baja visión

1. Survey of optometric low vision rehabilitation training
methods for the moderately visually impaired
Rebecca Kammer, O.D.,a
Christy Sell, O.D.,b
Richard J. Jamara, O.D.,c
and
Elli Kollbaum, O.D.d
a
Southern California College of Optometry, Fullerton, California; b
State University of New York, State College of
Optometry, New York, New York; c
New England College of Optometry, Boston, Massachusetts; and d
Indiana University
School of Optometry, Bloomington, Indiana.
KEYWORDS
Low vision
rehabilitation;
Age-related macular
degeneration;
Training;
Visual impairment;
Low vision
Abstract
PURPOSE: The goal of this survey study is to determine the low vision rehabilitation training practices
of optometrists who prescribe near magnifying devices for low vision patients who have moderate
visual impairment from age-related macular degeneration.
METHODS: A total of 2,028 surveys were sent electronically or by mail. A total of 136 optometrists
reporting a special interest in low vision rehabilitation responded to an 18-item survey about practice
mode, educational background, affiliations, and other demographic information. They were queried on
methodology, frequency, and specific strategic content of rehabilitation training.
RESULTS: Sixty-eight percent of the 136 respondents were private practitioners. Fifty-four percent of
all respondents agreed that they train patients for 1 hour or less. Nine percent provided 3 or more train-
ing visits and were more likely to utilize an occupational therapist. Forty-six percent of respondents
reported using various other personnel to perform the training. The majority of respondents spend
25% of their time examining low vision patients. Eighteen percent of all respondents were low vision
residency trained.
CONCLUSIONS: Descriptions of current practice patterns are difficult to ascertain without consensus
on terminology and management criteria among low vision practitioners. This survey and accompany-
ing literature review support the need for clinical research and education that will establish an effica-
cious and cost-effective model for private outpatient low vision rehabilitation for individuals with
various levels of vision impairment to determine the true availability of low vision rehabilitation care
in the United States.
Optometry 2009;80:185-192
Using measured prevalence rates of low vision and
blindness in the white and black populations, it was
estimated from the 2000 census data that approximately
1.5 million Americans over the age of 45 had worse than or
equal to 20/70 visual acuity, and 240,000 new cases of low
vision and blindness occurred each year. With the aging
population, the number of people with low vision is
expected to double over the subsequent 25 years.1
This
vision loss negatively impacts a patient’s quality of life,2
with increased rates of depression,3
increased need of care-
giver assistance,4
and increased risk of multiple falls.5
Corresponding author: Rebecca Kammer, O.D., Southern California
College of Optometry, 2575 Yorba Linda Blvd., Fullerton, California 92831.
E-mail: rkammer@scco.edu
1529-1839/09/$ -see front matter Ó 2009 American Optometric Association. All rights reserved.
doi:10.1016/j.optm.2008.10.015
Optometry (2009) 80, 185-192

2. Daily challenges include face recognition, reading, and
space perception resulting from decreased visual functions
such as contrast sensitivity, depth perception, and fixation
stability.6
To compensate for vision loss, patients with dis-
eases such as age-related macular degeneration (AMD)
need to adapt to changes in vision and may utilize various
low vision rehabilitation devices. Low vision rehabilitation,
‘‘incorporating both devices and training,’’2
has been shown
to improve aspects of visually impaired individuals’ perfor-
mances of activities of daily living and quality of life2,7-9
and contribute to a decline in depression.3
Most low vision
rehabilitation is done through a private outpatient model,10
whereas the Department of Veterans Affairs (VA) provides
intensive inservice rehabilitation lasting 4 to 6 weeks from
10 locations across the United States. This inservice model
has been shown to be highly effective.11
More recently, an
outpatient rehabilitation program was designed and evalu-
ated within the VA. This VA outpatient study (Low Vision
Intervention Trial [LOVIT]), which was a 2-center random-
ized, controlled trial, found a very large effect of rehabili-
tation with significant improvement in all aspects of visual
function compared with the wait-list control group.10
The
rehabilitation model in the study consisted of a low vision
evaluation, counseling, prescription and provision of opti-
cal and electronic low vision devices, and 10 hours of
low vision therapy, including a home visit and assigned
homework for patients with moderate and severe vision
loss from macular diseases.10
The visual acuities of the
subjects were worse than 20/100 to better than 20/500,
which would incorporate most moderately visually im-
paired (20/70 to better than 20/200) and some severely
impaired individuals (20/200 to 20/400) according to
ICD-9 (International Classification of Diseases, 9th edition)
levels.
