Overcoming Barriers to Low Vision Rehabilitation Alexis G. Malkin, OD, FAAO

Malkina@neco.eduVision-Aid

12 May 2020

No relevant disclosures

Setting the Stage• General shortage of low vision (LV) rehabilitation

services • Growing need with increasing incidence/prevalence of

LV• Challenges to providing LV: aging population with

reduced insurance reimbursement rates, long chair time and historically high no-show rates.

• Additional challenges: practitioner comfort level with integrating low vision

• Goal is to create a LV rehabilitation model that can be adapted for every community

Defining Low Vision• Permanently impaired vision in both eyes that causes

functional limitations• Can be defined in terms of visual acuity in the better

seeing eye (may also be defined in terms of visual field loss)

• Can be congenital or acquired

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International Definition of LV• Mild – presenting visual acuity worse than 6/12• Moderate – presenting visual acuity worse than 6/18• Severe – presenting visual acuity worse than 6/60• Blindness – presenting visual acuity worse than 3/60

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https://www.who.int/news-room/fact-sheets/detail/blindness-and-visual-impairment

Defining LVR• Low Vision: Vision loss which cannot be corrected by

medical treatment, surgical treatment or conventional eyeglasses(American Academy of Ophthalmology)

• Low Vision Rehabilitation: A multidisciplinary approach to improving visual function and maintaining independence– Team members may include:

• Optometrist, low vision therapist, occupational therapist, orientation and mobility specialist, teacher of the visually impaired, primary care physician, psychologist/psychiatrist, local agencies

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Preferred Practice Patterns• Provide low vision services or refer for low vision

services if a patient has reduced BCVA of 20/40 or worse, central scotoma/metamorphopsia, reduced contrast sensitivity, visual field loss or functional vision difficulties

• American Academy of Ophthalmology

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Defining the Problem

6/12 6/18 6/60

Prevalence Rates of LV in the US

Massof, OVS, 2002

Defining the Problem: LV provider shortage

• Providers are only serving 15-20% of low vision patient need in the regions that have been studied (MD/DC/DE, MA and TN)

• Providers include:– optometrists– ophthalmologists– occupational therapists– orientation and mobility specialists– others

Defining the Problem: Who are the LV Patients?

Most cases of low vision in the United States are caused by age-related eye diseases:– Macular degeneration (59%)– Diabetic Retinopathy and

other retinal vascular diseases (11%)

– Glaucoma (10%)– Cataract (5%)

Defining the Problem: Who are the LV Patients?

Goldstein, Arch Ophthal, 2012

Visual Acuity of LV Patients

Goldstein, Arch Ophthal, 2012

Self-reported Vision Status vs. Visual Acuity

Goldstein, Arch Ophthal, 2012

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Prevalence rates of LV in India• Dandona et al (2002) studied prevalence rates in

Southern India• Prevalence was ~1%• Most common causes: retinal disease (1/3), amblyopia,

optic atrophy, glaucoma, and corneal diseases• Higher prevalence with increasing age• Higher prevalence with decreasing socioeconomic status• Higher prevalance has been noted when studies report

on both treatable and untreatable causes

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Prevalence rates of LV in India

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Prevalence rates by age

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Pediatric Low Vision• Accounts for larger number of years per patient of vision

impairment• Common causes: toxoplasmosis, optic atrophy, cerebral visual

impairment, optic nerve hypoplasia, retinal dystrophies, dominant optic atrophy

• A multidisciplinary and collaborative approach is essential. Including members such as:

• TVI- Teacher of the Visually Impaired• OT- Occupational Therapist• O&M Specialist – Orientation and Mobility

Pediatric Low Vision in India• Cross-sectional Study from LVP reviewed records of 220

pediatric patients presenting for LVR• 49% were moderately impaired, 31% severely impaired,

and 20% were blind• Causes were: congenital glaucoma, hereditary macular

degeneration, RP and albinism• Refraction played a significant role in these cases• Would likely show different etiologies if analyzed now

given the greater understanding of CVI

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Pediatric Low Vision:• Multiple studies show improved visual function

with low vision aids in the pediatric population• Adaptive exams assist in determining visual

function and appropriate interventions

Low Vision TiersPrimary Care• Spectacle solutions (i.e.

high adds, single vision Rx)

• Trial frame refractions• Magnification• Education• Referrals for additional

services (i.e. O+M, OT)

Advanced Low Vision Care• Primary care plus:

– Higher power magnification (digital)

– Telescopic solutions– Technology

assessments (OCR, computer accessibility)

– Vocational Rehab– Sensory substitution

Levels of Visual Acuity• 20/20 normal

• 20/40 drive without restrictions• 20/60 read ordinary newsprint• 20/70 eligible for Medicare coverage of low vision

rehabilitation services• 20/125 eligible for blindness-related benefits

Mild low vision (20/40-20/60): 2.5 millionModerate low vision (20/70-20/200): 750,000Severe low vision (20/200 or worse): 1.25 million

