Treating Chronic Vision Impairment: Still The Best Kept Secret in Health Care (Part I)

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My other doctor told me “There’s nothing more I can do for your eyesight.”

This inaccurate and damaging statement is the most commonly reported phrase to doctors of optometry who treat people with vision impairment.  We hear it repeatedly from patients with chronic vision loss.  It is a frontrunner for the #1 health care delivery barrier to early clinical care and available treatment for improving vision and function from chronic vision impairment.  It’s devastating to the patient and their family, and a flawed proclamation for any doctor to make to someone experiencing vision loss.  Unfortunately, this behavior is nothing new – this negligence in health care has persisted from long before I became a doctor.

Here’s a simple, no-cost solution:  complete the sentence by adding “…but I know a colleague who can, and I’m sending you to a doctor of optometry who treats vision impairment.” Make a direct referral and appointment with the doctor before the patient leaves your office.  Give the person and their family time to process what you’ve told them cannot be done through your care, while at the same time championing a positive focus on additional readily available care provided by a colleague.

My first year out of training I saw a study from the early 80’s of patients in Michigan diagnosed with vision impairment that revealed 1) only 25% ever received referral to available optometric care, and 2) it took an average of two years for people to initially reach proper care addressing their vision loss.  Interestingly, this data arose from the state in which I was practicing, a recognized leading state where vision impairment was acknowledged in a progressive fashion – including everything from state funding for youth services to some of the first hospital-based and collaborative care models in the country – and where optometry established one of the first certification process to become a “low vision specialist”.  (NOTE:  the historic term ‘low vision’ remains poorly defined and without universal consensus, but is still begin used to refer to chronic vision impairment – for clinical terminology recommendations please see NASEM report.)  Almost 30 years later and despite 1)  national advances over several decades involving Medicare and third party funding recognition of, and coverage for, vision impairment, 2)  the recognition of doctors of optometry as physicians, and 3)  a priority national focus on reducing the impacts of vision impairment by the National Academies in 2016, health care colleagues still choose to make this statement, effectively burying their heads and patient’s hopes in the sand. Just ask your friendly optometrist how recently someone has told them this.

Yes, MUCH more can be done.  The profession of optometry has been doing more for a hundred years – more is currently being done across the country and will continue to be done by doctors of optometry and our teams dedicated to improving the lives of people with less-than-perfect vision.  It all starts with patient accessing proper eye examination and targeted clinical care focused on improving visual function.  Without this important step, optimal patient outcomes are forfeit.  The critical foundation for meaningful clinical care, treatment and rehabilitation, and ultimately improved overall function and quality of life is this:  the comprehensive and accurate clinical assessment, diagnosis, and treatment of vision impairment and how to optimally improve upon the patient’s current vision and visual function.

Here is a sampling of questions doctors of optometry clinically investigate in a systematic approach for patients who lose vision:

  • How much improvement can be gained in the patient’s sensory visual input?
  • What treatment options can improve the clarity and sharpness of images?
  • How can the window through which the patient views the world be improved?
  • Can the use of both eyes together become more efficient?
  • Is using one eye alone more efficient or required for certain visual tasks?
  • Can objects and steps be better discerned from each other?
  • Can I enhance the patient’s ability to discern colors, shapes, facial features?
  • How can I best return the patient to reading conventional size text and print, and images on the television?
  • Is driving an option?
  • How can I assist the patient in seeing the computer/tablet screen and/or classroom materials?
  • What is the most effective way to improve the patient’s ability to see and understand their medications, glucometer, and self-manage their health care?
  • Are other health-related issues negatively impacting the patient’s prognosis for success?

