Download What are the most serious eye health problems in Alabama

Eye Health Needs Assessment for
Alabama
Prepared for
The EyeSight Foundation of Alabama
(formerly Alabama Eye Institute)
By Janet M. Bronstein, Ph.D.
and Michael A. Morrisey, Ph.D.
April 2000
1
Acknowledgements
Torrey Smitherman, Executive Director of the Alabama Eye Institute, Inc. made
significant contributions to this report. Matthew Rousculp, School of Health
Related Professions, provided excellent research support.
2
Contents
Executive Summary ……………………………………..Page 5
Chapter I What are the most common eye health and
vision problems in Alabama……………….Page 9
Chapter II What services are available to address these eye
health and vision problems?……………..Page 17
Chapter III What services are provided by ophthalmologists
and optometrists?…………………..…….Page 38
Chapter IV What do eye care providers perceive to be major
needs?……………………………..……….Page 45
Chapter V What are the major gaps in service availability for
eye health and vision problems?……...…Page 61
Appendix A……Summary of Eye Disease Prevalence Data
.…………………………….………………..Page 64
Appendix B……Provider Survey…..………………….Page 66
Appendix C…...Rehabilitation and Organization Survey
……………………………..………………..Page 72
3
List of Tables
Chapter I
I-1
Estimated Portion of Alabama Population that is Legally Blind …...Page 15
I-2
Estimated Portion of Alabama Population that has
Difficulty Seeing ……..…………………………………………………Page 15
Chapter II
II-1
II-2
II-3
Map
II-4
II-5
Location of Providers in North and Eastern Alabama …………….. Page 18
Location of Providers in Central and Western Alabama ………….. Page 19
Location of Providers in South Alabama …………………………… Page 20
Eye Care Providers in Alabama ……………………………………. Page 22
Location and Service Areas of Blind Services Provided by the
Alabama Department of Rehabilitation …………………………….. Page 24
Providers of Low Vision Rehabilitation and Other Special
Services ……………………………………………………………….. Page 35
Chapter III
III-1
III-2
III-3
III-4
Percentage of Respondents Providing Preventive Services …….
Percentage of Respondents Providing Diagnostic Services …….
Percentage of Respondents Providing Treatment Services …….
Percentage of Respondents Providing Rehabilitation Services ..
Page 39
Page 40
Page 41
Page 43
Chapter IV
IV-1
IV-2
Most Common Referral Difficulties Reported by Ophthalmologists
and Optometrists …………………………………………………… Page 45
Eye Care Services Reported by Ophthalmologists and
Optometrists to be the most difficult for People to Obtain ……… Page 47
4
Executive Summary
What are the most common eye health and vision problems
in Alabama?
Strategic Plan documents from the National Eye Institute were used to
identify serious eye health problems in the United States. Applying rates derived
from the epidemiological literature to the Alabama population, seven significant
eye disorders and three major vision problems were identified. In addition, data
from the American Federation for the Blind were used to estimate the number of
legally blind and seriously visually disabled individuals reside in Alabama. The
major conclusions of this section are:



Approximately 24,000 individuals (0.6 percent of the population of the state) is
legally blind, with an additional 120,000 (2.9 percent) having permanent
serious difficulty seeing. Rates of these disabilities are much higher for
elderly individuals, and thus the portion of the population that is affected is
increasing. Within age groups, the rate of blindness and vision impairment is
higher for the Black population of the state.
The most common treatable eye problems are cataracts and refractive errors.
Two serious, relatively common eye disorders, diabetic retinopathy and
glaucoma, are potentially treatable or controllable if diagnosed early,
sometimes before symptoms become apparent.
What services are available to address these eye health and
vision problems?
Major preventive, diagnostic, treatment and rehabilitation services used to
address the major eye health problems were identified. These services are
provided, to varying degrees, by ophthalmologists, optometrists and rehabilitation
care providers. The geographic distribution of these providers across the state
was examined. The major conclusions of this section are:

Services provided by ophthalmologists require more patient travel than
services provided by optometrists.

There are multiple rehabilitation programs serving different client populations
in the state, with locations and catchment areas differing by program.

Many rural areas of the state are distant from any eye service providers.
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What services are provided by ophthalmologists,
optometrists?
Information to address this question was gathered via a survey of
ophthalmologists and optometrists conducted in September, 1999. Providers
reported whether they provided specific preventive, diagnostic, treatment and
rehabilitation services. The major conclusions of this section are:

When ophthalmologists and optometrists are present, the full range of
preventive, diagnostic, and treatment services are available.

In general, optometrists are somewhat more likely to routinely provide
preventive services and less complex diagnostic and treatment services
than are ophthalmologists.

Ophthalmologists are much more likely to routinely provide more complex
diagnostic and treatment services.

In general, the Birmingham area is more sub-specialized than elsewhere
in the state. General ophthalmologists in Birmingham more often refer
patients to specialized ophthalmologists for complex procedures.

Few rehabilitation services are provided by ophthalmologists or
optometrists.
What do eye care providers perceive to be major needs?
Ophthalmologists and optometrists were asked to identify the preventive,
diagnostic, treatment and rehabilitation services that were most difficult for
patients to obtain. They were asked which major barriers patients faced in
accessing services. Finally, they were asked two open-ended questions, one
concerning the major unmet eye care need in their communities, and the second
concerning the single action by a foundation that would make the greatest
improvement in eye health in their communities. In summary, they responded:

Ophthalmologists and optometrists perceive an absence of rehabilitation
training and equipment aids available for their patients with severe vision
problems. This need is not limited to those who are unable to afford such
services. In some places they are not conveniently available for any patients,
or physicians are unaware of service availability.
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
Ophthalmologists and optometrists also noted the need for more public
education to increase awareness of the need for routine preventive care to
prevent and treat eye problems.

Many providers are in contact with patients who would benefit from eye health
services, but who cannot afford them financially. Financial support for eye
health services is perceived to be an important need.

There is a perceived need for improved availability of specialty eye health
services outside of major urban areas.
An additional survey of vision rehabilitation and other service providers
was conducted in December 1999 – February 2000. These organizations were
also asked to identify major needs for eye care. They noted many of the same
issues as the ophthalmologists and optometrists. In addition, they identified:

A need for additional trained professionals to work in rehabilitation.

