Promoting Independence through Low Vision Rehabilitation

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the n&ionrs&isla. 467-paint health promotion - ,! and disease p ~ e v d objectives, ~ n the dep&& has made "inereas& m e s s to vision reh-p services and teohndogies for peaple with vbiap,:, . impairment" (HealthyPeople Vision 0 b j e ~ t i v e . e ~ 10)the top eye or vision-related priority for this , year. 'Promoting Independence through Low Vi-

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Healthy Vision Month 2005 is dedicated to low vision care. Optometrists should consider how to best serve the growing segment of the population with moderate to severe vision loss.

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sion Rehabilitatio11"has been designated the theme far this year'^ May abservance of "Healthy Eyes . Manth"bythe National Eye Institute. There is good reason for the emphasis on low vidon. Approximately 14 million Americas-about one of every 20 people-alre~dy have low visionr according to The Lighthouse National Survey on Vmim Loss: Ths Experience, Attitudes, and Knowledge of Middle-Aged and Older Americans, compiled by The Lithouse, Inc. of New York, in conjunctioqp&h , [ , { ;h,,.7, (SumR. Gomezano, O.D., is chair of the ACZA Law VZsion &hbiEt@'on Section. Opinions expressed are those of the authar and not necmrily those of AOA.) VOLUME 7blNUMBER 5IMAY 2005

takes notes and piaffom w ~ r pmm1ng d tasks, using a 2.5 x Rinbloom tahIcm&twpeand .enla~gjhgc o n ' puwr soWme to ;enhaw@text arrel $raplib-on the manitor.As &aby EkmmePs age and'requireI- vislon mw8cqhrneMsta will pla)r'WegrdtlW in the prestxjk tion 050ptloal sysi!ms, integmbd with e b t m b Baohnologies that contributeto productm, fulfilling lifestyles.

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Louis Harris and Associates. That number is ezpecied to increase to 20 million by 201'0, accordin6 to Lighthouse International. A National Eye Institutesponsored study has warned h a blindness due to age-related eye disease will become a major public health problem by the year 2020. About 135 million. OPTOMETRY

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people around the world have low vision, according to the report, the World Health Organization (WHO) estimates. People ages 65 and older, as well as African Americans and Hispanics over age 45, are considered to be at risk for low vision, according to HHS. About one in every eight Americans presently is 65 or older. That number is expected to grow as mortality rates drop. By 2030, the number of Americans 65 and older is projected to double. While low vision can result from a variety of diseases, disorders, and injuries that affect the eye (and are not necessarily unique to older adults), it is most often associated with conditions such as age-related macular degeneration, cataract, glaucoma, or diabetic retinopathy. Age-related macular degeneration accounts for almost 45 percent of all cases of low vision. Diabetes already affects 18.2 million Americans-an estimated 5.2 million of whom have not yet been diagnosed. It is the number one cause of acquired blindness, and is expected to increase. HHS considers African Americans and Hispanics over 45 to be at higher risk for low vision because they are at higher risk for developing diabetes and diabetic retinopathy. African Americans are also at a higher risk for developing glaucoma. Defined by NEI as a visual impairment (VI),not correctable by standard glasses, contact lenses, medicine, or surgery, that interferes with a person's ability to perform everyday activities, low vision over the coming years will clearly mean growing numbers of Americans will have trouble performing the daily activities of living and enjoying an optimum quality of life. "People with low vision experience physical, economic, and psychological changes that diminish their quality of life," NEI notes on its Healthy Vision Month (HVM)Web site (www.healthyvisionmonth2010.org). "Low vision affects daily routines (walking, going outside, cooking), leisure activities (reading, sewing, traveling, sports), and the ability to perform job-related functions that can lead to a loss of income. These consequences often lead people with low vision to become confused, grief-stricken, fearful, anxious, and depressed. In addition, people with low vision who lose their depth perception are at greater risk of falling and injuring themselves." One third of all people with visual impairments who responded to a 1994 survey by The Lighthouse said that their vision problems created some difficulty in performing their jobs. Half of all respondents said that the loss of income, as a result of low vision, was a somewhat serious or very serious problem, according to The Lighthouse National Survey on Vision

