multidisciplinary approach to low vision rehabilitation. "Optometry traditionally has more expertise at offering low vision services, but ophthalmology hasn't always wanted to refer," he said. "As a result of this political rift, many patients who need low vision services have not been able to take advantage of optometry's great resources."
As a high school student who saw his grandmother struggle with age-related macular degeneration (AMD) and resulting poor vision, Dr. Ginsburg said he was motivated to become a retina specialist and work with optometrists like the one who eventually helped his grandmother Belle Moore, for whom the Moore Eye Foundation is named maximize her remaining vision.
"Optometrists are the best trained to perform visual rehabilitation," he said, "and I would encourage all to do it because the need far outweighs the number of specialists. The more we're able to help the elderly population, the better."
Richard L. Brilliant, OD, and Jerry P. Davidoff, OD, co-chair the visual rehabilitation services of the Moore Eye Foundation. Dr. Brilliant, an associate professor at the Pennsylvania College of Optometry, also spends much of his time teaching low vision to interns of the Feinbloom Center at PCO as the senior low vision practitioner. He maintains his low vision private practice at the Moore Eye Foundation.
The Moore Eye Foundation has four goals, said Dr. Ginsburg:
- visual rehabilitation,
- indigent care for patients who cannot afford low vision care or devices,
- eye education for patients and the medical community and
- eye research to prevent or treat disease.
So far, Dr. Ginsburg noted, the only problem with providing complete low vision services is financial in nature. "From what we've seen, low vision is not a money-maker," he said. "All the low vision centers I've seen feel the best they can do is break even. So in a private practice, all of us should be committed to helping the people we serve by doing the best we can and by knowing where to refer if we can't do something."
Fine-tuning a reading Rx
On a recent morning, the first patient of the day represented the typical low vision patient Dr. Brilliant evaluates: a 72-year-old man with atrophic AMD who has had failing vision for 7 years. In otherwise good health, the only reason the patient, George, stopped driving, playing golf and working part-time as a building inspector 18 months ago was due to poor vision.
George's wife, Doris, said when his AMD was diagnosed in 1990 no one told them about low vision rehabilitation. They were referred to Dr. Brilliant by Doris's optometrist who, during her routine exam several months ago, asked how George was doing.
George told Dr. Brilliant that he struggled to read normal print with his magnifier, no longer wore his reading glasses because they did not help and could not make out his wife's face from across the room. George had tried a mounted telescope several years ago, but did not like it and returned it.
"The important things are the patient's concerns and goals, because that drives the process," Dr. Brilliant said. "Most AMD patients do better almost immediately for reading with good lighting or a better eyeglass prescription."
George's visual acuities measured OD10/400 and OS 10/80 without his prescription, and OD +0.75 -2.00 +110 and plano OS -1.75 +85 with his prescription for an acuity measurement of OD 10/200 and OS 10/40. Within minutes of wearing different trial lenses, George was able to read several lines of numbers and letters from a chart across the room.
George tested his new prescription at the computer station in the exam room; working at a computer is important to him. Reading slowly, and with concentration, he is pleased with the results.
After some additional fine-tuning, George's new reading prescription is OS +10.00 -1.75 +85 with an OD frosted lens. Dr. Brilliant also had him choose two hand-held magnifiers which helped him see text and small objects up close. George chose a 4X hand-held magnifier to see icons on the computer screen, and a 5X illuminated hand-held magnifier for reading a menu in a darkened restaurant.
Training with a therapist
Dr. Brilliant checks George's intraocular pressure and the condition of his cataracts, and tells George they are slight, and removing them would not help his vision. Then Dr. Brilliant turns the visit over to Maryellen Bednarski, MS, MEd, a vision rehabilitation therapist.
Mrs. Bednarski reviews proper viewing techniques with George, reminding him of distance and lighting. "Think about endurance," she says. "Your eyes might tire or you might get a headache because you're reading with a lot of concentration. You have to work harder than you used to, and if you get tired, take a break."
She concludes the 90-minute visit by scheduling a 2-week follow-up appointment and gives George and Doris a reminder sheet and some literature about low vision.
After the visit, Mrs. Bednarski said one of her goals is to start a low vision support group so patients can meet and support one another. She has retinitis pigmentosa and often shares her own experiences with patients.
The second patient evaluated by Dr. Brilliant is an elderly man with AMD who had cataract surgery years earlier and whose chief complaints were difficulty reading, a rough, sandy feeling in his eyes and tearing. During the exam, Dr. Brilliant learned the man suffered a retinal detachment in his right eye and was concerned about the same thing occurring in his left eye.
"Basically, he wanted reading glasses and not a magnifier," Dr. Brilliant said. "I made his reading glasses stronger and teach him to hold his reading material closer and to use better lighting. We concentrated on the vision in his left eye because there was very little in the right eye due to the detachment."
Dr. Brilliant also diagnosed dry eye for this patient, prescribing drops for his symptoms.
Dr. Brilliant's next patient, a 20-year-old college student born with tyrosinase-positive oculocutaneous albinism, said his goal was to obtain a full-time driver's license. Although he is developing pigment as he ages, Kevin (not his real name) finds that wearing wraparound sunglasses makes his daytime driving more comfortable.
He would also like to update his reading prescription he lost his reading glasses nearly 2 years ago and has made do without them to cut down on the eye strain and fatigue he experiences while doing homework.
"Patients with albinism all have high refractive errors and should be wearing glasses," Dr. Brilliant said. "His peripheral vision is similar to mine, except that he is more sensitive to glare. He actually functions better visually at night, without bright lights and glare, because it's simply easier for him to see."
After measuring Kevin's visual acuities, Dr. Brilliant fine-tunes his distance prescription that enables Kevin to read at 20/40 and, therefore, qualify for a full-time driver's license. "He'll also get a new prescription for near vision and we'll schedule a visual field for peripheral field assessment, which is important in helping him obtain a driver's license," Dr. Brilliant said.
On a day when he saw only new patients, refracting them seemed to provide most of the solutions, Dr. Brilliant said. "Today's patients required not much more than a good refraction and simple solutions to their visual problems. Sometimes, though, patients' concerns are more involved and require more sophisticated approaches."
While he knows many ODs could not have a full-time low vision practice, he feels more doctors today are aware of the benefits of low vision rehabilitation and refer patients for more intensive care.
Dr. Brilliant said he keeps the goals for low vision patients simple and applicable to real life. "It's important to note the difference for these patients in the real world, where they don't just read big numbers on a chart," he said. "I want to know what makes it more comfortable for them to read price tags in the store, see a menu in a restaurant and see a thermostat or clock at home."
For Your Information:
- Richard L. Brilliant, OD, Leonard H. Ginsburg, MD, and Maryellen Bednarski, MS, MEd may be contacted at the Moore Eye Foundation, Mercy Community Hospital, 2000 Old West Chester Pike, Havertown, PA 19083; (610) 449-0400; fax: (610) 356-4244.