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Title: Visual Disability: Cases from the Gray Areas
Authors: Judith Goldstein, OD, FAAO, Alexis Malkin, OD, FAAO, Tiffany L. Chan, O.D.,
F.A.A.O.
Abstract: The purpose of this Grand Rounds is to inform and educate low vision
specialists and general optometrists on implications of vision loss and other factors in
working age adults, and specifically how to weigh the individual considerations of
whether to support application for disability.
Learning Objectives:
1. To consider whether it is reasonable to obtain vision-related disability benefits for
being legally blind and yet still maintain driving ability and licensure
2. To recognize that there can be functional decline and loss of visual ability,
without significant changes in visual impairment measures
3. To understand the role of the visual efficiency score when counseling patients
(who are not legally blind) about disability
4. To increase the clinician's awareness regarding the psychological state of the
patient
Case Report 1 – “Looking at getting by – but at what cost?”
Abstract
Patient GC is a 50 year-old male with early onset visual loss noticed at age 6; he was
ultimately diagnosed with hereditary optic neuropathy (or dominant optic neuropathy)
and legal blindness. Patient objective is to maintain driving privileges, to continue to
work (self-employed) and to stay financially independent in order to support his family.
Patient is a mason and lives in rural Maryland. Physical, psychological, and cognitive
health states are excellent. Given the economy and his progressive self-imposed limits
on driving, vocational and financial success has been inadequate for the past few years.
His vocational rehabilitation counselor has suggested applying for disability. This case
highlights the financial, emotional and practical considerations for the practitioner and
the patient when contemplating disability despite a good work history, continued driving,
and fairly stable vision impairment findings and visual ability function.
I.
Initial evaluation at Johns Hopkins Vision Rehabilitation Service -1998 at
age 36
a) CC: Wants to renew driving license and has some difficulty reading work estimates
b) Case history
i)
ii)
iii)
iv)
v)
Problems noted with vision as early as age 6
September 1998 – first visit at Hopkins
Working self-employed in masonry
Driving fairly unlimited
Lives with very supportive spouse and 3 children (2 children with optic
neuropathy)
vi) No comorbidities
c) Exam findings
i) Entering: VA (cc) RE 10/63- and LE 10/100; BE 10/63(1) Refraction and BCVA RE 10/63+ LE NI
(a) With mild to mod myopic correction (minimal astigmatism)
(b) -3.00 with -0.50 x 180 in each eye
(2) Contrast sensitivity RE 1.35 and LE 1.05 (mild to mod reduction)
(3) Peripheral visual field (VF) intact; Central VF significant for multiple
scotomas on Goldmann testing
(4) Color testing (D-15) shows deuteranopia
(5) Distance magnification (2.2x, 3.3x, and 4.0x) evaluation shows VA
responsiveness which is fairly consistent across powers to 10/32 to
10/40
(6) Biomicroscopy normal and fundus exam shows optic nerve pallor BE
d) Plan
i) 3.0x spiral Galilean bioptic telescope to recognize overhead signage, judge
traffic lights from a further distance, recognize faults in masonry at a more
natural distance, see the computer for spotting
ii) Referral to state rehab agency for support
iii) Apply to the modified driving vision rehab program in Maryland for
maintenance of license
e) Results
i) TS obtained with state support
ii) Daytime driving license granted through MD modified driving vision program
iii) Yearly low vision rehab follow up required by MVA
II.
Subsequent LVR follow up evaluations
a) 2000- Patient applied to MVA to lift daytime restrictions on driving given work
schedule, daylight savings time and need to drive at dusk
i) Exception provided only for 1 hr. before sunrise and 1 hr. after sunset
b) Doing well with bioptic driving; also using TS for regular hunting outings.
