- Email: [email protected]
Low-vision services in Toronto—Author reply
CORRESPONDENCE Low-vision services in Toronto (Provision and utilization of low-vision rehabilitation services in Toronto.Vol. 42[5])
Dear Editor,
W
e appreciate this opportunity to comment on the article by Drs. Nia and Markowitz.1 Firstly, what exactly the authors mean by low-vision rehabilitation (LVR) is unclear. As they correctly point out, LVR constitutes a spectrum of activities, including low-vision services; orientation and mobility training; and independent living services, among others. The authors discuss the possibility that LVR can be made available by providers other than CNIB (Canadian National Institute for the Blind), and suggest that these services can be provided by ophthalmologists, optometrists, and others. Actually, it is, for the most part, only low-vision assessments that are provided in these settings, not the full range of activities provided by CNIB. Secondly, we question the ability to draw generalized conclusions from this observational study. It used an extremely small sample with a great variance in baseline acuities, ages, and length of time with low vision. The study employed no control group, nor were the subjects randomized. We also believe it is impossible to draw conclusions about the need for specific additional services when only half of the patients surveyed had received LVR services. We disagree with the authors that the awareness of LVR services by ophthalmologists is high. The fact that only 50% of ophthalmologists referred these patients bears this out. Furthermore, a recent study conducted by Adam and Pickering2 reported that the Toronto ophthalmological community had a limited understanding of the full range of CNIB services. Low-vision services in Toronto—Author reply (Provision and utilization of low-vision rehabilitation services in Toronto.Vol. 42[5])
Dear Editor,
W
e thank Gordon et al. for showing interest in our article.1 The following clarifies further our published article and we believe also responds to the comments made by the writers. Although the Canadian National Institute for the Blind (CNIB) has the most noticeable presence across the country and an illustrious and commendable track record of service, there are many others, mainly optometrists and ophthalmologists, who provide valuable, advanced, and comprehensive services to the visually impaired. Any concept of a modern low-vision rehabilitation (LVR) program should encompass a multidisciplinary team approach, at the core of which is a low-vision assessment performed by an optometrist or ophthalmologist specializing in LVR, resulting in a rehabilitation plan to be imple-
116
CAN J OPHTHALMOL—VOL. 43, NO. 1, 2008
Early referral by ophthalmologists to LVR is encouraged, since early rehabilitation is key to a successful transition to living with vision loss. Many of the serious side effects associated with vision loss, such as falls and depression, can be minimized with the appropriate training and counselling. We agree with the authors that the AAO SmartSight model3 is one that can solve some of these issues. CNIB also believes that a multidisciplinary, cooperative team approach that fully involves the comprehensive service provided by CNIB Low Vision Specialists in the rehabilitation of individuals with low vision is essential as Canada prepares for a simultaneous decline in the number of ophthalmologists and an increasing demand for LVR services. REFERENCES 1. Nia K, Markowitz SN. Provision and utilization of low-vision rehabilitation services in Toronto. Can J Ophthalmol 2007;42:698–702. 2. Adam R, Pickering D. Where Are All The Clients? Barriers to Referral for Low Vision Rehabilitation. Oral presentation, Canadian Ophthalmological Society, Edmonton; 2005. 3. Jackson ML. Vision rehabilitation for Canadians with less than 20/50 acuity: the SmartSight model. Can J Ophthalmol 2006;41:355-61.
