Currently, low vision care is offered in a variety of settings, including: hospital clinics (for-profit, community, Department of Veteran's Affairs); private practices (solo/group, single and multi-specialty); vision rehabilitation organizations and teaching institutions (ophthalmology/optometry). Each setting has its own unique characteristics and constraints. Clearly, there are diverse ways in which effective services can be provided. But despite this diversity, there are certain elements that are universally essential to successful service delivery.

a doctor teaching a lady how to use an amigo

The guidelines that follow represent these elements. They define the issues that each practitioner should consider when establishing low vision services and, as you will see, they leave much room for individual differences. These guidelines can also be beneficial for you to use in assessing services in your community to which you may refer patients with low vision to supplement the care you give.

Consider your answers to the following questions:

Is the service guided by a definition of vision impairment that recognizes a continuum of vision loss and the impact of vision loss on functional ability?

To use the Lighthouse International definition as an example, "functional visual impairment is recognized as a significant limitations of visual capability resulting from disease, trauma or congenital condition that cannot be fully ameliorated by standard refractive correction, medication or surgery, manifested by one or more of the following:

  • Insufficient visual resolution (worse than 20/60 in the better eye with best correction of ametropia).
  • Inadequate field of vision (worse than 20 degrees along the widest meridian in the eye with the more intact central field; or homonymous hemianopia).
  • Reduced peak contrast sensitivity (<1.7 log CS binocularly)1
    It is important to be comfortable with the thought that low vision is still usable vision, and to communicate this in your interactions with patients and colleagues.

Has the level of care that will be provided been defined, and have plans been made accordingly for delivery of that level? Have specific protocols been delineated for referral to services not available in-house?

Level 1: Near normal to moderate low vision (VA near normal to 20/60); low vision needs can be managed in the office with minimal other services needed.

Level 2: Moderate to severe low vision (20/70 to 20/200); low vision needs can be managed in the office with appropriate staff; vision rehabilitation services will be needed for some patients.

Level 3: Severe to profound low vision (20/320 to 20/1000); low vision needs should be managed by a low vision specialist; vision rehabilitation services essential.

Does the service have clearly defined guidelines for examination, care plan documentation, referral, exit protocol and service re-entry? Is there a dedicated time for low vision examination and instruction?

  • There is a structured low vision examination protocol.
  • A defined care plan is documented.
  • Established criteria for incoming patient referrals exist and are made known to all potential referents; the basis for referral is clearly defined (for example, all patients may be required to submit diagnostic eye reports prior to service; there may be an acuity/visual field criterion, etc.); documentation of referral exists.
  • An exit protocol exists, including guidelines for: return to clinic, transfer, reports to referents.
  • There is a specific procedure for service re-entry, and it is communicated to patients.

Are staff cognizant of vision rehabilitation services in the community or region?

Directories/listings of vision rehabilitation organizations, daily living product suppliers, special interest and support groups, consultants and other professionals are easily obtainable and should be available to aid service delivery, referral/transfer.

Is patient education an integral part of each patient's care?

  • Instruction is provided in optical device use related to daily activities.
  • Information on additional local and national resources in vision rehabilitation is provided.
  • Information regarding advocacy, self-help and support groups is made available to patients.

Have staff roles been identified, and are appropriately trained professionals/para professionals designated to accomplish required tasks?

Specific responsibilities include, but are not limited to, the following:

  • Patient care responsibilities

Pre-history/history
Refraction
Functional assessment
Device recommendation
Instruction in device use
Assessment of the need for additional follow-up (including practice with loaned devices, if the service has a set of optical devices for this purpose) and implementation of practice sessions

  • Prescription of optical devices

Dispensing
Vision rehabilitation services
Referrals/disposition

  • Administrative responsibilities

Intake/scheduling
Billing
Office management, including: maintaining equipment; maintaining the supply of optical devices on loan as a teaching tool

  • Staff education/training responsibilities

Understanding functional implications of vision loss
Technical/clinical skills
Sighted guide techniques
Patient education skills
Knowledge of ongoing developments in the field
Resource awareness

Do patient visits conform to accepted billing guidelines?