The need for active outreach to connect individuals with needs to service
providers.
What are the major gaps in service availability for eye health
and vision problems?
Combining information on disease prevalence, the distribution of
providers, the services provided, and the needs identified by care providers, four
major needs or gaps in service availability were identified. These are:
1. A need for public education concerning the importance of vision screening
and routine preventive eye care. This would be of particular benefit for young
children with vision problems and for adults in the early, non-symptomatic
stage of severe eye diseases such as glaucoma and diabetic retinopathy.
2. A need for financial support for eye health services. Many individuals in the
state lack health insurance that provides coverage for eye health services,
particularly for treatments, surgery, rehabilitation and adaptive aids.
3. A need for greater availability of rehabilitation and adaptation aids and
services. An increasing portion of the population, the elderly, are severely
affected by vision problems. Vision aids and adaptive training can assist with
these problems, but they are not widely available and not affordable for many
individuals. Although there are publicly supported programs in the state that
directly provide or subsidize the cost of many of these services, referral of the
public into these programs is inconsistent. The programs are scattered
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across the state, and many have waiting lists for clients due to limited
resources.
4. A need for improved geographic access to specialty services. Specialty care
tends to be centralized in larger cities. Distance is a barrier to access for
some individuals. In addition, some specialists in rural areas identified the
need for colleagues and for local access to specialty equipment. Providers of
subsidized and support services described a need for better outreach to make
potential clients more aware of available services.
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I. What are the most common eye problems in
Alabama?
Information was collected from the epidemiological literature on the most
common eye problems reported in the United States. These citations are shown
in Appendix One. However, to focus the discussion of eye health problems on
those that are of major concern, we reviewed the National Plan on Vision
Research for 1999-2003 from the National Eye Institute. That source listed major
problems in five categories, and also emphasized issues in visual impairment
and rehabilitation.
In the discussion below, we describe each of these key conditions and
indicate the estimated number of cases in the state. The estimates were
calculated by applying the population-based rates available from the medical
literature to county level census based population data. Where rates were
available separately for age, sex or race groups, these rates were applied to the
specific categories in the population. However, different studies of different eye
disorders report rates in different formats.
The conditions are presented separately as eye disorders and vision
problems, and listed in descending order of frequency of occurrence.
Eye Disorders and Diseases
1. Age related Macular Degeneration
Macular Degeneration is an eye disorder caused by the degeneration of the
retinal macula, the area of the eye where vision is the sharpest. It is a major
cause of vision impairment among the elderly. The disorder hampers central
vision, but peripheral vision is unimpaired. Macular degeneration is painless;
vision impairment may be slow or rapid. There is no known cause. One type of
macular degeneration can be partially controlled by laser treatments. Macular
degeneration accounts for roughly 11.7% of the blindness in the United States
and is the reason for over 16% of the new cases in blindness. There are two
forms of macular degeneration. Dry, or atrophic, is an atrophic pigment epithelial
change and is most often associated with a slow, progressive, and mild visual
loss. Wet, or exudative, form of the disease causes a rapid progression and
severe vision loss.
Study
Number of cases (AL-est.)
Beaver Dam Study (1988-1990)
230,298 – Early stage
24,000 – Late stage
Applying rates by sex to state population over age 43
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2. Cataracts
Cataract is a gradually developing opacity of the lens or lens capsule of the eye.
An individual with cataracts experiences a painless, gradual blurring and
eventual loss of vision. Generally speaking, the opacification and scattering of
light in the cataractous lens is the result of breakdown of the lens architecture.
(e.g. sugar cataracts – can be induced in animals by feeding them a diet
enriched with various sugars.)
There are at least five major causes of cataracts:
1. Senile – develop in elderly patients probably because of
degenerative changes in chemical state within the lens.
2. Congenital – occur in newborns as genetic defects or as sequela of
maternal rubella during first trimester.
3. Traumatic – develops after a foreign body injures the lens with
sufficient force to allow aqueous vitreous humor to enter the lens
capsule.
4. Complicated – secondary effects in patients with uveitis, glaucoma,
retinitis pigmentosa, detached retina, or in persons with diabetes,
hypoparathyroidism, or atopic dermatitis.
5. Toxic – results from certain drug or chemical toxicity.
Study
Framingham, MA (1973-1975)
Number of cases (AL-est.)
133,601
* Applying rates by sex to state population
3. Primary Open-Angle Glaucoma
Glaucoma is now defined as a disease of the optic nerve, in which the nerve
fibers are injured, usually by abnormally increased intraocular pressure (IOP), but
also by other conditions. Although abnormally high IOP is still recognized as the
leading cause of glaucoma, many people with elevated pressure in the eye do
not develop the disease, and some people with normal IOP develop optic nerve
damage characteristic of glaucoma. In these latter cases, one or more factors
may be involved, including reduced blood flow, early nerve cell death, and
irritation of the nerves. Elevated pressure in the eye, however, is still an
important component of glaucoma and reducing it is the primary goal of
treatment in most cases.
The two primary forms of glaucoma are open-angle and closed-angle glaucoma.
Infrequently, a person may have a combination of the two. Another less common
form is known as low- or normotensive glaucoma, in which damage occurs to the
optic nerve but the IOP is normal. People may also develop glaucoma as a
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complication of surgery, drugs, or medical problems. Rarely, a baby is born with
glaucoma, a condition known as congenital glaucoma.
The overwhelming majority of people with glaucoma -- about two-thirds -- have a
chronic form known as open-angle glaucoma, in which the drainage angle
remains open, but tiny drainage channels in the trabecular meshwork become
clogged. Increased pressure occurs when the fluid in the eye's anterior chamber
builds up; it is essentially a plumbing problem. The excess pressure results from
an imbalance between the production and the drainage of aqueous humor. In
most cases the imbalance is caused by impaired drainage, but in rare instances
the pressure is high because the eye produces too much aqueous humor. In
either case, the excess aqueous humor puts increased pressure on the optic
nerve at the back of the eye. If the pressure is untreated, it damages the delicate
fibers that convey images to the brain, and, eventually, the nerve deteriorates
until a person becomes irreversibly blind. Chronic open-angle glaucoma usually
occurs in both eyes but tends to start in one first.
Risk factors for POAG include the following
 Elevated intraocular pressure
 Large optic disk cup
 Ethnicity (African American)
 Age
 Family history of glaucoma
 Diabetes mellitus
 Systemic hypertension
 Myopia
Study
East Baltimore (1985-1988)
Number of cases (AL-est.)
33,366
Rates by race applied to state population over age 40.
11
4. Diabetic Retinopathy
Retinopathy, a disease of the retina, the light sensing tissue at the back of the
eye, is a common concern among people with diabetes. Diabetic retinopathy
damages the tiny vessels that supply the retina with blood. The blood vessels
may swell and leak fluid. When retinopathy is more severe, new blood vessels
may grow from the back of the eye and bleed into the clear gel that fills the eye,
the vitreous. While most people with diabetes may never develop serious eye
problems, people who have had diabetes for 25 years are more likely to develop
retinopathy. Experts think high blood pressure may contribute to diabetic
retinopathy, and that smoking can cause the condition to worsen.
Treatment for diabetic retinopathy can help prevent loss of vision and can
sometimes restore vision lost because of the disease. A yearly eye
examination with dilated pupils makes it possible for an ophthalmologist or
optometrist to notice changes before the illness becomes harder to treat.
Scientists are testing new means of treating diabetic retinopathy.
Study
Framingham, MA (1973-1975)
Number of AL cases
26,903
Applying rates by sex to state population, ages 52-85.
5. Keratoconus
Keratoconus is a degenerative eye disorder that is due to a genetic defect. This
disease is typified by the thinning and anterior protrusion of the cornea. More
specifically, it is an axial corneal dystrophy, usually starting between ages of 12 –
20. It results in a conical ectasia of the cornea and subsequent impairment of
vision. The “coning” is normally eccentric downwards.
Study
Minnesota (1935-1982)
Number of cases (AL-est.)
2,267
Rates by sex applied to state population
6. Retinitis Pigmentosa
Retinitis Pigmentosa is a degenerative condition of the retina of unknown cause.
Degeneration of the light-sensitive rod cells in the retina occurs first, and night
blindness is generally the first symptom. This usually begins in early adult life.
The color-sensitive cone cells become involved more gradually, daytime vision
12
deteriorates, and the field of vision is slowly reduced from the edges inward, a
condition know as telescopic vision. Genetically induced, the progressive
destruction of the retinal rods results due to the atrophy of the pigment epithelium
and eventually leads to blindness. Eighty percent of children with this disease
inherit it as an autosomal recessive trait. The onset of the disease usually occurs
prior to age 20. The disease initially affects night and peripheral vision and leads
to blindness by age 50.
Study
General population
Number of cases (AL-est.)
844 - 1,405
Vision Problems
1. Strabismus
Also called a squint, strabismus is a condition in which the axes of the eyes are
not parallel even when a person is looking at a distant object. It is usually the
result of an imbalance in the movement of the two eyes caused by poor muscle
control. The attempt to coordinate vision when one eye has better sight than the
other (amblyopia) or when one eye has farsightedness (hyperopia) is also called
strabismus. There are four major forms of this disease.
 Esotropia (cross-eyed)– eyes deviate inwards
 Exotropia (walleyed) – eyes deviate outwards
 Hypertropia – eyes deviate upwards
 Hypotropia – eyes deviate downwards
Study
General population (1971-1972)
Number of cases (AL-est.)
163,314
Rates applied to general population, ages 1-74
2. Myopia (nearsightedness)
Myopia is a visual defect in which distant objects can-not be seen clearly. It
occurs because light entering the eye is focused in front of the retina instead of
on it. Distant objects are out of focus because either the lens of the eye is too
curved, bending the light rays too much or the eyeball is too long, a condition that
seems to be inherited. Close objects can be seen sharply, and even in old age,
nearsighted people may be able to read easily without glasses.
13
It is suggested in other sources, that myopia affects 15-20% of the western
population. In comparison, hypermetropia (far sightedness) affects roughly 50%
of the population.
Study
General population (1971-1972)
Number of cases (AL-est.)
105,627
Rates by sex applied to the state population
3. Amblyopia
Amblyopia is due to a developmental defect of spatial visual processing that
occurs in the central visual pathways in the brain. There is a loss of visual acuity,
although the affected eye appears to be normal. When amblyopia is due to
strabismus, the condition is usually corrected by wearing a patch over the
stronger eye, thus strengthening the weaker one. If the condition is not
corrected, the weak eye can become legally blind.
Study
General population (1971-1972)
Number of cases (AL-est.)
99,582
Rates applied to general population, ages 1-74
Low Vision and Blindness
The National Eye Institute, in addition to reviewing specific eye disorders,
notes that a significant portion of the population has chronic, uncorrectable
vision impairment, for a variety of reasons. Vision impairment is one of
the 10 leading causes of disability in the United States. The majority of
those with serious visual impairment are elderly, with leading causes
including macular degeneration, cataract, glaucoma, diabetic retinopathy,
and optic nerve atrophy. Because the portion of the population in this age
group is growing most rapidly, blindness and serious visual impairments
will be an increasing problem in Alabama.
In the following table, prevalence rates for blindness and serious vision
problems by age and race (available from the American Foundation for the
Blind) have been applied to the Alabama population.
Table I-1. Estimated Portion of Alabama Population that is Legally Blind*
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Age
White Population
Non-White
Population
Rate/1,000
Rate/1,000
0-4
5-17
18-44
45-64
65-74
75-84
85+
Total
Number
0.1
0.9
1.4
3
5.7
21.1
125
19
483
1,694
2,193
1,447
3,431
7,121
16,388
0.3
1.2
3
9
22.4
29.3
135.1
Total
Number
32
338
1,484
1,708
1,377
1,177
1,950
8,066
Number
51
821
3,178
3,901
2,824
4,608
9,071
24,454
* Rates based on Baltimore Study
Table I-2. Estimated Portion of Alabama Population that has “Serious Difficulty
Seeing”*
Age
0-14
15-64
65-74
75+
Total

White Population
Rate
/1000
4.05
17.97
60.01
140.05
Number
2,430
37,219
15,236
30,749
85,634
Black Population
Rate
/1000
5.72
23.29
127.69
189.35
Number
1,718
16,161
7,555
10,122
35,556
Hispanic
Total
Population
Rate Number Number
/1000
3.81
40
4,152
22.66
542
53,403
89.74
105
22,881
102.32
64
40,973
751 121,190
Data from National Survey
Note that across age groups, the Black population has higher rates of blindness
and vision impairment that the White population.
I-Summary


Approximately 24,000 individuals (0.6 percent of the population of the state) is
legally blind, with an additional 120,000 (2.9 percent) having permanent
serious difficulty seeing. Rates of these disabilities are much higher for
elderly individuals, and thus the portion of the population that is affected is
increasing. Within age groups, the rate of blindness and vision impairment is
higher for the Black population of the state.
The most common treatable eye problems are cataracts and refractive errors.
15

Two serious, relatively common eye disorders, diabetic retinopathy and
glaucoma, are potentially treatable or controllable if diagnosed early, but they
generally must be diagnosed before symptoms become apparent.
16
II What services are available to address these eye
health problems?
After reviewing the recommended treatment guidelines formulated to date for
ophthalmic problems, and through discussions with health care providers, we
compiled a listing of four types of services useful for these and other eye
conditions. These include:
Preventive and Population-Based Screening Services
1. Education in eye protection, care of contacts, prevention of infection
2. Glaucoma screening
3. Infant and young child vision screening
Diagnosis
1. Exams for refractive errors.
2. Comprehensive adult and pediatric eye exams
3. Specialized diagnostic procedures
Treatment
1.
2.
3.
4.
5.
Optical correction
Exercises for amblyopia and strabismus
Topical treatment for infections and glaucoma
Cataract removal
Corneal transplant and other ophthalmologic surgery
Rehabilitation
1.
2.
3.
4.
5.
Assessment of functional disability and adaptation skills
Low vision exam
Training in adaptive technology
Training in adaptations for daily living
Counseling on impact of low vision, including vocational.
Optometrists and Ophthalmologists
These services are potentially available from three sources: ophthalmologists,
optometrists, and rehabilitation service providers. The next tables and map show
the availability of optometrists and ophthalmologists in the state. These data are
based primarily on office locations listed in the Alabama yellow pages, March
1999. Other available listings, including license data and voluntary listings (e.g.,
the Blue Book, a national directory of optometrists) rapidly become outdated due
to the mobility of these professionals. In addition, these other listings include
17
residential as well as business addresses. This table shows business
addresses, in order to indicate where patients must travel to receive services.
Note that not all of these services are available from all providers, as we review
in Chapter III. The following section describes the range of rehabilitation services
provided in the state, and notes the providers and their locations.
Table II-1 Location of Providers in North and East Alabama*
Location
Albertville
Alexander City
Anniston
Arab
Athens
Attalla
Cedar Bluff
Centre
Childersburg
Cullman
Decatur
Florence
Fort Payne
Gadsden
Geraldine
Hazel Green
Henager
Huntsville
Jacksonville
Lexington
Madison
Muscle Shoals
Piedmont
Rainesville
Russellville
Scottsboro
Sheffield
Stevenson
Sylacauga
Talladega
Trinity
Tuscumbia
Total
Ophthalmologists
1
3
3
0
2
0
0
0
0
5
3
0
0
7
0
0
0
21
0
0
1
0
0
0
0
0
1
0
1
2
0
1
41
Optometrists
0
7
11
2
1
1
1
1
1
11
5
1
3
9
1
1
2
7
2
1
1
1
2
4
1
4
0
1
3
3
1
0
89
*Based on on-line Yellow Pages, MD license data and AEI mailing lists.
18
Table II-2 Location of Providers in Central and West Alabama *
Location
Adamsville
Alabaster
Aliceville
Bessemer
Birmingham
Blountsville
Brookwood
Centreville
Clanton
Chelsea
Columbiana
Gardendale
Fairfield
Fayette
Gordo
Hamilton
Jasper
Leeds
Millport
Montevallo
Northport
Pelham
Pell City
Reform
Springville
Sumiton
Tuscaloosa
Trussville
Vernon
Vincent
Total
Ophthalmologists
(Practices)
0
0
0
4
147
0
0
0
0
0
0
0
3
1
0
0
4
0
0
0
1
0
1
0
3
0
7
0
0
0
171
Optometrists
(Practices)
1
3
1
7
109
1
2
1
5
2
3
10
1
2
3
1
8
3
4
1
0
9
5
2
1
4
1
2
1
2
195
*Based on on-line Yellow Pages, MD license data and AEI mailing lists
19
Table II-3 Service Providers in South Alabama*
Location
Andalusia
Atmore
Auburn
Brundidge
Daphne
Demopolis
Dothan
Elba
Enterprise
Fairhope
Foley
Geneva
Greenville
Greensboro
Gulf Shores
Jackson
Luverne
Marion
Millbrook
Mobile
Montgomery
Opp
Ozark
Prattville
Saraland
Selma
Semmes
Tallassee
Troy
Tuskegee
Valley
Wetumpka
Total
Ophthalmologists
(Practices)
0
0
1
0
0
0
16
0
1
4
6
0
0
0
1
3
0
0
0
37
59
0
0
0
0
10
0
0
12
1
1
3
154
Optometrists
(Practices)
1
5
2
1
7
5
19
2
5
1
0
2
2
1
2
0
3
1
1
54
33
1
2
2
3
5
1
2
3
2
1
1
122
*Based on on-line Yellow Pages, MD license data and AEI mailing lists
The following map shows the location of these practices geographically.
Particularly noticeable on the map are the large rural areas of the state that are
particularly distant from state-based ophthalmology services. It is likely that
residents of Northeast Alabama use providers in Chattanooga for care, while
residents of West Alabama probably use Mississippi based providers. However,
many residents of the Black Belt area of the state have few local eye service
20
providers and must travel long distances for care. This area of the state has a
large proportion of Black residents, who are at higher risk for disabling vision
problems.
21
Optometrists
Ophthalmologists
22
Low Vision And Rehabilitation Services
Low vision, rehabilitation and other special eye services are available
across the state. The publicly supported programs are regionalized, with all of
the counties in the state assigned to different regional offices. This section
describes the programs available to Alabama citizens, beginning with state and
federal mandated public rehabilitation programs available through the Alabama
Department of Rehabilitation Services. A table and maps identifying the location
of the regional offices for each program by county is included. Other various
providers of services are described also, followed by a table illustrating the type
of services provided by each organization.