These and other patient-focused priority visual outcomes are accomplished each and every clinical day.  The clinical work is time-consuming, multifaceted, and stressful.  The good news is that this optometric health care remains readily available.  The bad news is that it remains underutilized.  For people with less than perfect vision, there IS help.  This is what we do – we await people at the ‘end of the eye care road’.  The reward of using our unique training to provide high-value care to people of all ages is why we do it.  It’s the reason why I’ve directly provided, taught others about, and advocated for this optometric care my entire career.  But unless you, your family member, or someone that you know lives with chronic vision loss, you are probably unaware of us or the specialized care and all that can be done.

Caring for patients with vision impairment, a recognized major health issue that impacts population health, is something doctors of optometry take seriously.  We choose to practice the clinical science and art of vision rehabilitation care for chronic vision impairment. It takes the same specialized skills, knowledge, determination, and clinical experience to treat vision loss as it does to treat any other chronic health disease or condition.  Care for vision impairment exists. It’s a health care fact.  And it’s not a guessing game.  Doctors of optometry are formally trained to treat vision loss in the classroom, in the clinic, and in post-graduate residencies.  Here, optometrists are the OGs in health care.  Just as a family physician diagnoses and treats diabetes & hypertension, an oncologist treats cancer, and a physiatrist treats stroke, doctors of optometry have served and remain as the only health care professionals in the U.S. health care system with the formal education, training, and physician status for the comprehensive diagnosis, clinical decision making, and prescription of treatment required to inclusively manage vision impairment.  Optometrists write orders for other professionals and direct integrative rehabilitative teams and therapies when necessary.  We provide patient access to a world of treatment options and emerging technologies that help improve the patient’s vision and function.  Our care continues as visual status changes, even when vision continues to diminish.  It’s truly a dynamic chronic care process.

The overwhelming majority of people with chronic vision loss have useful remaining vision – and every person deserves to be made aware of this potential from a proper clinical perspective.  All that follows after the patient’s clinical diagnosis and treatment of vision loss and resultant improved vision and function related to vision – from clinical, educational, vocational, health care, individual, and independence perspectives – relies on patient access to this comprehensive care process.  Without the professional acumen to determining proper objective and quantifiable measures of optimal visual function, the patient and their health care team isn’t fully informed of potential outcomes. Without accurate clinical assessment of the patient’s potential for better function, patient motivation and engagement wanes and valuable resources are wasted.  And without patient-doctor shared clinical decision making and in-depth discussion of ALL available treatment options, patient preferences cannot fully be considered for effective evidence-based care.

For decades, the optometric care of people with vision loss has remained isolated from the nation’s traditional house of medicine. Like so many other doctors of optometry that I’m so fortunate to count as mentors and friends, my entire clinical career has been dedicated to the comprehensive care of people of all ages with vision impairment.  It’s still perplexing that within the U.S. health care arena there remains a lack of knowledge and advocacy for the tertiary care and rehabilitation of this major cross-cutting chronic condition.  And it’s not just ignored across eye care – it remains unrecognized and/or fragmented across primary, geriatric, pediatric, rehabilitative, and other specialized health care areas. 

With the proper treatment options and correctly assessed ‘pros and cons’, vision and function can be improved – the key is having the right doctors provide care at the right time to properly diagnose it, treat it, and help the patient and their stakeholders to understand it and best utilize it through a dynamic patient-centered approach, just as with any other aspect of the patient’s health care when facing a chronic disease or condition.

Here’s a brief overview of what the evidence* tells us about chronic vision impairment and its care (see list below):

