Download Interpreting Regular and Low Vision Eye Reports. One of the things

Interpreting Regular and Low Vision Eye Reports.
One of the things that is always a challenge is when you get information from a physician, an eye care
professional, ophthalmologist, or an optometrist, interpreting the results of what you get. One of the
things we want to do is look and see what kind of report it is, what kind of doctor it is, what the purpose
is. The big challenge is there's a lot of jargon that's used. If you're not familiar with medical terminology,
there are two resources I would highly recommend to you. The first one is a book by Cassin and
Solomon called the Dictionary of Eye Terminology. It was originally published in 1929, but it has various
updated editions. Easily found at amazon.com or anywhere on the Internet bookstores, you can order it.
The other is a book by Vaughan and Asbury called General Ophthalmology. It's now under 'other
authors,' but they're still expounding on the original book that they did. The most recent addition to that
is in 2012. If you have a question about some specific eye conditions that are mentioned in the eye
report and you're not sure what they are or what impact those are going to have, then that would be an
excellent resource for you to look those things up.
I would recommend those two things if you are somebody who's going to be reading and interpreting
eye reports on a regular basis. You're going to come across some terminology you're not familiar with.
But what I'd like to do in this session that we have is to go through some of the major terminology that
you'll hear, the different kinds of eye reports, what you might expect, and how it might look when you
receive the results.
The first thing we're going to be talking about is a regular eye exam. Now, there are two different kinds.
There's a regular eye exam-- it was actually three: regular eye exam, a low vision exam and a functional
vision exam. We're going to be looking at the first two, a regular eye exam and a low vision exam.
The goal of a regular eye exam is to check the general health of the eye, look and see if there's any
disease, any conditions that may impair vision, and to diagnose what those eye problems might be. The
next thing, obviously, is to develop some kind of a treatment plan. The treatment plan might be getting
glasses, might be having surgery, it might be medications for the eyes - something that's going to either
address a disease of the eye or do something to improve your functional vision. Basically, what you want
to do is to maximize vision using either traditional glasses, contact lenses, or sometimes LASIK surgery
for people who don't have any eye diseases (that may just have a refraction error of some kind).
Refraction is what we call the process of getting a good clear image on the retina, that then goes back to
the brain where it's interpreted. If that's fuzzy or it's double vision or it's out of focus or has some
distortion in it or something, you're going to be correcting that primarily through refraction.
What constitutes a regular eye exam? First of all, it can be done by either an ophthalmologist or an
optometrist, and it may typically be done in what we call a SOAP format, S-O-A-P. This is something
that's used in counselling too. It's just a procedural way to look at the various aspects of what happens
during the exam. We'll break those letters down. The S is for subjective, the O is for objective, the A for
assessment and the P for plan. Part of what you're looking at is why is the person here? What do they
want to get out of the exam?
The first part is subjective. The best way to find that out is to ask the patient. What's going on? Where is
your problem? Which eye? When did it start? Why did it start? Did you get hit in the head? Did you have
an infection in your eye? Did you just have difficulty reading in certain situations or seeing in certain
situations? Then often, they want to ask modifiers, adjectives. How difficult is it for you to see, in what
kind of conditions, just to see if anything helps, like if you shine more light on what you're trying to see,
does it work better? We do know that some of that is very much part of the natural aging process. The
older we get, the more light we need to see something. So it may be that it's not even a refraction error,
that it's just a matter of getting more light to the object that you're trying to see.
The subjective would go on then to look at their general medical health, any health history, have they-for example, did they have a brain injury, did they have something that might impact their vision
neurologically, had they had a stroke, what kind of medications does the person take? There are
medications that have side effects. Some of those are prescription medicines and some are over-thecounter medicines, supplements and things like that.
To give an example of an older woman I knew, who was in her 80s, and she was starting to have a little
trouble with her memory. She was taking vitamins that were specifically for improving your memory,
some supplements specific for improving her memory, and all of a sudden she started having
hemorrhages in her eyes. Part of what happened is that there was an increased blood flow to her head
and that was manifesting itself with some hemorrhaging and bleeding in her eyes. So, it's very important
that when you go for a regular eye exam that you take a list of what your medications are. Often, in an
eye report, you'll see a list of what those medications are.
They want to ask about previous eye care, what other kinds of-- if you had any surgery in the past on
your eyes, any situations that have come up that have required medical attention. Have you been
wearing glasses since you were 10 and now you're 50, or what's the situation?
Then, this is always kind of interesting to me. They also ask a brief psychological. What they're asking
here is what we call orienting times three. Are you oriented to the person, 'Do you know who I am?' the
doctor will ask. 'Do you know where you are?' - orientation to place. And orientation to time, 'What day
is it?' If it's an older person that's going in for exam and they're going to be billed through Medicare,
they require that as a part of the exam. That may show up on your eye report, and you're thinking, Why
are they doing this? That's because of the person's age and billing.
Then, after you've gone through the subjective and you have a general idea of what the person wants,
then it's time for you to do some objective testing. The first thing that's usually looked at is visual acuity
- sometimes referred to in a report as VA. It's not Veterans Administration or Veterans Affairs or
Virginia, it's visual acuity. You'll see additional notation, sometimes s, a small letter s means without
correction and a small letter c means with correction, and that correction would be either eye glasses or
contact lenses - traditional types of correction. The visual acuity is also looked at both near and distance.
