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Patient Education

Better Understanding Low Vision Care & Low Vision Devices

When you were age 20 or 40 or 60, if your vision changed, what did you do? You got new glasses, and they probably solved all your vision problems—seeing items better at distance, at intermediate, and up close. But when you are older, if you have macular degeneration, diabetic retinopathy, or any other eye disease, the problems are likely not at the front of the eye, the lens, or the length of the eye, which is often why we need new glasses. The problems often center near the back of the eye, such as on the retina or optic nerve. Once you have your correct prescription, changing glasses by 1/2 or 3/4 of a diopter (which is how we measure glasses and lenses, and this may be typical of an average change when a new prescription is given), probably won’t make much difference. What is needed is a much stronger correction. And importantly, what is also needed is improved illumination and enhanced contrast. Vitally, what is also needed is training—perhaps to view things slightly off to one side, rather than straight ahead, due to the presence of distortion, blurriness, or a spot (scotoma) near the center of vision.

Near the beginning of a visit with a patient and their family, I often tell them that they were probably expecting to get a magnifier or new glasses to help them. I explain that we will get to that, but tell them that there are things that are perhaps even more important than a magnifier or devices, or at least as important. If they have distortion, blurriness, or a central scotoma (spot), I explain that the first order of business is to help locate where the scotoma is most problematic, and conversely, where they see best. (In the field of low vision, we call it the “preferred retinal locus” or PRL). Help is then given for the first 25-30 minutes to look around that blurriness or spot (even though many people don’t realize they have a spot). I explain that no matter how good a magnifier or a pair of strong reading glasses are, or even a wonderful portable digital magnifier or CCTV, if they look straight ahead, that spot is in their way. I show the spouse or children simulator goggles to illustrate the spot at various degrees. I tell them about a patient who said that if they don’t want to see people’s faces in church, they just look straight ahead. Good low vision care includes training—to help a person use their remaining vision to the utmost. It may include training to help them look slightly off to one side, around their blurriness or that spot.

About 26 years ago I interviewed to be the low vision specialist for a center for the blind. They asked me what I would change in their services if I was hired. I stated that I would change their name. (It was “Low Vision Lens Service.”) They asked me why I would change that. I said that their name implied they were just giving out lenses, such as magnifiers. They asked me, “What is wrong with that?” I said that this implies that this is all they are doing, handing out magnifiers. They asked, “What is wrong with that?” I responded, “Low vision is much more than a magnifier.” They asked, “What is it, then?” I answered, “Low vision is more than a magnifier. It includes training, such as eccentric viewing training to see around a person’s blurriness or scotoma/spot. It includes helping to improve illumination. It includes helping to enhance contrast. It includes helping to reduce glare, and with so many other things. Incredibly, they still hired me, and we changed their name to “Low Vision Services.”

Good low vision care should help with training, and not just with magnifiers and devices. It helps with tutoring persons with low vision and their families about the need for improved illumination, and options for various lighting choices. It assists persons to learn to enhance contrast in every room and part of their home, school, or work place. It helps to reduce glare, as well as to improve organization and to reduce clutter.

Good low vision rehabilitation services helps people get help early in the process of their vision loss. It encourages doctors, staff, and others in the community to refer patients early. Doctors often ask, “At what point should I refer my patients to you?” I’m sure they are looking for a specific visual acuity that the person should be at before they refer them, such as 20/100, 20/200, or even 20/400. When I do presentations at doctors’ offices, I often show slides to the doctors and staff of patients with relatively good visual acuity (e.g. 20/40), yet with very challenging central scotomas or ring scotomas, and with very poor contrast sensitivity function (CSF). Some slides of patients with these scotomas or poor contrast functioning are superimposed over text, or in a scene when driving. We talk about the fact that it is no wonder that these patients have trouble reading, seeing faces, or driving, even with comparatively good visual acuity,. So the answer about when to refer a patient has nothing to do with their visual acuity. They should be referred when they have trouble doing these tasks. And the person themselves, their spouse, or their children, should seek help early on, whenever they feel they are having difficulty with these tasks.

To help better understand low vision devices, I like to compare them to the tools used to build a house. A hammer helps do some tasks, a screwdriver other things, a wrench, plane, or a saw still others. As helpful as a hammer is, it won’t help you build the whole house. You need different tools for different tasks. To get the tools to build a house, it’s not that Home Depot, Lowe’s or any other store is trying to sell you a bunch of tools. It’s that they are used for different tasks, and they do different things.

Similarly, low vision devices are used for different tasks, and do different things. A strong illuminated magnifier, digital magnifier, or reading glasses help for reading, but do not help for seeing TV or faces. Telescopic glasses or monoculars are very helpful for seeing TV, faces, or scenery, but are not very beneficial for reading or close tasks. A clip-on loupe, prism half-eye glasses, or other devices may help for seeing the computer screen, sheet music, or hand work, but may not work for other tasks. Therefore, most persons with low vision may have 4-5 devices (tools) to do different tasks. They may have a strong magnifier or device for reading at home, and a portable device for reading at a restaurant, store, or church. They may have telescopic glasses to see TV and programs, and perhaps a telescopic monocular to read signs, menu boards, and the aisle numbers in a grocery store. They may have a device for seeing the computer screen or sheet music better. And they may have sunglasses to help reduce glare, and perhaps even 2 pairs: amber/orange for bright sunny days, and yellow for cloudy days, early mornings, or indoors. It’s not that a low vision clinic is trying to sell them different devices, it’s that they do different things at different distances, and are used for different tasks.

Many persons with a vision loss expect that changing their prescription glasses, like they have done all their life, will solve all their problems. But just making their prescription glasses a little stronger by ½ or ¾ of a diopter will probably not solve the problem. The person with a vision loss may need +8 diopters, +12 diopters, +20 diopters, or even +40 diopters. And just as important, they probably need improved illumination. And one pair of glasses or one tool may not solve all of their problems or help with all tasks, just like a hammer won’t help build the whole house. Different tasks require different tools.

Finally, no tool is truly a miracle tool. No magnifier, no strong reading glasses, telescopic devices, or even electronic or digital device will make things perfect. It will require a willingness to do things in a new way, the patience to try and persist, and the will to work to make it happen. It takes desire, it takes the support and help of those around you, and it takes going back to the low vision rehabilitation service for further training and for revision of the devices you are using, if your vision changes or your needs change. Low vision care is not a “one and done” visit. I was strongly influenced by Dr. Randall Jose, who brought his optometry residents to our center in Atlanta. His belief for good low vision care was that it should be a 3 visit minimum. I think that this helps better insure good training and proper follow-up.

I love the quote by Ralph Waldo Emerson, ““That which we persist in doing becomes easier to do, not that the nature of the thing has changed but that our power to do has increased.” I wrote a song to that verse, and added these words at these ending: “Persist, keep trying.”

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