c) 2002 - VA LE decreased to 20/400 – referral to ophthalmology; no change in visual
ability function observed by patient. Neuro-ophthalmology eval did not reveal new
concerns, but rather felt to be natural deterioration in VA. (40yo)
d) 2008 – BCVA RE 20/100- and LE 10/200
i) Scotomas evident to R and L of fixation
ii) CS BE 0.95 log units (mod-severe reduction)
iii) Assessment
(1) Overall function adequate
(2) Do not recommend lifting night driving limitations
e)
f)
g)
h)
(3) Renewal of modified daytime license given
2009 – BCVA RE 20/100- and LE 10/200
i) Patient feels vision may have slipped a little; notices spot-reading blue prints with
hand magnifier not as good
ii) Wife doing all estimates and financial paperwork for masonry business
iii) Uses bioptic full-time when driving and will often rely on “older guy” who he works
with for driving in busy city areas.
iv) CS BE 1.15 log units (mod reduction)
v) 3x bioptic RE 20/60+2
vi) Plan: renewed modified license, however educated patient as length that we may
not be able to renew the following year as visual acuity appears to be borderline
for meeting the requirements.
2010 – BCVA RE 20/160+ and LE 10/320; BE 20/125i) 48yo - Patient feels that vision is unchanged from prior although notes dome
magnifier less effective for spot reading
ii) Patient reports that he continues to be cautious with driving, although he does
occasionally drive at night in familiar areas and notes no increase in difficulty
iii) CS 1.20 log units
iv) 3x bioptic RE 20/60+ ; 4x RE 20/40+2
v) Peripheral VF remains intact and unchanged
vi) Plan: re-engage with state rehab agency.
(1) Patient requires better reading solutions (e.g., blue prints and other workrelated documents) and appears more ready to engage in use of electronic
magnification systems
(2) Patient requires better TS technology with increased mag and better light
gathering
(3) Career counseling recommended
(4) Completed modified driving paperwork for limited driving
July 2011 – BCVA RE 20/160+ and LE 10/200
i) 49 yo - Based on discussions with rehab counselor, patient applied for disability
but has not yet received decision
ii) Masonry work has picked up
iii) Rehab agency provided support for new bioptic and desktop electronic
magnification. Patient reading newspapers and magazines now and able to read
medicine bottles.
iv) CS 1.20 log units
v) 4x TS RE 20/40+2 and proficient with accessing image
vi) Renewed confidence observed
vii) Completed modified driving paperwork for limited driving
October 2011 – BCVA RE 20/160 and LE 10/125-2; BE 20/125+
i) Denied disability but for reasons other than vision. Denied because age,
education and history of work ethic.
ii) He admits that he has noticed deterioration in his vision over the years.
iii) Driving
(1) Doing well with new bioptic which is clearer now for traffic lights and
identification of traffic patterns.
(2) Max driving now is 20-25 miles; only back roads
(3) 4x TS RE 20/40+2 and proficient with accessing
(4) Making good judgments and relying on others for driving wherever possible
iv) Extensive discussion re: disability
(1) Disability and continued driving – is there an impact?
(2) Engaging attorney services if he will be appealing the disability determination
(3) Financial and security implications of disability
(4) Continued work when disabled
i) October 2012 – BCVA RE 20/160- and LE 20/250-; BE 20/160+ or 20/125i) Disability hearing scheduled for the beginning of 2013. Patient did engage
attorney services.
ii) Notices he is a bit more fearful of heights
iii) Masonry work has gotten a bit busier and patient has hired an employee who
does the driving.
iv) Visual ability function stable
v) Uses CCTV all the time to read; dome to read if away from CCTV
vi) Driving – if there’s no need to drive he won’t. Drives the speed limit and within
15-20 miles from home. No accidents, no tickets.
vii) No contact recently with state agency
viii)Clinical findings unchanged from prior
ix) Plan
(1) Completed driving forms
(2) Discussed at length issues of financial independence and at what personal
cost
j) October 2012 – BCVA RE 20/125-+ (10/80 ETDRS) and LE 20/160 (10/125 ETDRS)
i) Social security disability was awarded after hearing with judge
ii) Awarded on the basis of physical/back issues
iii) Continues to work some masonry jobs, but financial pressure has lessened and
patient comfortable with determination. Patient is more relaxed and reports that
he feels less pressure.
iv) When driving, does so within rural 15-20 miles from home; wife does 90% of
driving
(1) Wears and uses bioptic full-time when driving but not for any other activities
(2) Feels comfortable with current driving
v) 4x TS RE 20/40+2 and proficient with accessing
vi) CS 1.15 log units
vii) Plan
(1) Completed driving forms
III.
