Low Vision Opportunities after Diagnosis

In Australia, men are expected to live until they’re 79 and women until they’re 84¹ – yet many will begin to suffer low vision by the time they’re over 65 because of the onset of eye diseases, such as age related macular degeneration, glaucoma and cataract.

These people are an often forgotten customer group and get lost in the system. Once a patient is identified with an eye disease, they’re usually referred to an ophthalmologist for treatment and assume their work is done. Yet over the next 10 to 20 years, there is so much more that an optom can do to help that patient retain their quality of life and independence.

When people are diagnosed with low vision they often enter into a grieving process – they need counselling and support. They need their optometrist to follow them up…

And, for the patient who is travelling a new path in their life that can be as psychologically threatening as it is physically challenging. The ability to retain the care of an optometrist, with whom they have an established relationship, could dramatically ease the way.

“When people are diagnosed with low vision they often enter into a grieving process – they need counselling and support. They need their optometrist to follow them up, during and after their treatment by an ophthalmologist, to support their refractive and optical needs,” said Dr. Sharon Bentley, convenor of the Low Vision Working Group which has been set up by the Optometry Association of Australia to look at what can be done to encourage more optometrists to offer low vision services.

“Yet once they’ve been diagnosed with low vision, patients say they are often given the impression – by their optometrist or ophthalmologist – that there is nothing more that can be done for them. Really, it’s just that there is nothing more that can be done to cure their condition. There is still plenty that can be done in terms of optical devices, lighting and contrast to maximise available vision and maintain independence,” she said.

Optometrist Dr. Alan Johnston provides specialised low vision care from his practice in East Melbourne. “Busy ophthalmologists treating complex eye conditions may not have the time to discuss the issues of functional vision and prefer to refer these patients,” he told mivision. “Our initial appointments are one hour long, providing us the opportunity to explore difficulties of daily living and advise and educate patients in the use of the optical aids we prescribe.”

“Even for people with mild low vision, basic optical aids require education. We teach patients how to adapt to enlarged images with smaller fields of view.

“Often it’s our small suggestions that make the difference. Magnifiers that are held incorrectly do not perform. Too close to the face may give blurred vision and too close to the page gives inadequate magnification. Holding a hand magnifier like a spoon by resting the hand on the table prevents fatigue and steadies the image, it’s also usually more relaxing. But every patient is different – what will be life changing for one may be of no benefit for another.”

Graham Sheil, director at European Eyewear, believes that increasingly, low vision services should be looked upon as a viable way to differentiate your practice.

“Optometrists are being forced, almost against their will, to take interest in low vision because we have an ageing population with higher aspirations than ever before. Many people of our parent’s generation were content to retire to the couch to listen to the radio. But these days in retirement, or quasi retirement, they do all sorts of things – University of the Third Age, they develop the small business they’ve dreamed of for years, they research their family history. All these things require input from their vision – but their vision is going down hill.”

He said optical aids are now so sophisticated that any amount of residual vision can be turned into useful vision.

“It’s all about changing your mindset. When people present at 6/9 or 6/12, you could say: ‘you’re 67 years old, what do you expect?’, then leave them feeling lost until they become legally blind and eligible for a pension ten years later. Or you could say: ‘with a bit of magnification, you can continue doing what you’re doing’.”

As a practice building opportunity, Mr. Sheil believes low vision shows promise. “Some optometrists tell me you can’t put any profit on low vision aids – they see what they’re doing as a charitable act. But our ageing population has been contributing to compulsory superannuation since 1992 and despite the economy, a large number have a lot of disposable cash. Many will pay anything to maintain their independence.”

Miniature spectacle-mounted telescopes or computer based, closed circuit television magnifiers are expensive, but for the active person with clear vocational or recreational tasks, the investment pays a dividend of good function.

Dr. Johnston said for about AUD$1,200, a low vision patient can purchase a bioptic telescope in new spectacles useful for many tasks, such as theatre, sports, religious services and education. “With care, expensive precision miniature telescopes may last 20 years (the telescope can be fitted to different frames over that time) so this investment has a long term benefit. Recently I renewed some telescopes for a patient that were purchased 25 years ago. We expect his new aids to last for another 25 years.”

Even so, Dr. Johnston says it is understandable that some patients are reluctant to pay for expensive equipment. “Elderly people losing their vision and existing on a retirement income worry about living to a grand age when money may run out or vision continues to fail. They may be investing in other equipment at the same time – hearing aids at AUD$6,000, mobility aids and so on. Many have hospital insurance but no ancillary benefits. To a large extent, what we prescribe depends on age, recreational interests, socio-economic issues as well as health. We need to be aware of their anxiety when vision futures are uncertain.”

Options for Service

Unless they choose to specialise in the area, most optometrists would find the concept of stocking a full range of low vision equipment for the occasional patient financially prohibitive. However this is not the only way to deliver low vision services.

