When I hear comments like these from my low vision patients, it reminds me that optometrists have the power to change lives. We have the skills and knowledge to help people who have impaired vision return to enjoying normal, active lives.

My practice is dedicated to helping people who have low vision remain active and independent. My patients have age-related macular degeneration (AMD), Stargardt disease and diabetic retinopathy, among other sight-threatening diseases. What they all have in common is that they want to see better.

My approach to helping people who have impaired vision includes the following steps:

Understanding their condition and its effect on their lives.

Evaluating their remaining vision.

Prescribing low vision glasses or other devices that help meet their visual goals.

In this article, I will describe how I approach these three steps, and I discuss the marketing and billing aspects of low vision care.

1 UNDERSTANDING

Obviously, it’s important to know what has caused the vision loss. Is the loss central or peripheral, progressive or stable, recent or long-standing?

It’s also important that I understand how the vision loss impacts the person’s life. I call each patient before scheduling the appointment and ask such questions as: Do you have enough vision remaining to read and watch TV? Do you drive? Have you given up any activities because of your vision? What are the activities most important to you that you would like my help with?

Most patients want help with reading and/or driving. Many ask for help with activities they are passionate about, such as computer use, crafts, sewing, art, reading music, watching sports, recognizing friends’ faces and watching their grandchildren play sports.

The more I know about how the vision loss affects the patient’s life, the better equipped I am to help. During the phone call, I also manage expectations. I explain the evaluation, discuss fees and answer any questions. It’s important for patients to know that low vision devices may help them see better — not perfectly.

Sometimes, I won’t be able to help because the patient’s vision loss is too great to achieve their goals. In these cases, I tell the patient. I think that it’s better to tell them in advance, rather than schedule an appointment whose outcome will be disappointing.

2 EVALUATING

During the low vision evaluation, I assess the patient’s vision and determine what it will take to provide the vision needed to achieve their goals.

First, I determine VA, both at distance and near. I ask patients to wear their present glasses. I refract the patient and determine whether the eyeglass prescription is still correct. If the patient is unable to respond to subjective testing, then retinoscopy or autorefraction can be done. Sometimes, an updated prescription — or more plus for near — may be needed.

Next, I evaluate vision utilizing low vision devices, keeping in mind the patient’s visual goals. Devices that help with reading and other near activities include hand magnifiers, electronic hand magnifiers, prismatic glasses, microscopic glasses, telemicroscopic glasses or some combination of them. It is not necessary to test the patient with all these. By learning about the patient’s activities and understanding the advantages and limitations of the various devices, I can begin with those most likely to help.

The same is true about telescopic glasses for distance vision. If the patient wants to drive, I evaluate them with bioptic telescopic glasses to determine which power and design will be best. For television viewing, I consider different types of full-diameter or wide-angle telescopic glasses.

Different activities, at different distances, require different types and powers of low vision glasses. Sometimes, the device can be modified to suit more than one activity. For example, adding a plus lens cap to telescopic glasses to change the focus from television to reading or computer distance. The interesting challenge is determining the best solution for each person depending on remaining vision and goals.

3 PRESCRIBING

After the evaluation, I’m ready to make recommendations. I demonstrate each device that I suggest, discussing its benefits and limitations, and get input from patients on how well the device meets their desired goals. The final decision of what I prescribe is based on my expertise and the patient’s acceptance of my recommendations. I take the time to be sure the patient understands the purpose of each device and how to use it. Of course, that instruction will be repeated when I dispense the device(s).

MARKETING LOW VISION CARE

My marketing, which targets the patient, his family members and the patient’s primary eye doctor, shows that it is possible to see better with low vision devices. This is a critical message, as many patients have been told by one or more eye doctors that nothing can be done to help them.

The Internet is a great way to market low vision services. Low vision patients or their family members often use a search engine to look for help. Some patients Google “low vision doctor” and self-refer. Therefore, a dedicated website is a must. My website, virginialowvision.com , includes contact information, testimonials and videos, among other educational resources. I also rely on the company that supports my website to provide search engine optimization.

I also advertise on and post to my Facebook page. Facebook advertising is affordable and allows me to target the geographic areas that my practice draws from.

I have posted many YouTube videos, which are very successful in attracting patients. (See “Dr. David Armstrong” and “Stargardt Eye Doc” on Youtube.com .) My videos often feature patients — a powerful way to show someone searching for help that there are ways to maximize vision. Choosing appropriate keywords makes the videos easier to find. Of course, it is important to follow all patient privacy guidelines and obtain written permission from patients before using their personal health information for marketing.

I often receive referrals from other optometrists, general ophthalmologists and retinal specialists. I reach out to the patient’s eye doctor in several ways. First, I request a copy of the notes from the patient’s most recent visit with the doctor. Referring doctors then receive a follow-up letter that includes fax referral forms and my practice brochures. If their patient does not schedule an appointment, I fax the doctor a “thank you” note and the fact that their patient has not scheduled.

Sometimes, I make a personal visit to referring doctors or potential referrers. I send information regarding new devices, different applications of existing devices or case histories of especially interesting patients. My goal is to help the doctors remember that I’m available to help their patients who have impaired vision.

 

 

 

 

 

 

 

 

 

 

A few of Dr. Armstrong’s patients with low vision correction, from top: Rosemary wears 2.2X bioptic telescopic glasses. Katherine is shown with 4X bioptic telescopic glasses. Brian and Teresa wear 3X wide angle telescopic glasses. Mark wears telescopic glasses designed for reading. Bernard is shown with 4X bioptic telescopic glasses.

Photos courtesy of Dr. David L. Armstrong.

BILLING FOR LOW VISION CARE

While a detailed discussion of billing and coding is beyond the scope of this article, recent changes have made it possible to bill Medicare and other health insurance based on time spent with the patient. This results in reimbursement that is more appropriate than the previous coding system. It would be best to consult with someone who is very familiar with optometric billing and coding before beginning.

Glasses for low vision, magnifiers and electronic devices are not billable to medical insurance. Patients must be told in advance that those charges are their responsibility. Use an advance beneficiary notice for services and devices that are likely to be non-covered.

I do not recommend billing a person’s vision insurance for low vision services or devices. Vision insurance is intended for routine eye care, not for specialized care. Additionally, the reimbursements will not be appropriate for the time spent and the specialized glasses and other devices required by low vision patients.

CHANGE A LIFE

Providing care for patients who have low vision is exclusively an optometric service. It can be life-changing for the patient and is very rewarding and satisfying for the doctor. Every optometrist should be prepared to maximize the vision of their low vision patients by providing the care themselves or referring to a colleague who provides the service. Our patients expect and assume that we are giving them the best possible vision. They deserve nothing less. OM

DR. ARMSTRONG has been practicing optometry in Roanoke, Va. for nearly 50 years. His practice is now exclusively dedicated to improving the quality of life for people with low vision by helping them remain active and independent.