Alabama Department Of Rehabilitation Services
The Blind Services Division of the Alabama Department of Rehabilitation
Services offers assistance for citizens who live with low vision or blindness
through a variety of programs offered at regional offices throughout the state.
Availability varies from region to region. Some of these services are provided
free of charge, while others incur payment. Some, but not all, services are
contingent upon financial need. Some ADRS blind services have waiting lists
due to limited capacity and resources. ADRS collaborates with other institutions,
such as the Alabama Institute for Deaf and Blind, the State Department of
Education, and Alabama Lions Sight Conservation Association.
ADRS provides blind and low vision direct services (such as eye exams and
referrals, transportation, equipment, training and rehabilitation services), and
support services (such as financial assistance or referrals) through the following
programs:

Early Intervention Program
For families of children from birth to two years of age.

Children’s Rehabilitation Services
For individuals from ages three to 21.

Vocational Rehabilitation Services
For those from ages 16 to 65.

Oasis (Older Alabamians System Of Information And Services)
For individuals 55 and above.
The following table identifies the different regional offices that are associated with
these different programs. Note that each program serves a different population,
23
so that referral sources, such as optometrists or ophthalmologists, need
information about a wide range of programs and eligibility criteria. Also, some
ADRS services are currently at capacity in terms of serving individuals with vision
impairment, so clients referred may remain on waiting lists for services.
Table II-4 Location and Service areas of Blind Services Provided by Alabama
Department of Rehabilitation Services
County
Birth-2 years
Early
Intervention
3-21 years
Children’s
Rehab
16-55 years
Vocational
Rehab
55 & older
OASIS
Autauga
Baldwin
Barbour
Bibb
Blount
Bullock
Montgomery
Mobile
Dothan
Tuscaloosa
Talladega
Montgomery
Montgomery
Mobile
Dothan
Tuscaloosa
Gadsden
Montgomery
Montgomery
Mobile
Dothan
Tuscaloosa
Birmingham
Montgomery
Butler
Dothan
Andalusia
Calhoun
Chambers
Cherokee
Chilton
Choctaw
Talladega
Montgomery
Talladega
Montgomery
Mobile
Anniston
Opelika
Anniston
Montgomery
Jackson
Clarke
Mobile
Jackson
Clay
Cleburne
Coffee
Colbert
Talladega
Talladega
Dothan
Huntsville
Conecuh
Coosa
Covington
Crenshaw
Dothan
Montgomery
Dothan
Dothan
Anniston
Anniston
Dothan
Muscle
Shoals
Andalusia
Montgomery
Andalusia
Andalusia
Cullman
Dale
Dallas
DeKalb
Elmore
Escambia
Birmingham
Dothan
Tuscaloosa
Talladega
Montgomery
Mobile
Birmingham
Dothan
Selma
Gadsden
Montgomery
Mobile
Montgomery
Mobile
Dothan/Troy
Tuscaloosa
Birmingham
Montgomery/
Troy
Andalusia/
Troy
Anniston
Opelika
Gadsden
Birmingham
Mobile/
Thomasville/
Jackson
Mobile/
Thomasville/
Jackson
Talladega
Anniston
Andalusia
Muscle
Shoals
Andalusia
Talladega
Andalusia
Andalusia/
Troy
Decatur
Dothan
Selma
Gadsden
Montgomery
Mobile
Montgomery
Anniston
Opelika
Gadsden
Birmingham
Mobile
Mobile
Talladega
Anniston
Dothan
Muscle
Shaols
Montgomery
Talladega
Dothan
Montgomery
Decatur
Dothan
Montgomery
Gadsden
Montgomery
Mobile
24
County
Birth-2 years
Early
Intervention
3-21 years
Children’s
Rehab
16-55 years
Vocational
Rehab
55 & older
OASIS
Etowah
Fayette
Franklin
Talladega
Tuscaloosa
Huntsville
Geneva
Greene
Dothan
Tuscaloosa
Gadsden
Tuscaloosa
Muscle
Shoals
Dothan
Tuscaloosa
Gadsden
Tuscaloosa
Muscle
Shoals
Dothan
Tuscaloosa
Hale
Henry
Houston
Jackson
Tuscaloosa
Dothan
Dothan
Huntsville
Tuscaloosa
Dothan
Dothan
Huntsville
Jefferson
Birmingham
Birmingham
Lamar
Lauderdale
Tuscaloosa
Huntsville
Lawrence
Huntsville
Tuscaloosa
Muscle
Shoals
Muscle
Shoals
Lee
Limestone
Lowndes
Macon
Montgomery
Huntsville
Montgomery
Montgomery
Opelika
Huntsville
Montgomery
Opelika
Madison
Marengo
Marion
Huntsville
Tuscaloosa
Huntsville
Marshall
Mobile
Monroe
Huntsville
Mobile
Mobile
Huntsville
Selma
Muscle
Shoals
Huntsville
Mobile
Jackson
Montgomery
Morgan
Montgomery
Huntsville
Montgomery
Huntsville
Tuscaloosa
Dothan
Dothan
Huntsville/
Scottsboro
Birmingham/
Bessemer
Tuscaloosa
Muscle
Shoals
Muscle
Shoals/
Dothan
Opelika
Decatur
Selma
Montgomery/
Opelika
Huntsville
Tuscaloosa
Tuscaloosa/
Jasper
Gadsden
Mobile
Mobile/
Thomasville
Montgomery
Decatur
Gadsden
Tuscaloosa
Muscle
Shoals
Dothan
Tuscaloosa/
Dothan
Tuscaloosa
Dothan
Dothan
Huntsville
Perry
Pickens
Pike
Tuscaloosa
Tuscaloosa
Montgomery
Selma
Huntsville
Montgomery
Randolph
Montgomery
Opelika
Russell
Montgomery
Opelika
Tuscaloosa
Tuscaloosa
Troy/
Andalusia
Talladega/
Anniston
Opelika
Birmingham
Tuscaloosa
Muscle
Shoals
Decatur
Opelika
Decatur
Montgomery
Montgomery
Huntsville
Tuscaloosa
Tuscaloosa
Gadsden
Mobile
Mobile
Montgomery
Decatur
Tuscaloosa
Tuscaloosa
Montgomery
Anniston
Opelika
25
County
Birth-2 years
Early
Intervention
3-21 years
Children’s
Rehab
16-55 years
Vocational
Rehab
55 & older
OASIS
St. Clair
Talladega
Talladega
Talladega
Shelby
Birmingham
Birmingham
Sumter
Talladega
Tallapoosa
Tuscaloosa
Walker
Tuscaloosa
Talladega
Montgomery
Tuscaloosa
Birmingham
Tuscaloosa
Talladega
Opelika
Tuscaloosa
Birmingham
Washington
Mobile
Jackson
Wilcox
Winston
Tuscaloosa
Huntsville
Selma
Muscle
Shoals
Talladega/
Gadsden
Birmingham/
Columbiana
Tuscaloosa
Talladega
Opelika
Tuscaloosa
Tuscaloosa/
Jasper
Mobile/
Thomasville/
Jackson
Selma
Tuscaloosa/
Jasper
Birmingham
Tuscaloosa
Talladega
Opelika
Tuscaloosa
Tuscaloosa
Mobile
Montgomery
Tuscaloosa
In addition to the low vision and rehabilitation services provided by
the state through ADRS, a variety of non-profit organizations throughout
Alabama offer programs to assist the blind and visually impaired, as well
as to conduct other special eye services such as research. Referrals
between these groups do occur, although in an inconsistent manner.
Some groups are very specialized, both in focus and in geographic
coverage. Some are able to fulfill their purpose only partially due to lack
of funding. Qualifications for free services vary with these groups and
limit their ability to assist some people. Following is a list and brief
description of the organizations identified through this assessment.

Alabama Association For Parents Of Visually Impaired
Based in Birmingham, AAPVI is a support group for parents of children who are
blind or otherwise visually impaired.

Alabama Child Caring Foundation
Based in Birmingham and affiliated with Blue Cross-Blue Shield, this foundation
provides payment for professional eye exams, lenses and frames for Alabama
children, 18 and under, who are uninsured.

Alabama Deaf-Blind Project
26
ADBP is a federally-funded technical assistance program that supports a
statewide registry of students who are blind or visually impaired. This program
also provides training to service providers and parents. It is based in
Birmingham.

Alabama Eye Bank
The objective of the Alabama Eye Bank is to obtain donations of quality human
eye tissue for distribution to qualified physicians for use in sight restoring corneal
transplants, medical education, and research. The Eye Bank has headquarters in
Birmingham and regional offices in Huntsville, Mobile and Montgomery.

