Many of us have referred patients to "low-vision specialists," only to find that these patients were examined, evaluated and sent home with one or more magnifiers. More often than not, when we saw them again, we learned they had purchased expensive aids that wound up occupying space in a drawer without producing any level of satisfaction or assistance.

Because of these experiences, we stopped making such referrals. The unfortunate result was usually a gap in patient care. But just as it's the obligation of the orthopedic surgeon who removes a limb to refer his patient for a prosthesis, rehabilitative therapy and counseling, it's the responsibility of the eyecare practitioner to make sure the same continuum of care exists for patients with pathologies that cause visual impairment.

By referring our low-vision patients to the appropriate services, we'll enable more of them to live independently, allowing for a decrease in costly long-term support services.

What's changed

Though the science and practice of low-vision care has been around for decades, dramatic advances have been made in recent years. Today, we have easy-to-use, effective, advanced technologies incorporated into vision aids from magnifiers to fiber optic light sources to lightweight, wearable auto-focus systems. We've also come to better understand the vast potential of low-vision therapy.

In this article, I'll highlight some of the advances in low-vision care and provide guidance on finding and evaluating the best resources and services available to your patients.

As we discuss your referral options, keep in mind that any comprehensive low-vision program should include:

�        a thorough evaluation of the patient's status

�        design of aids where appropriate

�        therapy in fixation and ocular motility, as well as in related activities of daily living

�        ongoing support and referral to allied agencies to help improve the quality of the patient's life.

When a program includes those services, the low-vision care experience is rewarding for the patient and you, the referring practitioner.

Ensuring a productive continuum of care

Consider the following example of how drastically a patient's quality of life can improve when a referral provides a continuum of care.

Six months ago, I saw a 79-year-old female patient. She had been a certified public accountant and an avid bridge player. She was diagnosed with age-related macular degeneration (AMD) and told that nothing could be done to stabilize her condition following the course of laser treatment.

Her ophthalmologist had handed her a pamphlet describing the condition -- which she couldn't read -- and when it was read to her, it didn't give her information beyond the basic description of the condition.

At her follow-up, she noticed that her vision was worse than it had been before the laser, but was told that the laser would help slow the progression of the condition. Despite this reassurance, she still didn't really comprehend her condition well enough to know why it had to be this way, and neither her surgeon nor his staff seemed to have the time to explain it to her fully.

She was also being fed through a stomach tube, which required a nurse to come to her home daily, greatly reducing her independence and self-image.

Independence gained

When I first evaluated this patient, I found that she was using a Preferred Retinal Locus (PRL), giving her a central acuity of 10/400. However, she had a functional eccentric fixation point (a healthy area of the retina that had been spared the degenerative process), that she wasn't aware of.

This eccentric fixation point permitted her to see 10/80 for distance using conventional spectacles and viewing her targets approximately 10 degrees to the left of center. I prescribed a 2.2x full-diameter telescope (FDTS), coupled with a course of eccentric fixation therapy carried out by one of our staff occupational therapists.

Within 6 weeks, she was able to read 12-point type with a reading cap over her FDTS. And with auxiliary caps she could view her computer screen. She was also able to see 10/30 for distance, enhancing her television viewing.

Now, she can once again do all of the bookwork for her condo, play bridge, and feed herself. She has regained her independence to a great extent, and the change in her personality is remarkable.

Patient education is crucial

She's one of the approximately 30% of patients evaluated at the Low Vision Institute who can benefit from the use of an eccentric fixation point. We find that 40% of our patients have vision that's so poor we can't help them through the services we offer, so we refer them to more traditional services for the blind. The remaining 30% are still able to view centrally, but require some form of aid and proper training in its use.

What most of our patients have in common, however, is a poor initial understanding of what macular degeneration is. When I initially evaluate a low-vision patient, I can usually count on being asked two questions.

The first question, which normally comes at the start of the examination is: "What's macular degeneration?" That's a relatively easy question to answer to a patient's satisfaction.

An hour and a half later, following the examination, I almost inevitably hear the second question: "Why didn't someone send me for a low-vision evaluation sooner?" I have a much more difficult time trying to answer this one to the patient's -- and my own -- satisfaction.

I find that a good explanation of the condition is perhaps one of the most valuable parts of the low-vision experience for patients and their families. Even those who we can't help have a much clearer understanding of what they are dealing with following their evaluation -- and what they must then do to try to improve their situations.

