Low Marks for Low Vision Coverage

I continue to be disappointed by the lack of attention given to low vision rehabilitation as a valuable component of the treatment models described in Review of Optometry. Two recent examples include “Blindsided” (May 2021) and “Five Questions on Dry AMD Monitoring and Management” (April 2021). 

In “Blindsided,” which outlines next steps in caring for a patient with newly diagnosed retinitis pigmentosa, clinical and genetic testing are discussed but no mention is made of the functional implications of this young patient’s severe (and likely progressing) visual field loss. 

Discussions regarding driving and other daily activities need to be had as soon as possible with this patient, with an eye toward preparation for the reality of future worsening and efforts to allow the patient to maintain functional vision. Even if the diagnosing provider is not in a position to personally provide comprehensive low vision rehabilitative care, mention should be made of timely referral as a key component in this patient’s treatment plan.

In “Five Questions,” the author makes mention of low vision services, but undermines this by advising that low vision referral be “considered” only in cases of advanced AMD. Referral shouldn’t have to wait until a patient demonstrates geographic atrophy or a choroidal neovascular membrane. Multiple studies have concluded that low vision rehabilitation results in improved quality of life and that early referral better prepares patients with progressive conditions to handle further vision degradation. 

The American Academy of Ophthalmology has defined early referral as the standard of care for patients with loss of visual acuity (<20/40), visual field or contrast sensitivity that interferes with one’s activities. All optometrists should be leading the charge in making sure that any patient who meets the criteria has a comprehensive low vision rehabilitation evaluation performed, either in their own office or by referring to another optometrist experienced in performing these examinations. 

When a leading publication like Review of Optometry continues to overlook this important treatment modality, it goes against the oath we’ve all taken to best care for our patients and it harms efforts by optometry and ophthalmology to solidify low vision rehabilitation as the standard of care. We’ve all received outstanding training in medical eye care, but we need to see past the diagnosis and take better care of the person experiencing vision loss.

—Joshua L. Robinson, OD 
Director, Low Vision Rehabilitation
Vanderbilt Eye Institute

I found the April letter by Megan Lott, OD, especially interesting. Her comments about lack of attention to vision therapy also apply to low vision, both long-time, effective services that are exclusively optometric. I agree with Dr. Lott that in taking on the medical model of eye care, we have moved away from the basics of our profession: providing patients with the clearest, most comfortable and most functional vision possible. 

Optometry has become a profession that has focused on eye care and forgotten that we are dealing with the whole person. People come to ODs because they want clear, binocular vision so they can function normally and enjoy important activities. They do not come to us because they want to be tested and monitored. I also agree with Dr. Lott that it is astounding that our colleagues do not refer patients to other optometrists when they would benefit from low vision care or vision therapy.

I then found, four pages later, the column by Dr. Karpecki. He discusses how he feels that optometry should be the primary provider for AMD management. He mentions how exciting it is that there are new methods for early detection and monitoring of AMD. As exciting as these new techniques are to Dr. Karpecki, he should understand that what patients want is to see well. They don’t want to be monitored, they want to be helped. They want to continue reading, driving, using a computer, watching their grandchildren, recognizing friends’ faces and many other activities. They want to be independent. Dr. Karpecki would serve patients better by providing low vision help or referring to a low vision OD.

The medical model may represent advances for our profession, but let’s not forget why the patients come to us and what they expect from us. 

—David L. Armstrong, OD, low vsion optometrist
Roanoke, VA

Neuro Neglected 

My takeaway from the April news story “Missed Neuro Diagnoses Lead to Patient Harm” was that the schools of optometry—and ophthalmology—are not keeping pace with needs of today’s eyecare providers to adequately evaluate, diagnose, treat or refer ophthalmic neuro encounters. If they think they are, the statistics don’t reflect this. 

—Howard Levenson, OD
San Rafael, CA