Keith D. Gordon, Dawn Pickering CNIB Toronto, Ont. Correspondence to: Keith D. Gordon, PhD; [email protected] Can J Ophthalmol 2008;43:116 doi:10.3129/i07-214
mented by opticians, occupational therapists, and the various rehabilitation teachers, instructors, and other service providers for the visually impaired.2 This concept was recently adopted as the optimal LVR model by leading representatives of the American Academy of Ophthalmology, the American Optometric Association, the American Occupational Therapy Association, and the Association for Education and Rehabilitation of the Blind and the Visually Impaired, all in the United States.3 The multidisciplinary approach adopted implies that every service provider provides specialized services (low-vision assessment, prescribing, dispensing, training, counseling, etc.), none contemplates or endeavors to provide all services, and referrals are made to the appropriate specialist when the need for specific services is identified. Estimates show that only 10% to 20% of all low-vision patients receive rehabilitation services, often because of a lack of referrals from eye care providers such as optometrists and ophthalmologists.4 While this may be the case in other parts of the country, the fact that Toronto ophthalmologists showed a higher rate of referrals to LVR services, as high-
Correspondence lighted in our study, demonstrates a commendable high awareness of the needs of visually impaired patients, which is unusual, but not surprising to the authors. Since most referrals were made to the CNIB, it also demonstrates the high esteem of Toronto ophthalmologists toward the CNIB as a provider of LVR services. Recent data show that the number of ophthalmologists graduating from residency programs in Canada is on the rise.5 Also noticeable is the fact that ophthalmology residents in Canada receive LVR training as part of their curriculum and many, as witnessed at the University of Toronto, have an interest in research in LVR, as illustrated in this paper. Every year, the university also graduates a fellowship-trained ophthalmologist in LVR. There is a growing interest among ophthalmologists in Canada and the United States in getting involved with LVR, and a recent study showed, in fact, that LVR is one of the fastestgrowing segments of office practice.6 The main issue raised by the visually impaired patients in our current pilot study was the need for additional LVR services to address their needs and to supplement the services currently provided. The change in demographics that we see today, with estimates of growing numbers of visually impaired patients descending on our offices, as well as recent scientific advances in the assessment and practice of LVR, require an urgent review of all models of LVR currently in use in Canada. Our American colleagues are starting the process of reviewing and reforming the models of LVR services currently in use in the United States. We in Canada should do the same, to address the issues raised above and to address the dis-
Necrotizing scleritis and fibromyalgia: a potential link?
A
57-year-old woman presented with intense injection and severe pain in the right eye for more than 2 weeks. She had undergone right cataract surgery 5 months prior and had developed an episode of episcleritis. History was remarkable for fibromyalgia, type II diabetes, and hypertension. On examination, vision was 20/200 in the right eye and 20/50 in the left, corrected. Anterior segment examination revealed an area of scleral necrosis extending approximately 3 to 4 clock hours. Uveal tissue was visible with multiple infiltrates along the superior corneal limbus, and the anterior chamber revealed a 4+ cellular reaction. Intraocular pressure was 6 mm Hg. A general medical workup was negative for connective tissue disease. She was treated with oral prednisone, 50 mg twice daily, moxifloxacin, tobramycin, dexamethasone, and atropine, and later received 3 doses of intravenous cyclophosphamide. With close follow-up over 4 weeks, her vision gradually improved to 20/80. The superior aspect of the globe, however, showed a large staphyloma, with an adjacent area of avascular sclera with positive fluorescein
satisfaction expressed by our visually impaired patients with the current services. There is no doubt in our minds that ophthalmologists across the country will support the incorporation of the CNIB into any future model of service for the visually impaired, if and when one is adopted in Canada. REFERENCES 1. Nia K, Markowitz SN. Provision and utilization of low-vision rehabilitation services in Toronto. Can J Ophthalmol 2007;42:698–702. 2. Markowitz SN. Principles of modern low vision rehabilitation. Can J Ophthalmol 2006;41:289–312. 3. Mogk L. Personal communication. Vision Rehabilitation Education Day, American Academy of Ophthalmology meeting, New Orleans, November 2007. 4. Gold D, Zuvela B, Hodge WG. Perspectives on low vision service in Canada: a pilot study. Can J Ophthalmol 2006;41:348–54. 5. Trope G. Personal communication. Staff Research Day. Department of Ophthalmology and Vision Sciences, University of Toronto, October 2007. 6. American Academy of Ophthalmology. Academy Notebook. Available at: http://www.aao.org/publications/eyenet/200602/ notebook.cfm