Inexpensive low vision trial sets are available, that include a selection of optical aids. The patient can take some of the aids to try in their own home then, once a decision is made, the optom simply prescribes and orders the equipment.

Alternatively, optometrists can offer a comprehensive low vision assessment and eye health check – for which there is a Medicare item number – then provide advice and refer the patient on to a provider of low vision products and services.

There are a few to choose from – from not for profits, like Vision Australia and Guide Dogs Australia – and the commercial suppliers we’ve listed in this special feature.

Tim Connell from Quantum is one. He has representatives who visit people in their homes to determine their needs for low vision aids, provide products to trial then arrange supply.

“When people first think about low vision equipment, they’re usually thinking about a tool that will let them read a book. But that’s just a small part of it – we talk to our clients about how they access a range of information – food packaging, medication labels, emails – a whole range of day to day activities. Importantly, we also delve into their hobbies – and that can change our recommendation completely.

“We have clients who are able to be involved in all sorts of activities because they have optical aids. For example, we have an elderly gentleman who collects antique coins – he has Greek and Roman coins dating back 2,000 years and he tells me he can see more detail now using the magnifier than he could ever see before. I have another elderly man who uses his optical aid to do soldering. Others want optical aids to access their music collection or bring their photo albums, from 40-50 years ago, back to life.”

In his practice, Dr. Johnson said as well as offering patients purpose developed optical aids, he talks to them about using smart technologies like iPhones, iPads,
and Kindles.

“There are some very useful applications on iPhones for people with low vision – camera capture of signs then image zoom for recognition, Dragon Dictate, which inserts speech into documents and text messages. Font sizes and images on both phones and tablet computers can be enlarged for easier reading of messages, books and information. And some Kindle eReaders have voice output so users can listen to a book or use both text on screen and voice output as a support,” he said.

Julie Heraghty, CEO of the Macular Degeneration Foundation, said low vision aids and technologies are the key to ensuring people have quality of life and independence. “The area has changed so dramatically over the last five years because technologies being used by everybody in the community are so suited to people
with vision loss and blindness.

“But for many of our older Australians, it is hard to find the technology that will suit them because they weren’t born into the tech world. However there are simple aids – talking watches, big button telephones, simple magnifiers and electronic magnifiers, which can all make a difference. In the end, it’s about finding out what the person needs – what is suited to them to be able to engage in the community, enjoy quality of life and independence,” she said.

Quality of lighting is another tool that can make an enormous impact on people with low vision and it is an area currently receiving attention.

“More so than any other form of lighting, LEDs have enabled us to increase contrasts without giving a glare problem, by using specific colour temperatures of light,” said Mr. Sheil. “Black becomes blacker and white becomes whiter, which makes it much easier for people with low vision to differentiate.”

Not Just the Elderly

Mr. Connell said as well as catering to the needs of older patients, Quantum works with young children. “Our oldest client is 104 but our youngest is four years old,” he said.

“Young children have very different needs for optical technology – they need portability – they need to be able to take their equipment from home into the classroom, and outside.

He said that like all technology, most kids learn to use optical aids very quickly – it’s the people around them who usually need support.

“If you can get to them early enough, and provide them with the tools to maximise their remaining vision, you can give them self esteem and confidence. If they know they can do things, even if the way they do them is a bit different from other kids, they’ll be fine. The problem comes if they think they can’t do something because they’re different.”

Dr. Johnston notes that about 90 per cent of children who have low vision will have stable low vision for the whole of their lives. “That makes low vision care an extremely valuable investment for them,” he said. “And interestingly, educationally, children with low vision tend to do well – this is so rewarding.”

Maintaining Skills

The number of people with low vision needs may be increasing, but still, when including people with uncorrected refractive error, it only represents around 2 per cent of the entire population or 5 per cent of the population aged over 40.² That means that in any one week, most optometrists won’t encounter any patients with these very specific needs. As a consequence, it can
be a challenge to maintain the necessary skills and knowledge.

It’s something the Optometry Association Australia is currently addressing.

“Optometrists lose touch with the skills they’re taught at university because they see low vision patients infrequently, then they lose confidence,” said Dr. Sharon Bentley. “We need lectures, workshops and forums to provide more continuing professional education – which is something we’re trying to do – all practitioners in private practice should have basic skills in low vision they can use, especially for patients with mild low vision.”

Guide Dogs Australia encourages optometrists to volunteer for low vision clinics it runs around the country. Bashir Ebrahim, Rehabilitation Services Manager for Guide Dogs in Queensland, offers lectures on low vision services to optometrists in the area and said they are well attended.

“I recently gave a talk about low vision services in Queensland and 71 optometrists turned up. At another after hours professional development evening, one ophthalmologist from Rockhamptom paid six of his staff to attend. So the interest is there – eye care professionals are keen to learn about low vision and to volunteer their time to work in the Guide Dogs clinics,” he said.

