Low Vision Specialists

Hadley

Low Vision Specialists

Presented by Ricky Enger

Ricky Enger: Welcome to Hadley Presents. I'm your host, Ricky Enger, inviting you to sit back, relax, and enjoy a conversation with the expert. In this episode, Hadley's chief program officer, Ed Haines speaks with Dr. Sanbrita Mondal about what to expect from a visit to a low vision specialist. Welcome to the show everyone.

Ed Haines: Thank you, Ricky.

Dr. Mondal: Thank you for having me here.

Ricky Enger: So happy to have you both. I know this is going to be just an incredibly informative episode, and so I'm looking forward to getting right into things. Before we get into the questions and learn about what a low vision specialist is and what you might expect from a visit when you book an appointment with one, let's get a couple of introductions. So Ed, we'll start with you.

Ed Haines: Thanks, Ricky. My name is Ed Haines and I'm the chief program officer at Hadley. I've held that position for I guess about five or six years. I've spent a lot of time as a vision rehabilitation therapist in the field working for various agencies. So this is a topic that's really important to me and I know it is important to a lot of our listeners. So I'm thrilled that Dr. Mondal can be here today.

Ricky Enger: Agreed. And Dr. Mondal, why don't you tell us a bit about yourself and what you do?

Dr. Mondal: Sure. So thank you both for having me here today. A little bit about myself. I'm an optometrist and a clinical professor at the Department of Ophthalmology and Visual Sciences at the University of Wisconsin. At the university I run the vision rehabilitation service. In the past, we used to call it the low vision service, but now we have grown into a multidisciplinary service encompassing various professionals to care for people in all aspects of their daily life. We call our service, the vision rehabilitation service. I've been using resources through Hadley for some time, and I find them very practical and helpful for anyone going through vision loss. And so I'm so glad that you're doing this podcast today.

Ricky Enger: That's wonderful. Thank you. And we're so glad that you and others like you are there to assist our members as well. I know one thing that we do at Hadley is not only put people in touch with the right resources as they're going through their vision loss journeys, but just to let them know that certain resources exist. Not everyone knows the various types of doctors. Often, we hear from people, and Ed, I think you're actually going to cover this in one of your questions, "Hey, I've been to this doctor, I've been to that doctor, so I guess I'm done." What we hope to do with this podcast is show that there are other resources that you may not be aware of that can assist you. So with that, Ed, why don't we jump right into your questions?

Ed Haines: Sure. Thanks, Ricky. Dr. Mondal, as I mentioned, I was an itinerant vision rehabilitation therapist for a long time, and I would go into people's homes, and I would do an assessment. And when we'd sit down with my recommendations, almost always, I would say to them, "Look, it's going to be really important for you to get a low vision exam with a low vision specialist." And almost always people would respond by saying, "You know what Mr. Haines, I've already seen an optometrist, I've seen a retinologist. I've traveled all over to see these people. They've both told me nothing more can be done. I'm really tired of seeing doctors. Why should I go see a low vision specialist?" So my question to you initially is what would you say to that kind of comment? What does a low vision specialist actually do that other eye doctors do not?

Dr. Mondal: Let's first go over addressing that patient's frustration of yet again having another appointment. People going through vision loss might have to see a lot of specialists or they have multiple appointments very frequently. This can get tiresome and frustrating, especially when the vision continues to worsen and as they're told, nothing can be done. So losing vision is similar to losing a limb. People who have lost a limb, they're automatically referred to rehabilitation. So this is the same for vision loss. Rehabilitation is meant to help maximize the remaining vision one has as well as learn adaptations for independence and day-to-day activities like reading, cooking, using technology, and many more activities.

And as you mentioned earlier, you probably addressed all those with the patient at their home visit, but then had to explain to them why they should still see a low vision optometrist. I can talk more about what we do in the exam that's very different than what they would be doing with their specialist that they see regularly. So when we first see the patient, we start with a functional vision history. In my clinic, we have a social worker on staff, who usually goes over this history intake with the patient. And with that, we find out how the person's currently doing with their vision, have they tried any adaptations on their own? What do they feel they need help with? What are their visual goals? How much does that patient know about their eye disease and prognosis? So a lot of the time we do spend answering questions that the patient might have particularly about their eye disease and why vision can't improve and what to expect over time too.