Alabama Eye Injury Registry
This registry, based in Birmingham, tracks eye injuries and outcomes, providing a
database for physicians on ways to minimize damage and, when possible,
partially restore vision in the event of eye injury.

Alabama Institute for Deaf and Blind
The Alabama Institute for Deaf and Blind is a comprehensive education,
rehabilitation and service program for children and adults who are deaf, blind and
multidisabled. AIDB services include early intervention, traditional and nontraditional education and vocational programs, rehabilitation and employment
opportunities for clients of all ages ranging from infancy through senior citizens.
AIDB includes four residential schools and an industrial venture in
Talladega and eight regional centers serving every county in the state.
Following is a summary of its programs.

Alabama School for the Blind
This school provides a well rounded education program for blind and visionimpaired children ages 3 through 21 focusing on academic and
vocational curriculums, championship athletics, music, independent l
iving skills, assistive technology and mobility.

Instructional Resource Center for the Blind
This center is a statewide provider of special media materials (in Braille, large
print and tape) for blind and visually impaired students and clients at
AIDB, local education agencies and rehabilitation programs. Located
on the ASB campus, the center maintains an equipment inventory of
educational aids such as cassette recorders, Braille writers and other
specialized tools, and is a full production and duplication facility for Braille and
large print and recorded textbooks. All materials are available on loan, free of
charge to eligible students and clients.
27

Helen Keller School of Alabama
Designed for children ages 3 through 21 who are deaf, blind, deaf-blind and
multidisabled, this program focuses on the unique needs of each child with an
educational plan strong in independent living, motor and communication
skills. The school’s transition program helps families develop a plan for
integrating graduates into their homes and communities.

E. H. Gentry Technical Facility
This facility is a post-secondary education and rehabilitation program focused
on evaluation, adjustment and vocational training for deaf and blind adults.
Strong emphasis is placed on assistive technology and the Gentry program
also features college preparatory and career exploration services and GED
preparation.

Alabama Industries for the Blind
A diverse manufacturing complex, AIB provides job and career opportunities
for blind persons who prefer to be tax producers and not tax consumers. AIB
employees produce more than 100 items including all the military neckties for
the U.S. Armed Forces.

Office of Health, Evaluation and Outreach
This office coordinates health-related programs, evaluation, admission and
outreach services for students and clients. Health care services include
psychology, audiology, physical therapy, low vision, nursing, dental and
orthopedic clinics.

Low Vision Clinic
In cooperation with the University of Alabama at Birmingham School of
Optometry, AIDB’s low vision department offers clinics, assessments and
technical assistance for optimal diagnosis, treatment and understanding of
eye and vision care. The on-campus clinic is furnished with up-to-date
equipment and a digital video imaging system allows the transmission of eye
images directly to the office of consulting physicians. A consulting
ophthalmologist who is a glaucoma specialist also works with the program to
follow students with glaucoma.

Elderaction
Elderaction currently provides audiological and vision screenings for seniors
in most areas of the state and offers a hearing aid repair service for residents
28
of Northeast Alabama through a grant from the East Alabama Commission on
Aging. Counseling and in-service training is available statewide for caregivers
and those working with older people with sensory loss

Marianna Greene Henry Special Equestrians
This program combines horseback riding with physical therapy for a
motivating and beneficial exercise experience for blind children and adults.
The MGH Arena is one of the largest in the Southeast and the hippotherapy
program is nationally accredited.

Regional Centers
The regional centers are designed to address the needs of blind and vision
impaired children and adults in their home communities. AIDB’s outreach
programs serve all 67 counties of the state through eight regional centers
located in Auburn, Birmingham, Dothan, Huntsville, Mobile, Montgomery,
Tuscaloosa and the Shoals.
The Parent Infant Preschool Program provides early intervention, inhome education and counseling for infants, toddlers and their families.
Regional centers also offer Kinderprep classes for preschoolers.
Adult Services include counseling, mobility, assistive technology training,
transportation, information and referral and other services as needed in
individual communities.

Alabama Lions Sight Conservation Association, Inc.
A project of Alabama Lions, ALSCA provides eye services to medically indigent
patients throughout the state, including eye exams, glasses, contact lenses, low
vision aids, prescription medications, prosthetics and surgery/hospitalization.
Traveling eye screening services also are delivered through the ALSCA Mobile
Screening Unit. ALSCA headquarters are located in Birmingham.

Alabama Public Library Service, Regional Library for the Blind and
Physically Handicapped
Based in Montgomery and accessible throughout the state library network, the
regional library provides services for the blind and physically handicapped,
including circulation of books, magazines and other reader advisor services.

Alabama Radio Reading Service Network
Designed for the blind and physically handicapped, this network provides access
to in-depth coverage of local and national news, consumer information, books,
29
magazines and entertaining features through programs broadcast seven days a
week.

Alabama State Department Of Education--Services For The Blind &
Vision Impaired
The State Department of Education mandates that all students with
disabling conditions, such as blindness or low vision, be provided an
individual educational plan addressing their special assistive technology
needs. Educational services, orientation and mobility, and other adapted
activities are provided from pre-school through 12 th grade through local
school systems throughout the state and coordinated with each school’s
coordinator of special education.

American Diabetes Association
With headquarters in Birmingham, the Alabama division of the American
Diabetes Association sponsors education, research and service programs
regarding the prevention and treatment of diabetes, including potential
complications leading to vision loss or blindness. Screenings for diabetic
retinopathy are conducted in some areas at various times during the year.

Birmingham Museum of Art—Visually Impaired Program
A national leader in museum tours created specifically for sight-impaired visitors,
the museum features a program called Hands Across Art which provides tours
led by specially trained docents and sight guides and includes three-dimensional
tactile reproductions of European and American paintings and art.

Helen Keller Foundation for Research and Education
Based in Birmingham, this foundation’s mission is to end blindness through
medical research, rehabilitation and public education. Among the programs it
supports is the Eye Injury Registry, a database for physicians which provides
ways to minimize damage and, when possible, partially restore vision in the
event of eye injury.

International Retinal Research Foundation
Based in Birmingham, the mission of the IRRF is to support research on eye
diseases, especially diabetic retinopathy and age-related degeneration of the
retina, including the macula.
30

Kid One Transport
This statewide transport system provides free rides to children who are suffering
from a medical, mental or physical illness, including eye conditions, and whose
families have no transportation of their own.

Knights Templar Eye Foundation, Inc.
A national organization that, through state networking efforts, provides
assistance to people who face loss of sight due to the need for surgical treatment
but who are unable to pay or receive adequate assistance from current
government agencies or similar sources. It also provides funds for research in
curing diseases of the eye. The Alabama office is located in Birmingham.

Liz Moore Low Vision Center
Located in Birmingham at Medical Center East, the goal of this center is to assist
people throughout Alabama with low vision to use their functional vision to the
utmost capacity. This is accomplished through evaluation, training, counseling
and education, referral to other agencies, support groups and other activities.

Mobile Association For The Blind
Located in Mobile, this program provides mobility training, rehabilitation, work
adjustment training, employment preparation service and job placement for
individuals who are blind or visually impaired.

Sight Savers Of Alabama—The Children’s Eye Care Network
Based in Birmingham, this program provides eye services to low-income
patients, including the medically indigent, throughout the state. These services
include eye exams, glasses, contact lenses, vision screening, low vision aids,
prescription medications, and surgery. This outreach program emphasizes
identifying needy children whose visual impairments have been overlooked or
neglected and then obtaining the appropriate treatment and follow-up in a timely
manner. Sight Savers has patients throughout Alabama, but its efforts are
concentrated in the greater Birmingham area.

Special Equestrians
This program, based in Indian Springs near Birmingham, provides
therapeutic/recreational horseback riding for Alabamians with disabilities,
including blindness and low vision.

University of Alabama at Birmingham

24-Hour Eye Emergency Room, Callahan Eye Foundation Hospital
31
The only round-the-clock eye emergency room in Alabama, this program
provides emergency eye care, including diagnosis, medical and surgical
treatment.

Lion’s Eye Clinic, Callahan Eye Foundation Hospital
The Lion’s Eye Clinic provides eye exams, patient and family training, and
referrals for low vision assistance, transportation and other services. It is
located at the University of Alabama at Birmingham and serves
Alabamians who are indigent.

School of Education, Visually Impaired Program
This program provides graduate teacher training in blindness/deaf-blindness.
It is the only such program in Alabama.

Department of Ophthalmology
The mission of the department is the prevention and treatment of eye disease
and vision impairment through medical education, patient care, research and
public service. Among its education services is the only ophthalmology
residency program in Alabama. Research conducted in the department
includes investigation into basic mechanisms of the eye and eye diseases
and applying laboratory findings to developing and evaluating new
treatments.

Driving Assessment Clinic, Department Of Ophthalmology
Located at the Callahan Eye Foundation hospital, this program
provides driving assessment, including risk assessment and on -road
evaluation, for patients with visual and/or cognitive impairment.

School Of Optometry
Widely considered the best optometry school in the nation, the UABSO
includes programs in educational training for optometrists, vision science
research, and service and outreach initiatives in Alabama and beyond.

School of Optometry Community Vision Services
This mobile unit conducts vision screenings for children (ages three and
up) and adults; eye health exams, including dilation, for adults; triage to
specialty groups; and in-service training for various groups, primarily
within the Birmingham metropolitan area.

School of Optometry Eyecare for the Homeless
32
Serving the Birmingham metropolitan area, this program provides eye
exams and glasses for homeless men and women. Eligibility is based on
admittance to local homeless shelters.

School of Optometry Low Vision Clinic
Located in Birmingham, this program offers comprehensive eye exams,
non-surgical management of acute and chronic eye disease, surgical comanagement, and low vision rehabilitation services to people of any age
with vision impairment. The primary low vision clinic in the state, it also
has an affiliated clinic at the Alabama Institute for Deaf and Blind in
Talladega.

School of Optometry Vision Science Research Program
The mission of this center is to promote vision science research, facilitate
collaborative research, and add to the scientific knowledge of the eye and
central visual pathways leading to improved diagnosis, treatment and
prevention of blindness and visual impairment..

University of South Alabama College of Medicine, Department of
Ophthalmology
Located in Mobile, the USA Department of Ophthalmology offers education,
research and service programs with expertise in a wide range of ophthalmic
diseases and conditions, including low vision. The department has offices in the
Health Services Building located on USA’s main campus and in Baldwin County.

Very Special Arts
This statewide organization, based in Birmingham, provides opportunities for
people with visual and other impairments in the arts, both visual and performing
arts.

Veterans Administration Southeastern Blind Rehabilitation Center
Located in Birmingham, this program provides comprehensive services for
low vision and blindness to veterans in Alabama and throughout the
Southeast.

