BScOptom GCertUniTeach PGCertOcTher PGDipAdvClinOptom Lecturer,
Clinical Teaching Co-ordinator, the University of Melbourne
BSc (Hons) Optometry Aston UK
Guide Dogs QLD, Low Vision Clinic Townsville
BOptom PGCOT, Clinical Policy Adviser OAA
Optometrists know there are many reasons someone may develop low vision. It may not be `the big four' of cataract, glaucoma, diabetic retinopathy and macular degeneration, low vision could also be the result of corneal dystrophy, vascular incident or retinal detachment.
Your tool kit for examining these patients will contain more than your standard consulting room set-up; it will include three things: a current knowledge of service providers and support groups, common sense and a willingness to make a difference.
Fortunately, this accounts for the majority of optometrists in practice. Even though optometrists are in a key position to offer valuable treatment and advice, many consider low vision daunting. As the rapidly evolving world of low vision care continues to grow, it is important for optometrists to remember these basic facts and that you can have a positive impact on patients in need.
10942 Low vision assessment
Optometrists should be aware that since 2004, there has been a Medicare item number available to charge when they are managing patients with low vision. This item can be charged in addition to another appropriate Medicare item—for example, 10900 or 10914.
According to the Medicare Benefits Schedule Book, Medicare service item 10942 covers:
Testing of residual vision to provide optimum visual performance involving one or more of spectacle correction, determination of contrast sensitivity, determination of glare sensitivity and prescription of magnification aids in a patient who has best corrected visual acuity of 6/15 or N.12 or worse in the better eye, or horizontal visual field of less than 120 degrees within 10 degrees above and below the horizontal midline, not being a service associated with a service to which item 10916 or 10921 to 10930 applies, payable twice in a 12-month period. Fee: $35.55 Benefit: 85% = $30.25
The procedures listed in the OMBS item 10942 descriptor are all familiar tests. Optometrists should use this consultation item in the provision of low vision care to patients, which will allow them to more fully determine their patients' visual capabilities and limitations. If nothing else, these procedures will provide the optometrist with more information to share with the patient and with a referred eye-care professional or low vision service provider for additional assistance.
Preserve best visual acuity
We know that many patients with low vision, including some who are legally blind, still require some form of optical correction to achieve their best visual acuity and best functioning. For these patients, as with all patients, spectacles, contact lenses or other vision aids must be maintained and updated. Additionally, low vision aids still need to be replaced from time to time. Each visit from a low vision patient offers the opportunity to discuss new developments and devices.
Optometrists can also use each return visit as an occasion to discuss the patient's eye condition and discuss their prognosis. Reinforcing simple tips can make a great difference to a patient with low vision, such as the importance of improving lighting and contrast, enlarging reading material where possible and controlling glare.
Many patients are undergoing anti-VEGF treatments with an ophthalmologist and they often appreciate discussions with informed optometrists about these treatments. This is not to overlook the fact that optometrists are perfectly placed to monitor the ocular health of a patient, regardless of whether this forms a shared-care relationship with an ophthalmologist. Six- or 12-monthly reviews are often appropriate to monitor a patient's optical and non-optical needs. In scheduling these consultations, bear in mind that typically, you will need to allow low vision patients a little more time to discuss their vision needs and diagnoses. Importantly, patients with low vision should not be given the impression that nothing more can be done for them.
Organisations providing low vision service
Many patients will benefit from a referral to a low vision service provider. Most low vision service providers include a multidisciplinary team that is able to assist patients with full-scope service, encompassing the provision of visual aids, orientation tips and training as well as the supply of a range of assistive technology to complete routine daily tasks. Service providers may also facilitate patient support groups or provide counselling for those struggling to accept their diagnosis. For some patients, simply meeting or witnessing the lives of others who face similar problems can be very valuable.
Most low vision service providers are accessible to optometrists and patients alike via websites, but many organisations look to optometrists to make appropriate referrals and recommendations to patients. It is important to be aware of these organisations, where they are located and what they can provide for patients.
This will take a few clicks online, a phone call or a visit to a facility to learn more about what patients can access.
Vision aids and resources as well as counselling and access to social groups are also often provided by smaller organisations within each state and territory.
It is important for optometrists to consider mentioning condition-specific organisations for patients affected by specific ocular or medical conditions. These groups provide a wealth of information to patients about their specific condition of interest and the services that are available to them.
All patients can feel overwhelmed and may be unsure of where to access trustworthy information. An informed, caring health professional can enrich a patient's life.
Optometrists are frequently called on to assist with blind pension and taxi concession applications, and can inform patients about companion cards and other services such as theatre audio description access in major cities.
Too much information can be overwhelming, especially in the early stages of developing eye disease or vision loss. There are steps optometrists can take to ensure this information will not be lost and that it is delivered in a thoughtful way that can be retained and revisited by patients in their own time.
A low vision patient support plan is a considerate way to incorporate the names, contacts, resources and important details of your patients' conditions. This is all part of the rapport building that begins when patients enter your practice.
Prepare a support plan
Patients will take comfort and reassurance from being looked after and it is important to present a clear and simple management plan to address their likely ongoing needs. Such a plan can be copied for carers, family members or staff at residences and nursing homes, or shared with a patient's general practitioner and ophthalmologist. A low vision service provider will be interested to know what has been arranged prior to them meeting a patient, and will appreciate a detailed referral including refraction and acuities, field plots and any other relevant information.
Consider including the following
- Information about their particular eye conditions, for example, Optometrists Association patient brochures or MD Foundation.
- Recommendations of measures to preserve eye health, for example, information on nutritional supplements for MD, or material about optimal UV and glare protection—hats, fit-overs and so on.
- A review or appointment schedule, and details of what will happen at future appointments. A patient may be reassured to know that, for example, the scheduled six-monthly examinations may include perimetry, retinal photographs or OCT scans to help monitor their condition.
- Referral to an ophthalmologist where appropriate. It can be communicated that ophthalmologic assessment is often important, regardless of whether any improvement in vision is possible and that other ocular diseases must always be considered.
- Referral or report to the patient's GP. This is an opportunity to express any concerns regarding psychological issues and mental health.
- Referral to a low vision service provider. Explain that a low vision service team may include a specialist optometrist, orientation and mobility officer, occupational therapist and trained counsellor.
- Referral to any appropriate local low vision support groups. It may be possible for you to establish such a group of your own patients.
- A final comment that the patient can book in to see you at any time if they have concerns, and that it is important they contact you the same day in the event of sudden changes in vision. Often, we assume patients understand such simple things and we find that we are wrong.
Macular Disease Foundation Australia
Macular Degeneration New Zealand
Retina New Zealand
Glaucoma New Zealand
Diabetes New Zealand
Keratoconus New Zealand