Role of Vision Rehabilitation, Barriers to Its Access, and Interventions to Optimize Vision in Patients With Glaucoma
abstract
This abstract is available on the publisher's site.
Access this abstract nowPURPOSE OF REVIEW
Vision rehabilitation services are important but underutilized resources for patients with glaucoma. Glaucoma and its impact on vision can affect patients' abilities to read and drive, two activities of daily living that are associated with quality of life and functional independence. In this review, we provide an overview of low vision, discuss barriers to vision rehabilitation, and outline various strategies and interventions to optimize visual function and quality of life in patients with glaucoma.
RECENT FINDINGS
Studies have shown that glaucoma negatively impacts reading, driving and overall quality of life. Decreased visual acuity, visual field loss and reduced contrast sensitivity play a role. Low vision services and interventions can help patients maximize visual function and improve their quality of life. Barriers to receiving these services exist at multiple levels and an increased awareness and integration into routine ophthalmic care are needed to deliver comprehensive care.
SUMMARY
Glaucoma is one of the leading causes of low vision. Ophthalmologists who treat glaucoma often tend to focus on objective measures to monitor progression and disease severity, but the functional impact of glaucoma should also be addressed. Low vision services can benefit patients, particularly for reading and driving, and should be considered as an essential component of patient care.
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Additional Info
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Vision rehabilitation in glaucoma patients
Curr Opin Ophthalmol 2023 Mar 01;34(2)109-115, A Shi, S SalimFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
This article reiterates an old theme — too few patients are being referred for low vision management by ophthalmologists who are either unaware of the potential benefits of referrals to low vision services or are increasingly constrained by the limited time allotted to counsel patients. Although the article generally provides a nice overview of the available aids for patients with low vision, I was disappointed by its lack of a multidisciplinary focus and, in particular, its lack of discussion on the role of optometric low vision specialists.
The authors of this review discuss vision rehabilitation (or lack thereof) for patients with glaucoma, starting with the statement that "despite this population burden and the impact of low vision on patients’ daily functioning, low rates of referral to vision rehabilitation services exist among ophthalmology residents and attendings." However, it is not about just ophthalmology residents and attendings, as an article we reviewed years ago reported that "despite the large number of patients who could benefit from low vision services, rates of uptake are low, with only 5% to 10% of those with low vision enrolling in these services," and "64.7% of patients who qualified for low vision cited a lack of communication between them and their eye care provider as the explanation for not attending low vision services."1 Additionally, although I appreciate that the authors presented the barriers to accessing rehabilitative services, the one that is most unconscionable is that "even physicians who have some understanding of the purpose and benefits of vision rehabilitation may have limited time in clinic to conduct important but often lengthy conversations with patients regarding what low vision rehabilitation involves, and its potential benefits." Conversations with patients need not be a lengthy process; a reasonably simple solution is to request handouts from low vision rehabilitation eye care providers to make available information to patients about resources in their community or look to their professional organizations for written handout materials. Having said that, doctor and staff time should be similar to that required to discuss, for example, extremely high intraocular pressures or newly diagnosed neovascular age-related macular degeneration. As for the question of when to refer, a simple query such as "are you having difficulty with any visual activities?" can initiate the referral process.
The authors of this article correctly point out the importance of reading and driving in terms of vision-related quality-of-life issues; however, there can be more vision-related difficulties (for patients with glaucoma as well as for other patients with vision loss) that impact daily functioning and quality of life, such as watching television, identifying medications, recognizing faces of loved ones and friends, as well. However, the authors spent a considerable amount of time discussing the impact of glaucomatous visual impairment on driving, the use of simulators, the legality of driving, restricted driving, or no driving in some states, including counseling patients about their driving. Notably, counseling can take considerably more time than discussing an appointment for low vision rehabilitation, which seems counter to the prior statement about limited time to talk and concern about the lengthy conversation. For that matter, driving concerns can also be deferred to the low vision practitioner as part of the total rehabilitative process. Finally, for those who may not be aware, the authors do a cursory job of describing optical, electro-optical, and nonoptical options available to patients with a visual impairment.
"Low vision rehabilitative services are not considered alternative or complementary treatment, potentially accepted as legitimate therapy by only a few, but rather are mainstream eye care, with both optometry and ophthalmology having established specific guidelines for low vision rehabilitation. For optometry, it is Care of the Patient with Visual Impairment (Low Vision Rehabilitation), and for ophthalmology, it is Vision Rehabilitation Preferred Practice Pattern."2 I believe that there is no ophthalmologist or optometrist (even eye care student) who is unaware that low vision rehabilitative services exist. A call to action is not new, as John Tanton, MD, wrote in 1994, "even though it may be true that nothing more can be done for the eye, it is almost never true that nothing more can be done for the patient."3 "Although glaucoma is the platform for this discussion, the troubling symptom of lack of referrals for appropriate rehabilitative care for this growing segment of the population persists and indeed extends far beyond [this pathology]."2 I applaud the authors for writing about this gap in patient care and their comment that "vision rehabilitation is an essential component in the care of patients with glaucoma with low vision, and ophthalmologists [as well as optometrists] have a responsibility to screen and refer these patients for additional services."
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