European Eyewear has also noticed an increasing number of optometrists interested in brushing up on their low vision skills. “Four years ago we sponsored the Low Vision seminar in Hobart and the Tasmanian Optometry Association said they expected 40 delegates. In the first year we had 80, the following year 90 and last year the OAA had to close off registrations six weeks before the event because they’d reached capacity. This year we had just under 100 – with people attending from Victoria, Queensland, New South Wales and South Australia,” said Mr. Sheil.

Building Public Awareness

Genevieve Quilty, National President of the Optometrists Association of Australia said as well as encouraging optometrists to provide low vision services, the OAA aims to build public awareness of the role optometrists can play in helping manage low vision.

“The Association will continue advocacy work to ensure the public awareness is such that they realise optometrists can do low vision work as we are trained and educated to, and that we are a gateway to other services for them. We believe optometry is under-utilised here but has a lot to offer.”

She said, “what is important is that optometrists offer low vision services and where necessary refer to optometry colleagues who have a special interest in low vision when this inter-professional referral is required.”

Early Referrals Required

Jennifer Moon, Community Education Coordinator for Guide Dogs NSW, said ideally, patients should be referred to a low vision provider such as Guide Dogs as soon as they are identified. “There is the perception that the Guide Dogs service is only for people who are blind, and all we provide is Guide Dogs, but we can help people maximise the vision they have, rather than going down the path of becoming more and more isolated because their vision is not as it was.

“So we recommend that it is better for an optometrist, once they’ve identified a patient with low vision, to send the patient our way. By giving as much information as possible, we can help people prevent trips and falls, help them maintain their confidence and remain as independent as possible,” she said.

Guide Dogs Australia has a presence right across the country, although in each State, the services provided vary slightly according to the resources available.

“In NSW we have an existing low vision clinic at Chatswood which we jointly run with the School of Optometry at the University of New South Wales,” said Ms. Moon. “In addition to the optometrist, we have an orthoptist and an orientation and mobility instructor on board to visit patients in their home where the environment differs enormously from a clinic. We are actively looking at developing further partnerships with optometrists throughout the State.

“Our team works with people to ensure they are maximising their vision at home, during the day and night. We also help them in the community – with crossing roads and catching public transport – which can be a challenge for a person who has driven all their life.

Vision Australia works with optometrists to provide services to more than 20,000 patients in Australia each year many with low vision. People with low vision are seen at the organisation’s clinics around Australia. In Victoria, the Australian College of Optometry contracts and supplies optometrists to work in Vision Australia clinics.

“The optometrist does the testing, the assessment and eye health check, then based on the patient’s visual history, goes through a range of visual aids. Once the appropriate aids are selected, the optometrist prescribes and arranges supply,” said Graeme Craig from
Vision Australia.

“We have our own orthoptists and occupational therapists to offer advice and problem solving techniques that the patient can apply in their own home – like increasing contrasts, being aware of lighting and how it can be altered for improved vision, the use of magnification and so on.

“For some clients that may be the extent of our service, but for others with less vision, or more complex issues, we provide more services in the home. Our occupational therapist checks on environmental safety and helps set up orientation and mobility services. Then we provide technology beyond visual aids – screen magnification and screen readers for PCs and so on.”

Referral Pathways Must be Opened

The Royal Society for the Blind (RSB) in Adelaide runs a low vision rehabilitation clinic with clients who undergo a comprehensive low vision assessment by an optometrist, a counselor, as well as an ophthalmologist on site. Appointments last for around one and a half hours and include an assessment of the patient’s vision and visual fields, and a discussion about their vision needs, goals and any challenges they are facing as a result of their current eye condition.

RSB has a supply of around 200 magnifiers and daily living aids and, once the optometrist has explored the patient’s goals for near and distance vision, the patient is offered a one month trial of the most appropriate aids to assist them with their daily tasks. The organisation stresses the importance of patients retaining relationships with their primary eye care professionals.

“We ask patients to come to us having been to see their optometrist or ophthalmologist,” said Loucia Calder, Manager for Low Vision Services at RSB. “Once they have the best corrective glasses, we can offer magnification that really works wonders.”

“We always send reports back to the patient’s primary eye health providers with details of what we’re prescribed, any recommendations, or with any changes to vision acuity we’ve noticed.”

Ms. Calder said the RSB plans to run educational evenings on low vision for optometrists and ophthalmologists. “We want to build relationships with optometrists and ophthalmologists so that we can improve referral pathways. It is important for eye care professionals to understand the way in which we can complement their services,” she said.

Dr. Bentley agrees that relationships between eye care professionals are the key to delivering continuity of care for members of the community. “We have a responsibility to help people with low vision. That means recognising when a patient has mild low vision and doing something about it. Then recognising when it gets beyond that – when the patient needs more comprehensive services from a team of people, along with optical devices – and facilitating this as well.

“Optometrists need to proactively maintain communication with the ophthalmologist, the patient, and their GP, and bring in organisations like Vision Australia, RSB and Guide Dogs, when the time comes.”

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