Loss: The Experience, Attitudes, and Knowledge of Middle-Aged and Older Americans. Evidence suggests that the loss of stereoscopic vision and depth perception increases a person's chances of tripping, falling, or running into objects, such as an open cabinet door, according to 1995 studies in the American Journal of Occupational Therapy and Kansas Medicine. Moreover, more than $68 billion is spent annually on care and services for people who are blind or have visual impairments. These costs include treatment, education, loss of personal income, and associated costs, such as Social Security disability benefits, according to testimony by National Alliance for Eye and Vision Research during a March 2005 hearing before the Labor, Health and Human Services, Education and Related Agencies Subcommittee of the House Appropriations Committee. There is good news. New technology that can help low vision patients maximize available sight and lead productive lives continues to be developed. Moreover, low vision rehabilitation, the critical step beyond the process of merely prescribing low vision devices through which patients are trained on how to best utilize their available sight, is proving on a daily basis to be effective in helping patients to continue leading fulfilling, productive lives. Low vision care is far-and-away most often within the realm of the optometrist. Optometrists pioneered-and continue to develop-low vision care. Optometrists probably provide the vast majority of low vision care in the nation. Moreover, as primary eye and vision care providers, optometrists are the trusted health care providers often best suited to working closely with their patients during a period of great visual change and uncertainty. AOA has a strong and demonstrated commitment to promoting accessible low vision care for people with vision impairments. In 1959 the AOA established the Committee to Aid the Partially Sighted, becoming the Low Vision Section in 1982 and the Low Vision Rehabilitation Section (LVRS)in 2002. AOA Resolution 1858, approved during the Congress of the American Optometric Association in 2002, encourages "every optometrist to continue to either provide, co-manage, or refer every visually impaired patient for appropriate low vision rehabilitation care." Clearly, it is the responsibility of optometrists to now step forward and meet the challenge posed to the nation by low vision. AOA has established low vision rehabilitation as a priority for its Healthy Eyes Healthy PeopleTM program-the association's effort in support of the eye and vision-related Healthy People 2010 objectives. A variety of organizations

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VISUAL IMPAIRMENT CODES*

'Adapted from the World Hulth OrgaoizationStudy Gmup on F~cvmtion of Bhdness (Geseva: November 6-10.1972; WHO Techuinl RepoR Series 518)

368.46 Homonymow bilateral field defects

368.47 Heteronymotls biiated &Id defects 368.41 Central l paracentralmtoma 368.45 General coatmetion or consMrtlon

pJ Legal Bliidnaw Moderrte Visual Impairment Normal or Near Normal

Designed by Mkhael Fbeher, 0. D. Lightboere Inte~~ltlonal. New YO* New York

Practitionersmust remember that diagnosis of vision impairment (ICDCodes 369.01, total vision impairment in each eye to 369.25, moderate vision impairment in each eye, andlor visual-field losses) is a very important aspect of diagnosis of the complete manifestation of the ocular pathology. The vision impairment diagnosis should be documented for each patient who manifests fkctional loss from ocular disease.

and agencies, notably the NEI's National Eye Health Education Project, are providing materials to assist practitioners in providing or educating the public about low vision. However, low vision practice is one of the few areas of eye and vision care that is not growing. The 1999 AOA State of the Profession report found the percentage of optometrists providing low vision services had decreased from 49.9 percent to 44.9 percent. Too often, optometrists generally hold low vision practice to be time-consuming, difficult, labor-intensive, and, above all, unprofitable for the typical private practitioner. Reimbursement for low vision services is considered a problem. Low vision patients are regarded as difficult to diagnose-and to please. The perception is that, if they can be provided at all, low vision services must be provided through specialized agencies devoted solely to low vision and subsidized through grants and government programs. However, the data regarding incidence of low vision problems suggests optometrists, as America's primary eye care providers, are already seeing a fair VOLUME 7MNUMBER 5/MAY 2005

number of patients who are visually impaired in their offices and are going to see more. Optometrists, as a matter of necessity, must be prepared to help handle this growing health problem.

The General Practitioner's Role Virtually all optometrists are already managing patients with vision impairment at some level-even though they may not think that they provide low vision care per se. Once a low vision condition has been properly diagnosed and documented, a practitioner can determine whether low vision devices, vision rehabilitation, or other options are in order and, if so, whether the diagnosing practitioner should provide the patient those treatment options or the patient should be referred to an optometrist whose practice centers primarily on low vision. However, at the very least, the primary optometrist should be able to co-manage or refer patients who have problems that exceed the practitioner's comfort level at any juncture. Not every patient with a vision impairment requires the complex level of care offered by a pracOPTOMETRY

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tice that specializes in low vision rehabilitation. In fact, the primary care optometrist can provide early intervention as soon as a moderate vision impairment posing functional difficulties is diagnosed. There is great value to early intervention, as soon as functional difficulties are identified. This would prevent the common problem of individuals who fall through the cracks and experience years of unnecessary frustration and anxiety about their vision loss. The primary care optometrist can and should provide initial strategies, such as higher-add bifocals and/or supplemental hand magnification with instruction. The primary care optometrist should be able to counsel the patient regarding supplemental services and resources that may be helpful in the near future. For a more detailed look at the factors a primary care optometrist should consider in the examination of a low vision patient, see AOA's Optometric Clinical Practice hidel line: Care of the Patient with Low Vision.

"Vision rehabilitation is the process of treatment and education that helps individuals who are visually disabled attain maximum function, a sense of well being, a personally satisfying level of independence, and optimum quality of life," AOA1sofficial definition states. "Function is maximized by evaluation, diagnosis and treatment including, but not limited to, the prescription of optical, non-optical, electronic and/or other treatments. The rehabilitation process includes the development of an individual rehabilitation plan specifying clinical therapy and/or instruction in compensatory approaches." Vision rehabilitation may be necessitated by- any- condition, disease, or injury that causes a visual impairment resulting in functional limitation or disability, the AOA definition note; In addition to the evaluation, diagnosis and management of visual impairment by an optoietrist or ophthalmologist; rehabilitation mav include, but is not limited to, optometric, medical, allied health, social, educational and psychological services. For most patients services may include activities to assist in integration of low vision systems for daily living tasks, adaptive procedures for accomplishing activities of daily living, communication, safety, and community re-integration, oculo-motor and eccentric viewing techniques, and gait training. Not all optometrists will wish to provide such vision rehabilitation services through their practices. However, all optometrists should be able to explain low vision rehabilitation services to patients, refer patients to practitioners who provide such services, and incorporate those services into a treatment plan.