Although there have been other studies of outpatient
rehabilitation with encouraging results, the measured ef-
fects of rehabilitation were small.12-15
Additional random-
ized, controlled studies are needed to determine which
components of the LOVIT program are responsible for
the very large effect observed in that trial and presumably
underlie the general consensus that low vision rehabilita-
tion is effective.16
Although an interdisciplinary low vision rehabilitation
model has been in existence for decades, incorporating
rehabilitation teachers, social workers, and psychologists,
there has been a more recent trend toward a rehabilitation
medicine model for low vision rehabilitation.17
In this
model, an occupational therapist (OTR/L) has been added
to the team, and rehabilitation training, in this instance,
can be billed to Medicare. The physician (defined by Medi-
care as either an optometrist or ophthalmologist) provides
the visual function evaluation (e.g., visual acuities, refrac-
tion, visual fields, contrast sensitivity) and the functional
vision evaluation (analyzing the nature of the visual task
and evaluating performance with and without the assistance
of low vision devices)18,19
and finally prescribes low vision
rehabilitation assistive devices (optical, nonoptical and
electronic). In this model, the therapist provides a critical
piece of the functional vision evaluation in the patient’s
home and then provides the rehabilitation training portion
in the office or home.20
In May of 2002, the reimbursement
for rehabilitation training for patients with a visual impair-
ment was established by Medicare in the Program Memo-
randum for Visual Rehabilitation (PM).21
The PM has
resulted in national coverage by Medicare of rehabilitation
training for individuals with visual impairments within the
medical system. Reimbursement is restricted to occupa-
tional therapists and physicians. A 5-year Centers for Medi-
care & Medicaid Services Demonstration Project began
in 2006 in 6 areas of the country to assess the impact of
adding 3 groups of nonmedical vision rehabilitation pro-
fessionals as providers of Medicare-reimbursed vision
rehabilitation services: Certified Low Vision Therapists,
Certified Vision Rehabilitation Therapists (formerly Reha-
bilitation Teachers), and Certified Orientation and Mobility
Specialists.20
Ideas and methods exist concerning low vision rehabilita-
tion training that date back to the 1970s with pioneers such as
Watson and Jose regarding the length of training, content of
training, and even who should perform the training.22,23
His-
torically, common practice among low vision optometrists
was to prescribe optical low vision devices and provide train-
ing that incorporated instructions on the maintenance of the
device, working distances, lighting requirements, and the
relative advantages and limitations of the optical system.24
We refer to this type of training as optical device training
(ODT) in this report for simplicity.
The goal of an optical device training program is to
make patients comfortable with their device and to improve
their efficiency with their remaining vision.22
Therefore, it
is important that the program be individualized for each
patient. The training is aimed at enhancing the patient’s
quality of life by making daily activities manageable. The
majority of those who are visually impaired have some
residual vision and can benefit from vision services.25
Clin-
ical experience shows that some low vision patients are sent
home with optical devices without proper instruction, ulti-
mately resulting in frustration and mistrust in the device.26
The device may be put away in a drawer unused until their
next visit with their doctor.26
Follow-up training in the pa-
tient’s home may be one way to avoid disuse of the devices,
and reinforcement with written instructions could assist the
patient through in-home practice. Instructions should in-
clude care of the instrument, purpose of the device, length
of practice sessions, and type of lighting.23
Other than the LOVIT study, there are a few studies and
reports that offer guidelines for the number of visits and
location of visits, with some promoting in-office and others
in-home therapy. The subjects in the studies are not usually
stratified based on ICD-9 visual impairment levels (i.e.,
near-normal, moderate, severe). It is possible that rehabil-
itation may be strongly influenced by the visual acuity level
of the subjects. The general sequencing of reading training
seems to be agreed on among clinicians; however, these
186 Optometry, Vol 80, No 4, April 2009

3. studies leave out the exact activities and specific steps
within the sequence.22,24,25
As investigators in low vision research move forward to
provide answers to the many questions surrounding low
vision rehabilitation training, it is beneficial to develop an
understanding of the current practices of optometrists
providing low vision rehabilitation in the private practice
and non-VA settings. The purpose of this study was to
survey the practices of the low vision rehabilitation op-
tometrists in the United States for management of a specific
group of low vision patients. These patients were charac-
terized with AMD and moderate visual impairment in an
attempt to provide a picture for the practitioner of what
may be the most common group of low vision patients seen
in their practices so as to elicit the most accurate responses
as to the most common or usual training practices.