They might be notated on your report as a DVA or an NVA for near and distant. Then, there'll be some
reference to which eye. They'll be looking at the right eye, the left eye and both eyes together, but that's
too easy to say that, so they use Latin terms. For the right eye, it's oculus dexter and they abbreviate
that as OD. For the left eye, it's oculus sinister, abbreviated as OS. Then, oculus uterque means both
eyes, which is notated as an OU.
Those three terms, you probably won't ever see the actual Latin on there, or will you see right or left
most frequently form unless it's one that an agency that you work for prints up, but anything coming
from the doctor's office is probably going to say OD, OS, or OU. Then sometimes, you'll see the
terminology of BVA, that's for best-corrected visual acuity. They may do something, maybe you're 20/40
in your right eye, 20/60 in your left eye, together 20/40 because the dominant eye is the one that has
the better vision. Then when they do some correction with glasses, you're 20/20 vision. That would be
where you'd see those kind of things.
It will make a little bit of a difference on what kind of chart is being used. In charting visual acuity for
social security purposes in terms of determining if somebody is legally blind, what's used is a Snellen
chart. I'm sure you recall the definition of legal blindness, is vision of 20/200 in the better eye with best
correction, or a restricted field of vision of 20 degrees or less. The first half of the vision requirement is
visual acuity, and if a person's normal vision is 20/20 and a person sees 20/200, then their vision is much
less and that 200 is based on the size of a letter. However, we often interpret that to mean the person
sees at 200 feet what somebody with normal vision would see at 20 feet. It actually, though, it refers to
the size of the letter, and that's done on a Snellen chart, S-N-E-L-L-E-N, Snellen, and that was developed
way back, long before any of us were born. But sometimes to use the Snellen chart correctly - and that's
the chart that has the big E on the top usually - it's going to be in a room that's 20 feet long. Most
doctors' offices don't have that kind of space, so they may halve the space and they may report it as-rather than using 20 feet, they'll say 10 feet. So they just divide it by two. Or sometimes, they use
something called a Project-O-Chart. POC, so it might say POC, and many of you may have-- if you've had
an eye exam recently, you go and you see a little TV screen and they have letters that are projected up
into this TV screen and that's just another version of the Snellen reporting.
You can get more details on a Snellen chart, but in terms of social security, in terms of looking at
whether or not the person is legally blind, it's on a Snellen or a Snellen-like chart that looks the same
way. Now, the reason that's important is the big E on the Snellen chart is 20/200. The next line down has
two letters on it, usually an F and a P, although there are some variations of the actual letters there, but
that second one is 20/100. So if somebody's vision is 20/150, if they can't read the 20/100 line, they're
considered to be legally blind because all they can read is the 20/200. That may explain why you see a
lot of variation in the vision of people who are counted to be 20/200 legally blind. But nevertheless,
that's the way it's reported. Now sometimes, you'll see for example 20/100-1. It means that they can
read the 20/100 line minus one letter. You might see plus one. Maybe it's 20/70+1. That means he can
read one letter on the next line correctly. That kind of gives you an idea of the Snellen chart.
Continuing on with the objective testing, the next thing they want to look at is how the pupils are
reacting. If you recall, the pupil is that opening in your eye that's hidden behind your cornea that allows
light to go in and hit the retina on the back of the eye. And the iris, which is the colored part of the eye,
it works like an aperture. If there is a lot of light, it will close up a little bit, and if there is not so much
light, it will open up to let more light in because the whole thing is about getting light waves to the
retina so you can see. The testing that they will do for pupils, there's two different things that they'll do.
One is to take a light and shine it directly into your eye and then move it away. What they're looking at
is when the light moves into your eye, does the iris then cause a smaller opening in the pupil, and when
they move it away, does the opening then get bigger? That's referred to as an afferent pupillary defect
if that does not happen correctly. It will be a plus or a minus, having to do with whether the light comes
in or the light moving away. It's also referred to sometimes as a Marcus Gunn pupil, and that's the name
of the test to look at how that would be interpreted.
The other thing that they want to look at, are the pupils equally round and reactive to light and
accommodation, and this is often referred to as PERRLA, P-E-R-R-L-A - Pupils Equally Round and Reactive
to Light and Accommodation. And accommodation has to do with focusing near and distance, and also,
it could have something to do with light and accommodation here. The doctor may say, 'Look at my
nose, now look at my ear,' might shine a light in your eye, and they're checking out how those pupils are
acting. If the pupils are not acting properly, that may give some indication of some kind of a neurological
problem that may be causing the vision issues that somebody has.
The next thing they'll look at is EOM, extraocular muscles, and they're looking at the movement of the
eye. We have six large muscles around the eyeball, one on top that moves the eye at an angle, one on
the bottom that moves the eye at an angle and then four that move it straight back and forth and up
and down. Those particular muscles, we want to make sure that the movement is smooth in both eyes,
that both eyes are moving together. They might have you look into the upper right-hand corner and the
upper left-hand, lower right, lower left. Often, they do it as a quadrant kind of report. Taking a look
there and making sure that that movement is smooth and that there is no jerkiness in the way the eye
moves. That again, would indicate maybe some type of neurological problem or if one eye moves much
more readily than the other, it could be some kind of a problem with the muscle alignment, also
referred to as strabismus.