Keon Nia, Samuel N. Markowitz University of Toronto Toronto, Ont. Correspondence to: Samuel N. Markowitz, MD; [email protected] Can J Ophthalmol 2008;43:116–7 doi:10.3129/i07-206
staining. The nasal sclera was very thin, with a bluish hue. Her condition has now been stable for more than 12 months (Fig. 1). Scleritis is an inflammatory disease of the sclera that presents with severe pain, photophobia, a red eye, and decreased vision. Necrotizing scleritis, in particular, is the most destructive form, and its presence is strongly associated with a systemic connective tissue disease in 50% to 81% of patients.1
Fig. 1—External examination showing superior staphyloma at the site of previous necrotizing scleritis. CAN J OPHTHALMOL—VOL. 43, NO. 1, 2008
117
Dear Editor,
W
e appreciate this opportunity to comment on the article by Drs. Nia and Markowitz.1 Firstly, what exactly the authors mean by low-vision rehabilitation (LVR) is unclear. As they correctly point out, LVR constitutes a spectrum of activities, including low-vision services; orientation and mobility training; and independent living services, among others. The authors discuss the possibility that LVR can be made available by providers other than CNIB (Canadian National Institute for the Blind), and suggest that these services can be provided by ophthalmologists, optometrists, and others. Actually, it is, for the most part, only low-vision assessments that are provided in these settings, not the full range of activities provided by CNIB. Secondly, we question the ability to draw generalized conclusions from this observational study. It used an extremely small sample with a great variance in baseline acuities, ages, and length of time with low vision. The study employed no control group, nor were the subjects randomized. We also believe it is impossible to draw conclusions about the need for specific additional services when only half of the patients surveyed had received LVR services. We disagree with the authors that the awareness of LVR services by ophthalmologists is high. The fact that only 50% of ophthalmologists referred these patients bears this out. Furthermore, a recent study conducted by Adam and Pickering2 reported that the Toronto ophthalmological community had a limited understanding of the full range of CNIB services. Low-vision services in Toronto—Author reply (Provision and utilization of low-vision rehabilitation services in Toronto.Vol. 42[5])
Dear Editor,
W
e thank Gordon et al. for showing interest in our article.1 The following clarifies further our published article and we believe also responds to the comments made by the writers. Although the Canadian National Institute for the Blind (CNIB) has the most noticeable presence across the country and an illustrious and commendable track record of service, there are many others, mainly optometrists and ophthalmologists, who provide valuable, advanced, and comprehensive services to the visually impaired. Any concept of a modern low-vision rehabilitation (LVR) program should encompass a multidisciplinary team approach, at the core of which is a low-vision assessment performed by an optometrist or ophthalmologist specializing in LVR, resulting in a rehabilitation plan to be imple-
116
CAN J OPHTHALMOL—VOL. 43, NO. 1, 2008
Early referral by ophthalmologists to LVR is encouraged, since early rehabilitation is key to a successful transition to living with vision loss. Many of the serious side effects associated with vision loss, such as falls and depression, can be minimized with the appropriate training and counselling. We agree with the authors that the AAO SmartSight model3 is one that can solve some of these issues. CNIB also believes that a multidisciplinary, cooperative team approach that fully involves the comprehensive service provided by CNIB Low Vision Specialists in the rehabilitation of individuals with low vision is essential as Canada prepares for a simultaneous decline in the number of ophthalmologists and an increasing demand for LVR services. REFERENCES 1. Nia K, Markowitz SN. Provision and utilization of low-vision rehabilitation services in Toronto. Can J Ophthalmol 2007;42:698–702. 2. Adam R, Pickering D. Where Are All The Clients? Barriers to Referral for Low Vision Rehabilitation. Oral presentation, Canadian Ophthalmological Society, Edmonton; 2005. 3. Jackson ML. Vision rehabilitation for Canadians with less than 20/50 acuity: the SmartSight model. Can J Ophthalmol 2006;41:355-61.