Discussion Points
a) Is it okay to be legally blind and obtain disability for reasons other than vision?
b) Is it okay to obtain vision-related disability benefits for being legally blind and yet still
maintain driving?
c) The importance of legal representation when applying for disability
d) How is it that disability was granted to patient for reasons other than vision?
IV.
Conclusion and Clinical Pearls
This case exemplifies the essential role that visual ability plays in overall functional
ability and, that even without decline in visual impairment measures over time, overall
functional ability can decline with small changes in physical (e.g., minor back issues)
and psychological health states (concern and worry over providing for family). Although
financial independence was important, it was not sustainable given the vision loss.
Clearly, the importance of driving in rural areas for business and the necessary selfimposed restrictions did not allow the patient to compete fairly in the marketplace. The
provision of visual assistive equipment (e.g., bioptic TS) made the difference in his
comfort and ability behind the wheel for many years, however, with time, expected selfimposed drive-space restrictions become the reality that required encouragement of
disability consideration by his rehabilitation counselor. Discussion of disability should
not wait until frustration and anxiety set in, but rather be an ongoing conversation with
every working age patient maintaining or managing employment (self or otherwise).
Case Report #2 – “More than a passing grade”
Patient TL is a 50 year-old male with a complicated ocular history including CNV
secondary to angioid streaks, juxtafoveal geographic atrophy in both eyes, keratoconus
in the right eye and a history of herpes zoster affecting the right eye. The patient’s
original objective was to continue working as a 5th grade teacher as long as possible.
The patient experienced a progressive decline in vision and loss of visual ability,
causing greater concern over his ability to perform required tasks at work, including
near visual demands for print and computer reading as well as managing student safety
at recess. At follow-up exam, the patient demonstrated notable anxiety, visual fatigue
and stress even though work demands had remained stable and the patient continued
to receive good reviews from employers. This case begins with determinations of visual
assistive equipment for vocational rehabilitation, and then highlights discussion points
when determining disability including visual fatigue, job-related anxiety and job
confidence.
1/26/12
Referred by retina specialist to Low Vision Rehabilitation
CC: Difficulty reading and working on the computer
HPI:
1. Functional domains:
a. Employment:
i. Teaching fifth grade and additional adult classes at night.
1. His work requires inputting data and creating lesson plans
on the computer. He has tried to increase font whenever
possible but finds he is unable to increase the size of the
font for all programs.
2. He removes his glasses for reading and holds material very
close. Additionally, he utilizes a hand-held magnifier as
needed for small print but still has difficulty seeing numbers
and letters accurately.
b. Reading:
i. His daughter and wife will assist with reading the material to him.
He is currently utilizing an iPod to listen to the audio newspaper
and reads on a Kindle with enlarged font.
c. Visual information/Seeing:
i. He feels his vision fluctuates and is extremely lighting-dependent.
ii. Watching television: difficult to see the closed captioning or game
scores, but he is able to see the pictures fairly well.
d. Driving:
i. He is currently limiting his driving to daytime only in good weather
in very local areas. He reports his work is only 3 blocks from his
home.
ii. He feels extremely confident with his limited driving.
iii. He obtains rides with friends and family for any other situations or
lets another person drive if they are going to the same location.
e. Mobility:
i. no mobility concerns at this time.
ii. He utilizing polarized fit-over sunglasses to relieve outdoor glare.
f. Visual motor/ADLs
i. He is currently living in a house with his wife, adult daughter and 9month-old grandson. He is responsible for many tasks at home
and feels he is managing well.
Medical history: diabetes, last hemoglobin A1c was 7.1% in September, and
hypertension.
Ocular Hx:
1. Angioid streaks with vitelliform material in both eyes.
2. Juxtafoveal geographic atrophy in both eyes with choroidal neovascularization in
the left eye status post intravitreal Avastin injections x4 between 8/11, the most
recent was 11/30/11.