Many aids, much support

Today, there's wide diversity in the types of aids available to assist low-vision patients. Aids range from the traditional hand-held magnifiers to fiber optic-based high-clarity magnifiers to powerful light sources whose fiber optic technology generates no heat near the user.

Even more advanced are aids such as the lightweight Flipper and Jordy auto-focus systems with built-in TV capabilities. Patients wear these devices like a pair of glasses, or in the case of the Jordy, on the forehead, with electronic magnification providing enhanced vision through the equivalent of a large TV screen. Another lightweight system, the VES Autofocus, uses optical magnification to help the user identify near and far objects through an auto focus bioptic mounted scope, which is attached to an eyeglass frame.

Closed-circuit television systems (CCTVs), commonly referred to as reading machines, incorporate a camera and an x/y table to enable the patient to read written material on a television screen. CCTV functions with little or no distortion, providing the patient with a means to read that's easy to master.

A practice that's truly dedicated to helping patients with low vision will make a commitment by having a variety of these aids on hand, with easy access to almost all forms of other currently available aids.

All of the aids we prescribe are dispensed in the patients' homes, even the simplest hand-held magnifiers. This gives the therapist the opportunity to assess the layout and lighting in a particular patient's environment, and make suggestions that enable that patient to get the greatest benefit from the aids.

This results in a high level of patient satisfaction and function, and greatly reduces the additional chair time I have with patients who may find that aids don't work as well at home as they did when we prescribed them in the office.

As illustrated by the example previously given, when appropriate, patients receive therapy to enable them to fixate properly and use their aids more efficiently. Low-vision aids are like musical instruments. Without proper training they won't make any music, but with the right training, patients learn to use their residual vision, opening up all kinds of opportunities for them to utilize other aids to regain many of the hobbies and skills they formerly possessed.

Evaluating success

It's important for you, as the referring physician to be able to access the competence of the low-vision practice to which you are sending your patients.

There currently aren't enough low-vision practitioners to meet present or immediate future needs. If you're lucky enough to have a low-vision specialist, or more then one, to choose from, be especially tuned to the feedback you receive from the patients you refer. This is your best resource for evaluating the success of your referrals.

A bad or incomplete low-vision experience may be worse than no experience at all for your patients. If they don't achieve success because of an incomplete or improper evaluation, they may balk at going to another practitioner who may be better able to truly meet their needs.

It's important for you to do some background checking on any low-vision practice you plan to use. Try to find a few patients you can talk to who have had experience with the practice. You may also consult some of the organizations that the practitioners belong to. (See "Sources of Low-Vision Information" below)

Track the patient's progress

Any low-vision specialist you refer to should also send you a full report of all initial patient evaluations, including the assessment and treatment plan for each patient. The low-vision practice should provide regular progress reports as well.

Additionally the practice should have occupational therapists specializing in low-vision therapy on staff, or be affiliated with a group practice of occupational therapists.

More often then not, low-vision practitioners will be actively involved in support group organizations within their community, and frequently at state and national levels as well.

I've had the pleasure of sharing many patients with Retina Vitreous Consultants, of Fort Lauderdale, Fla. The practice administrator there, Helene Slonin, has worked in this capacity with two large retinal practices.

It's been her experience that when patients are shown a video explaining their condition in detail, followed by a question and answer session, and presented with a manual containing addresses of support organizations and services, they have the most positive attitudes. They tend to initially deal far better with their condition than those individuals who weren't afforded a similar opportunity.

Every ophthalmologist who refers patients to a low-vision specialist should try to provide patients with at least some of this information before a patient visits the specialist. It can eliminate a great deal of doubt and fear.

Lewis Dan, M.D., of North Miami Beach, Fla., for example, makes time for a high level of personal interaction with his patients and understands the benefits that this provides. He explains each patient�s diagnosis in great detail, generally finding the bright spots relating to their situations. By doing this, he makes each patient feel better. In busy surgical practices where this level of involvement isn't possible, the referral to outside low-vision services is all the more crucial.

Medicare helps in some states

Remember, Medicare now provides payment for some level of low-vision rehabilitative services in areas where the regional carrier has approved such reimbursement (See "AAO Asks All Regional Carriers for Low-Vision Medicare Coverage" below).