Methods
The survey (Appendix 1) was administered to doctors of
optometry who may have practiced or had an interest in
low vision rehabilitation. A total of 2,028 doctors were con-
tacted through various listings of low vision rehabilitation
providers such as the American Academy of Optometry
(AAO) Low Vision Section and the American Optometric
Association (AOA) Low Vision Rehabilitation Section
members, vision rehab forum listserv, Ocusource.com,
and the Vision Rehabilitation Forum. Although the lists
were checked for duplication, several providers received
more than one prompt for survey completion as noted by
several e-mail responses. Each practitioner was assigned a
random number that allowed only one survey completion
on a specified Web site. If the survey was returned by
mail, the assigned number was entered manually by the
investigator. This allowed for an anonymous response so
as to encourage the most truthful admission of practice
methods. Most doctors (N 5 1,413) were contacted through
e-mail and then asked to complete an online survey. The
doctors who were unreachable electronically were mailed
a printed version of the survey (N 5 615). The survey
was sent to anyone who might have practiced low vision
rehabilitation at any time in their career.
The survey was designed with multiple choice re-
sponses for the ease of data analysis. The first half,
questions 1 through 8, was designed with multiple choice,
quantitative answers for general background information.
Instructions for the first half of the survey included the
following statement: ‘‘The goal of the questionnaire is to
survey practitioners about training in the use of near low
vision devices for patients who are moderately visually
impaired due to age-related macular degeneration.’’ Moder-
ate visual impairment was a term used in this survey to de-
scribe a specific patient group (20/70 to better than 20/160)
that might be encountered in a low vision practice. (Mod-
erate visual impairment is usually defined based on visual
acuity parameters by the ICD-9.) However, it was not
defined in the survey, and practitioner understanding of
the term could be a large variable that was neglected in
the study design. The term near low vision devices in the
description of the survey was used to describe a general
group of treatment options.
The respondents were queried on the number of visits
that were spent training patients in reading activities with
the magnifying device(s). The choices were none, 1, 2, or 3
or more. The 3 or more response was aimed at determining
who might be providing more extensive rehabilitation
above and beyond 1 to 2 visits of ODT.
Instructions for the second half of the survey included
the following statement: ‘‘Each of the following statements
refers to training with prescribed low vision near devices
(i.e., spectacles, hand magnifiers, stand magnifiers, telemi-
croscopes). For each of the following statements, choose
the response that best fits your current practice of low
vision rehabilitation.’’ The questions (9 through 18), were
arranged with frequency-based answers such as ‘‘all the
time,’’ ‘‘most of the time,’’ ‘‘some of the time,’’ or ‘‘never.’’
The examples of near devices purposefully did not include
video magnification so as to correlate with the probable
management of moderate visual impairment level (20/70
to better than 20/200) as opposed to management of severe
or worse visual impairment.
In the set of questions about training (or second half of
survey), items 9 through 11 asked about ODT, and ques-
tions 12 through 18 asked about specific strategies that
might be incorporated in a training sequence lasting one
visit or longer. (This is being called reading rehabilitation
training [RRT] in this report for simplicity.) The survey
queried the frequency of inclusion of specific strategies
into the training sequence (e.g., scanning, tracking, eccen-
tric viewing, practice with optical devices on activities of
daily living, incorporation of homework, and home visits).
The generic word training was used more frequently in the
survey (as opposed to ‘‘rehabilitation’’) because of the
unknown factor of who actually performed the training in
outpatient settings. If optometrists serve as the solo pro-
viders of low vision care, then they may not consider them-
selves providing ‘‘rehabilitation,’’ and the most accurate
view of optometrists’ current low vision practice was
sought by using the term training.