V.I.P.—Visually Impaired People Who Are Very Important People
Based in Selma, V.I.P. provides recreation and socialization activities for the
visually impaired.
33

Workshops, Inc.
Located in Birmingham, Workshops, Inc. provides on-the-job vocational training,
counseling and related employment services to people with disabilities, including
blindness and low-vision.
The following table illustrates the type of low vision, rehabilitation and
other special eye services provided by the organizations previously listed. Again,
the depth and breadth of these services varies greatly.
34
Table II-5 Providers Of Low Vision, Rehabilitation And Other Special
Eye Services
Organization
Ala. Asso. For
Parents of
Visually Impaired
Ala. Child Caring
Foundation
Ala. Deaf-Blind
Project
ADRS-Early
Intervention
ADRS-Children’s
Rehabilitation
ADRS-Vocational
Rehabilitation
ADRS-OASIS
Daily
Living
Skills/
Mobility
Training
Family
Training
Job Skills
&
Training
Eye Exams,
Surgery &/or
Restoration
Low
Vision
Evaluations
Vision
Aids &
Adaptive
Equipment
Low
Vision
Training
Transportation
Assistance
Support
Groups
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Ala. Eye Bank
Ala. Eye Injury
Registry
Ala. Institute for
Deaf & Blind
Ala. Lions Sight
Conservation
Ala. Public
Library Service
Ala. Radio
Reading Service
Ala. State Dept.
of Education
American
Diabetes Asso.
Birmingham
Museum of Art
Callahan Eye
Foundation Hospital 24-hr. ER
CEFH Lions Eye
Clinic
Driving
Assessment
Clinic
Helen Keller
Foundation
Eye
Research
&/or
Other
Special
Efforts
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
35
Organization
International
Retinal Research
Foundation
Kid One
Transport
Knights Templar
Eye Foundation
Liz Moore Low
Vision Center
Mobile Asso. For
the Blind
Sight Savers of
Alabama
Special
Equestrians
UAB Dept. of
Ophthalmology
UAB School of
Educ.-Visually
Impaired
Program
UAB School of
Optometry
USA Dept. of
Ophthalmology
Daily
Living
Skills/
Mobility
Training
Family
Training
Job Skills
&
Training
Eye Exams,
Surgery &/or
Restoration
Low
Vision
Evaluations
Vision
Aids &
Adaptive
Equipment
Low
Vision
Training
Transportation
Assistance
Support
Groups
Eye
Research
&/or
Other
Special
Efforts
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Very Special Arts
VA Southeastern
Blind Rehab
Center
V.I.P.
X
Workshops, Inc.
X
X
X
X
X
X
X
X
II-Summary
This overview shows that, as expected, ophthalmology services tend to be
available in larger communities, while optometrists practice in smaller as well as
larger communities. Rehabilitation services are more centralized geographically,
and are also fragmented according to the population served. Demographic
factors also affect service distribution: there are more ophthalmologists located in
36
the Baldwin County area than would probably be expected by population size.
This is probably related to the growing retiree population in the area.

Services provided by ophthalmologists require more patient travel than
services provided by optometrists.

Many counties fall into different catchment areas for different types of
rehabilitation services. Different types of clients are eligible for different types
of services, which are provided in different locations, thus complicating
referral and patient travel for care.

Many rural areas of the state are distant from any eye service providers.
37
III What services are provided by ophthalmologists,
optometrists?
To address this question, the needs assessment undertook a survey of
ophthalmologists and optometrists in the state. In this chapter we summarize the
extent to which these eye care providers routinely provide preventive, diagnostic,
treatment, and rehabilitative services. We also describe the extent to which the
availability of these services differ among Birmingham, other major metropolitan
areas (Huntsville, Mobile, Montgomery and Tuscaloosa), and the rest of the
state.
Methods
Project staff developed a four page, 37 item questionnaire for optometrists
and ophthalmologists. The survey was developed based upon discussions with
the Alabama Eye Institute executive committee, information from the National
Eye Institute, and the health services research literature on eye care. A draft
was reviewed by members of the AEI executive committee, their designates, and
faculty in the UAB School of Optometry. The final survey instrument is contained
in Appendix B.
In late September 1999, the survey was mailed to 163 ophthalmologists
and 238 optometrists practicing in Alabama using mailing lists provided by AEI.
In addition, copies of the survey were distributed to attendees at the Alabama
Ophthalmological Society meetings in Gulf Shores, AL in August.
Of the 402 surveys mailed, 22 were returned as undeliverable. 134 were
completed and returned. This yielded an overall response rate of 35.3 percent.1
Of the returned surveys, seven were completed by non-ophthalmologist or nonoptometrist responders. These were excluded from the analysis, yielding a
useable response rate of 34.0 percent. The response rate for ophthalmologists
was 38.1 percent, and 30.0 percent for optometrists. These rates are
comparable to small employer surveys which typically achieve response rates of
19 to 48 percent.2
1For
purposes of calculating response rates, the conference attendees are
considered a subset of those on the mailing lists.
2Gail
A. Jensen and Michael A. Morrisey, “Managed Care and the Small
Group Market,” in M.A. Morrisey, ed., Managed Care and the Changing Health
Care Market (Washington: AEI Press, 1988), p. 57.
38
Characteristics of Respondents
A plurality of respondents (44.5 percent) were from the Birmingham area,
23 percent were from other major metropolitan areas (Huntsville, Mobile,
Montgomery, and Tuscaloosa), and the remaining 32.5 percent were from other
counties.
For the most part, respondents were experienced practitioners. Less than two
percent of respondents had been in practice for less than one year; 81 percent had
been in practice for more than five years. Rural providers tended to have less
experience on average, but even so, 71 percent of rural respondents had been in
practice for over five years.
In a typical week, the average responding ophthalmologist saw 122.2 patients;
the average optometrist saw 69.7 patients. The survey did not inquire about the fulltime or part-time nature of a practice.
Preventive Service Provision
Table III-1 presents the percentage of optometrists and ophthalmologists
routinely providing selected preventive services. In general, preventive services were
readily available from Alabama practitioners. Newborn and young child vision screening
was the preventive service least likely to be provided. There were no meaningful
differences in the provision of preventive services across the urban and rural county
groupings.
Table III-1 Percentage of Respondents Providing Preventive Services
Ophthalmologists
Optometrists
78.7 %
83.3 %
Instruction on the proper care of
contact lenses
80.3
100.0
Education on hygiene to prevent
spread of conjunctivitis
91.8
98.5
Glaucoma screening to identify
asymptomatic individuals with
elevated intra-ocular pressure
85.2
95.5
Newborn and young child vision
screening
60.7
66.7
Instruction on the use of protective
eye wear in hazardous occupations
and activities
39
Optometrists were more likely to routinely provide each of the services than were
ophthalmologists. This difference was most pronounced in the instruction on the proper
care of contact lens where nearly 20 percent more optometrists routinely provided the
service. The difference was least in instruction on the use of protective eye wear in
hazardous occupations and activities.
Diagnostic Service Provision
Table III-2 presents the percentage of respondents routinely providing diagnostic
services. Comprehensive adult and pediatric eye examinations were provided by
virtually all practitioners, as were optical exams for refractive errors. Optometrists were
slightly more likely to provide these services than were ophthalmologists.
Table III-2 Percentage of Respondents Providing Diagnostic Services
Ophthalmologists
Optometrists
91.8 %
98.5 %
Comprehensive adult eye
examination
93.4
98.5
Comprehensive pediatric eye
examination
83.6
90.9
Specialized diagnostic procedures:
angiography, ultrasound,
electrophysiology
45.9
13.6
59.0
19.9
66.9
15.2
Optical exam for refractive errors
Culture for conjunctivitis
Corneal scraping for culture, corneal
biopsy
In contrast, more specialized diagnostic services were at least three times more
likely to be routinely provided by ophthalmologists. Fifty-nine percent of
ophthalmologists routinely provided cultures for conjunctivitis, for example, compared to
only 20 percent of optometrists.
40
Importantly, however, not all ophthalmologists provide these specialized
services. Less than half (45.9 percent) of responding M.D.s routinely provide
angiography, ultrasound, or electrophysiology procedures. There were urban-rural
differences in specialized diagnostic services. Ophthalmologists in rural counties were
more likely to routinely provide these services than were those in the Birmingham area.
This probably reflects specialization within the larger metropolitan area.
Treatment Services Provision
Table III-3 presents the percentage of ophthalmologists and optometrists
routinely providing eye treatment services. The pattern is similar to that of diagnostic
services. The less complex treatments were widely available. Optical correction, for
example, was routinely provided by 97 percent of optometrists and 82 percent of
ophthalmologists. As with diagnostic services, optometrists were somewhat more likely
to provide these less complex services. Note that optometrists are not licensed to
provide surgical interventions.
Table III-3 Percentage of Respondents Providing Treatment Services
Ophthalmologists
Optometrists
82.0 %
97.0 %
Occlusion, defocusing, defogging
(for amblyopia)
75.4
77.3
Topical treatment for infections
96.7
97.0
Topical treatment for reduction of
corneal edema and of intra ocular
pressure
93.4
90.9
Keratorefractive surgery
54.0
0.0
Cataract removal
82.0
0.0
Corneal transplant
41.0
0.0
88.5
0.0
Optical correction
Other incisional ophthalmologic
surgery (glaucoma, eye muscle,
eyelid)
41
Therefore, more complex eye treatments such as keratorefractive surgery and
corneal transplants were only provided by ophthalmologists. Ophthalmologists differed
widely in the extent to which they routinely provided these services. Only 41 percent
provided corneal transplants, while over 88 percent provided “other incisional
ophthalmologic surgery.”
M.D.s in Birmingham were less likely to provide the specialized procedures than
were ophthalmologists in either the other urban or the rural areas. Only 30.8 percent of
Birmingham M.D.s routinely provided corneal transplants, while 55 percent of those in
other urban areas did so, and 40 percent of rural physicians did. Presumably this
reflects a higher degree of sub-specialization within the larger Birmingham market. The
survey was not designed to provide information on the volume of specific procedures
performed.
42
Rehabilitation Service Provision
Finally, Table III-4 summarizes the extent to which responding Alabama
ophthalmologists and optometrists routinely provide rehabilitation services.
Unlike the other eye care services, these were infrequently provided. Virtually all
of the services were routinely provided by fewer than half of providers. For
example, only 49 percent of ophthalmologists and 42 percent of optometrists
provide assessments of functional disability and adaptation skills. Less than 12
percent of M.D.s and less than 15 percent of ODs provided training in
adaptations for activities of daily living.
Table III-4 Percentage of Respondents Providing Rehabilitation Services
Ophthalmologists
Optometrists
49.2 %
42.4 %
39.3
54.5
Training in use of magnification,
lighting and contrast enhancement,
maximizing residual vision
23.0
50.0
Training in adaptations for activities
of daily living
11.5
14.7
Counseling on the impact of low
vision (e.g., vocational, mobility, job
placement, adaptive equipment)
21.3
37.9
Assessment of functional disability
and adaptation skills
Low vision exam
The lack of rehabilitation services provided by optometrists and
ophthalmologists was particularly acute outside of Birmingham. In Birmingham
approximately 23 percent of these providers routinely provide training in
adaptations for activities of daily living, for example. Only 10 percent and 12
percent, respectively, of providers in other urban and rural counties routinely did
so. As we show in the next chapter, providers are aware and concerned about
the lack of availability of rehabilitation services.
43
III-Summary

When ophthalmologists and optometrists are present, the full range
of preventive, diagnostic, and treatment services are available.