Now, when we talk about eye alignment, if an eye turns constantly, it's called tropia. If it sometimes, but
not all the time moves, it's called phoria. Then, if it's moving in towards the nose, it would be eso, and if
it's moving out, away from the nose, it would be exo. Esotropia means that it's a constant turn in.
Exophoria means that it's an intermittent turn outward.
Then, the next thing they'll be looking at are your visual fields, kind of a confrontation. Confrontation
means that - not that they're having a fight - but they're looking right straight at you. Again, they'll do
count my fingers in various quadrants - upper right, upper left, lower right, lower left. So, they'll hold up
two fingers, one finger, or three fingers. Count my fingers, move the fingers, and they want you to be
looking straight at their nose while they do that. They're looking to see if there is any really gross thing
that they can tell. They'll often have you do it with one eye occluded and the other eye occluded, and
then with both eyes. Part of that is the brain is an amazing thing, it will fill in the blanks if you're not
careful. Because it's seen the environment and you may look and you think you see something just fine,
but actually, the brain has filled in the blanks. So when you count the fingers, you may be thinking you'll
see just fine in the upper left quadrant, but in fact, he's only holding up one finger whereas in the
previous quadrant, he was holding up two, or she. Therefore, you're missing out on what it is. In a
report, that would be FTFC, full to finger counting in all quadrants, and they can give you some very
gross general mapping of places where you might have blind spots.
Sometimes too, they'll use an Amsler grid, and I have a slide here that has an Amsler grid on it's-- it
varies a little bit in how many squares there are, but it's basically a 10 by 10 grid most of the time. The
lines are straight, and there's a dot in the middle. It's used a lot with people who have macular
degeneration. They'll tell you to put it on your refrigerator and let me know if the lines change. And I
have two diagrams, one where the lines are very straight, and the other one, there's a dark spot and the
lines are a little bit twisted and kind of morphing into something a little bit different, making it look like
there's a hole in the grid. That would show that there was some progression of the disease, in this case,
macular degeneration that we're talking about and that allows a patient to be an active person in telling
how things are progressing with their eye, with their vision, and that's something they would then
report back to the doctor.
The other things they'll often do in looking at field, and the Amsler is more of a central, but it also does
look a little bit at the field visions. The other thing would be automated fields, and the automated fields
that you most frequently see is a machine called the Humphrey, the Dicon or the Octopus. They give a
very detailed view of vision loss and can be used for either a central or a peripheral loss. Looking back to
that in just a second, let me talk about some of the other kinds of objective tests and then we'll look a
little bit more into those objective field things because I think that's where a lot of our confusion comes.
Some of the other terminology that you'll see then on the objective would be refraction manifests as
traditional. That means there's no dilation of the eyes and cycloplegic is when the eyes are dilated. Now,
usually the dilation of eyes doesn't happen until near the end of the exam because your vision is never
going to be quite as good with the dilated-- your vision gets a little bit blurred. I will just make a little
note here that sometimes people who are deaf and have a vision impairment are very concerned
because they'll dilate their eyes and then they have a little difficulty seeing the interpreter as somebody
that's helping them with the eye exam process. So, it's good to make sure that everything is said and
done before the person's eyes are dilated.
They also may do some things with a Jaeger near vision chart. Also, checking out your intraocular
pressures, which are referred to as the IOP or tonometry, and this is done to check for glaucoma. The
normal pressure is between 14 and 20. So, part of what we'll be looking for on this IOP is to make sure
that there's normal pressure. They also will look in the eye and do a fundus examination. Fundus is
when they're looking straight in the eye after the eye is dilated, and they want to look and see if there's
any cupping in the optic nerve, which would accompany glaucoma or anything that causes an increased
pressure inside the eye. They'll be looking at the health of the blood vessels, seeing everything smooth
and nice on the retina, that is pink and healthy, doesn't have any big blotchy spots on it and things like
that.
On the next slide here, I have a picture of the Humphrey visual field test. It's a large machine and there
are others like this that have like a half of a sphere inside, and the sphere has little places where lights
are on it. The light will come up, and the person has a little device where they click when they see a
light. They're supposed to be looking at one spot inside, so they're focusing on a central spot and then
lights come in around, they indicate as they see them as they come in. In this particular case, what you
have is static lights, so the lights are not necessarily moving, they're staying still, rather.
Then, if you look at the next slide, here I've got two different pictures, one has the Humphrey results,
and you'll see that anywhere where there is a dark place that indicates that there is a restricted field,
there's a blind spot or the vision isn't very good. So this particular person has an upper field loss in both
the upper right and left quadrants, and a little bit sneaking down here in the left eye. But just see that-it's indicating to you the darkness. The darker it is, the more restriction there is in the vision.
Now, the other report on the right is a Goldmann. In the Goldmann, you have more of a-- rather than a
static light coming on, more of a movement, and it's done more of a-- the doctor is more involved in the
process, it's not an automated system. There's an area here on this particular diagram where there's
some lines that are drawn in indicating there is a blind spot there, which is in the lower-- mostly I guess
in the right hand quadrant, but it's kind of in the center. That would indicate that the area that has the
pencil mark around it - and sometimes they do those in red or blue - and it'll give you some indication of
where that blind spot is.
