Vision Loss in Seniors: We Can Do MORE
It's time to make visual rehabilitation a priority.
By Lylas Mogk, M.D.

Ophthalmologists are in the quiet eye of a growing storm. The storm is the epidemic of adult vision loss, which for the first time in the more than 80 years of our specialty has catapulted ophthalmologists into the position of oncologists and neurologists. We now have to deliver devastating news, often.

Even if we can't affect our patients' vision, we have tremendous power to improve the quality of their lives -- and we don't even realize it. This article will explain what we, as ophthalmologists, can easily do to ensure that our senior patients with vision loss get the help they desperately need, and why it's important for us to do this.

Our message to patients must be positive

Vision loss has more global impact on function and causes more depression in seniors than any other single impairment. Most of us intuitively know that we would rather lose an arm or a leg than our sight. Our patients would make the same choice. When they hear that they are losing vision, they hear it as a death sentence. For them, it means the end of their life as they know it.

Yet what we tell our patients is: "You have macular degeneration. Nothing can be done, but you won't go completely blind, so you'll be okay. Just stop driving, check your grid, and come back in 3 months." This is akin to a neurologist saying: "You've had a stroke. You'll never use your right arm again, but you still have the left one, so you'll be okay. Just get an automatic shift car, take your aspirin, and come back in 3 months." Neurologists would never dream of saying that. They would refer their patients to rehabilitation, so why don't we? Because visual rehabilitation hasn't been part of medicine. By sheer happenstance, rehabilitation for people with visual impairments developed separately from other forms of rehabilitation, and outside the medical system.

For most of the past 50 years, vision rehabilitation focused on veterans, blind children and young adults. The new wave of visually impaired seniors, however, has turned those demographics upside down and also swamped a system that was developed for smaller numbers of younger people.

This acute and escalating need has prompted ophthalmologists to include visual rehabilitation under the umbrella of medicine and bring occupational therapists to it as well. Medical visual rehabilitation programs tailored to patients' individual needs and capabilities are gradually developing, and with them hard-earned Medicare coverage.

Five years ago, only three states had Medicare reimbursement for visual rehabilitation. By April of this year, 36 states had gained coverage and several more were pending. Then, on May 29, the Centers for Medicare and Medicaid Services adopted a national policy to cover visual rehabilitation, effective immediately. Bills are now before the U.S. House and Senate to add new providers with training and experience outside the medical system: rehabilitation teachers, orientation and mobility specialists, and certified low-vision therapists, the latter a specialty designed specifically to team with physicians.

Adapting patients' lifestyles

What exactly is visual rehabilitation?

It's training to enable people with visual impairments to maintain their independence, safety and quality of life in spite of vision loss. Comprehensive visual rehabilitation employs techniques of:

• scotoma identification and awareness
• preferred retinal locus (PRL) training
• PRL-hand coordination, tracking and scanning
• environmental adaptations in lighting, contrast, glare control, organization and labeling
• adaptive devices, including a range of hand-held, head-mounted, and video magnifiers, computers and nonoptical tools (Note: Prescribing optical devices is an essential part of visual rehabilitation, but only a part.)
• community reintegration and safe mobility
• attention to the emotional and psychological impact of vision loss
• directing patients to local and national resources.

Without these resources and the skills that rehabilitation imparts, seniors with vision loss are at high risk for falls, injuries, medication mix-ups, nutritional decline, social isolation, and depression at far higher rates than reported for any other disease process. Few can reverse the slide toward dependence on their own. "When a man loses his sight he does not know himself what he can do," said Helen Keller. "He needs someone with experience to teach him."

In the following sections, I'll outline some tips for everyday living that you can provide to your low-vision patients, plus some specific services you can offer these patients and resources you can use to improve your own ability to better serve low-vision patients.

Improve lighting. Use directed lighting for all near tasks, such as a gooseneck lamp with an indoor 45- or 65-watt floodlight bulb. Make sure to install good hall, closet and stairway lighting.

Increase contrast. Pour coffee into white cups. Put oatmeal in dark bowls. Use white plates on dark place mats. Have a black cutting board for onions and a white one for meat. Hang a black towel behind you to see light hair in the mirror. Use a felt-tip pen, not a ballpoint.

Control glare. Wear amber or dark yellow fitovers, or clip-ons and a visor outside. Wear yellow clip-ons inside. (Contact Noir at 800-521-9746 or www.noir-medical.com for information on these products.) Also, cover shiny surfaces with a cloth.

Enlarge. Get large-size checks from your bank, a large-dial phone, large TV remote, large-print crossword books and large-print playing cards. Copy and enlarge recipes, addresses, sheet music and menus from favorite restaurants. Use the accessibility features on your computer or purchase inexpensive enlargement software (for example, Big Shot by Ai Squared at www.aisquared.com).

Label. Mark key positions on stove, washer and thermostat dials with bright, raised "hi marks" from the fabric store. Put rubber bands on similar containers to differentiate them. Label spices and meds with a dark marking pen. Put a safety pin in the labels of black clothes to differentiate from navy; pin socks together before washing.

Organize. Have a place for everything, including specified spaces on kitchen shelves and in the refrigerator. Request that everyone else in the household respect and maintain the organizational system.