We also ask them how vision loss is affecting transportation, food, or finances. After that, we assess their distance and near vision and we do this a little differently than the regular eye care provider would. Usually, for distance, we'll use a different chart, but also for reading, instead of looking at a reading chart with only letters that usually our eye care providers show, we might have them read text instead because the number one complaint of vision loss is usually difficulty with reading. And so this gives us a more practical understanding of where exactly this patient's struggling and how we can help them further. We also double check their eyeglass prescription, and from that we also make recommendations on what kind of lenses would be the best option lens design to help them with their visual needs to meet their goals.

We also do some more in-depth testing of the patient's functional vision. We assess their contrast sensitivity, their visual field if they're having glare sensitivity, and this helps us understand where the patient's struggling in their real world and make recommendations on devices in lighting adaptations and further vision rehabilitation services.

Ed Haines: Well, that's an awful lot. So that leads me to my next question. If someone decides, "Yes, I'm going to go for a low vision exam," what does that appointment look like in terms of time and effort and how should someone prepare? Should they set aside an entire morning? Can you give us sort of an idea of what people might expect just in terms of the experience?

Dr. Mondal: So when we have patients scheduled in our clinic, we usually tell them to expect about two to three hours for their visit. That way they can prepare in advance and also make sure if they need transportation, that they arrange it according to that. Also, we ask them to bring any kind of devices that they use, that they find useful so we can see what's working. Also, we ask them to bring all their eyeglass prescriptions or any sunglasses they use and also to bring their questions. Another thing we recommend, but it's not mandatory, is if they can bring somebody along with them because vision loss is so overwhelming. Sometimes it's hard to process all the information you're receiving, and especially in a long visit, that's difficult to remember everything that the provider went through with them or what recommendations were discussed.

And so having a second pair of ears in that room helps to retain that information and reinforce it after you leave the exam. But also it helps if you bring a friend or caregiver or even a family member. It helps that person also understand what you're going through with your vision loss and so they can help you a little bit better at home or also help you set up those recommendations that the provider discussed at the exam portion.

Ed Haines: That's a great point. It's overwhelming when you go to any kind of medical exam and it's really hard to remember all the information you're given. So fantastic point. Are there any common misconceptions people have about a low vision exam? When you have people come in, what's the most common thing that people think is going to happen that’s not going to happen?

Dr. Mondal: That's a great question because this is very common. When we receive patients for the first time in our clinics, most people sometimes think that we are going to help them see like they used to prior to their vision loss. And so there is some education involved where we tell people we're here to help them reach their visual goals, but they'll have to learn to do things a little differently to reach their goals. So we can't bring the vision back that they lost. But what we're trying to do is help them find out ways how we can help enhance their remaining vision, maybe through optical aids or magnifiers, and we'll take them to that extent. But then beyond that, if they need further help, then we look into different types of adaptations, like holding things closer, using brighter task lighting, increasing magnification, or using reverse contrast on digital devices. We can help them continue to do the things they enjoy.

Ed Haines: That's really interesting. And I've also heard people tell me, "I just want to see the way I used to. That's all I want. Can you make that happen for me?" And I also think folks often hope that they'll find one device that will solve all their problems, that there'll be one pair of glasses or one certain magnifier that will work in every situation for them. And of course, you may prescribe several different devices and quite a few as a matter of fact. So if someone's out there listening to this and they don't have a vision rehab therapist or someone else that can guide them to a low vision specialist in their area, how would they go about finding a low vision specialist?