Then some of the other objective testing they do, moving on, is something done with the slit lamp called
biomicroscopy. Here, what they're doing is they're looking for two things. One, they're examining the
external structures of the eye. They're looking to see the eyelids, the eyelashes. Along the edge of the
eyelid, a lot of times older persons get little, almost like little blisters along the edge of their eyelid, and
that is something that can be treated. They're looking at the conjunctiva, which is a small membrane
that goes from the outside edge of the cornea, which is the clear front of the eye, all the way back
around inside the eyelids. If anybody has had pink eye or conjunctivitis where your eye - that little
membrane - gets inflamed, it can be very uncomfortable. But, they're looking to that to see if it's good.
They're looking at the cornea. Now, one of the things they want is for the cornea to be round and
smooth, so you may think about a ping pong ball. Your eye is about the size of a ping pong ball, and that
front cornea should have that nice, smooth, round, like a ping pong ball. But if your eye is slightly oval
and not quite perfectly round, then it may have more of an oval shape to the front, that would indicate
an astigmatism. You may also have maybe a little ripple-like effect in the cornea or maybe you've got a
scar on your cornea or something like that. That would be able to be examined very carefully with the
slit lamp. Now, the slit limp, also because it has a bright light in it, as it moves across, it will also give an
indication of what's happening with the iris in terms of its ability to act as an aperture to let light in. And
the lens of the eye, you can see if there is some opacity in the lens of the eye, which will be the
development of cataracts.
The next thing you'll see is that dilated fundus exam, DFE, and that's where they're looking at the
internal structures of the eye, I mentioned just a moment ago. They're looking at the cup-disc ratio of
the optic nerve. Here, for many years, we thought glaucoma was just increased pressure inside the eye,
but now, we understand that that's a symptom of glaucoma, but that's not what causes the vision loss.
What causes vision loss is pressure on the optic nerve. And there's a pretty wide rim around the optic
nerve, so that if you think of two concentric circles - the inside one being where all the nerves go back to
the brain and the outside edge being an area that's kind of a wide stem for the optic nerve - as the
pressure builds, that cup on the inside gets bigger and bigger and the rim gets narrower and narrower.
That ratio is an indication also of vision loss, so that's what a lot of times what they're looking at when
they do this fundus exam, particularly in people that have glaucoma.
If they do that, they have a C/D is how that would be on the report. And then VV, that has to do with
your blood vessels. They'll be looking to see if they're all in good shape. They may refer to your vitreous.
They may make a mention of the macula/posterior pole. The macula is the area right in the center of
your retina. The light comes right straight in your eye and goes to the macula, and the optic nerve is
slightly off-center. If somebody has macular degeneration, they may have some macular edema, which
is a little swelling. They might indicate that in this fundus exam.
Periphery, they're going to be looking at the peripheral part of the eye inside. They're looking to see if
there's any-- perhaps, looking for an indication of something like retinitis pigmentosa where they would
see some discoloring of the pinkness in the pigmentation in the retina.
The other thing too on this exam I want to mention is that if somebody has diabetic retinopathy and if
it's somebody who has had some other visual problems from childhood, where they might have
nystagmus, sometimes this is a very difficult exam to do. Somebody with severe nystagmus, it's very
difficult for them to hold their eyes still enough for the doctor to get a good look in. Sometimes they'll
be looking in with a slit lamp. Sometimes they'll have what looks like a half-dome magnifier that they'll
hold up, and they'll shine a very bright light through that into the eyes so that they can see. If somebody
has nystagmus, this dilated fundus exam is a little difficult to do. The reason I mention it with diabetic
retinopathy is that one of the treatments for diabetic retinopathy is to use a laser to seal up any leakage
in the blood vessels in the eye. If somebody has nystagmus, that's very difficult to do, because at that
point, the eye is not going to stay still enough to be able to allow you to hit it with a laser. Just
something to keep in mind. Often, people that we work with don't just have one eye condition, they
have several. Sometimes those two things can work against each other.
I have a photograph here of a slit lamp and you can see there's a light that is slightly curved, like a slit,
hence the name, and it moves across the eye from right to left and left to right. Then, I have another
picture here of a dilated fundus exam, a DFE. And if you look in the center, there is a little pinker spot
and that pinker spot is the macula. You can see the optic nerve is kind of a yellow area off to the side,
and the blood vessels come out from the optic nerve area.
Then, the next slide that I have has some diseased retinas, so when the doctor is doing the fundus exam,
he or she may see some different conditions. Here are some examples of retinitis pigmentosa, of a
macular bleed, an area where there is lots of edema or swelling of the blood vessels and so forth. Those
are just some things that you might see in that exam, and the doctor would then describe that in a
report.
Now, the Jaeger, which is J-A-E-G-E-R, near vision exam is a little card that somebody would read and
the print starts out small and gets larger. The notation on there often is an M - M.1 being newsprint size
print, the larger print that is necessary for them to read, holding it at usually a normal vision, which is
about 12 to 16 inches from the eye. That would be the end of the objective testing. Now, there could be
some other things, could be an electroretinogram or something, if somebody has possibility of retinitis
pigmentosa or something else, but generally, the ones we've gone over are the ones you most likely
would see.
