Vision rehabilitation care can be an important tool to growing and strengthening your practice—whether you are looking to add value to primary eye care services, starting to incorporate vision rehabilitation care into your practice or already an expert in the field.
In June 2019, the AOA Board of Trustees approved a new definition of vision rehabilitation.
Model of care: Vision rehabilitation is a process of care for individuals with vision impairment(s) managed by doctors of optometry (or other eye physicians) as part of the eye and vision care continuum. This clinical process begins with an eye examination which includes all areas of a comprehensive adult or pediatric eye and vision examination as the physician deems necessary or appropriate[1, 2], with evaluation to specifically assess the visual impairment which may include visual and non-visual pathways and its impact on function. It also includes development of an individualized treatment plan, shared clinical decision making and management of the patient's vision impairment(s). The model of care for patients with vision impairment parallels the physical medicine and rehabilitation care model for individuals of all ages with visual impairment(s) where the doctor of optometry identifies and leads an appropriate patient-centered care team. Ongoing re-evaluation of the patient to address changing vision and/or patient needs and priorities leads to subsequent changes in treatment strategies to meet desired health outcomes.,
Defined treatment: Vision rehabilitation care and services managed by doctors of optometry can include, but are not limited to: clinical procedures necessary to assess and document the level of vision impairment, history, evaluation and plan of care; counseling; coordination of care; prescription of optical, non-optical, electronic and other treatment options; integration of treatment with clinical therapy and use of treatment to optimize visual functioning; and the prescription and/or performance of therapeutic procedures, strategies and/or techniques that may be administered as appropriate by state-licensed, certified and/or regulated professionals that reduce, stabilize or prevent vision disability, improve function and support activities of daily living including, but not limited to, enhancements to reading, learning, ambulating safely and the pursuit of activities associated with improved and protected individual health. It is important to note that continued optometric care of the eyes and visual system and diseases/conditions related to the visual impairment must continue parallel to the process of vision rehabilitation.
Vision rehabilitation referrals and evaluations
Without a proper referral and a visual efficiency and function evaluation, patients with uncorrectable vision impairments may never receive the vision rehabilitation services they need to maximize health, quality of life and independence. The AOA is committed to advocate and provide resources so that more patients will visit doctors of optometry and receive the vision rehabilitation services they need.
Regardless of whether you specialize in vision rehabilitation, your patients depend on you to identify their vision rehabilitation needs and help them find appropriate follow up care. A comprehensive eye examination is an essential step to connecting your patients with low vision to the services they need. As primary eye care physicians, doctors of optometry should be able to:
- Identify signs of low vision.
- Identify signs of depression amongst individuals with vision loss.
- Identify the signs of Post Trauma Vision Syndrome and concussion.
- Be aware of practices in the area that offer vision rehabilitation services if they do not provide those services themselves.
- Refer sooner than later to a vision rehabilitation specialist.
Visual efficiency and function evaluation
Once a vision rehabilitation patient has been identified and referred, the patient should be administered a visual efficiency and function evaluation.
Comprehensive visual efficiency and visual function evaluations identify the patient ability to function with their residual vision. It helps the patient, family and care givers understand their limitations, and establish realistic goals for their treatment plans.
The AOA is committed to encouraging more patients to see doctors of optometry so that patients suffering from uncorrectable vision impairments can be identified and referred to the vision rehabilitation services that they need. Our advocacy goals include:
- Promoting the importance of an in-person comprehensive eye exams to help connect more people with vision rehabilitation services that they need.
- Educating patients, policymakers and other professions of the importance of comprehensive eye exams, and visual efficiency and functional evaluations.
- Provide resources to doctors of optometry so that every doctor can identify and refer patients in need of vision rehabilitation services.
- Provide resources to help more doctors of optometry perform visual evaluations and services.
Low vision services
Low vision services are provided to individuals with reduced visual acuity or visual field deficit that is not correctable by conventional spectacles, contact lenses or surgery. These individuals are often told that "nothing more can be done" for them and are at risk of spiraling into depression due to their loss of independence and ability to perform daily activities. However, even individuals with severe to total vision loss can maintain an active and independent lifestyle. The practice of low vision rehabilitation empowers doctors of optometry to maximize their patient's function, independence and overall health. These services help patients move beyond the belief that "nothing more can be done" for their vision loss.
Optometric low vision services include consultation includes:
- A functional and social history, which includes patient's ability to read instructions, administer medications, use a microwave, write checks, walk, see food on their plate, pour beverages or position a key in a lock; and their living arrangement, transportation concerns, social/familial responsibilities, etc.