3. Keratoconus in the right eye and previously wore a contact lens.
4. History of herpes zoster possibly affecting his right eye.
Exam findings:
1. DVAcc PALs:
a. OD 20/100-1, +2
b. OS 20/200-1 with eccentric viewing and a scotoma to the left.
2. Manifest refraction
a. OD -5.50 -4.75 x 003
20/70-1,
b. OS -2.75 sphere
20/150-1, +1.
c. He reported subjective improvement with the manifest refraction
compared to his current spectacles.
3. Contrast sensitivity was moderately reduced to 1.10 log units.
4. NVA:
a. cPALs: 2.0M at 35 cm (equivalent to 20/100 or 16 point font) with effort
(Reading speed slows at 3.2M)
b. sPALs: 1.3M (equivalent to 20/100 or 16 point font)
c. Additional task lighting was beneficial.
5. Visual field by confrontation: full to finger counting in both eyes with a central
scotoma in the left eye
6. Patient was evaluated on several hand-held magnification devices as well as
strong reading glasses to determine the best options to assist with reading.
a. +6 with 8 base-in prismatic readers with cylinder correction over the right
eye improved near visual acuity to 0.6M, which is approximately
equivalent to 20/30 visual acuity. He was able to read the newspaper
fluently with the assistance of task lighting.
b. +16-diopter LED hand magnifier was the best hand-held magnification
option to allow accurate reading of very small print.
Recommendations:
1. +16-diopter Eschenbach LED hand magnifier for fine print and spot reading.
2. +6 with 8 BI prismatic spectacles for continuous reading tasks.
3. PAL Rx with notable improvement in distance vision.
4. VDT/computer Rx with a +3.50 add.
5. Task lighting such as a natural daylight desk or floor lamp for reading and near tasks
to enhance contrast.
6. I recommend consideration of a contact lens evaluation especially for the keratoconic
right eye.
7. Return to Low Vision Services in 4 weeks for follow-up.
Exam 2/29/12 4 week f/u
Patient obtained all recommended visual aids and reports he is doing great. He reported
confidence with ability to perform work-related tasks.
Exam 7/1/13
CC: Decreased visual acuity. Retina specialist recommended the patient return to Low
Vision
HPI:
1. Ocular health report from retina specialist: atrophic scarring in the right macula
and fibrotic scarring in the left macula, with no subretinal hemorrhage or lipid.
Slightly increased atrophic change in the foveal aspect in the right eye.
2. Functional domains
a. Employment:
i. On summer vacation from teaching 5th grade in Delaware. Working
in tandem class with another teacher.
ii. Large print material provided: 24 pt font provided by school. School
is very supportive and accommodating.
iii. Difficulty seeing faces
1. Worries about recess duty watching kids on the playground
b. Reading/computer:
i. Rarely uses +6 w/8 BI prismatic reading glasses - prefers large
print/font.
ii. Uses VDT lenses for computer at work. Also uses built in
accessibility.
iii. ZoomCaps (large print keyboard) work well
c. Visual information/Seeing
i. TV: occasionally blurry. Sometimes just listens instead of watches
TV
d. Driving:
i. Rarely drives, during the daytime and good weather only. Rides
with friends and family (wife and daughter).
ii. Work is a few blocks from home.
iii. License expired last month, but the patient is unsure he will renew
his license. Feels he would be capable for the very limited driving
he does.
iv. No accidents or close calls.
3. Current Visual Assistive Equipment:
1. iPhone with large font
2. iPad
3. +6w/8 BI prismatic NVO (minimally using)
4. +16D Esch LED HM
5. Large Print material at school
6. Large font on computer
7. ZoomCaps
Exam Findings:
1. BCVA
a. OD 20/125
b. OS 20/100-2
c. Central scotomas and eccentric viewing in both eyes
2. Contrast sensitivity moderately reduced to 1.05 log units
3. NVA
a. Patient’s +6 w/8BI: 1.3M (approx. equivalent to 20/70 or 14 point font)
i. Last year he was able to read 0.6M with these spectacles
b. Patient’s +16D LED HM: 0.8M (approx equivalent to 20/40 or 6 point font),
but poor fluency with continuous text
4. Visual field
a. CVF full OD/OS
b. GVF full OD/OS with large central scotoma in both eyes
5. Refer to Rehab Therapist for assessment of visually assistive equipment
a. Video magnification
b. ZoomText / computer software accessibility
c. Telescopes for distant spotting
Recommendations:
1. Refer to Delaware State Rehabilitation services – vocational rehabilitation, continue
employment
2. Desktop CCTV (Recommend 22" screen) and portable CCTV with variable
magnification and contrast enhancement options.