Not every patient with a

vision requires the complex level o f care offered by a practice that specializes in low vision. In fact the primary care optometrist can provide early intervention as soon as a moderate vision impairment, posing functional difficulties, is diagnosed.

Vision rehabilitation is a treatment option for the functional manifestations of ocular disease and should be referenced in the treatment plan once a vision impairment is documented. It is im~ortantfor ODtometrists to adequately explain to patients the concept of low vision rehabilitation. For most patients, the correction of vision means the dispensing of eyewear and a examination thereafter to ensure the eyewear prescription remains adequate. For patients with eye disease, care may mean continuing visits to the eye care practitionerls office for checkups or treatment, a prescription for medicine, and perhaps a regime of care outside the office. Relatively few patients conceive of eye care as involving a program of education or therapy. Yet education is very often necessary to ensure that patients properly use and adapt to low vision devices. A program of therapy is often necessary to help patients maximize the use of their remaining available vision.

LOW Vision Providers However, while not all optometrists will choose to emphasize low vision care and rehabilitation in their practices, some do and, the AOA Low Vision Rehabilitation Section believes, many more will in the coming years. Low vision practitioners serve as consultants to primary care optometrists and other

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physicians and professionals when advanced clinical skills are needed. They have expertise in the prescription of complex optical systems (e.g. telescopes and microscopes), electronic technologies and establishment of specific vision rehabilitation treatment plans. The treatment plan, which includes the low vision device and additional rehabilitation activities, may be carried out in the optometric clinical setting, other medical facilities, rehabilitation agencies, or sometimes in educational settings. Most care is provided through close interaction with the multi-disciplinary members of the vision rehabilitation network. AOA and the AOA Low Vision Rehabilitation Section offer a variety of materials and education opportunities to assist practitioners who wish to develop or maintain expertise in low vision practice. AOA's Optometric Clinical Practice Guideline: Care of the Patient with Low Vision offers a detailed overview of the diagnosis and care required for a low vision patient. The AOA Low Vision Rehabilitation Section has initiated plans to establish state low vision committees in all state optometric associations to assist low vision practitioners at the local level. The section has also begun offering continuing education programs at state optometric association meetings.

Reimbursement As noted previously, reimbursement has long been an issue in low vision care. Fortunately, most Medicare carriers can provide answers on coverage of low vision care by the nation's largest public health plan. Most Medicare carriers have Vision Rehabilitation Program Local Coverage Decision Policies (LCDPs)that describe application of rehabilitation medicine procedure codes (97000 series) for rehabilitation of vision impairment. Optometlists are defined as physicians for the purposes of management andlor provision of vision rehabilitation services. With low vision likely to emerge as a major health issue over the coming years, AOA and the AOA Low Vision Rehabilitation Section already are actively advocating health care and public policy that uniformly recognizes optometry as the primary provider of the clinical evaluation and management within a multidisciplinary low vision care model.

In addition to the previously mentioned AOA Optometric Clinical Practice Guideline, Care of the Patient with Low Vision, AOA and the AOA Low Vision Rehabilitation Section are actively facilitating the development of standards to ensure competent, quality low vision rehabilitation patient care. Both the AOA Advocacy Group and the section are actively working to win increased funding from the National Eye Institute and other sources in support of clinical research related to low vision conditions. AOA, in conjunction with the section, offers continuing education programs at Optometry's Meeting '"to help optometrists provide stateof-the-art low vision care, as well as at annual State Affiliate Low Vision Care Leader Symposia, allowing interchange on low vision rehabilitation techniques and policy issues between national and regional leadership. Low Vision University, a new continuing education program, is being developed by the section for presentation at AOA state affiliate meetings as well as regional optometric meetings. However, meeting the anticipated future increase in demand for low vision care will ultimately be a matter of increasing the number of optometrists providing such care. In addition to taking advantage of opportunities that may be presented during Healthy Vision Month to educate the public regarding low vision, the AOA Low Vision Rehabilitation Section encourages all AOA members this month to become more involved in the evaluation and management of patients with vision impairment, be it at the primary or more complex level of practice. The section hopes all AOA members, who have not yet already done so, will take a few moments this month to download and read the AOA Optometric Clinical Practice Guideline, Care of the Patient with Low Vision, available through the AOA Web site (www.aoa.org)and then consider how they might better provide care for low vision patients through their practices. The AOA Low Vision Rehabilitation Section is ready to assist practitioners who wish to provide low vision care and rehabilitation at any level. For more information contact: AOA Low Vision Rehabilitation Section, Stephanie Brown, Manager, (800) 365-2219 ext. 225; [email protected].

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