In general, optometrists are somewhat more likely to routinely
provide preventive services and less complex diagnostic and
treatment services than are ophthalmologists.

Ophthalmologists are much more likely to routinely provide more
complex diagnostic and treatment services.

In general, the Birmingham area is more sub-specialized than
elsewhere in the state. General ophthalmologists in Birmingham
more often refer patients to specialized ophthalmologists for
complex procedures.
44
IV What do eye care providers perceive to be major
needs?
This question was addressed by the optometrist and ophthalmologist
survey described in Chapter III. We asked four sets of questions of Alabama
optometrists and ophthalmologists. First, we asked which particular preventive,
diagnostic, treatment, and rehabilitative services was the most difficult to make
referrals. Second, we asked which three eye care services were the most
difficult for people to obtain, and in the judgment of the provider, what were the
major reasons for these difficulties. Third, we asked providers to identify the
greatest unmet eye care need in their communities. Finally, we asked what
single action by a private foundation, such as the Alabama Eye Institute, would
make the greatest improvement in eye care in their communities.
These last two questions were also posed to the rehabilitation and support
service providers who received a second survey mailed out in December 1999
(see Appendix C). In this chapter we also report their responses to these
inquiries.
Difficulties in Making Referrals
Table IV-1 reports the extent of difficulty in making referrals in Alabama for
eye care services. A relatively large number of providers, nearly 29 percent,
found difficulty in making referrals for rehabilitation services. Nearly 60 percent
of those identifying difficulty referring for rehabilitation services indicated that low
vision services were the area of greatest concern. This finding was common
among both ophthalmologists and optometrists.
Table IV-1 Most Common Referral Difficulties Reported by Ophthalmologists
and Optometrists (N= 134)
Rehabilitation
Percent
Identifying a
Difficulty
28.6%
Greatest Referral Difficulty
(Percent of those identifying any
difficulties)
Low Vision Rehabilitation
(58%)
Diagnostic Services
Treatment Services
13.5%
13.5%
Specialized diagnostic services
Neuro-ophthalmic treatment
Low Vision Aids
(41%)
(18%)
(12%)
Prevention Services
10.3%
Screening for high risk groups
(31%)
45
There were few difficulties with preventive, diagnostic or treatment services.
Only 10 to 14 percent of providers indicated any difficulties in making referrals for these
types of services. Of those who did, ophthalmologists and optometrists agreed that
screening for high risk groups, and specialized diagnostic services were the most
common referral difficulties. M.D.s and O.D.s did differ over referral difficulties for
treatment services. M.D.s found neuro-ophthalmic treatment referrals problematic,
while O.D.s indicated that referrals for low vision aids were difficult. However, these
reflect comments by only 3 ophthalmologists and 2 optometrists and may not be
generalizable.
Difficult to Obtain Services
The preceding analysis focused on provider difficulty in making referrals. Even
with easy referrals, people may nonetheless forego clinically indicated care for a variety
of reasons. To address this we asked Alabama eye care providers open-ended
questions about the three eye care services that they believed were the most difficult for
people in their community to obtain. We then asked the providers to suggest why
access to these services was difficult. The results are summarized in Table IV-2
46
Table IV-2 Eye Care Services Reported by Optometrists and Ophthalmologists to be
the Most Difficult for People to Obtain
Number of
Providers
Identifying
Difficulty
Reasons for Lack of Service
(percent identifying each) *
Cost
Travel
Distance
Lack of
Providers
Lack of
Social
Support
Low Vision
17
41%
35%
59%
18%
Rehabilitation Services
10
20
20
80
10
Retinal Diagnosis and
Treatment
5
------
80
40
20
Surgery (ocular,
refractive)
5
80
-----
20
20
Low Vision
14
57%
50%
64%
36%
Rehabilitation Services
10
30
40
60
20
Retinal/Special Services
6
-----
33
83
33
Treatment
5
80
20
-----
-----
Diagnosis
4
50
75
25
25
Ophthalmologists (N=61)
Optometrists (N=66)
* Rows sum to more than 100 percent due to multiple answers.
47
As is clear, relatively few providers, either ophthalmologists or
optometrists, indicated that people in their communities had difficulty obtaining
needed services. While there were some differences in emphasis, the M.D.s and
O.D.s also tended to agree on the gaps in services and the reasons for them.
Both groups believed that low vision services were the most difficult for
people to obtain. Clear majorities attribute this to a lack of providers, followed by
the cost of care, and travel distance.
Similarly, both M.D.s and O.D.s believed that rehabilitation services were
relatively difficult to obtain, again because of lack of providers as well as travel
distance and cost. Retinal diagnosis and treatment was the third most commonly
mentioned difficult service. Surgery (or treatment generally) followed by
diagnosis completed by common responses.
Greatest Unmet Need
The needs assessment survey of ophthalmologists and optometrists
asked two additional open ended questions. The first was “What are the greatest
unmet eye care needs in your community?” Many respondents chose not to
reply to this question. The 85 responses we did receive were sorted by content
and enumerated. We did not distinguish between the responses of
ophthalmologists and optometrists.
1. Low Vision and Rehabilitation Services
The most common response to the question concerning unmet needs was
the need for low vision and rehabilitation services (28 responses, 33% of all
responses). Sample comments in this category include the following:
“I have given up on low vision care for most patients. Older patients with a
need for low vision devices are frustrated by the cost, the difficulty in
obtaining assistance for payment, and I believe a lack of acceptance for
such devices. In ____ County, there are more than enough providers of
the other services, and all in close proximity.”
“_____ County is one of the poorest counties in the state, with a large
proportion of African Americans. We have a number of patients whose
lives could be improved with low vision aids such as CCTV Reading
monitors which cost between $1,700 and $2,800 each. Very few patients
can afford this so they are unable to read.”
48
“Rehabilitation services – they are expensive and most insurance
companies do not reimburse providers for these services so the cost is
passed on to the patient.”
“Teaching elderly individuals with loss of macular function how to cope
with daily living.”
2. Financial Support
The second most common response to the question concerned financial
support for services provided to low income patients (19 responses, 22% of all
responses). Sample comments include the following:
“Some patients are not able to afford their glaucoma medications.”
“Glasses/medications for indigent patients.”
“Paying for surgery for those patients not eligible for Medicaid and too
poor to afford insurance.”
“I see mostly children. Financial (insurance) resources are still a problem.
Early diagnosis of many problems will continue to be a problem. Many
children do not see pediatricians and also do not have any eye
evaluations until they are out of the amblyogenic age and it is too late to
treat.”
“We need more eye care professionals in this area to accept Medicaid.
The few that do are inundated with patients. If everyone took it then there
would be less burden on each practice. As you know, Medicaid does not
pay enough to cover overhead.”
“Need for coordination for eye care services for the working poor. There
are programs such as Vision USA, Sight savers, etc., but there is a lack of
a specific plan for such services.”
3. Local Specialty Services
The third most common response to the question concerned specific
specialty services in local areas (13 responses, 15% of all responses). These
included 4 (30%) responses listing retinal specialists, 4 (30%) responses listing
pediatric and developmental vision services, 3 (23%) listing neuroophthalmology, 1 (8%) listing nursing home care services, and 1 (8%) listing iritis
work-up availability.
4. Public Education
49
The fourth most common response to the question of unmet community
needs referred to public education needs (12 responses, 14% of all responses).
Sample comments include the following:
“Education regarding risk factors for blinding ocular diseases and
prevention.”
“Education regarding who is at risk for injury and how and why injury can
be prevented.”
“A general belief that eye care on a routine basis is less important than
routine dental care (i.e., lack of understanding or education).
“Public education regarding – what is proper eye care, - who should
provide that care, - appropriate avenue to pursue in obtaining that care.”
5. Screening Services
The fifth most common response to the question referred to the need for
screening services (8 responses, 9% of all responses). Five of these responses
referred to the need for screening young children for vision problems, including
the following comment:
“Many children in elementary school are known to need eye care, but go
for months or even years without it. Usually this is due to financial
hardship or a lack of education in the family. Sometimes it is due to
parental neglect. These children need someone to be proactive and
intervene to obtain their eye care needs, which many times can be
resolved with eyeglasses.”
In addition, one response mentioned screening for diabetic retinopathy,
one mentioned the need for screening for glaucoma, and one mentioned the
need for screening of high risk groups.
6. Miscellaneous comments
Finally, seven respondents (8%) noted that they did not believe there were
any unmet eye care needs in their communities. Three (3%) respondents
commented on the need for better cooperation between optometrists and
ophthalmologists. One mentioned the need for transportation, one mentioned
the need for “routine care”, and one mentioned the need for emergency care at a
reasonable cost.
Single Action by a Foundation That Would Make the Greatest Improvement
50
The second open ended question on the survey asked respondents to
comment on what single action a foundation such as A.E.I. could take that would
most improve eye health in their community. The 87 responses we received to
this question were similar in many ways to the responses described above,
although there were somewhat different expectations for a foundation concerning
action to address needs.
1. Financial Support
The most common response to this question concerned financial support
for care for low income patients (23 responses, 26% of all responses). Several
responses described specific needs for financial support, including rehabilitation
services, surgery, routine care, medications and glasses. One sample comment
noted:
“Provision of funds for indigent eye care. These funds should be available
to cover primary, secondary and tertiary eye care, as well as glasses.
When I see indigent patients (in my primary eye care setting) who require
referral for secondary or tertiary care, this referral is awkward at best,
because of the patient’s inability to pay.”
Two comments suggested that the foundation could play a role in coordinating
the services of other agencies that provide financial support. These comments
were:
“Fund program dedicated to providing eye care to needy Alabama
citizens, so that these organizations can dedicate more of their time and
efforts to helping individuals. Also help coordinate eye care services in
the state so that various agencies can work together more effectively.”
“Support and coordination of needed eye care services throughout the
state.”
2. Low Vision and Rehabilitation Services
The second most common response to the question of what single action
a foundation could take that would make the greatest improvement concerned
low vision and rehabilitation services (21 responses, 24% of all responses).
The general idea expressed in these comments was that the Institute could
actually find a way to support and deliver rehabilitation and adaptive services
around the state. Sample comments include the following:
“Mobile low vision services – training and devices. Our community has a
large population of ARMD [age related macular degeneration] patients
who are low income; they can’t travel to Birmingham and often can’t afford
low vision devices.”
51
“A low vision/rehabilitation clinic. These needs are met locally only on a
limited basis, due to the investment in staff and devices availability to try
out. I believe our local vocational rehabilitation office provides counseling
and some training, but little is done to evaluate sophisticated optical aids,
etc.”
3. Public Education
The third most common response concerned support for public education
campaigns (15 responses, 17% of all responses). Sample comments include the
following:
“Public education – when asked what, next to life itself, is the most
precious physical asset most patients state that it is their vision. There is,
however, a woeful lack of public awareness of the most basic details of
eye health. Education about visual anatomy, pathology and preventive
care would provide benefits across all socioeconomic and cultural/ethnic
strata.”
“By maintaining good relations with ophthalmologists and the local media
in order to get publicity about problems out to the public and offer the
solutions which are available.”
4. Improved Cooperation
Fourth were a set of comments related to improving cooperation and
coordination between optometrists and ophthalmologists, and between care
providers in rural areas and urban-based specialists (9 responses, 10% of all
responses). The specifics of these comments were varied. Sample comments
include the following:
“I don’t know if your Institute can improve upon the working relationship
between ophthalmologists and optometrists. There is still room for
improvement, as this only hurts the patients.”
‘In my community, helping in the following areas: (1) emphasize the use of
the basic services already available; (2) arrange to provide specialty
services locally through the existing basic service locations; (3) foster this
partnership arrangement for the betterment of the patients, the
community, the providers and the future.”
5. Local Specialty Services
The fifth most common set of comments were related to the supply of
ophthalmologists in local communities. Although one respondent complained of
an over supply, the others felt that they needed more ophthalmologists in their
52
communities, and some felt they needed more subspecialists nearby (6
responses, 7% of all responses). In addition, another set of respondents
requested support for the purchase of sophisticated diagnostic equipment to be
placed in local hospitals for use by local ophthalmologists, so that patients would
not have to be referred out for these tests (3 responses, 3% of all responses).
5. Screening and Preventive Care
A sixth set of responses related to the direct provision of screening and
preventive care (5 responses, 5% of all responses). It is not clear whether the
respondents meant that they thought the Institute should support the provision of
these services financially, or actually employ providers who could supply these
services. Sample comments included the following:
“Glaucoma screening (by dilated exam and visual fields) for young African
Americans (< age 50), especially relatives of known glaucoma patients.”
”Routine eye exam every 1-2 years. Patients often won’t come in if
insurance won’t pay.”
6. Miscellaneous Comments
Another set of respondents suggested that the Institute fund clinical and
basic research on a range of eye diseases (3 responses, 3% of all responses).
Finally, one respondent mentioned the need for transportation services to and
from eye care providers for elderly and low income patients.
Rehabilitation and Support Service Providers’ Perception of Needs
Recipients of the second survey of rehabilitation and support service
providers were also asked to describe “the greatest unmet needs in your service
area” and “what single action by a private foundation would make the greatest
improvement in eye care in your service area”. Many respondents answered
these questions primarily with reference to the services they provided, while
others gave more generalized comments.
Greatest Unmet Eye Care Needs

