All optometrists should offer at least some form of low vision services (LVS) to their patients.

Here, I explain why and how ODs can get started.

The reasons 
I would argue that there are five main reasons optometrists should offer some form of low vision services:

1. Vision rehabilitation therapists have started offering them. As is the case with some primary care doctors providing neuro-optometric rehabilitation, some vision rehabilitation therapists have begun offering low vision services. Vision rehabilitation therapists are adept at teaching orientation and mobility skills, braille, and the use of assistive tools. ODs, by virtue of their focus on the magic of optics in optometry school, are adept in the optical principles needed to change the way a patient perceives images with a pair of lenses/prisms and maximize retained vision from a retinal disease.

2. A large patient population needs them. According to a recent Johns Hopkins Medicine article, roughly 4 million Americans live with low vision, defined as “a chronic visual impairment that can’t be corrected with glasses, contact lenses or medical treatments.” (See bit.ly/HopkinsLowVision.)

3. They improve quality of life. Patients who have low vision face losing their independence to drive, travel, run errands, participate in hobbies, prepare meals, and read, among other activities of daily living. Low vision services enable these patients to maximize the vision they’ve retained, enhancing their quality of life.

4. They show you genuinely care. We all know the adage, “actions speak louder than words.” This is never truer than when offering low vision services. This is because these patients are often shuffled in and out of exam rooms hoping for answers on how to improve their current situations, only to be viewed as a set of eyeballs. As prominent low vision optometrist Dr. Roderick D. Fields once said, “While it is often true nothing more can be done for the eye, it is rarely true nothing more can be done for the patient.” Through providing low vision services, ODs can show patients how to improve their current situations, which shows these patients they genuinely care about their wellbeing. Displaying such care can lead to both patient loyalty to their OD and word-of-mouth referrals that will enable other patients to witness firsthand the value of optometry in this area.

5. They are often not covered by health insurance. As is the case with the out-of-pocket-pay optometric services of in-office dry eye disease treatments, ocular nutritional supplementation, and aesthetic services, low vision services are often paid out-of-pocket, allowing you to set fair and appropriate fees for the services you provide. That said, billing and reimbursement for low vision services differ by state, so it makes sense to check with your state’s optometric association regarding any requirements.

For those reading this and thinking (or replying out loud), “that’s one of the reasons I don’t offer it,” please re-read reason No. 2, and consider this: Most optometrists offer one or more of the aforementioned out-of-pocket pay services because they recognize that when they educate patients on their benefits, patients place a great deal of value on them and are, therefore, willing to pay out of their own pockets for them. The same goes for low vision patients. Often elderly, these patients don’t adapt well to change, and this includes surrendering independence due to newly decreased vision skills. When given the opportunity to hold on to that independence, you better believe they’re interested in pursuing low vision services.

Getting started
1. Listen for these words. Low vision often enters the picture when a patient says, “I can’t see to do (fill in the blank) with these glasses/contact lenses.” To suss out the specific issue, I use a checklist that contains the tasks I find most low vision patients perform (or miss performing) daily. These include basic daily living tasks, such as reading. As an example, if a patient answers “yes” to “do you have difficulty reading?” I’ll then ask follow-up questions, such as, “what format do you use to read,” so I can get an idea of the magnification tool or tools they may need.

2. Intervene with the basics. As low vision is often associated with lack of lighting and blurred central vision, prescribe a direct light source, such as a high-intensity lamp (it is amazing what more light and more contrast will do for many low vision patients), and consider magnification options.

The low vision patients who tend to benefit from a direct light source are those who complain of difficulty reading and writing. I demonstrate for them the amount of light on an object reduces exponentially as it is moved away from the object. In witnessing this, these patients are able to see the importance of task lighting while performing activities. This often leads to needing multiple lights around the house.

Regarding the latter, use the patient’s case history to determine their vision goals, and select one of these action steps to intervene:

• Enlarge written material. Specifically, recommend patients read materials that have large print, bold print, and a double-spaced font to facilitate their reading. Additionally, discuss with patients how to “zoom in” on their phones, tablets, and computers. Patient candidates for this intervention tend to be those who have brain injuries. This is because the change in print facilitates fixation, eye movements, and figure-ground perceptions.

• Hold print closer. If a patient is having difficulty reading a utility statement, a letter from a family member or a recipe, suggest they hold the printed material closer. This is simple geometry. As an object moves closer, the visual angle enlarges proportional to the distance. This principle can also be utilized with high-power plus lenses. A +6.00 D lens will focus at approximately six inches. This allows for magnification by moving the object from 16 inches to six inches, enlarging an image by almost three times. As convergence becomes a problem at six inches for many patients, however, base-in prism can be induced to allow for the working distance.

Although decreasing the working distance for those patients who express a desire to see their TV better can be a wonderful solution, it is often not feasible for some patients. Working on a computer, the need to write, and to perform a task that is at arm’s length, such as sewing or woodworking, are examples. All these visual demands require a lens that can be adjusted for their preferred working distance.

• Use a magnifying lens. While the value of employing one is obvious, be aware that each manufacturer has varying ways of measuring their magnification, so a magnifying glass identified as 2x may not be exactly 2x. As a result, let patients know that finding their ideal magnifying lens is often accomplished by trial and error.

Handheld magnifiers are not for everyone, as low vision patients can have difficulty with dexterity. For patients who may have difficulty holding a magnifying glass, you can discuss a wearable device that can be prescribed with the patient’s prescription at their preferred working distance. That said, handheld magnifiers can be beneficial for short-period tasks, such as reading a label, seeing the dial on the stove, etc. I recommend having magnifiers on hand that range from

2x to 8x, so you can demonstrate to patients how they may help them. If a patient is reading 20/200 and they need to see large print font, then a 5x may be suitable.  (200 / 5 = 40; so this would potentially allow roughly 20/40 size material.) A caveat:

Bigger is not always better. By enlarging the text, the patient will see less of it, meaning instead of seeing a few words when reading the text, they may only see a few letters, making reading difficult.

Beyond the basics      
Digital devices, virtual reality headsets, electronic devices that read print aloud, smartphone applications and low vision specialists themselves are also available for your practice. In fact, there are optometrists specializing in low vision services who may come to your practice to provide their services. (Personally, I visit multiple offices that utilize my services for their low vision patients.) Regardless of whether you decide to employ and stick with the basics or increase your knowledge in this area, low vision services are inherent to optometry, so I hope you’ll offer some form of it. (See "More on Low Vision Services," below.) OM

Megan Lott, practices optometry at Belle Vue Specialty Eye Care, in Hattiesburg, Miss. She has low vision training, including being a fellow in the International Association of Low Vision Specialists as well as the Optometric Vision Development and Rehabilitation, and she provides low vision services across Mississippi.