In some states, a low-vision assessment is provided and the appropriate therapy is covered.

Low-vision aids aren't currently covered, so we always try to use the most basic aids that will meet the patient�s needs and goals, given the large variety of resources at our disposal. In many instances, multiple aids are required to meet the wide range of activities in which the patient wants to participate.

Everyone can win

With the continued aging of our population, we'll see more patients with age-related ocular conditions, and the need for quality low-vision services will continue to increase.

Arranging for the continuum of care suggested here can only serve to improve the quality of patients' lives, while at the same time fulfilling the obligation of the ophthalmologist to his or her low-vision patients. To use a football analogy, if each professional on the healthcare team delivers a clean handoff to the next professional, patients can live more independently, avoiding more expensive care. The whole healthcare team scores a touchdown.

Sources of Low-Vision Information

Today, there is a wealth of information that can assist us in the evaluation and treatment of low-vision patients, and much of it is readily available over the Internet.

Most manufacturers of low-vision aids have Web sites that can be accessed. Collectively, they have formed an organization called The Low Vision Council (www.info@lowvisioncouncil.org). Almost all of the major manufacturers and distributors can be identified and reached online. The Lighthouse Web site (www.lighthouse.org) provides access to practitioners offering low-vision services, as well as equipment and allied support organizations.

Other helpful sites for information about low vision include:

�        The American Optometric Association (www.aoanet.org)

�        The Low Vision Gateway (www.lowvision.org)

�        The International Society for Low-Vision Research and Rehabilitation (www.islrr@lighthouse.org)

�        American Macular Degeneration Foundation (www.macular.org)

�        Low Vision Institute (www.lowvisioninstitute.com).

Most states have an office of services for the blind and a panel of specialists who are qualified to provide appropriate assistance. The Lions Club, Kiwanis International, the Jaycees and other civic organizations may be of service to patients who can't otherwise afford aids, assisting them in obtaining these instruments when required.

AAO Asks All Regional Carriers for Low-Vision Medicare Coverage

With 22 states currently providing at least some Medicare payments for low-vision rehabilitative therapy services through their regional carriers, the American Academy of Ophthalmology (AAO) has begun an initiative to make such coverage national.

The Academy's initial aim is to convince those regional carriers that currently allow no -- or very limited -- Medicare payments for low-vision services to adopt a new, comprehensive AAO policy that suggests limits and conditions for Medicare coverage related to these services. The Academy is currently presenting its policy to more than 15 regional carriers and anticipates responses from each of them.

The AAO's longer-range goal is to have the Health Care Financing Administration (HCFA) implement a uniform national low-vision coverage policy -- based on the Academy's suggested policy -- within 2 years.

"This is a thoroughly researched policy that offers a well-defined benefit for a well-defined pool of individuals," says Justin Nelson, Washington representative for the AAO, noting that low vision affects 21% of adults aged 65 and older. "Coverage of 12 hours of rehabilitative low-vision therapy for eligible patients will provide a significant payback to the healthcare system, with more people able to function successfully in their daily lives and less people suffering burns, falls and fractures."

The proposed AAO policy targets only those patients with clear potential for significant improvement. Patients must meet criteria that indicate that they are likely to receive long-term benefits from such therapy.

As part of the Academy's proposal, certified low-vision specialists would be under general supervision as opposed to direct supervision. An ophthalmologist would not have to be in the office at all times, and could leave to perform surgery or other duties without disrupting the low-vision treatment.

The concept of general supervision breaks with traditional Medicare regulations governing the supervision of physician extenders. However, the Academy believes specially trained and certified low-vision experts deserve this exception.

Specialists who would qualify under the "general supervision" proposal include thosewho have been certified as: Specialist in Low Vision, Low-Vision Therapist, Orientation and Mobility Specialist, and Rehabilitation Teacher. Non-certified rehabilitative service providers would still have to be under the direct supervision of a physician.

Joining the AAO in this effort are the National Eye Institute, organizations representing the visually impaired and several members of Congress.

"What we are proposing constitutes an effective policy for an important segment of the population that has been underserved in the past," concludes Nelson. "The precedent is well-established for Medicare to cover a wide variety of rehabilitative services, and we believe low vision should be no exception."

Marc Jay Gannon, O.D., is the director of the Low Vision Institute. You can reach him at (954) 776-5223.