Eye Care Education/Awareness/Screenings




Education.
Vision screenings.
Early identification
Awareness and preventive care.
53



Access/Transportation








Qualified and/or experienced professionals.
Lack of certified teachers in our area
Increased training in Alabama for staff to serve the blind and visually
impaired
Faculty support to continue the teacher training activities of the Visually
Impaired Program (at the UAB School of Education).
Training of professionals to serve children who are sensory impaired.
Elderly Services





No resources for adaptive technology.
Financial assistance for low vision items and glasses for children and
adults.
Funding for training for assistive technology for individuals not eligible for
Vocational Rehabilitation.
Increased mobility and orientation services.
Awareness and preventive care.
Professional Training




Access to basic vision care.
Transportation-3 responses.
Low Vision Needs



Access to populations with eye and vision care needs—today’s climate of
“managed” care isolates populations instead of bringing them together
where services are located
Education regarding eye care importance; participation in available
programs; willingness to follow-up if eye problems are detected.
Senior citizen services.
Assistive technology for low income visually impaired seniors.
Senior services.
Senior education and on-site vision screenings for the four leading causes
of new blindness among seniors: 1) diabetic retinopathy, 2) glaucoma, 3)
cataracts, and 4) age-related macular degeneration.
Children Services

Vision expertise with infants and toddlers with an early
education/intervention focus.
54




Financial Assistance
















Limited resources for clients’ medications.
Funding for individuals who do not have insurance or Medicaid.
Older adults facing visual impairment have extremely limited resources
available in the community.
Funding is needed for medical needs and equipment needs for individuals
not covered by private insurance, Medicaid, Medicare or personal funds.
Medical care for people who cannot afford it.
Funding for surgery.
Assistance in covering the cost of adaptive equipment for the blind and
visually impaired.
Adequate funding for eye care.
Indigent care,
Funding (for patient care) is the major problem. The resources are here
but out of reach financially for many.
Financial support for low vision devices.
Low vision aids—no third party covers these important prosthetic devices.
Eye glasses for the financially challenged.
Funding to provide vision aids and training in their use for persons with
low vision.
Insurance does not cover driving assessment, even in patients with
medical conditions and functional impairment. So this is our greatest
need—all our services are self-pay, so this is burdensome to our patients.
Vocational Needs




Pediatric ophthalmologists—families must travel to Birmingham for quality
medical care by specialists with skills and training to work with families of
young visually impaired children.
There are many children with visual problems whose eye care is
neglected. This is well known in school systems and has been confirmed
by numerous studies. One local study done by Sight Savers and Alabama
Power showed that there was one child with neglected eye care for each
child receiving the appropriate eye care. Most of these children need
glasses, but some have more severe vision problems.
Children without proper eye care and glasses in rural areas of the state.
Increased job opportunities for the blind.
Properly equipped job readiness and job club facilities for the blind and
visually impaired.
Job training and placement services.
Other

List of resources for minor eye problems.
55






Housing for adults with deaf-blindness.
Interpreters who sign for persons with deaf-blindness.
Social/recreation opportunities for blind.
Service coordination
Public education of eye donation. Public education and research
materials are dependent upon the public’s donation of eye tissue.
Vision correction.
Single Action by a Private Foundation that would Make the Greatest
Improvement

Education




Education and more resources for eye case load (among rehab
counselors and teachers).
Fund a program to emphasize/educate the populace regarding the
importance of regular ongoing eye care.
Notification of the availability of services.
Financial Assistance










Funding for adaptive technology to be used for loaner equipment for
children, adults, and senior citizens would make a significant difference
(i.e. magnifiers—electronic and hand held, adaptive software and
computers). In some situations, low income children and working age
adults may have the opportunity to get adaptive technology through
organizations such as the Department of Rehabilitation Services or
Medicaid. Often times, senior citizens do not have any options for
assistance with the purchase of some of the more expensive adaptive
technology that can help them maintain an independent lifestyle.
Funding of care for populations of unmet eye care needs patients—i.e. the
working poor not covered by Medicaid.
Funding of major low vision care initiatives.
Funding for clinical trials and other related eye and vision care resource.
Funding for children’s (eye) programs, such as summer camp, Space
Camp.
Replacement funding when Vision Service Plan completes its commitment
to Alabama’s low income children in 2001 (administered through the
Alabama Child Caring Foundation).
Fund a program to match contributions of in-kind services value and/or
monetary donations to provide services.
A controlled fund of money to be used toward solving the needs of
affordable eye exams, glasses, technology (including computers with
JAWS, etc.), funds for reader services.
Make more funding available for actual eye care, not just equipment.
Awareness coupled with providing resources for program development.
56



Professionals






Grant support will enable every organization serving the visually impaired
to reach more individuals in the state. Increasing the resources of service
providers will allow them to add staff if needed, subsidize the costs of
services delivered to low income individuals, and to expand outreach
efforts, better informing citizens throughout the state of services available
to them.
Without question, funding programs to provide eye are to children with
neglected vision problems. Successful treatment at an early age, in a
timely manner, benefits the long term social and educational development
of these children.
Recruiting of pediatric ophthalmologists and vision certified educators.
Long term action: Create a school of blind studies that would house the
following training areas--Orientation and Mobility Certification-BS and MA
levels, Blind Development and Placement Training special studies and BS
level, Rehabilitation Teaching Certification, BS and MA levels. Why?
These areas are where the real need is, and to serve the blind and
visually impaired in this state, these areas are the hardest to recruit for
and to obtain training for on a consistent basis. Directly affecting the
quality and level of services to the blind and visually impaired.
Assistance with training of professionals in education/rehab for blind and
deaf-blind, including interpreters.
Since the Visually Impaired Program trains teachers in a “low incidence”
disability, we don’t have large numbers of students. This negates
university support of faculty. We are successful with tuition support
(recruitment of trainees, etc.) but desperately need long-term support or
seed dollars to begin an endowed faculty position so our program will not
close. AEI could assist in collaboration of other Alabama agencies, (AIDB,
UAB, Alabama State Department of Education) to provide long term
funding/planning.
Support of educational mission of eye and vision care programs in
Alabama (i.e. endowed chairs, endowed research funds, endowed special
population care funds).
Elderly Services


Senior services: public awareness, lending library of adaptive items.
One, technology provides the most benefit in assisting a visually impaired
person to function in his environment. Funding for adaptive technology to
be used for demonstration and use in the home on short term loan basis
would meet a real need for low income visually impaired seniors. There is
also a need for direct services from a low vision specialist in the early
intervention area, and in support services (technical assistance) to local
education and community agencies.
57



Low Vision











Low vision clinic with easy accessibility for persons in our service area.
Assistance with appropriate examination/prescription of low vision devices
and purchase or loan of this equipment.
Provide a large grant to help us meet our “greatest unmet needs” (low
vision aids—no third party covers these important prosthetic devices; eye
glasses for the financially challenged). It should have a responsible level
of guidelines but minimal “red tape.” Why? 1)There is significant need.
2)There is no third party coverage for low vision aids.
Provision of a system whereby persons with vision impairment could
receive low vision aids and training in their use as well as other rehab
services at reduced or no cost dependent upon their income. Most low
vision patients are living with a fixed income that barely meets their
minimum needs. They have no extra for low vision aids/exams.
Funding is needed for equipment needs for individuals of all ages.
Funding for low income low vision clients.
Additional funding to identify visually impaired children and adults.
Funds for the purchase of assistive technology for demonstration and
dispensing purposes, equipment needs (for low vision) and funds for for
purchase of glasses and glasses repair.
Funding to open, train and operate a low vision department.
Funds are very much needed to sustain the Driving Assessment Clinic (at
UAB Department of Ophthalmology) operation because our services are
not currently reimbursable in Alabama.
Rural Eye Care


Providing equipment to utilize with older adults determining their needs to
improve their quality of life. This equipment would allow us to provide
support services to this population as they continue to maintain an active
lifestyle.
Provide funding for service coordinators in order to reach more seniors
and provide indepth and ongoing case management services required,
such as scheduling appointments and linkage with agencies such as the
Department of Human Resources, Alabama Rehabilitation Services,
Green Thumb, and other members of the aging network.
Mobile medical assistance in rural counties, accessibility for low vision
aids, surgery, etc. People in rural counties often do not have the
transportation or means to get to Birmingham.
Vocational Needs
58



Medications


Need for long term eye medications such as those needed for glaucoma,
surgery, hospitalization (low vision aids). Those that may not be eligible
for vocational rehab services need the above assistance.
Transportation



Short term action: (More assistance so) that blind and visually impaired
individuals can prepare for the world of work and be able to access the job
markets and information available. This is one of the greatest needs in
our area and is a major barrier in preparing a blind and visually impaired
individual for work and getting them there.
Availability of long term medical care and treatment for individuals who
have met with a degree of successful vocational rehabilitation but still
don’t have the resources to acquire medical care: medications, laser,
annual or semi-annual checkups and long term ongoing treatment.
Funding for transportation.
Additional funding to support transport related expenses.
Other

To be able to connect with AEI to be able to provide those services that
fall outside the realm of “medical.” There are so many needs: support
groups (families and adults), assistive technology training, advocacy for
the blind community, public education on eye care, etc.
IV- Summary

Providers of eye care perceive an absence of rehabilitation training and
equipment aids available for their patients with severe vision problems. This
need is not limited to those who are unable to afford such services. In some
places they are believed to be not conveniently available for any patients.
While it is clear from this review that there are, in fact, publicly sponsored
rehabilitation services and other non-profit eye care services around the state,
ophthalmologists and optometrists perceive a difficulty making referrals. The
rehabilitation providers themselves describe needs for expanded capacity to
serve clients, financial support for clients and the need for more trained staff.