Services you can offer

To the above lists of resources and tips, add:

A complete handout packet. Provide basic information about low vision/vision rehabilitation programs in your area: what services they offer, whether training in activities of daily living is included, and whether optical devices are loaned for trial use, or are returnable. Information about resources in your community may include transportation services, support groups, community newspapers on tape, radio reading services and free phone assistance.

Basic low-vision aids. Prescribe high adds. These alone will be helpful to many of your low-vision patients. Just demonstrate the closer working distance. Prescribe up to 4D add-in for bi- or trifocals, and higher in separate readers with base-in prisms to ease the convergence demand. High reading powers with good light work well for many with acuities 20/50 to 20/100, and even beyond.

You can also offer the following vision aids to patients:

• stock base-in prism readers, which are available in +4 to +12D; also monocular spectacles to +20D
• tinted fitovers and clip-ons: amber, dark yellow, plum, light yellow (with UV and blue-light filters)
• a selection of magnifiers and closed-circuit television (CCTV) devices. These can include 3, 5 and 7x lighted stand, hand and pocket magnifiers, brightfield dome, Walters headband with multiple lenses, and Coil TV glasses. Demonstrate these devices so your patients can see exactly how they work.

CCTVs include:

• Max, Flipper and Merlyn by Enhanced Vision
• ClearView by Optelec
• Aladdin by Telesensory
• Primer and Magnicam by Innoventions
• Explorer by MagniSight.

Comprehensive services. A retired or semi-retired colleague can develop the expertise to join your staff doing visual rehabilitation part time (OMIC will provide low-cost malpractice insurance for these physicians). Or hire a low-vision optometrist who believes in comprehensive rehabilitation.

You can also hire or contract with an occupational therapist with skills in visual rehab, or a certified low-vision therapist, rehabilitation teacher or orientation and mobility specialist. Occupational therapists may work and bill independently; the others must bill incident to a physician and work in the building where you are present.

Another alternative: Pool resources with your local colleagues to create a visual rehabilitation program for your whole community. An example is the Deicke Center, founded by the Wheaton (Ill.) Eye Clinic, and run by a low-vision optometrist with a staff of rehabilitation professionals.

Additional resources you can draw upon

The American Academy of Ophthalmology (AAO). The AAO offers the following instruction and publications. For information, and to register or order, contact the AAO at 415-561-8500 or online at www.aao.org:

• Oh Say Can You See?-- a low-vision education day sponsored by the AAO Vision Rehabilitation Committee in Orlando, Fla., on Sunday, Oct. 20. No charge.
• instruction courses at the Academy on the practice and business aspects of visual rehabilitation. Contact the Academy for specific dates and times.
• AAO publications: Preferred Practice Pattern in Low Vision Rehabilitation, 2001, and Low-Vision Rehabilitation: Caring for the Whole Person, Ophthalmology Monograph 12, Ed. D. C. Fletcher, M.D.

Lighthouse International. The Lighthouse, which can be reached online at www.lighthouse.org, offers:

• A New Look at Low-Vision Care, ophthalmology resident training manual, by E. Faye, M.D., D. Albert, M.D., et al. Call 718-997-4023 to order.
• Low-vision instruction courses. Call 212-821-9470 for information.

The Joint Commission on Allied Health Personnel in Ophthalmology JCAHPO. Instruction courses. Phone 800-284-3937 or go online at www.jcahpo.org for details.

The Association for the Education and Rehabilitation of the Blind and Visually Impaired (AER). Phone 703-823-9690 or go online at www.aerbvi.org for information on regional and international educational conferences.

Eschenbach. Day seminars are offered by this manufacturer of optical devices. Call 800-487-5389 for details.

Optical devices: contacts for professionals

• Lighthouse Professional Division: phone 888-777-4495
• Eschenbach: 800-487-5389
• NOIR (sunglasses): 800-521-9746
• CCTVs: Enhanced Vision 800-440-9476; Optelec 800-828-1056; Telesensory 800-804-8004; Innoventions 800-854-6554, MagniSight, Inc. 800-753-4767.

Why us?

We're the only ones who truly understand the nature and progression of our patients' vision loss, and the only ones who can lead them to safe ground, or at least point the way. Everyone else in the medical system leaves vision to us. Seniors' primary care physicians, their clergy and their families all believe that we've told our patients about every option they have. If we don't provide the guidance that gets these patients involved in meaningful visual rehabilitation, they're unlikely to find out about it.

Soon, baby boomers will develop vision loss in record numbers. They'll demand more from us than today's seniors. They won't leave our offices until we explain how they can keep living fully and independently in spite of vision loss. And they'll trigger a revolution in access for people with visual impairments on a par with what happened for people in wheelchairs 30 years ago. We as ophthalmologists have an intrinsic role in this process. Ideally, we can lead it; next best is to help point the way, but at the least we need to be aware of it.

Lylas G. Mogk, M.D., is director of the Visual Rehabilitation and Research Center, Henry Ford Health System Eye Care Services, Detroit, a member of the Visual Rehabilitation Committee of the AAO, and chair of the Strategic Planning Group for Visual Rehabilitation in Michigan. She can be reached at 343-824-4800 or via e-mail at lmogk@aol.com.