- Screening for depression and behavioral changes associated with loss of activity and independence due to vision loss.
- Assessment of visual status including:
- Visual acuity assessment.
- Visual field assessment.
- Determination of a preferred retinal locus.
- Contrast sensitivity assessment.
- Determination of refractive status.
- Patient education on:
- The nature of their eye disease.
- Why conventional glasses or surgery will not improve their vision.
- Availability and benefits of low vision therapy/training.
- Exploration and education of low vision strategies, aids and adaptations.
- Referral, when appropriate, to occupational therapy or other vision rehabilitation professionals for therapy/training options that may include in-office, in-home, outpatient facility or combinations of care.
Primary eye care and low vision
Although not every doctor of optometry specializes in low vision rehabilitation, primary eye care physicians should be able to identify, refer and guide patients to needed low vision services. All doctors of optometry should educate individuals with vision loss about the basic nature of their disease/pathology and why conventional glasses or surgery will not improve their vision. This understanding helps individuals with vision loss move forward and be more accepting of low vision services. Doctors of optometry should also look for signs that their patient's vision impairments may be causing difficulties in performing normal activities. Subjective complaints of individuals with seemingly normal visual acuity could indicate a need for low vision services.
The AOA is committed to helping connect more low vision patients with low vision services, as well as helping our doctors provide those services. Our goals include:
- Educating policymakers, patients and other professions about the importance of low vision services provided by doctors of optometry and the impact of those service.
- Providing resources that help members provide more low vision services.
- Advocating for scope of practice laws that allow doctors of optometry to practice low vision to the fullest extent of their training and expertise.
- Advocating for increase coverage and access to low vision services.
Neuro-optometric services are provided to individuals who have vision-related problems associated with neurological disease, trauma, metabolic or congenital conditions. When the visual system is disturbed neurologically, it can adversely affect activities of daily living for both children and adults. All patients suffering from neurological disease, trauma or conditions should be referred to a doctor of optometry for comprehensive eye and neuro-optometric services.
What is neuro-optometry:
Neuro-optometric services include:
- Comprehensive evaluations of sensory motor, visual field, accommodative and oculomotor function.
- Visual processing evaluations.
- Ocular health examinations.
- Special testing, such as electro-diagnostic services.
- Therapy options.
- Coordination of care with other health care professionals and rehabilitation specialists, such as occupational, physical and speech therapists.
Primary eye care and neuro-optometry:
As primary eye care physicians, doctors of optometry should be able to identify and refer patients in need of neuro-optometric services, as well as educate them on how optometry can benefit their rehabilitation. All optometric practitioners should ask specific questions when patients present with stroke, brain injury, double vision, developmental and problems with cognition. The patient's history should document when the condition started, what testing was done and the results of the testing and information on present and past treatment. Binocular and oculomotor testing to help with the diagnosis is the basic responsibility of the doctor. In addition, visual fields, pupil testing, ocular tracking and a dilated fundus evaluation are necessary. More extensive testing would be done for those doctors of optometry who practice in this field. Doctors that do not provide neuro rehabilitative services should be aware of those practices that do offer these services and be prepared to refer.
The AOA is committed to helping to connect more patients with the neuro-optometric services they need, as well as helping our doctors provide those services. Our goals include:
- Educating policymakers, patients and other professions about the importance of neuro-optometric services provided by doctors of optometry and the impact of those services.
- Providing and guiding members to resources that help them provide more neuro-optometric services.
- Advocating for scope of practice laws that allow doctors of optometry to practice neuro-optometric services to the fullest extent of their training and expertise.
- Advocating for increased access and coverage of neuro-optometric services.
For patients with low vision, ordinary prescription glasses are usually not sufficient to help with many distance and near tasks.
Low vision devices can enhance remaining vision or other senses to substitute for lost vision and help patients become more independent. Low vision devices can be non-optical, optical or electronic assistive devices. Typical low vision devices include microscopes, hand-held magnifiers, stand magnifiers, telescopes and telemicroscopes (See P. 22-26 of AOA's Vision Rehabilitation Resource Manual for more detailed descriptions). Each device has its optical and functional advantages and limitations, which must be matched with the patient's needs. Vision rehabilitation practitioners must evaluate and match patients to the low vision device that best addresses their needs, as well as train patients on how to properly use these devices (See P. 7-13 of Vision Rehabilitation Resource Manual).