3. ZoomText computer accessibility software (Magnification and contrast enhancement)
4. "Pearl" text-to-speech technology to reduce visual fatigue.
5. +16 diopter illuminated hand magnifier – quick spot reading and verification tasks
6. Educated patient on the impact of reduced contrast sensitivity and discussed optical
and non-optical strategies to improve visual function. Task lighting recommended
7. 4x12 monocular telescope for distance spotting. This device may be helpful to see
distant details (i.e. Spotting children during recess at school)
8. If patient decides to pursue renewing DE state driver's license, I will complete the
MVA visual information form, which will be reviewed by the DE medical advisory board
RTC LV 4 months (same day as retina appointment). LV appointment should be before
dilation.
Exam 10/11/13
4 month f/u
CC: Decreased vision. Presents for DE driver’s license renewal (failed vision screening
at DE MVA)
HPI:
1. Ocular health report from retina specialist (following patient monthly):
a. atrophic macular scar in both eyes with new hemorrhage noted in the right
eye s/p anti-VEGF injections
b. Diabetes mellitus with mild-moderate non-proliferative diabetic retinopathy
both eyes
2. Functional domains:
a. Driving:
i. Driver’s license expired. Patient has been walking or having others
drive him to work.
ii. If license were renewed, he would continue previous restrictions
when driving: daytime only, good weather, only to work and back,
which is a few blocks away. Often has others drive him if they are
traveling to the same area.
b. Reading
i. Patient is discussing obtaining a portable CCTV
c. Computer:
i. Kurzweil computer accessibility software provided at work.
ii. “Pearl” scanner attached to computer: Able to scan printed
documents into the computer to enlarge.
d. Employment: continues to work at 5th grade teacher.
i. Work demands are the same, but feels like he comes home
exhausted every day.
ii. Anxious when watching kids on the playground, because he is
constantly worried about their safety. Doesn’t trust his vision on the
playground.
iii. Continues to receive good reviews from employer
iv. School is very supportive
3. Current Visual Assistive Equipment:
1. iPhone with large font
2. iPad
3. +6w/8 BI prismatic NVO
4. +16D Esch LED HM
5. LP material at school
6. Large font on computer
7. ZoomCaps
8. Kurzweil computer software accessibility
9. “Pearl” scanner attached to computer
Exam findings
1. BCVA (ETDRS)
a. OD 20/160 with eccentric viewing
b. OS 20/160 with eccentric viewing
2. Contrast sensitivity: moderately reduced to 1.05 log units
3. CVF full OD/OS
Recommendations
1. Completed Delaware MVA form
a. Patient's current driving patterns (daytime only, local/familiar areas, good
weather only) appear appropriate. I recommend the patient continue
driving with these restrictions. Glasses should be worn while driving.
b. Edu patient the form will be reviewed by the DE medical advisory board
2. Continue with Delaware State Rehab services - maintain prior recommendations:
a. Desktop CCTV and portable CCTV with variable magnification and
contrast enhancement options.
b. Continue with Kurzweil computer accessibility software (Magnification,
contrast enhancement and speech output)
c. Continue with "Pearl" text-to-speech technology to reduce visual fatigue
when reading printed documents.
d. Continue with+16 diopter illuminated hand magnifier, iPhone with large
font and iPad, +6w/8 BI prismatic NVO and large print material at school
e. Task lighting
f. 4x12 monocular telescope for distance spotting. This device may be
helpful to see distant details (i.e. Spotting children during recess at school)
3. RTC LV same day as retina. LV appointment should be before dilation.
At the end of the consultation, patient hesitantly says, “I love what I do. I want to keep
working, but just wondering, who determines disability?”