As in the delivery of other clinical care, clinical procedures should be appropriately documented to provide a clear audit trail. All appropriate potential payers (for services and/or optical, adaptive devices) should be clearly identified for the population, including: Medicare, Medicaid, State Services for the Blind and Visually Handicapped, State Offices of Vocational Rehabilitation, private insurance, managed care plans, local private vision rehabilitation agencies and self pay. This is a rapidly changing area, and requires attention and follow-up.

Does the clinical environment support the examination, instruction and dispensing procedures for this population?

  • Areas are designed to accommodate the
    low vision examination -- space and equipment to support functional tests
  • Instruction in the use of low vision devices -- space and equipment to support patient education/practice in use of devices for specific tasks
  • Dispensing space and equipment to support reinforcement of device use and delivery of prescribed devices to patients

Environmental considerations

Enhanced accessibility

  • Color and contrast
  • Elevators (accessibility features of call buttons, hallway lanterns, hoistway entrances, illumination levels, car control panels)
  • Room for wheelchairs/walkers, cane detection areas
  • Detectable warnings
  • Handrails on stairways/ramps
  • Signage
  • Lighting

Maximized visual efficiency

  • Adequate, adjustable lighting
  • Large-print reading materials in waiting room
  • Print legibility of all patient forms
  • Signature guides at workstations where patients need to sign their names

Does the available equipment allow for the delivery of the stated level of service?

Understanding the characteristics and potential needs of the patients you plan to serve makes a difference. A service that purports to be specialized and comprehensive, but has only a limited supply of optical devices and no specialized charts for low vision testing cannot hope to deliver services commensurate with its goal. Optical device supply in low vision practices where resources are severely limited can be a problem, but consultation is available to help explore device availability and cost issues.

Think broadly about equipment in all relevant areas of the service:

Waiting room

  • Task lighting
  • Large-print reading material
  • Arm chairs

Examination room

  • Diagnostic equipment
  • Refraction instrumentation, including full-diameter trial lenses, trial frame, prism lenses
  • Acuity charts for distance and near in logMAR notation
  • Continuous text reading cards with graduated print size
  • Function tests: Amsler grid, contrast sensitivity test, brightness acuity tester, color identification test
  • Low vision devices: spectacles and loupes, hand magnifiers, stand magnifiers, telescopes, absorptive lenses, adaptive and assistive devices, video magnifiers (CCTVs)

Instruction area

  • Workstation: non-glare tabletop, electrical outlets for plug-in magnifiers and illumination, task lighting and bulbs of different types
  • Reading material (regular and large print) and task-related materials (needlework, labels, hobbies, etc.)
  • Reading stands and other assistive devices (clamps, etc.)
  • Assistive devices: "talking" watches/clocks, signature guides, kitchen tools
  • Low vision devices: spectacles and loupes, hand magnifiers, stand magnifiers, telescopes, absorptive lenses, adaptive and assistive devices

Is documentation consistent with professional guidelines, and does it support the information needs of the team of vision rehabilitation and other professionals working with the patient?

  • Incoming referral
  • Examination findings -- consistent with documentation guidelines and clinician requirements
  • Care plan
  • Follow-up care
  • Dispensing
  • Disposition
  • Consent for release of information
  • Billing
  • Referral/transfer for additional services

Are standard operating procedures for medical emergency and universal precautions defined and implemented?

  • Medical emergency protocols
  • Infection control procedures consistent with legal mandates/ recommendations

Does the service provide or refer patients for vision rehabilitation services (in-house or external), including:

  • Rehabilitation Teaching -- specialized daily living skills training for people with vision impairment
  • Orientation & Mobility instruction -- safe, independent travel techniques
  • Counseling -- for adjustment to vision loss; for employment
  • Educational services -- across the lifespan

References:
Arditi, A. & Rosenthal, B. Developing an Objective Definition of Visual Impairment. New York: Arlene R. Gordon Research Institute, The Lighthouse Inc., 1996
Adapted for this use by Clare M. Hood, RN, MA, from the Levels of Visual Impairment coding in the ICD-9 CM (International Classification of Diseases -- Clinical Modification).

Source: Lighthouse International's The Lighthouse Ophthalmology Resident Training Manual -- A New Look a Low Vision Care

 

 

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