Dr. Mondal: I would say the best person to ask is your regular eye care provider or the eye care specialist that you're seeing regularly for your eye disease. Because offering low vision or vision rehabilitation services is now standard of care by the American Academy of Ophthalmology and the American Optometric Association. And so most eye care providers know what services are local to them or in their state, and they can direct their patients that way, either sending a referral or providing contact information or a phone number to the patient. Also, most states offer low vision services, and there are many non-profit organizations across the nation that have low vision specialists on staff. So sometimes asking around or if you can do a search online to find out where services are located where you live, that's useful as well.

Ed Haines: Okay, thanks. Great. You mentioned identifying devices like magnifiers or different lenses that can help. Once you've identified those, are those covered by Medicare and insurance? How do people obtain those devices?

Dr. Mondal: That's also a great question. We get that a lot in our practice as well from patients. Medicare and most insurance companies pay for the medical portion of the low vision exam when they see us. However, they don't typically cover the refraction portion or the portion that we determine like eyeglass prescriptions, and they don't pay for the devices that we recommend to help improve functional goals. And so this gets a little bit difficult because sometimes when we're offering multiple devices, depending on what types of tasks the visual goals are, it can get costly. And so then we can help the patient find out if there are any nonprofits or state organizations that could probably help them find out if there's any funding to help them afford those devices if they’re having financial issues to obtain those devices.

Also, if a person is a veteran, oftentimes the VA will pay for the device. If a person is working or employed the employer or the State Department of Vocational Rehabilitation most times will pay for the device needed to help them in the workplace. So there are some opportunities out there to help afford devices, but unfortunately, medical insurances do not cover the cost.

Ed Haines: That's good information to know because I do imagine that some of these devices are not cheap. And so that being the case, if people really are committed to getting the devices, is it normal practice to try them out at home first? Is there a trial period so that if they're going to commit a lot of money, they have a chance to actually use them first before they actually buy them?

Dr. Mondal: In my practice, we do not have that option. However, at least in my state where I practice, I'm in the state of Wisconsin, our state vision rehab services or nonprofit organizations sometimes have loaner programs. So they might not have every single device that's out there, but most of the popular devices. They might be able to provide a loaner so that somebody can try them out before they make the investment to get one for themselves. So you can always ask your low vision provider if they can direct you to that program or find out if your provider offers that program as well.

Ed Haines: That's terrific. Because I know I've visited homes where I've asked folks, "Where are your magnifiers? What are you using?" And they'll pull out a drawer and they'll say, "Well, here they are. But they never quite worked for me, or I never really got it. They seemed like they worked in the office, but at home it wasn't the same." So that's great that people can find other avenues to try them out first. I think that's really important. Wonderful.

I'm going to bring up a topic that could be a subject for another podcast entirely, but it's really common for someone to be at the senior center or at church or some other gathering and someone will come up to them and say, "Hey, look, my relative in another state got this special pair of glasses and they can drive again. So you should go to a low vision doctor and get those glasses so you can drive," and people get all excited. I know we can't cover this question in its entirety, but there is such a thing as bioptic driving and what would you say initially to someone who gives you a call or comes in and says, "I want those special glasses so I can drive"?

Dr. Mondal: It depends on the state the person lives in. Each state has a different policy about bioptic driving. In my state, Wisconsin, the driver has to pass the road test without the bioptic. And most of the time, even for places that do offer bioptic driving, it's not meant to be used for the purpose of driving per se. It's more for reading signs or checking to make sure what you're seeing out there is accurate. People need to understand that a bioptic is not something that you would look through the whole entire time to help you with driving. It's a difficult question to answer, and what we do the majority of the time is counsel our patients and tell them, "We can't really help improve your vision to that point."

We also want to keep in mind that driving requires more than just vision. It involves physical fitness, reflexes, and cognition. So if we do find that we can help somebody maybe through a better pair of glasses, we can help them maybe get to that minimum standard for driving in our state. If they haven't driven in a long time, maybe years because of their vision loss, we usually will recommend and refer that patient to a driving assessment specialist. That way, the person is being taken care of in terms of safety, so that if they do go back to driving, they could safely do that again because it's been so long since they stopped driving. And so based off of those recommendations, we take the next step. So it's a process.