  • Treating chronic vision impairment is effective in improving visual function.
  • Preventing vision loss is cost-effective, as is the high-value of treating chronic vision impairment.
  • Over 95% of the U.S. eye doctors providing care for chronic vision impairment (a.k.a. vision rehabilitation) are doctors of optometry, or ODs, who are found in every state in private practice, hospitals, military bases and VA’s, multidisciplinary clinics, academic centers, and health agencies.
  • Vision impairment is a major chronic condition with far-reaching consequences and negative impacts on population health.
  • Treating chronic vision impairment remains as the only clinical care option for people whose surgical, pharmacological, and conventional eye care options have been exhausted and cannot repair or replace lost vision.
  • Over 6 million Americans are currently living with chronic vision impairment.
  • A national lack of awareness in the U.S. health system exists regarding the value, scope, delivery, and population health benefits of comprehensive eye & vision care including the targeted treatment of chronic vision impairment.
  • In addition to the American Optometric Association and American Academy of Optometry, advocates for specialized clinical care of chronic vision impairment in the U.S. include the National Eye Institute and its National Eye Health Education Program, Centers for Disease Control, National Academies, American Public Health Association, American Academy of Ophthalmology, and other entities.
  • Doctors of optometry lead the clinical vision impairment team due to their unique formal professional didactic, clinical, and residency training.
  • The clinical process of vision rehabilitation begins with examination focused primarily on the impairment, not the underlying disease or condition – this important step provides proper entrée into care for optimal patient outcomes.
  • Treating chronic vision impairment is recognized by CMS and the majority of needed clinical care is covered by Medicare and Medicaid; Medicare also covers most rehabilitation therapy and Medicaid covers a variety of treatment options across a majority of states.

The obvious question remaining then, is “WHY?”  Why is the care and leadership that optometrists provide in treating chronic vision impairment the best kept secret in health care?  I’ll try to tackle this in Part II so please stay tuned…

*Selected References:

National Academies of Sciences, Engineering, and Medicine. Making Eye Health a Population Health Imperative: Vision for Tomorrow. Washington, DC: The National Academies Press; 2016.

Stelmack JA, Tang XC, et al.  Outcomes of the Veterans Affairs Low Vision Intervention Trial (LOVIT).  Arch Ophthalmol. 2008 May;126(5):608-17.

Stelmack JA, Tang XC, et al.  The effectiveness of low-vision rehabilitation in 2 cohorts derived from the veterans affairs Low-Vision Intervention Trial. Arch Ophthalmol. 2012 Sep;130(9):1162-8.

Stelmack JA, Tang XC, et al.  Outcomes of the Veterans Affairs Low Vision Intervention Trial II (LOVIT II): A Randomized Clinical Trial. JAMA Ophthalmol. 2016 Dec 15 (e-pub).

Grover LL. Access To Health Care, Eye Care and Vision Rehabilitation Care For Older Adults With Chronic Vision Impairment In The U.S. [Doctoral dissertation]. The Johns Hopkins University Bloomberg School of Public Health; 2012.

Grover LL. Examination Of The Patient With Low Vision: Entrée Into Vision Rehabilitation. In: Albert and Jacobiec’s Principles and Practices in Ophthalmology, 3rd ed. Elsevier; 2008.

Frick KD, Gower EW, et al.  Economic impact of visual impairment and blindness in the United States. Arch Ophthalmol. 2007 Apr;125(4):544-50.

Grover LL. Making Eye Health a Population Imperative: A Vision for Tomorrow – A Report by the Committee on Public Health Approaches to Reduce Vision Impairment and Promote Eye Health. Optom Vis Sci 2017;94:444-45.

Grover LL.  Closing the Gap: Accessing Technology Through High-Value Care for Chronic Vision Impairment.  Optom Vis Sci 2018 (submitted).

American Optometric Association.  Optometric Clinical Guideline Care of the Patient with Vision Impairment (Low Vision). 12007. Available at:  https://www.aoa.org/documents/optometrists/CPG-14.pdf.

Stroupe KT, Stelmack JA, et al.  Economic evaluation of low-vision rehabilitation for Veterans with macular disease in the US Department of Veterans Affairs.  JAMA Ophthalmol.  Published online April 12, 2018.

Grover LL. Strategy for developing an evidence-based transdisciplinary vision rehabilitation team approach to treating vision impairment. Optometry. 2008;79;178-188.

Rein DB. Vision problems are a leading source of modifiable health expenditures. Invest Ophthalmol Vis Sci. 2013;54(14):ORSF18-22-F22.

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