Then, the next thing in our SOAP. We've done the subjective and the objective, and now is the
assessment or sometimes referred to as the impression. This is what the doctor thinks is going on. So
they're going to name an eye condition, and they're probably going to put down an abbreviated form of
that. Macular degeneration, they may say AMD. Glaucoma, GLC. Nonproliferative or background
diabetic retinopathy, background being BDR. NPDR is nonproliferative. Proliferative diabetic retinopathy
is PDR. Cataracts, they would put down NS, which is nuclear sclerosis. Myopia, nearsighted. Hyperopia,
farsighted. Presbyopia, that's that thing that we get when we get over 40s, where we have difficulty
accommodating to different distances and that's where you have to sometimes end up getting bifocals.
After they've come up with the assessment, then they're going to come up with the treatment plan how the patient is going to be treated. The first thing would be medical management, maybe they're
going to give them some medications, some drops for their eyes, or maybe an oral medication. They
might recommend surgery or sometimes they say, “Come back and see me in three months.” They want
to follow what's happening with the progression of the disease.
They may do some kind of optical management here, so they might be saying that the person needs
some refraction changes, and they will have been doing some testing for refraction. They'll say, “Which
is better, this or this?” Once it gets down to the fine tuning, it's sometimes very difficult to tell the
difference of which is better, this or this, as they change the lenses for you to look through. But they'll
be indicating some kind of medical management, so maybe prescription glasses or something like that.
And hopefully, there may be-- part of the plan would be referral. One of the things we like to see is
referral to-- if somebody has a severe vision impairment - 20/70 or worse or 20/200 in some states - that
they would refer to vocational rehabilitation or rehabilitation services for people who have low vision,
and that would vary in state to state. But if they make that referral, then there may be other services
that could be picked up that would be very beneficial to the person to help them to be as independent
as possible.
The reason I mentioned 20/70 is that is where most states - some are a little bit less or a little bit more but most states, that's where you can no longer get a driver's license. Once somebody has lost their
driver's license, their life changes drastically, so they may need some additional services to help them
through that. That's the end of a regular eye exam, what I want to say about that.
I'm going to go talk a little bit about a low vision exam and then we'll talk a little bit about the reporting
of these two things. A low vision exam or a low vision evaluation is done by somebody who is trained
specifically in low vision. This is where the person already has a diagnosis. They've been to the eye
doctor, they've gotten a diagnosis, what we call a regular eye exam. But the best that they can do to
improve their vision is 20/70 or 20/100, they can't get it any better than that. So they might recommend
that a person go to a low vision clinic.
Now, the majority of those are operated by people who are optometrists. There're some that are run
also by ophthalmologists, so it's not exclusively optometry. They may also have a certified low vision
therapist that works with them or a vision rehabilitation therapist. So you can see a variety of setup
sometimes. For example, Massachusetts has a mobile clinic that goes out to the more rural areas. You
may have to go into a clinic in an urban area. There aren't a lot of clinics around there. I think the last
time I looked, there were about 275 low vision clinics in the country, so they're not in every small town
or municipality. You might have to go to a larger city to go find a low vision clinic.
A low vision valuation is to maximize the functional vision through somewhat nontraditional means. It
may be using a magnifier, maybe a therapy that is suggested. It might be an environmental modification
or it could be something that the patient themselves is going to do to try and enhance their functional
vision.
It's very important for a low vision exam-- a lot of times people go for the low vision exam, and they
think they're going the same as they would go to a regular exam. It's good to prepare the person - if
you're a rehabilitation professional - that you let them know that this is not necessarily going to bring
their vision up to 20/20, that they may still have a problem with their vision, but this will help them to
maximize the use of what vision they have. Then also, it's important for them to be prepared to tell the
doctor the situation in which they find themselves and what they're trying to see.
For example, if somebody is diabetic and it's very important for them to read the nutrition facts on a can
and they like to eat a lot of soup and they use those cans that are red and they have black print on it, it's
hard for them to read. They've got two issues there - the size of the print, the lack of contrast in color and it's difficult for them to see. When they go to the doctor's office - as many people have this
experience - everything goes out of your head. You don't think about it. So it's good if you can prepare
ahead of time to take samples with you of what it is you have difficulty seeing. If it's a can of soup, if you
want to, you can take the can of soup, but you might want to just take the label. If you want to read the
phonebook but you have trouble with that, or the newspaper, or you have your favorite book you like to
read, or a Bible that you want to see or something. But to take an example of what it is you want to see
and to be prepared to describe the environment in which you try to read.
For example - whatever it is you're trying to do - you may be in the kitchen and you have a central light
overhead in the kitchen, but when you bend over, you create a shadow on whatever it is you're trying to
fix in the kitchen. So, you don't have kind of bright light, you don't have under-the-cabinet lights. Even to
the extent of your favorite reading chair, you check the mail, look and see what size light bulb is in there.
Is it a 60 or 100-watt bulb? Do you have an energy saving bulb in there? Is it a halogen bulb? The more
you can be informed to go into a low vision clinic, I think the better experience you're going to have.