Results
One hundred thirty-six optometrists responded to the
survey (response rate of 6.7% based on 2,028 surveys
sent). A total of 122 responded through the online method
(response rate of 8.6% based on 1,413 emailed), whereas 14
responded by mail (response rate of 2.3% based on 615
mailed). Private practitioners (N 5 93) comprised 68% of
the respondents (see Figure 1) and 18% (N 5 25) of all
respondents were low vision residency-trained. With regard
to the level of participation in optometric associations, 79%
were members of the AOA Low Vision Rehabilitation
Kammer et al Clinical Research 187

4. Section, and 32% of all respondents were AAO members.
Twenty-four percent were members of both associations,
and 40% of the AAO fellows were also low vision diplo-
mates. A total of 62% of all respondents reported that no
more than 25% of their patient encounters would be consid-
ered low vision rehabilitation, whereas 21% responded that
the 75% to 100% of their patient encounters would be con-
sidered low vision rehabilitation.
Training practices
When queried about training patients with moderate visual
impairment for reading tasks, 7% of all respondents
reported not training patients at all, 47% reported training
for 1 visit, 37% reported 2 visits, and 9% reported 3 or
more visits (see Figure 2). Twenty-five percent performed
training in the patient’s home. Just more than half, 54%,
of the respondents did the training themselves, whereas
the others utilized personnel including OTR/Ls, rehabilita-
tion teachers, and technicians (see Figure 3). Of the 21
(15.4%) practitioners who utilized an OTR/L, 13 (62%)
were in a private office setting, whereas 4 (19%) were in
an educational facility, 2 (9.5%) were in a hospital setting,
and 2 (9.5%) were in a nonprofit low vision rehabilitation
center.
Training strategies
The items 9 through 18 were arranged by the most frequently
used response categories: ‘‘all of the time,’’ ‘‘most of the
time,’’ ‘‘some of the time,’’ and ‘‘none of the time’’ with
regard to how the optometrist incorporated specific training
activities when prescribing near magnifying devices. Optical
device training: items 9 through 11 (see Table 1) included
questions about device maintenance, optical properties,
lighting of the device, and the relative advantages and limi-
tations of the optical system. In the entire group of 136
clinicians, most practitioners frequently incorporated ODT
(most or all of the time), but for other areas of training,
responses were more varied (see Table 2).
The breakdown of the 12 respondents who provided 3 or
more visits on training near tasks (31) included 4 who
utilized an OTR/L and 1 who utilized a technician; the
remaining 7 performed the training themselves. Two of the
respondents were residency trained.
Distribution of primary mode of practice of low vision
providers
Commercial
1%
Educational
facility/
teaching clinic
12%
Hospital/clinic
(non-VA)
8%
Others
4%
Private practice
68%
VA medical
Center
7%
Figure 1 Mode of practice of low vision providers.
Patient visits spent on low vision rehabilitation
training for the moderately visually impaired with
central vision loss
no visit
7%
1 visit
47%
2 vists
37%
3 or more visits
9%
Figure 2 Number of training visits for low vision rehabilitation.
Who provides the low vision rehabilitation training
at the practice
Physician/
optometrist
54%
Occupational
therapist
15%
Supervised
technician
18%
Other
4%
Rehabilitation
teacher
8%
Not applicable
1%
Figure 3 Percentage of training visits provided by optometrist or other
personnel.
188 Optometry, Vol 80, No 4, April 2009

5. The 31 training visits group was more likely to answer
‘‘all’’ or ‘‘most of the time’’ to incorporation of RRT, such
as homework, home therapy sessions, and eccentric view-
ing training when compared with the mean of all responses
for survey questions 9 through 18 when compared with the
whole group.
Private practitioners
Ninety-three private practitioners constituted 68.4% of the
surveyed practitioners. Only 6 within this group (6.5%)
provided 31 training visits for their AMD patients with
moderate visual impairment. For their general training of
zero to 3 or more training visits, 13 (14%) utilized OTs, 21
utilized supervised technicians, 9 utilized rehabilitation
teachers or others, and 49 (53%) did the training them-
selves. A total of 14 (15%) were residency trained. Sixty-
seven (72%) of respondents reported that no more than 25%
of their patient encounters would be considered low vision
rehabilitation, whereas 11 (12%) responded that the 75% to
100% of their patient encounters would be considered low
vision rehabilitation.