Image Courtesy of Dr. Richard Jamara and Dr. Nissa C ll

Low Vision Decision Tree

Research on perceived barriers in the US and India

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Perceived Barriers in the US• Practitioners who do no low vision also don’t integrate

primary low vision strategies (high add, low mag, etc)• Reported barriers for providing low vision care included:

– Cost of exam/devices– Patients are not interested/would not go– Not feasible to stock devices in office

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Perceived Barriers in India• Reporter barriers:

– Lack of training– Lack of awareness/availability of services– Lack of access to LV devices– Lack of motivation was also noted

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Barriers to providing LV service

• Low vision is “slow”

• Low vision is “no show“

• Low vision requires “devices”

• Low vision requires a “store”

• Low vision requires “follow-up”

Breaking Through Barriers to Serving LV Patients

– Community outreach programs to education eye providers, patients, and the public about low vision and low vision rehabilitation

– Community eye and vision screening and education programs for seniors

– Increased training of primary eye care providers to perform low vision care in the mildly to moderately impaired population

Poor referral rates for low vision rehabilitation

Improve Care Delivery

• Measure patient reported outcomes and provide continuous professional education to improve the quality and effectiveness of low vision rehabilitation services

• Develop best practices to educate providers in the future

Improve Show Rate• Staff/Volunteers can provide or coordinate:

• Transportation• In home follow-up/support• Phone histories and confirmation calls

– Once a patient has completed a phone history, they will have a better understanding of what to expect from the visit and be more confident in the importance of coming in for the appt

Reduce Chair Time• Histories prior to the visit reduce the time the patient will

spend in the clinic• Setting up a telemedicine follow up visit will reduce the

burden on the patient returning for additional clinic visits

John Public03/22/1938

Considerations for your clinic

LV Inventory to Consider for Your Clinic

Basic LV Aid Diagnostics•Lighted Hand Held Magnifiers:

– +6D, +8D, +10D, +12D, +20D•Lighted Stand Magnifiers: +10D, +12D •Prism Half Eyes:

– +4 w/ 6Δ BI, +6 w/ 8Δ BI, +8 w/ 10Δ BI•Telescope:

– 2X Binocular System/low powered monoculars•Fit Over Filters:

• Yellow, Amber, Gray, Plum•Electronic Magnification: Portable or desktop unit

Role of Lions (Volunteers)• Community Outreach

– Ophthalmologist outreach program (patient referrals)– Public education– Vision and eye health screening – Resources for people with low vision

• Direct Service to People with Low Vision– Transportation– In home follow up

• Computer-assisted telephone interview before and after provision of clinical services

• Volunteer staffing of LOVRNET administration• Program Sustainability/National Expansion

Research and Best Practices

• Utilize outcome measures to provide real-time provider feedback on patient successes/additional goals

Massachusetts Expansion of Services• Recruited community volunteers and trained

these community members to present at retirement communities, departments of aging and other organizations

• Community members serve a key role in providing information about low vision services and they can assist with setting up appointments, transportation and other needs

Massachusetts Expansion of Services• Completed the 2nd annual 2-day low vision training for

providers this spring• Total of 50+ providers trained in both primary and

advanced low vision skills• Providers can now reach out to the existing network of

advanced care through the NECO clinical system when they run into difficult or challenging cases

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New initiatives• Will be setting up telemedicine consultation services to

assist new providers• A doctor at the NECO clinic will be available via video

chat while the provider has a patient• The NECO clinician will be able to provide insight into

potential device solutions, community resources and additional history questions

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Barriers to Providing LV Service Lions LOVRNET Solutions

Low vision is “slow” Patient histories taken ahead by staff/students/volunteers

Low vision is “no show“ Prior histories plus transportation resources and telemed will improve access

Low vision requires “devices” A limited supply of devices can be a good starting point for services

Low vision requires “follow-up” Telemedicine allows for troubleshooting and f/u in the patient’s home

Take Home Message• Access to low vision care is an increasing

challenge • There is an increased incidence and prevalence of

age-related eye disease in the aging population. • Optometrists and other eye care providers are

best suited to provide LV care, but require a different model of practice than has previously been used.

References• Dandona R, Dandona L, Srinivas M, Giridhar P, Nutheti R, Rao GN. Planning low vision services

in India : a population-based perspective. Ophthalmology. 2002;109(10):1871-1878• https://www.who.int/news-room/fact-sheets/detail/blindness-and-visual-impairment• Khan SA, Shamanna B, Nuthethi R. Perceived Barriers to the Provision of Low Vision Services

among Ophthalmologists in India. Indian J Ophthalmol 2005;53:69-75• Malkin AG, Ross NC, Chan TL, Protosow K, Bittner AK. U.S. Optometrists’ Reported Practices

and Perceived Barriers for Low Vision Care for Mild Visual Loss. Optometry and vision science : official publication of the American Academy of Optometry. 2020;97(1):45-51

• Gothwal VK, Herse P. Characteristics of a paediatric low vision population in a private eye hospital in India. Ophthalmic & physiological optics : the journal of the British College of Ophthalmic Opticians (Optometrists). 2000;20(3):212-219

Special thanks to Dr. Tiffany Chan and Dr. Bob Massof for their assistance with some of the slides and materials!

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