That's something to be aware of.
The low vision exam is a little bit different than the other. The first thing that they'll do is a history. What
is a patient having trouble doing? Why are you here, in other words. You have trouble seeing your TV?
Well, how far do you sit from your TV? They may ask those kind of questions. It's surprising, a lot of
people have had their chairs in the same place and the TV in the same place for ages. It never occurs to
them to move their chair closer to the TV. They just say, I can't see it as well. The doctor will want to
know those kind of things. What type of reading light do you use? How much reading do you need to
do? What kind of hobbies do you like? Do you use a computer? If so, do you have any special technology
that you use in that computer? Those questions are going to be asked, so it'll be good for the patient to
come prepared to answer those questions.
They'll also ask them about the glasses. How long have you had those glasses? You just got them? Great.
Then they may check them again. They might also look for some buzzwords. For example, the person
might say, Well, I have a reading machine. A reading machine might mean different things for different
people. It could be what we would think of as the old CCTV or it could be a newer technology that would
read in an auditory manner like the SARA or something like that.
Then, the other thing they're going to be asking as part of the history is what is the one thing that you
most want to do? Do you want to read? Which is probably the two things that come up the most - is
being able to read and be able to drive your car. But occasionally, maybe somebody wants to go to the
theater and they want to see who's on the stage, or they want to be able to see street signs or maybe
they want to see what it says on the front of the bus. It's not always near-close things, it could be
distance things.
Now, there are some similarities with the regular exam, but there are also some differences. The history,
again, is more of a functional history. One of the questions they often will ask too - because everyone
that comes to a low vision clinic has vision less than 20/20, and often significantly less than 20/20 - they
might ask how did they get to the exam. Did they drive themselves? And might also ask about things like
alcohol and drug abuse. Those are things that might not come up on a regular exam. They will also do
some visual acuity, but they're going to use different charts. One of the big differences is for distance,
they'll use something called a Feinbloom chart. It's like a spiral notebook type thing with big numbers on
it. It flips over and it goes up very high, 20/700. Then, it gets down very small to 20/40, maybe even with
many more increments. So somebody could have gone to a regular eye exam, then told their vision was
20/200 and they were legally blind. Then they go to a low vision exam, they test them with more
increments, they find out their vision is 20/150. But because it's not on a Snellen or a Snellen-like chart,
they're still considered to be legally blind because of the way that is defined by the Federal government.
We often say more people are blinded by definition than any other cause, but in fact, that's part of
what's happening here. So make sure that you-- if you go for an exam or if you're a service provider who
is assisting someone else, help them to understand that it isn't that the other doctor made a mistake, it's
just a different way they measure things. They also will check more about things related to contrast and
glare. A lot of times, people have difficulty with contrast, and so, there will be some tests they can do for
that. They'll check their near vision, and the most common things they do are the Bailey-Lovie, the
[Hoff?] or the MN Read. Again, this is a little bit like the Jaeger chart, but it has more increments again.
Then, they'll check the visual fields confrontation, measure out where those scotomas might be. They
use an Amsler grid again, looking at scotoma density, how thick is the scotoma, whether you're able to
see through it all. Metamorphopsia, which is when those lines-- like on the Amsler grid, when they
would get very curved and contorted, that would be referred to as metamorphopsia.
Again, they might do some automated fields for field vision, perhaps using a little different technology.
The Nidek MP-1 maps central scotomas. Scanning laser ophthalmoscope could be used for looking at
some other types of field restrictions. They also will be looking at pupil and eye movements. Also, one of
things that you'll see as a major difference between a regular eye exam and a low vision exam, is in a
low vision exam, they almost will never dilate the person's eyes. I say almost, because there's probably
one person out there doing it, but generally, they're not going to dilate your eyes because they want to
enhance the vision as much as possible.
Then, they'll start trying different kinds of devices. A low vision exam is going to take much longer than a
regular exam. Regular exam might take 20 minutes, half hour. Half hour waiting in the office, then a half
hour for the exam. You actually see the doctor for maybe seven, eight, nine, ten minutes. But in a low
vision exam, they'll take from one to two hours. They'll be much longer in time, so people need to be
prepared for that. They'll try different kinds of things to enhance the vision, usually starting with
magnifiers, different kinds. There's a stand magnifier. If somebody has a tremor in their hand, they have
difficulty holding the magnifier still, they might use a stand magnifier. It might be one that has light
coming into it or maybe they don't need the extra light. There may be-- where they would use
something like a closed circuit TV system or what we now refer to as electronic magnification device,
where they would put it underneath the screen that has a camera on it, that puts it up on something like
a monitor or a TV screen type thing.
They may try a lot of different things for distance and for near. In some places, they'll lend people
devices. Other times, you have to purchase them. A lot of times, people will go to the local drugstore or
variety store and they'll pick up a magnifier saying, oh, this magnifier doesn't work. There's a big
difference in the quality of the optics between a $3 magnifier and a $50 magnifier. There really is a
difference. So sometimes, the devices that are recommended from low vision valuation will seem kind
of expensive to people, and they're thinking, well, why don't I just get something down at Walmart.
There is a difference in the quality of what you get.