Discussion
There are several limitations to this study that may have
affected how the practitioners responded. The final number
of survey invitations that were not rejected electronically or
by mail was 2,028. This is a relatively high number of
possible respondents when considering the lack of pub-
lished data confirming the number of optometrists practic-
ing low vision rehabilitation in the United States. There are
approximately 1,000 low vision rehabilitation section
members of the AOA (Personal communication, S. Brown,
American Optometric Association, St. Louis, Missouri,
May 21, 2008). The surveyed practitioners may not have
all been low vision rehabilitation providers, and several
practitioners responded via e-mail to this effect. Those
individuals who did not actively examine low vision
rehabilitation patients were asked to not complete the
survey. Six incomplete surveys were received, and data
from these surveys were not included in the results. Also,
the e-mail system used to contact the practitioners did not
allow a large number (N 5 361) of the e-mails to go
through to Yahoo accounts because of spam-filtering pro-
grams. Multiple e-mail addresses were outdated and thus
returned to the original sender as well.
The term moderate visual acuity was not defined in the
introduction of the study to the potential respondents. The
optometrists who responded to the survey may have made
assumptions about the characteristics of the patient because
no definition for any specific characteristics of the patients
or their visual acuity or description of their vision loss was
offered. For example, no consideration for the type of treat-
ment (or resulting retinal scar from photocoagulation or
newer injection methodology) or for the presence of a sco-
toma or contrast sensitivity loss was incorporated in the
definition of the type of patient characterized in the survey.
These factors alone may significantly affect visual perfor-
mance with near low vision devices and therefore affect
the length or type of training that an optometrist recom-
mends. Many patients have acuities better than 20/70, but
worse than 20/20, and suffer from functional vision loss,1
and respondents may have included this group in their
responses, which would most likely negate the need for
extended training.
Approximately half the practitioners in the entire sample
provided 1 hour or less in optical device training on
average for each patient, and 10% provided more than 3
hours of training personally or through a therapist or
technician. Twenty-five percent of patients were provided
training in the home. When comparing the private practi-
tioners with the remainder of the group (e.g., educational
settings, VA, hospitals, other multidisciplinary settings),
there were a few differences. The percentage of OTs
utilized (15% nonprivate versus 14% private) and the
number of 1-hour or less training visits (approximately
50% in both groups) in both groups were similar. The
percentage of residency graduates (26% nonprivate versus
15% private), the percentage of 31 training visits (14%
nonprivate versus 6.5% private), and the number of full-
time (.75% practice time) optometrists who practiced low
vision rehabilitation (26% nonprivate versus 12% private)
were higher in the nonprivate modality. These comparisons
Table 1 Questions 9 through 11
Categories
Device
maintenance
Optical
properties Lighting
None of the time 6 (4%) 0 (0%) 1 (1%)
Some of the time 19 (14%) 10 (7%) 6 (4%)
Most of the time 34 (25%) 32 (24%) 29 (21%)
All the time 77 (57%) 94 (69%) 100 (74%)
Table 2 Questions 12 through 18
Categories Scanning Eccentric viewing Spotting Sustained reading Materials vary Procedures same Homework
None of the time 9 (7%) 12 (9%) 4 (3%) 1 (1%) 0 (0%) 35 (26%) 13 (10%)
Some of the time 61 (44%) 74 (54%) 31 (23%) 20 (15%) 9 (7%) 64 (47%) 67 (49%)
Most of the time 42 (31%) 32 (24%) 49 (36%) 66 (48%) 39 (29%) 36 (26%) 34 (25%)
All the time 24 (18%) 18 (13%) 52 (38%) 49 (36%) 88 (64%) 1 (1%) 22 (16%)
Kammer et al Clinical Research 189

6. should not be surprising considering the nonprivate group
contained the various modalities (e.g., hospital, VA, edu-
cational facility) that would be more likely to have access
to multidisciplinary rehabilitation teams practicing on a
full-time basis.
More than a third (36.2%) of the optometrists respond-
ing to the 2006 AOA Scope of Practice Survey said they
provided some level of low vision services.6
The survey did
not define what level of low vision was provided by those
who said they did provide services. However, without a
clear definition of what level they may offer within their
practices, we are uncertain of the true availability of low
vision rehabilitation care in the United States.
This survey attempted to capture a representative portion
of those practitioners to provide a better understanding of
the training practices for what may be a common group of
patients for these practitioners. However, what was learned
is that there is not a common language and standard of
practice for optometrists who practice low vision. Without
fully defining the terms in the survey, we may not have
captured a true representation of practice patterns. Care
must be taken in interpreting the results and generalizing to
all optometrists in the United States.