Ed Haines: It really sounds like it. As I mentioned, I know it's a big question and it's a subject for another podcast entirely, but it's a common one, and I think we have a little time. If you could just explain briefly, you talked about bioptics. If you could just define what that is and explain what you mean by that term.

Dr. Mondal: Sure. So bioptics, like mountable compound lenses or telescopes that are mounted on somebody's glasses, usually it's mounted on the top of the lens, so it's not obstructing your vision. When it is needed, the user will dip their head down to look through that lens on the top of their glasses to receive a magnified view of whatever object they're trying to see in more detail. Suppose they're trying to find a street sign and they see where the sign is, but they can't read what the street is on that sign. The person will dip their head down to look through the bioptic and maybe they'll have a more magnified view of the letters of the street sign so then they can easily read what that sign says.

Ed Haines: Got it. Thank you. I appreciate that. Just a couple more questions, really. One thing that people do ask me also, when I recommend a visit to the low vision specialist, they say, "Well, I do go to a lot of doctor's appointments. Will I have to see a low vision specialist on a regular basis now? Is this another doctor I'm going to have to add to my list of folks I have to visit?" Or do you see people as needed or do they start coming every six months or every year? Or does it depend?

Dr. Mondal: How often we see the patient depends on the patient's visual need. It could depend on their age and their health. Sometimes I might see a patient back every few months or every year, if they have a progressive eye condition like cataracts or maybe they're having issues with driving and they need to get a yearly renewal, then we'll see them once a year. Sometimes my patients will call me for a visit in between we see them, when they have any new visual goals or their vision changes, they always know to contact me, and we get them in sooner. But at the end of every visit when I talk to my patients, we always come up with a plan that we agree on, on how often we want to follow up with that patient. So it's usually driven by how often the patient would like to be seen and also how progressive their eye condition is.

Ed Haines: Got it. So they should be guided by you with regard to their visit schedule, and then of course contact you if their vision changes unexpectedly, it sounds like.

Dr. Mondal: Yes.

Ed Haines: Fantastic. Just a final question, Dr. Mondal, is there anything else that we haven't covered that you'd like to say to prospective patients about a low vision exam or what you do in general?

Dr. Mondal: I would like to let people know that you don't have to wait to get a low vision exam or ask about low vision services until your vision is really bothersome. Even if your eye disease is in the early stages and it's just bothering you with even simple tasks like reading, or maybe you're getting more sensitivity, or you're having trouble recognizing faces or reading street signs from a distance. Start that conversation with your eye care provider or your specialist that you see regularly and say, "Hey, I'm really struggling with my day-to-day activities because of my vision. Can you refer me to a low vision specialist, or can I learn more about resources out there?"

Just start that conversation. Sometimes when we see our eye care providers, they're so concentrated on treating the eye disease and making sure they're doing the best they can to prevent progression or help improve the vision that they forget to talk to you about resources. But it's important that we always give you hope that there's always somebody or something out there that can help you maybe do your activities a little bit easier, and you don't have to suffer a lot.

Ed Haines: That's terrific advice. Thank you.

Dr. Mondal: Yes.

Ricky Enger: That's perfect. And I knew this episode was going to be info packed, and it has been. I think it helps so much not only to know what to expect, but also to have an idea of some questions to ask that you might not have even thought about before. So I so appreciate your time, Dr. Mondal and Ed, thank you both so much again for sharing your information, your knowledge, and I appreciate your passion for what you do. Thank you so much.

Dr. Mondal: Thank you Ricky and Ed, thank you for this opportunity today.

Ed Haines: It was great to talk with you Dr. Mondal and thank you Ricky for the opportunity. Appreciate it.

Ricky Enger: Got something to say? Share your thoughts about this episode of Hadley Presents or make suggestions for future episodes. We'd love to hear from you. Send us an email at [email protected] That's P-O-D-C-A-S-T @HadleyHelps.org or leave us a message at 847-784-2870. Thanks for listening.