Even though the exam takes a couple of hours, there may be some follow-up where they may have
somebody from their office - a low vision therapist - who will go out to the person's home and help
them learn how to use whatever device it is. They may have them come back in the office to learn to use
it there, it can go either way. That's the difference between the two types of exams. One is to diagnose
an eye condition and do refractive correction. The other, low vision may do a refractive correction, but
often, there'd be some kind of device. They might recommend additional lighting. They might
recommend some therapies to help the person. If they have macular degeneration, instead of looking
right at the page, to look slightly off to the side - eccentric viewing we refer to it as. They might even
suggest something like painting the walls a different color in an environment where somebody is, or
using different kinds of sheer curtains over the windows, or a bold line marker to write with, sometimes
referred to as a 20/20 pen. So, there'll be a lot of different types of recommendations.
Then, we come down to reading those reports. The first thing you want to look at is who is the report
from? Is it from-- who is the eye care professional? Is it an optometrist or is it an ophthalmologist?
They're going to use slightly different terminology. Is it from a low vision therapist? Is this something
that's done within an agency or did it come from another agency? Sometimes, you have different kinds
of jargon or lingo that you use within your agency or not. For example, I had seen a report that said
ARMD, and I hadn't seen that terminology before and that was age-related macular degeneration. Prior
to that, I'd always seen AMD, which also stands for age-related macular degeneration, but it's just a
slight subtle difference so you may see some of them.
If it's a neurological exam, they may have seen a neuro-ophthalmologist or a neurologist. Sometimes we
see something called cortical vision impairment where everything in the eyes works fine, but the person
still has some vision impairment problems, which could have been caused by a stroke or some kind of
neurological incident or a traumatic brain injury, something like that. So that would involve maybe a
report from a neurologist that might have some different things written on it.
There'll be some objective findings. There'll be a diagnosis from the primary eye doctor when you go for
that regular exam. They'll be talking about how much-- how often they want to see the patient. Maybe
you'll get some case notes. They may or may not ever say anything about low vision. Some doctors make
that referral, some do not.
The format, you may have a form from your agency. If you're a rehabilitation personnel, you may have a
form that your agency fills out. On it, you may have certain things that you're specifically looking for or
you may get a letter from the doctor, or you may accept both. Things you want to look for are the
diagnosis, the level and severity of the vision loss, are they legally blind, the prognosis and what the
treatment plan is going to be? Is there expected to be improvement or is this something that you want
to maintain where it is?
If you get an eye exam letter, rather than a written report, here's an example of how it might be. Starts
out, Dear so-and-so, I had the pleasure of seeing - whoever the patient is - a very pleasant, let's say, 70year-old female for a comprehensive eye exam on such and such a date. The chief complaint was
blurred vision. She has a history of macular degeneration, worse in the right eye than the left. Medical
history includes hypertension and hyperthyroid, both controlled by medication, and the following is the
summary of her exam. Best-corrected visual acuities, 20/200 in her right eye, 20/80 in her left eye. Now,
here it says OD and OS, but we know that-- right and left. The pupils, PERRLA. Pupils are equally round
and responsive to light and accommodation, so there's no APD there. EOM, which is the extraocular
muscles, smooth and full movement. No problem with that. Visual fields full to finger counting, so she
doesn't seem to have any kind of peripheral field loss. IOPs or intraocular pressure in her right eye was
18, in her left eye was 17, so both of those are in the range between normal, which is 14 to 20.
Biomicroscopy - using the slit lamp when they did the examination - she did have nuclear cataracts, both
in left and right, otherwise unremarkable. This could indicate that there is just the beginning of the
cataract; doesn't mean necessarily that they're recommending surgery at this time. The cataract can
develop very slowly.
Then, the next thing is the DFE, which is the dilated fundus exam. Macular drusen. So when they look in
there, they see - if you recall from maybe what you know about macular degeneration - there is this
little substance that can develop in the retina called drusen. It's yellow, looks a bit like scrambled eggs
when they look at it. They're seeing some drusen and RPE changes, that's the retinal pigment
epithelium. So they're seeing some changes in the way the retina looks, but other than that,
unremarkable. Those are fairly standard for somebody that has macular degeneration. Because her
vision is 20/80 in one eye and 20/200 in the other, she is not legally blind because it's a better eye. So
the better eye is 20/80, but she does have macular degeneration in both eyes, which is what was
diagnosed.
The plan at this point for this doctor is to see her again in six months. 'If there are questions, do not
hesitate to call me, best regards,' doctor makes a lot of bucks. What you have here is what you might
see in a letter from a regular eye doctor. There are a few terms here that we hadn't gone over like the
RPE, and if that's something that you're not familiar with or if you find there are some things that you
don't know, for example, if you get a copy of that dictionary, you could look it up in the dictionary and it
will tell you of eye terminology, would tell you what the RPE is. If you get the General Ophthalmology
book, you could look in the back, and it would tell you what the RPE is, or if you want to take our course
on anatomy and physiology, we would go over things like that. There are several ways where you can
find out what those abbreviations are that you may not have been familiar with.