A significant number of patients seen in optometric
clinics may in fact benefit from an entry level of low vision
care (i.e., primary low vision care) that is clearly defined and
includes guidelines for referral of patients to more compre-
hensive low vision rehabilitation services. Clearly defined
referral criteria and education about comprehensive low
vision rehabilitation services is critical for appropriate care
to be provided when activities of daily living are affected.
It is difficult to extend the results of this survey to the
general population of low vision practitioners because of
the low number of responses. Also, it is unclear whether the
respondents understood the framework of the survey as
intended for a certain group of patients seen in their
practices as they actually would have treated them versus
how they may have been treated. It may have been better to
create a sample case that practitioners were asked to
manage theoretically; however, the authors wanted a simple
survey with a short time requirement so as to gain the most
responses possible.
The low number of training visits on average may mean
that the majority of patients that these practitioners see do
not require extended rehabilitation training (assuming that
the survey description of ‘‘moderately visually impaired’’
was understood to mean acuities on the better end of the
spectrum), or it could mean that the survey did not provide
a clear view of practice patterns within this sample of 136
practitioners because of a misunderstanding of terminology
used. What we believe the results of the survey reveal a
looming problem in the area of low vision rehabilitation
in the use of terms, the description of practice patterns,
and the consistency of how rehabilitation is practiced in
the United States in all practice modes.
Our findings are in agreement with impressions reported
in the literature. There appears to be tremendous variation in
the amount of low vision rehabilitation training provided in
the VA versus the private sector.10,24
Goodrich et al.24
sur-
veyed a small sample of non-VA low vision rehabilitation
clinics (‘‘the private sector’’) and concluded that the average
time spent with device and reading training on a general low
vision rehabilitation patient population was less than 1 hour
for most of the 16 clinics.
For a sample of optometrists who provide low vision
care, when training is provided, it is provided by OTR/Ls
(15%), technicians (30%), or the doctor (54%). Most of the
training is completed in 1 or 2 visits for the patients with
AMD and is not likely to be performed in the patient’s
home. Only 9% of surveyed practitioners reported provid-
ing extended training of 3 or more visits. This raises the
question: Do individuals with moderate visual impairment
caused by AMD require or benefit from extended training?
In spite of current Medicare coverage of 12 to 15 hours of
OTR/L training in the United States, there is not a general
inclusion of other training activities, such as eccentric
viewing training or spotting, scanning and tracking activ-
ities, or even the inclusion of homework. The results of the
study could be influenced in part by the lack of established
practice patterns for various types of patients who present
to a low vision rehabilitation clinic. Because there are few
studies that establish the effectiveness of low vision reha-
bilitation to specific groups of patients with varying visual
acuity levels and other visual functions affected, practi-
tioners (specifically those in a private practice setting) may
find it difficult to determine what level of rehabilitation is
necessary or determine that it is too difficult to find local
and experienced therapists with whom to establish a
rehabilitation team.
Conclusion
These results expose a need for studies that evaluate which
training strategies are effective for improving reading
performance and improvement in sight-related activities
of daily living, studies that evaluate the length of time
necessary to produce effective and long lasting results, and
what types of patients benefit from training. Cost of
training is also a critical component that may ultimately
determine how much time a private practitioner spends or
refers for rehabilitation. Currently, OTR/Ls are the only
Medicare reimbursable therapists (outside of the demon-
stration project areas) who can bill for rehabilitation
services. They must have orders from a physician and can
work independently through referral or be employed by the
physician in an incident-to arrangement, which precludes
in-home therapy (other than 1 home evaluation).9,20,21
OTR/Ls can also assign their Medicare number to the
physician practice in which they provide care, and this
arrangement would enable in-home therapy. However, the
accessibility of an OTR/L experienced in low vision
rehabilitation can be a major concern. Not all OTR/Ls
have educational curriculum and experience working with
190 Optometry, Vol 80, No 4, April 2009

7. low vision rehabilitation patients, and the current certifica-
tion programs are relatively new; many OTR/Ls that would
qualify have not yet completed the process. Consequently,
there is a limited number of OTR/Ls readily available,
especially in rural communities.
This survey and accompanying literature review support
the need for clinical research and education that will
establish an efficacious and cost-effective model for private
outpatient low vision rehabilitation for individuals with
moderate visual impairment.
