CLINICAL

  specialty eye care

The Highs of Low Vision

Three steps to grow your practice — and have your phone ring off the hook — by providing low vision care

RICHARD J. SHULDINER, O.D., F.A.A.O., CORONA, CALIF.

E.K., an 85 year-old female AMD patient presented to my practice looking for help retaining her driver’s license. One month later, she left my office with bioptic telescope glasses and a DMV vision report form. Her driver’s license was renewed, and I was reasonably compensated.

The local newspaper ran the story, and my phone started ringing off the hook. As a result, in a short period of time, I transformed my non-profit, agency-based low vision care model to a financially viable for-profit model.

Here, I outline the three steps that helped my private practice achieve low vision success.

1 Advertise

It is difficult to establish a referral base of M.D.s and O.D.s to a private low vision practice, which is why marketing your services is critical to success. We use display advertising in various sizes: 2” x 2” ads and half-page “advertorials” in places seniors will notice them, such as senior monthly publications. As with all advertising, frequency is key.

2 Filter patients by phone

This filtering technique will help you assess whether new patients would benefit from care, temper their expectations of treatment and provide the necessary information before their appointment.

► Acquire patient information. First, ask for the patient’s diagnosis from his previous healthcare provider and what he hopes to gain from care. Then, ask functional questions (e.g., “Can you read newsprint?”) to assess his level of vision and predict the chance of success with his goals. If the patient says he can read newsprint with a magnifying glass, I can reasonably predict success in reading with glasses. A patient who cannot read headlines receives a guarded prediction.

► Provide patient education. Next, discuss what the patient can expect from the exam, including cost: “Mr. Smith, I’m going to assess your exact level of vision through a series of tests and determine the type and amount of magnification needed to improve your vision. Medicare and most insurance plans do not cover low vision glasses. Patients spend anywhere from $500 to a few thousand dollars, depending on their vision goals. We will make sure the glasses work before they are ordered.”

3 Perform a careful exam

It’s important to conduct a thorough exam. To ensure the best results, we follow a 12-step process.

► Establish the relationship. There should be no paperwork for visually impaired patients — they can’t see, and you don’t want them to become upset because someone else must fill out their paperwork. Greet the patient and escort him to the exam chair; it pleases the patient, and his mobility and visual abilities can be observed.

► Open with an explanation. Let the patient know that the information you need from him is different from what other doctors ask. If he wanders off topic, you may need to interrupt so you can keep your promise to “send you home better than you walked in.”

► Acquire a patient history. The low vision exam is offered to those already under eye medical care, so a full history is not always necessary. Yes, you want to know the medical conditions and medications, but you are more interested in the patient’s current level of function, living conditions and level of independence.

► Ask about daily activities. Ask about distance activities (e.g., driving) and intermediate visual tasks (e.g., TV and handcrafts.) When it comes to near tasks, query what kind of reading is the goal to determine the exact the nature of the patient’s visual demands.

► Determine an exact level of acuity. If VA is good enough, use your projector. I always start with a handheld chart; it has easy-to-see numbers, can be held at any distance, and I can watch the patient during the test. I teach the patient eccentric viewing techniques while taking his acuity, and start with the better eye to keep the exam upbeat. After acquiring distance acuity, I use the new ETDRS chart for near acuity.

► Perform the refraction. Most patients have glasses close enough to their correct prescription that a change is not necessary. Therefore, the “refraction” is mostly performed with a hand retinoscope over the patient’s current glasses. Compare the result with his acuity to determine whether a trial frame refraction is necessary. Never use the phoropter during a low vision exam.

► Discuss what you know “so far.” Let the patient know that you will be working on his goals one at a time because low vision devices/glasses are task specific. For example, “Mr. Smith, your left eye is much better than your right eye, but will still need a stronger lens for reading. In a moment, we will start with a strong lens for the left eye and see how that works. Then, we’ll move on to other tasks, such as TV and computer use. More than likely, you will need a pair of glasses for reading with the left eye and another pair for TV for both eyes.”

► Provide near-task solutions. Solve the patient’s near task problems with at least two low vision devices so the patient has a choice. For example, first I get the patient reading with a high-plus microscope lens. Then I’ll try a near telescope and ask which is easier for them to read.

The doctors I train and coach prefer a prescription prismatic, doublet microscope and telemicroscope and telescopic glasses because we believe that low vision patients prefer hands-free magnification.

► Supply distance-task solutions. Take the patient outdoors and show what prescription telescope glasses can do for him. Always place the patient’s prescription behind the telescope.

► Provide intermediate-distance solutions. Use prescription telemicroscopes that have various near-focusing caps for TV or computer viewing. Use prismatics for handcrafts.

► Provide recommendations, answer questions, and address concerns. Show the patient exactly what their low vision solution(s) will look like, train him on proper use of the glasses, and discuss the dangers of using them improperly.

Present a total fee before breaking down each device. For example: “Mrs. Smith, you said you wanted to read books, watch TV from your couch and read signs when driving. I can help you with all of that with three different pairs of glasses. The total cost for your exam, the glasses and the reading lamp will be $4,500.”

► Finish the appointment. Write the order, take the deposit, and make the dispensing appointment. If available, send patients home with educational materials explaining the devices ordered to share with family, friends and caregivers.

Financial viability

My practice has been successfully limited to low vision care for the last 13 years. As William Feinbloom, O.D., once said to me, “Don’t be afraid to make money in low vision; the more you make, the better you will do it.” OM

Dr. Shuldiner is the clinical director of Low Vision Optomerry of Southern California, founder of the International Academy of Low Vision Specialists, president of Vision Vitamins, Inc., and owner of Optometric Practice Consultants. Send comments to optometricmetricmanagment@gmail.com.