-
Patient would like to continue working, but is concerned over ability, especially
student safety
Not ready to apply for disability, but would like to know options
Discussed with patient that his vision meets the criteria for legal blindness, but
ultimately it would have to be his decision if he would like to apply for disability
Recommend discussing situation with financial counselor to determine if taking
retirement (if eligible) vs. disability is a better decision at this point
Patient continues to receive positive reviews from school, but anxiety, visual
fatigue and concerns over student safety are major factors.
3 months later, the patient calls and reports he would like to apply for disability. Visual
fatigue and anxiety are overwhelming and he no longer feels he is capable to
maintaining job duties.
His disability case is currently pending.
Discussion Points
1. How do we clinically measure visual fatigue, anxiety and job competence?
2. Patient is able to perform required tasks at work, but experiences emotional
distress and constant worry over his own ability
3. At what point do we stop recommending visual assistive equipment and discuss
disability?
Conclusion and Clinical Pearls
This case highlights the challenges of considering disability for a patient who continues
to receive positive reviews from his employer, but demonstrates significant distress over
maintaining job-performance. Visual acuity declines slightly over the course of care, but
this case also shows the role of visual aids in vocational rehabilitation as vision loss
progresses.
Case Report 3 – “I really need help getting disability”
I. Introduction and patient background
Patient LH is a 56-year-old Caucasian gentleman with a history of Stargardt
Maculopathy in both eyes. He is anxious about his visual status and feels that the blind
spots in his vision are interfering with his work. He has a long history working as a mail
carrier in a relatively rural area. Patient LH has atypical Stargardt disease in that he has
a small island of spared central vision (and near normal visual acuity) in the left eye
making the disability determination less straightforward. The patient began to rely on his
wife to assist with job duties and was hoping for support from the low vision service in
submitting a disability claim to his employer as well as to social security. This case will
discuss the functional assessments used to assist patient LH in this request and the
overall clinical picture of a patient with relatively good acuity big significant functional
impairment.
II. Ocular History
a. Patient has been followed by a local retinal specialist for many years
b. Diagnosed with Stargardt Maculopathy with asymmetric progression
OD>>OS
c. Past history of laser treatment OD for a “bleeding blood vessel” and past laser
treatment OS for a peripheral retinal tear
d. Non-visually significant cataracts OU
e. Minimal refractive error (wears bifocals)
f. Referred by his retinal specialist to the low vision center due to reported
difficulties managing his work-related vision
g. LH presents with a chief complaint of “I need help getting disability; I cannot
see to manage my job like I used to”
h. LH has been told that he will likely not qualify for disability due to his acuity
III. Social History
a. Lives in a house with his very supportive wife who was present at all
evaluations
b. Plays tenor saxophone (hobby)
c. No relevant medications or medical history
IV. Functional History
a. Reading/computer:
a. At initial presentation, patient LH complains of difficulty reading large
print (even headlines are difficult)
b. He is unable to read “visual displays”
c. LH requires significant additional task lighting for any reading, including
spot reading
d. Frequently loses track of the cursor when using the computer
e. Frequently loses his place when attempting to read
f. Significant visual fatigue with any reading tasks; often closes his right
eye
b. Driving:
a. Has reduced driving activities significantly; his wife drives him to and
from work
b. He has driven 2-3 times in past 2 months
c. Mobility:
a. Reports extreme caution with mobility especially for uneven ground
b. Denies falls
d. ADLs/Visual-Motor:
a. Difficulty plugging cords into sockets
b. Difficulty setting the dishwasher
c. Difficulty inserting keys into locks
d. Reports general frustration with cooking
e. Visual Information/Seeing
a. Significant indoor and outdoor glare concerns
f. Work-Related Vision Concerns
a. LH is not comfortable driving his mail route; his wife is driving him
much of the way and he will walk as much of the route as he can, with
his wife doing the longer part of the driving
b. LH has been staying late at work to sort the mail for the next day;
finding addresses on envelopes is becoming overwhelming; his wife
will often assist and sort the mail for him in while he delivers to a
different part of the route
c. LH feels very committed to his job but does not feel that he can