Acknowledgments
Statistics assistance provided by Li Deng, Ph.D., New
England College of Optometry, Boston, Massachusetts, and
Andrew Loc Nguyen, Ph.D., Southen California College of
Optometry, Fullerton, California.
References
1. Massof R. A model of the prevalence and incidence of low vision and
blindness among adults in the US. Optom Vis Sci 2002;79(1):31-8.
2. Walter C, Althouse R, Humble H, et al. Vision rehabilitation: recipi-
ents’ perceived efficacy of rehabilitation. Ophthalmic Epidemiol
2007;14:103-11.
3. Horowitz A, Reinhardt JP, Boerner K. The effect of rehabilitation on
depression among visually disabled older adults. Aging Ment Health
2005;9:563-70.
4. Schmier JK, Halpern MT, Covert D, et al. Impact of visual impairment
on use of caregiving by individuals with age-related macular degener-
ation. Retina 2006;26:1056-62.
5. Coleman AL, Stone K, Ewing SK, et al. Higher risk of multiple falls
among elderly women who lose visual acuity. Ophthalmology 2004;
111:857-62.
6. Stelmack JA, Massof RW, Stelmack TR. Is there a standard of care for
eccentric viewing training? J Rehabil Res Dev 2004;41:729-38.
7. Stelmack J. Quality of life of low-vision patients and outcomes of
low-vision rehabilitation. Optom Vis Sci 2001;78:335-42.
8. Hinds A, Sinclair A, Park J, et al. Impact of an interdisciplinary low
vision service on the quality of life of low vision patients. Br J Oph-
thalmol 2003;87:1391-6.
9. Lamoureux EL, Pallant JF, Pesudovs K, et al. The effectiveness of
low-vision rehabilitation on participation in daily living and quality
of life. Invest Ophthalmol Vis Sci 2007;48:1476-82.
10. Stelmack J, Tang XC, Reda DJ, et al. Outcomes of the Veterans Affairs
Low Vision Intervention Trial (LOVIT). Arch Ophthalmol 2008;126:1-10.
11. Stelmack JA, Szlyk JP, Stelmack TR, et al. Measuring outcomes of
vision rehabilitation with the Veterans Affairs Low Vision Visual Func-
tioning Questionnaire. Invest Ophthalmol Vis Sci 2006;47:3253-61.
12. Reeves BC, Harper RA, Russell WB. Enhanced low vision rehabilita-
tion for people with age related macular degeneration: a randomised
controlled trial. Br J Ophthalmol 2004;88:1443-9.
13. Brody BL, Williams RA, Thomas RG, et al. Age-related macular de-
generation: a randomized clinical trial of a self-management interven-
tion. Ann Behav Med 1999;21:322-9.
14. LaGrow S. The effectiveness of comprehensive low vision services for
older persons with visual impairments in New Zealand. J Vis Impair
Blind 2004;98:679-92.
15. Smith HJ, Dickinson CM, Cacho I, et al. A randomized controlled trial to
determine the effectiveness of prism spectacles for patients with age-re-
lated macular degeneration. Arch Ophthalmol 2005;123:1042-50.
16. Hooper P, Jutai J, Strong G, et al. Age-related macular degeneration
and low vision rehabilitation: a systematic review. Can J Ophthalmol
2008;43:180-7.
17. Stelmack J. Emergence of a rehabilitation medicine model for low vi-
sion service delivery, policy, and funding. Optometry 2005;76:318-26.
18. Jackson AJ, Wolffsohn JS. Low vision manual. New York: Butterworth
Heinemann/Elsevier; 2007:xvi, 381 [316 p. of plates].
19. Colenbrander A. Aspects of vision lossdvisual functions and func-
tional vision. Visual Impairment Research 2003;5:115-36.
20. New Requirements for low vision rehabilitation demonstration billing.
Availableat: www.cmshhs.gov/ContractorLearningResources/downloads/
JA3816.pdf: Centers for Medicare & Medicaid Services; January 4, 2006.
Last accessed May, 2008.
21. ProgramMemorandumIntermediaries/Carriers.TransmittalAB-02078.
In: Department of Health & Human Services CfMaMS, ed. Baltimore
MD: Centers for Medicare and Medicaid Services; 2002.