Keith D. Gordon, Dawn Pickering CNIB Toronto, Ont. Correspondence to: Keith D. Gordon, PhD; [email protected] Can J Ophthalmol 2008;43:116 doi:10.3129/i07-214
mented by opticians, occupational therapists, and the various rehabilitation teachers, instructors, and other service providers for the visually impaired.2 This concept was recently adopted as the optimal LVR model by leading representatives of the American Academy of Ophthalmology, the American Optometric Association, the American Occupational Therapy Association, and the Association for Education and Rehabilitation of the Blind and the Visually Impaired, all in the United States.3 The multidisciplinary approach adopted implies that every service provider provides specialized services (low-vision assessment, prescribing, dispensing, training, counseling, etc.), none contemplates or endeavors to provide all services, and referrals are made to the appropriate specialist when the need for specific services is identified. Estimates show that only 10% to 20% of all low-vision patients receive rehabilitation services, often because of a lack of referrals from eye care providers such as optometrists and ophthalmologists.4 While this may be the case in other parts of the country, the fact that Toronto ophthalmologists showed a higher rate of referrals to LVR services, as high-
Correspondence lighted in our study, demonstrates a commendable high awareness of the needs of visually impaired patients, which is unusual, but not surprising to the authors. Since most referrals were made to the CNIB, it also demonstrates the high esteem of Toronto ophthalmologists toward the CNIB as a provider of LVR services. Recent data show that the number of ophthalmologists graduating from residency programs in Canada is on the rise.5 Also noticeable is the fact that ophthalmology residents in Canada receive LVR training as part of their curriculum and many, as witnessed at the University of Toronto, have an interest in research in LVR, as illustrated in this paper. Every year, the university also graduates a fellowship-trained ophthalmologist in LVR. There is a growing interest among ophthalmologists in Canada and the United States in getting involved with LVR, and a recent study showed, in fact, that LVR is one of the fastestgrowing segments of office practice.6 The main issue raised by the visually impaired patients in our current pilot study was the need for additional LVR services to address their needs and to supplement the services currently provided. The change in demographics that we see today, with estimates of growing numbers of visually impaired patients descending on our offices, as well as recent scientific advances in the assessment and practice of LVR, require an urgent review of all models of LVR currently in use in Canada. Our American colleagues are starting the process of reviewing and reforming the models of LVR services currently in use in the United States. We in Canada should do the same, to address the issues raised above and to address the dis-
Necrotizing scleritis and fibromyalgia: a potential link?
A
57-year-old woman presented with intense injection and severe pain in the right eye for more than 2 weeks. She had undergone right cataract surgery 5 months prior and had developed an episode of episcleritis. History was remarkable for fibromyalgia, type II diabetes, and hypertension. On examination, vision was 20/200 in the right eye and 20/50 in the left, corrected. Anterior segment examination revealed an area of scleral necrosis extending approximately 3 to 4 clock hours. Uveal tissue was visible with multiple infiltrates along the superior corneal limbus, and the anterior chamber revealed a 4+ cellular reaction. Intraocular pressure was 6 mm Hg. A general medical workup was negative for connective tissue disease. She was treated with oral prednisone, 50 mg twice daily, moxifloxacin, tobramycin, dexamethasone, and atropine, and later received 3 doses of intravenous cyclophosphamide. With close follow-up over 4 weeks, her vision gradually improved to 20/80. The superior aspect of the globe, however, showed a large staphyloma, with an adjacent area of avascular sclera with positive fluorescein
satisfaction expressed by our visually impaired patients with the current services. There is no doubt in our minds that ophthalmologists across the country will support the incorporation of the CNIB into any future model of service for the visually impaired, if and when one is adopted in Canada. REFERENCES 1. Nia K, Markowitz SN. Provision and utilization of low-vision rehabilitation services in Toronto. Can J Ophthalmol 2007;42:698–702. 2. Markowitz SN. Principles of modern low vision rehabilitation. Can J Ophthalmol 2006;41:289–312. 3. Mogk L. Personal communication. Vision Rehabilitation Education Day, American Academy of Ophthalmology meeting, New Orleans, November 2007. 4. Gold D, Zuvela B, Hodge WG. Perspectives on low vision service in Canada: a pilot study. Can J Ophthalmol 2006;41:348–54. 5. Trope G. Personal communication. Staff Research Day. Department of Ophthalmology and Vision Sciences, University of Toronto, October 2007. 6. American Academy of Ophthalmology. Academy Notebook. Available at: http://www.aao.org/publications/eyenet/200602/ notebook.cfm
Keon Nia, Samuel N. Markowitz University of Toronto Toronto, Ont. Correspondence to: Samuel N. Markowitz, MD; [email protected] Can J Ophthalmol 2008;43:116–7 doi:10.3129/i07-206
staining. The nasal sclera was very thin, with a bluish hue. Her condition has now been stable for more than 12 months (Fig. 1). Scleritis is an inflammatory disease of the sclera that presents with severe pain, photophobia, a red eye, and decreased vision. Necrotizing scleritis, in particular, is the most destructive form, and its presence is strongly associated with a systemic connective tissue disease in 50% to 81% of patients.1
Fig. 1—External examination showing superior staphyloma at the site of previous necrotizing scleritis. CAN J OPHTHALMOL—VOL. 43, NO. 1, 2008
117