Primary eye care and low vision devices
As primary eye care physicians, doctors of optometry should be aware of available low vision technology and how it can benefit patients with low vision. When examining patients, doctors of optometry should identify patients that would benefit from low vision devices/services, explain the range of options to those patients and make referrals to vision rehabilitation practitioners.
Many patients do not realize that low vision devices, adaptations and training can help improve their quality of life or that doctors of optometry can help provide such services. Many other patients do not have access to devices due to lack of coverage or vision rehabilitation practitioners in their area. The AOA is committed to helping connect more patients in need of low vision services and devices with doctors of optometry, which includes:
- Educating policymakers, patients and other professions about the importance and impact of low vision services and devices provided by doctors of optometry.
- Providing and guiding members to resources on:
- The newest vision rehabilitation technologies.
- How to identify and educate patients in need of low vision devices.
- Refer, educate or provide low vision devices.
- Advocating for increased coverage and access to low vision devices.
Management and coordinator of vision rehabilitation team
Eye doctors are an integral part of the health care team for patients with low vision and neurological conditions. It essential that these patients are referred to a doctor of optometry in order to identify, treat and manage their vision health, as well as coordinate care among other providers.
As patients, health care professionals and policymakers better understand optometry's role in patient care, more patients will regularly visit optometry practices and other professions will refer patients to doctors of optometry.
Because low vision impacts so many aspects of a patients' quality of life and independence, there are many different professions involved in vision rehabilitation treatment.
The vision rehabilitation treatment team includes:
- Low vision specialists (doctors of optometry/ophthalmologists specializing in low vision).
- Assess the visual impairment.
- Prescribe low vision devices to improve function.
- Create a treatment plan and coordinate services with vision rehabilitation treatment team.
- Work with the primary care physician, neurologists and other health care professionals to treat the vision and overall health of patients.
- Occupational therapy and physical therapy in outpatient rehabilitation centers.
- Train new skills, such as eccentric viewing modify tasks and environments.
- Orientation and mobility specialists.
- Train patients to move around better.
- Social workers.
- Find solutions to problems of social adjustment.
- Vocational rehabilitation counselors.
- Help patients overcome barriers to accessing, maintaining or returning to employment or other useful occupation.
- Retinal specialists.
- Provide medical or surgical intervention of retinal disease.
- Certified low vision therapists.
- Train the use of low vision devices and adaptive equipment.
Primary eye care and vision rehabilitation treatment team
Regardless of whether you specialize in vision rehabilitation, your patients depend on you to identify their vision rehabilitation needs and connect them to a specialist. As primary eye care physicians, doctors of optometry should be able to:
- Identify signs that their patient needs vision rehab services.
- Be aware of practices in the area that offer vision rehabilitation services if they do not provide those services themselves.
- Work with a patient's primary care physician and other treatment providers to identify health care concerns that impact the patient's vision.
- Refer sooner rather than later to a vision rehabilitation specialist.
- Follow up with patients and the vision rehabilitation specialist to help manage the patient's overall vision health.
The AOA is committed to helping our members manage the vision health of their patients, including:
- Providing resources to help members coordinate and manage the vision rehabilitation treatment team.
- Educating patients, policymakers and other professions of:
- Optometry's role in vision rehabilitation and overall health of the patient.
- The importance of regular, comprehensive eye exams to identify and refer patients in need of vision rehabilitation services.
- Referring all patients with possible vision impairments or neurological conditions to doctors of optometry.
Vision Rehab & Clinical Pearls Resources
The AOA's Vision Rehabilitation Committee provides information on common clinical scenarios in vision rehabilitation.
- AOA Help for Vision Impairment, Low Vision and Blindness Fact Sheet
- Demystifying Dizziness with TBI and Sports Injuries and Concussions
- Optometry and Social Work
- Reading Strategies to aid AMD Pa with Central Scotomas
- Lens RX prescribing for the TBI Patient
- AOA Optometry Brain Injury
- Traumatic Brain Injury Manual, Volume 1A
- Traumatic Brain Injury Manual, Volume 1B
Join the Vision Rehab Advocacy Network
Are you interested in helping AOA advocate for better vision rehabilitation policies, regulations and laws? The Vision Rehabilitation Committee provides strong leadership and expertise for AOA's advocacy initiatives, but the real change comes from the coordinated efforts of our members. Joining AOA's Vision Rehab Advocacy Network (VRAN) will not only keep you updated on the AOA's vision rehabilitation advocacy efforts and resources but also help the AOA identify opportunities for you to get involved in promoting vision rehabilitation on local, state and federal levels.
To join VRAN, please follow these instructions and complete the survey below.
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