22. Watson G, Jose R. A training sequence for low vision patients. Low
Vision 1976;47:1407-15.
23. Kelleher D. Training low vision patients. Low Vision 1976;47:1425-7.
24. Goodrich G, Kirby J, Oros T, et al. Goldilocks and the three training
models: A comparison of three models of low vision reading training
on reading efficiency. Visual Impairment Research 2004;6:135-52.
25. Scanlan JM, Cuddeford JE. Low vision rehabilitation: A comparison
of traditional and extended teaching programs. Journal of Visual Im-
pairment & Blindness 2004:601-11.
26. Stoll S, Sarma S, Hoeft WW. Low vision aids training in the home.
J Am Optom Assoc 1995;66:32-8.
Appendix 1. Survey of training practices in
low vision
Thank you for taking your valuable time to complete this
survey. The goal of the questionnaire is to survey practi-
tioners in the prescribing and training of near low vision
devices for patients who are moderately visually impaired
due to age related macular degeneration.
1. What is your primary mode of practice?
a. Private office
b. Educational facility/teaching clinic
c. Hospital/clinic (non-VA)
d. VA medical center
e. Commercial (i.e., Wal-Mart, LensCrafters)
f. Other ___________________________
2. How did you receive your low vision training?
Please circle all that apply.
a. Low Vision as part of the required optometry
curriculum
b. Low Vision Elective in Optometry School
c. Low Vision training (e.g. Lighthouse)
d. Residency (Low Vision)
e. Other_____________________________
3. What is your level of involvement in the low vision
optometric community? Please circle all that apply.
a. Low Vision Diplomate of the American Acad-
emy of Optometry
b. American Academy of Optometry Low Vision
Section Member
c. American Optometric Association Low Vision
Section Member
d. none of the above
Kammer et al Clinical Research 191

8. 4. How many patient encounters (low vision or other)
do you have in an average month?
a. %50
b. 51-100
c. 101-150
d. .150
5. What percentage of patient encounters involves low
vision rehabilitation?
a. 0%
b. 1-25%
c. 26-50%
d. 51-75%
e. 76-100%
6. On average, for the moderately visually impaired
individual with central vision loss, how many low
vision rehabilitation therapy visits are spent on
training for near tasks?
a. 0
b. 1
c. 2
d. 3 or more
7. On average, for the moderately visually impaired
individual with central vision loss, how many low
vision rehabilitation therapy visits are spent on
training in the patient’s home?
a. 0
b. 1
c. 2
d. 3 or more
8. Who provides the low vision training in your
practice?
a. Physician/Optometrist
b. Occupational therapist
c. Rehabilitation Teacher
d. Supervised Technician
e. Other
f. Not applicable/training not performed
Each of the following statements refer to training
with prescribed low vision near devices (i.e., spectacles,
hand magnifiers, stand magnifiers, telemicroscopes). For
each of the following statements, choose the response
that best fits your current practice of low vision
rehabilitation.
9. Training includes instruction on the proper cleaning
and care of the device, as well as demonstration of
maintenance including changing of batteries and
bulbs where applicable.
B All the time B Most of the time B Some of the
time B Never
10. Training includes discussion of the optical proper-
ties of the device, including demonstration of work-
ing distance, focal length, and field of view.
B All the time B Most of the time B Some of the
time B Never
11. Training includes discussion and demonstration of
effect of illumination on device performance.
B All the time B Most of the time B Some of the
time B Never
12. Training includes scanning, searching and/or track-
ing exercises.
B All the time B Most of the time B Some of the
time B Never
13. Training involves practice with eccentric viewing
strategies.
B All the time B Most of the time B Some of the
time B Never
14. Training includes use of the device in spotting activ-
ities (i.e. mail, bills, medicine labels, phone books,
and/or food packaging labels).
B All the time B Most of the time B Some of the
time B Never
15. Training includes use of the device for sustained
reading (i.e. newsprint, magazines, novels, etc.).
B All the time B Most of the time B Some of the
time B Never
16. Training materials vary based on the individuals’ goals.
B All the time B Most of the time B Some of the
time B Never
17. Training procedures are the same for all near
devices prescribed.
B All the time B Most of the time B Some of the
time B Never
18. Training includes exercises that the patient will use
for practice at home.
B All the time B Most of the time B Some of the
time B Never
192 Optometry, Vol 80, No 4, April 2009