Now, the other kind of report would be from a low vision exam, and the low vision exam is probably,
maybe a lot different. You probably do not have a standard report form in your agency. Some agencies
do, but most agencies do not. But what happens if you're working in an agency who works with people
that are blind and visually impaired and you contract out with a subcontractor to do a low vision exam,
oftentimes if the person is financially eligible, you may be purchasing some equipment for them. So
you'll get a report back, which has something to do with how-- what recommendations for equipment
were? If you're an individual who's going for a low vision exam and you're not working with an agency,
you may find that you don't get a report as such. You would just get a recommendation from the doctor
for equipment. That equipment could be a device or a magnification device or something like that. It
could be a recommendation for a 20/20 pen, which is a bold line marker or bold line paper. It could be
better lighting in whatever situation you find yourself.
Here's an example of a letter from a low vision exam. Dear so and so, I had the pleasure of meeting your
patient, Mrs. what's-her-name, for a low vision evaluation on such and such a date. As you know, she is
a very nice 70-year-old woman who suffers from macular degeneration. As you're familiar with her
medical history, I will not recount that here. This is a doctor who's writing a letter back to the regular
doctor. That's one of the things that is a little bit different here, although they might be sending it to
your agency. It says that she lives at home with her husband. You think, why would that be in there?
Well, the living situations can be a lot different. They're looking at function. What does a person need to
do? Do they have somebody else in the household that they can depend on to help them with things, or
do they have to be able to do these things independently? Mrs. so-and-so's main concern is reading. She
also has difficulty with personal hygiene and other daily tasks. Following is a brief summary of her
evaluation.
With her current glasses, her reading is measured OD 10/100, apparently his office is not as big as the
ophthalmologist's office or his or her office, and so they were using 10 feet rather than 20. But to get
that out, you just multiply it by two, so the physician has, in parentheses, put here 20/200. OS, left-- that
was the right eye. In the left eye, 10/40, which is 20/80, so the findings are the same as the other
doctors. Reading measured at 2.5 M, which is large print. So she needed large print in order to read, and
that was measured most likely on something like the MN Read or one of the other exams that would
test that near vision. Pupil reactions were minimal and eye movements were full. That's a good report,
no problem there.
Visual fields by confrontation. Amsler grid showed large, dense, central scotoma in the right eye and a
smaller area of metamorphopsia, which is that moving in of those straight lines. They're getting more
contorted centrally in the left eye with periphery full to finger counting in both eyes. Additional findings
were consistent with the diagnosis. They didn't do a dilated fundus exam, so may not have seen the
scrambled eggs kind of thing in there - in the eye - of the drusen, but they did see that there was some
things going on that may be consistent with macular degeneration.
Then, the next paragraph talks a little bit about what's going to be prescribed. The various low vision
aids were demonstrated. We also demonstrated-- instituted a course of eccentric viewing training, so
this woman is going to learn how not to look directly at something, but slightly off to the side. Best
response to low vision aids were 4.0X brand, and they put in LED lighted stand magnifier for reading,
which allowed 1.0 M print, which is newsprint. Normally, she needs 2.5 size print. She can get down to
reading regular newsprint - which maybe that's what she wanted to read - by using a 4X Eschenbach - or
whatever brand it is - lighted stand magnifier. We also demonstrated a 4.0 LED hand magnifier for
portability. So, there is a stand magnifier and then one that she can hold. But, they were also concerned
about some glare issues, so they recommended medium plum sun filter - NoIR - that's the name of a
company. U81, which is the brand of the plum filters, their number was recommended. We plan to see
her for initial evaluation training at which time we'll demonstrate CCTVs and other low vision aids.
Thank you for allowing us to share in the care of this delightful woman. If there are any questions, feel
free to contact us. You can see the reports that you get back is very different. It's more concerned about
the magnification aids, what the person is going to be able to do with those kind of things.
We did talk about the 20/200, but again, I just want to say again for the visual acuity, the first number is
the test distance, which is 20 feet. The second number is the letter size, although we sometimes think of
it as being what somebody with normal vision sees, that's often interpreted that way. The larger the
second number, the worse the vision. As we saw for this second doctor here, many of the low vision
doctors work in much smaller conditions-- shorter distances. Ten feet was used and so you just multiply
it by two. So 20/40 equals 20/80. And you can do it with other numbers too, like 7/40 equals 20/125. So
you just have to pull out that college algebra and get it too.
Just another little review here about legal blindness as we talk about this. This was again put together by
the Social Security Administration in 1943. Best-corrected vision of 20/200 or worse in the better eye or
a field restriction of 20 degrees or less. So you can't be legally blind in one eye, you can't be legally blind
with your glasses off. My friend, Greg Griswald who helped me with this - who is a low vision clinician -
he said he wished he could convince doctors of that fact because there were so many reports that he
had where a doctor would say a person was legally blind in one eye or something like that. But it's not a
medical condition, legal blindness, it's a governmental condition, a legal definition.
Then, I'll put just a little bit in here that I thought you might be interested in the difference between
diopters and magnification in terms of magnification that you see - 12 diopters equals 3X, so there is
really a 4 to 1 ratio there to help you in the US. But the results should be very functional, the person
should be informed if they come out of a low vision exam. Or if they've gone through both of these
exams, they should know more about their eye condition. They should ask questions about their eye
condition, about the prognosis, how things will be. Should they expect some deterioration, should they
expect some improvement and--