Ask the Doctor

by Randall T. Jose, O.D.
Director, Houston Delta Gamma Low Vision Center
University of Houston College of Optometry

Dr. Randy Jose is a Diplomate of the Low Vision Section of the American Academy of Optometry and a founding chairman of the Diplomate Program. He received his Professional Doctorate in Optometry from UC Berkeley School of Optometry in 1969. He has authored more than 50 articles on subjects related to low vision, written a textbook on the subject, and contributed to other textbooks on low vision.

Vision Rehab Vs. Dispensing Models

Q. Without third-party reimbursement, will the low vision rehabilitation model ever replace the less-than-satisfactory (in my opinion) dispensing model?--Optometrist in New Orleans

A. Actually, third-party reimbursement will most likely pursue the concept of "dispensing" low vision. First, this means it is not a medical problem, and it will not need to be covered. Secondly, if the older insured customers finally demand this service for themselves, the insurance providers will look at the two delivery systems and, without blinking, opt for coverage of the cheaper system, usually without thought to quality of care or outcomes.

Unfortunately, for those of us who believe, as you do, that the vision rehabilitation model provides the best care for individuals with low vision, there are very limited (if any) outcome measurements that testify to this. The future of vision rehabilitation depends on our ability to show insurance providers that comprehensive low vision is not only a more effective way to reduce the morbidity of visual disorders, but it is a very cost-effective rehabilitative service. I am optimistic the battle will be won and comprehensive vision rehabilitation services will be covered automatically by all insurance providers.

Mirror, Mirror on the Wall...

Q. We've just started with low vision in our group. I have had several patients already decline my recommendation for a device because of its appearance and because it calls attention to the wearer. Are manufacturers doing anything about this cosmetic issue?--Optician in Seattle

A. Yes, manufacturers are doing a lot to improve the looks or acceptance of the devices. In addition to appearance, the ergonomic aspects of the design of the optical system are being given much more consideration. Much attention is being given to the design of handles, switches, and field-of-view for the older patient. Much of the black housing is now found in a more pleasing neutral color.

Sunwear and filters are also becoming much more fashionable, while maintaining the importance of the quality of the filters as well as the reduction of glare with visors and sideshields.

The best optical system in the world is useless if not worn. Patients will tell the clinician that "it does not make a difference what I look like, as long as it allows me to see." This sounds great, but usually is just a lot of bravado on the part of the patient. As soon as someone embarrasses them in public, the low vision device gets a new home in the top bureau drawer.

The clinician can help by having the patient wear the device in the privacy of the home. Tell the patient to use the device when only family and close friends are around. As they become more comfortable physically using the device, eventually it will appear in the classroom, the grocery store, or church. Good family support is important to the successful adaptation to the appearance of a low vision prescription.

To AR or Not

Q. Can anti-reflection coatings benefit the low vision patient? It seems that they should, but to my knowledge, AR is rarely prescribed.--Optometrist in Green Bay, Wis.

A. Lighting, contrast, and glare reduction are all very important factors related to successful use of low vision devices. The few prescriptions that come with AR coatings are appreciated by the patient, but often patients do not appreciate the increase in price associated with this add-on.

If we are prescribing for maximum visual efficiency, the coatings should be included. However, since we only have anecdotal evidence that coatings do make a difference in low vision, the practitioner must decide on its use for his or her patients.

It may be more beneficial to use coatings for microscopic lenses as well as magnifiers when the patient demonstrates a significant loss of contrast sensitivity. I would imagine that the better optics and illumination provided by the AR coating would also address the issue of long-term use of the device and reduction of fatigue.

Without further research in this area, it is probably up to the individual practitioner and patient to determine if coatings will improve comfort and efficiency. Do not overlook comfort as an important factor in the successful use of low vision devices.

Devices

Q. An associate told me one of his patients uses five different low vision aids. Isn't that a lot?

A. Low vision prescriptions are usually quite limited in the tasks an individual can perform. It is expected that each patient will be assessed for and possibly prescribed a distant device (telescope), a near reading device (microscope), a near spotting device (like an illuminated hand magnifier for dimly lit areas and short visual tasks), a lamp, and perhaps a reading stand. So five devices would not seem to be unusual.