adequately meet the demands
d. LH has concerns about the financial implications of disability but does
not feel that he has another choice
V. Relevant Clinical Findings
a) Visual Acuity (BCVA)
b)
c)
d)
e)
OD: 20/400-4 ETDRS @2M with Eccentric Viewing
OS: 20/30+ ETDRS @2M; slow and with a large left scotoma noted
during clinical assessment
Contrast Sensitivity: 0.95 log units OU (severe loss)
Near Visual Assessment: reads 0.8M print (~8-10 pt font); increased difficulty
noted when prompted to read moderate to large print; no fluent reading at any
size
Visual Fields:
a. Confrontations: FTFC OD and OS
b. Goldmann: full periphery but large scotomas in each eye (to the Size III
target); scotoma OD spanned 30 degrees of central vision; scotoma OS
had a 10 degree island surround by a 30 degree (diameter) ring scotoma
Rehabilitation Plan:
a. Extensive education on scotoma and impact on function; LH had good
insight into the scotoma size and felt that the visual field better
represented his vision than any other testing
b. Recommended high contrast materials with minimal magnification to take
advantage of his small island of vision; LH had the best reading fluency on
the CCTV (21”) at the lowest magnification setting; the same was true with
computer settings; LH responded to Zoomtext but only for contrast
enhancement and the enlarged mouse pointer
c. Portable CCTV and Pearl were also recommended with further evaluation
scheduled at the technology center at the Department of Rehabilitation
d. LH responded well to speech output combined with Zoomtext’s contrast
enhancement
e. Recommend yellow filters for contrast enhancement and control of indoor
glare
f. Referral was made to the Department of Rehabilitation to explore the
above recommendations and to consider additional vocational and
independent living strategies
g. Additional referral was made to a clinical social worker to help with the
significant anxiety and depression that LH was feeling as he was dealing
with these vision changes
h. Referral to a disability attorney/patient advocate
i. Encouraged LH to discontinue driving until follow-up visit and further
discussion regarding functional concerns; considered behind-the-wheel
assessment
i. At follow-up visit LH reported that he had discontinued all driving
and did not plan to resume due to the vision loss
Because of the distance to travel to our low vision center, LH did not return for
additional follow-up after his first two visits. He began to work with the Department of
Rehabilitation and called to inform us that he was successful in his application for
private and social security disability.
VI. Discussion Points and Clinical Pearls
a. Although we know that acuity is not representative of visual function, taking a
sufficient history and performing detailed testing (such as mapping a scotoma
on a Goldmann or other test) can help strengthen a patient’s case for
disability. This can also help the patient understand his overall visual function
better.
b. Be aware of the patient’s emotional state as they present to you discussing
concerns such as maintaining their job or applying for disability. Many
patients experience significant anxiety and depression as they face these
very emotional decisions about their ability to earn an income for their family.
Consider appropriate referrals to manage this component.
c. Consider the nature of your patient’s work; although social security disability
applies to the ability to do any kind of work, private disability is specific to the
job. Some jobs may have more significant visual demands as we saw with our
letter carrier.
d. Consider the role of visual fatigue and attempt to obtain objective measures
of fatigue and loss of accuracy in reading with fatigue (this was not done in
this case but most likely could have strengthened the patient’s disability
application)
e. There may be patients with good acuity who you suspect are malingering or
exaggerating their difficulty to be able to obtain disability; be objective and
take as many measurements as possible to ensure that this is not the case.
With my patient, I did not suspect malingering given the lengths he was willing
to go to in order to maintain his job (having his wife drive and assist with mail
sorting, etc).
f. Disability was determined by clinical reports and patient interview. The patient
was not sent for additional ophthalmologic exam nor was a visual efficiency
score provided to social security. The visual efficiency score is 64.3% based
on size of the scotomas and the reduced acuity in the right eye. Social
security sets 64% as the cut off for a progressive condition, and Stargardt
should fall into this category because it is unclear if the patient will maintain
his small island of vision (he has already maintained it past when would be
expected for most patients). This additional information only reinforces the
need for a thorough review of all findings to make the determination for the
patient.