Providers of eye care also noted the need for more public education to
increase awareness of the need for routine preventive care to prevent and
treat eye problems. In some cases, active outreach is needed to be sure that
potential clients make contact with providers.
59

Many providers are in contact with patients who would benefit from eye health
services, but who cannot afford them financially. Financial support for eye
health services and vision aids is perceived to be an important need.

There is a perceived need for improved availability of specialty eye health
services outside of major urban areas. Additionally, there is a perceived need
to link patients who need services with providers who have the capacity to
serve additional patients.
60
V What are the major gaps in service availability for eye
health problems?
So far this needs assessment has reviewed the major eye health
problems facing the Alabama population, examined the distribution of service
providers available to address these problems, explored which services are
available from these providers and described the care providers assessment of
major eye health needs. This brief chapter presents a list of the major gaps in
service availability for eye health problems based on this information. They are
presented in order based generally on the largest number of people affected by
the problem. Note this is not necessarily a priority order for the most important
eye health needs.
1. There is a need for public education concerning the importance of routine
screening and preventive eye care.
Both visual problems for young children and serious eye diseases with nonsymptomatic early stages, such as glaucoma and diabetic retinopathy, can be
treated and improved if identified early. Both optometrists and
ophthalmologists can provide these services, so they are geographically
available in most parts of the state. However, eye care providers believe that
the public is generally not aware of the importance of this care. In particular,
children may be deprived of vision care because their caretakers are unaware
of their needs and available resources.
2. There is a need for financial support for eye health services.
Approximately 18% of the Alabama population is uninsured, and this
proportion is likely to grow. Even state residents who have insurance may not
have coverage for preventive eye services. As many providers pointed out,
funds are needed to pay for vision aids and rehabilitation services for
individuals with other types of health insurance. Cost is clearly a barrier for
many individuals needing treatment for eye problems. While some
organizations provide reduced-fee eye health services, these are not widely
available around the state.
3. There is a need for greater availability of rehabilitation and adaptation aids
and services.
Permanent vision impairment from a variety of ailments is not uncommon,
particularly for elderly individuals. As the elderly portion of the population
increases, such vision impairments will be increasingly common. There are a
61
number of adaptive aids and skills that would be helpful for these individuals,
but there are relatively few providers of aids and training in the state. Cost
barriers are also a problem for these services. In addition, it appears that
there is not a systematic referral system that enables potential clients to
identify available rehabilitation services, and some services have waiting lists
for clients.
4. There is a need for improved geographic access to specialty services.
Several providers noted that they must refer patients long distances for
specialty services, including retinal care and pediatric ophthalmology. They
felt that provider scarcity and travel distances constituted important barriers to
receiving needed care. There was an interest in improving local cooperation
between optometrists and ophthalmologists and strengthening local care
systems. In related comments, some organizations described the need for
better linkages between available services and patient populations,
particularly when they are geographically distant from each other or when the
individuals involved are not knowledgeable or mobile.
62
Appendix A
References for
Epidemiology of Eye
Disorders
63
REFERENCES
1. National Advisory Eye Council. VISION RESEARCH--A NATIONAL PLAN: 1999-2003,
EXECUTIVE SUMMARY. Bethesda, MD: National Institutes of Health, 1998. NIH
Pub. No. 98-4288. http://www.nei.nih.gov/publications/plan/plan.htm
Diabetic Retinopathy
1. Leibowitz HM, Kruger DE, Maunder LR, Milton RC, Kini MM, Kahn HA,
Nickerson RJ, Pool J, Colton TL, Ganley, Lowenstein JI, Dawber TR. The
Framingham eye study monograph. Surv Ophthalmol 1980; 24 (Suppl):335610.
Retinoblastoma
1. Weir HK, Holowaty EJ. The incidence of pediatric cancer in Ontario (19751985). An investigation of unconfirmed cancers. Chronic Dis Canada 1993;
14:126-130.
2. Mahoney MC, Burnett WS, Majerovics A, Tanenbaum H. The epidemiology
of ophtalmic malignancies in New York state. Ophthalmol (Rochester) 1990;
97:1143-1147.
3. Tamboli A, Podgor MJ, Horm JW. The incidence of retinoblastoma in the
United States: 1974 through 1985. Arch Ophthalmol 1990; 108:128-132.
Retinitis Pigmentosa
1. Pagon RA. Retinitis pigmentosa. Surv Ophthalmol 1988; 33:137-177.
2. Bunker CH, Berson EL, Bromley WC, Hayes RP, Roderick TH. Prevalence of
retinitis pigmentosa in Maine. Am J Opthalmol 1984; 97:357-365.
Macular Degeneration (Age-related)
1. Leibowitz HM, Kruger DE, Maunder LR, Milton RC, Kini MM, Kahn HA,
Nickerson RJ, Pool J, Colton TL, Ganley, Lowenstein JI, Dawber TR. The
Framingham eye study monograph. Surv Ophthalmol 1980; 24 (Suppl):335610.
2. Klein R, Klein BEK, Linton KLP. Prevalence in age-related maculopathy: The
Beaver Dam eye study. Ophthalmol (Rochester) 1992; 99:933-943.
3. Krumpaszky HG, Klauss V. Epidemiology of Blindness and Eye Disease.
Ophthalmologica 1996; 210: 1-84.
64
Keratoconus
1. Bechrakis N, Blom ML, Stark WJ, Green WR. Recurrent keratoconus.
Cornea 1994; 13:73-77.
2. Kennedy RH, Bourne WM, Dyer JA. A 48-year clinical and epidemiologic
study of keratoconus. Am J Ophthalmol 1986; 101:267-273.
Cataracts
1. Sperduto R, Hiller R. The prevalence of nuclear, cotical, and posterior
subcapsular lens opacities in a general population sample. Ophthalmology
(Rochester) 1984; 91:815-818.
2. Leibowitz HM, Kruger DE, Maunder LR, Milton RC, Kini MM, Kahn HA,
Nickerson RJ, Pool J, Colton TL, Ganley, Lowenstein JI, Dawber TR. The
Framingham eye study monograph. Surv Ophthalmol 1980; 24 (Suppl):335610.
Primary Open-Angle Glaucoma
1. Leibowitz HM, Kruger DE, Maunder LR, Milton RC, Kini MM, Kahn HA,
Nickerson RJ, Pool J, Colton TL, Ganley, Lowenstein JI, Dawber TR. The
Framingham eye study monograph. Surv Ophthalmol 1980; 24 (Suppl):335610.
2. Tielsch JM, Sommer A, Katz J, Royall RM, Quigley HA, Javitt J. Racial
variation in the prevalence of primary open angle glaucoma. The Baltimore
Eye Survey. JAMA 1991; 266:369-374.
STRABISMUS, AMBLYOPIA, AND VISION PROBLEMS
1. National Center for Health Statistics, Ganley JP, Roberts J. Eye conditions
and related need for medical care among persons 1-74 years of age: United
States, 1971-1972. Vital and Health Statistics. Series 11, No 228. DHHS
Pub No (PHS)83-1678. Public Health Service. Washington: US Government
Printing Office, March 1983.
2. Krumpaszky HG, Klauss V. Epidemiology of Blindness and Eye Disease.
Ophthalmologica 1996; 210: 1-84.
65
Appendix B
Survey of Alabama
Eye Care Providers
66
ALABAMA EYE INSTITUTE, INC.
September, 1999
Dear Colleague:
We are the Alabama Eye Institute, Inc., a non-profit foundation formed with the
proceeds of the sale of the Eye Foundation Hospital in Birmingham. Our board consists
of independent business, medical and community leaders in Alabama. Our mission is
to promote research, teaching, and indigent care related to the human eye. In order to
meet this mission, we are conducting a comprehensive needs assessment of the state
of eye care in Alabama. The attached survey is an important part of this study.
Please take a moment to fill out this brief survey. As a member of Alabama’s eye care
community, your knowledge and experience with eye health services will provide us
with important information. The more responses we receive to this questionnaire, the
more likely we are to gain a complete picture of eye care services in the state, and a
better understanding of where the needs are greatest.
The questionnaire is anonymous. We ask only your county and type of practice to
add to our inventory of available services. Please complete the survey and return it to
us in the enclosed envelope.
Thank you so much for your help. If you have any questions, please speak with Ms.
Torrey Smitherman. Her number in Birmingham is 205-325-8508.
Sincerely,
Torrey Smitherman
Executive Director
Hartwell Davis
Chairman, Board of Trustees
Attachment
700 SOUTH 18TH STREET - SUITE 601 - BIRMINGHAM, ALABAMA 35233
67
PHONE 205-325-8508 - FAX 205-325-8532
ALABAMA EYE INSTITUTE, INC.
Survey of Alabama Eye Care Providers
What type of eye care provider are you?
____Ophthalmologist
____Optometrist
____ Optician
____
____
Rehabilitation Service Provider
Other (please identify __________________)
Please indicate the Alabama county in which you predominately practice: __________________________
Please indicate the number of years you have practiced in this county:
____Less than 1 year
____1 to 5 years ____More than 5 years
Please indicate the number of patients you see in a typical week: _________
For each of the following types of eye services, please circle whether you routinely provide the service, whether
you routinely receive referrals for this service, and whether you routinely refer patients to other providers for this
service. In the last column, please identify the county to which or from which you typically make or receive
referrals.
SERVICE
Routinely
Provide
Routinely
Receive
Referrals
Routinely
Make
Referrals
5. Instruction on the use of protective
eye wear in hazardous occupations
and activities
Yes
No
Yes
No
Yes
No
6. Instruction on the proper care of
contact lenses
Yes
No
Yes
No
Yes
No
7. Education on hygiene to prevent
spread of conjunctivitis
Yes
No
Yes
No
Yes
No
8. Glaucoma screening to identify
asymptomatic individuals with
elevated intra-ocular pressure
Yes
No
Yes
No
Yes
No
9. Newborn and young child vision
screening
Yes
No
Yes
No
Yes
No
County to Which
You Typically
Make or Receive
Referrals
Preventive Services
68
SERVICE
Routinely
Provide
Routinely
Receive
Referrals
Routinely
Make
Referrals
10. Optical exam for refractive errors
Yes
No
Yes
No
Yes
No
11. Comprehensive adult eye
examination
Yes
No
Yes
No
Yes
No
12. Comprehensive pediatric eye
examination
Yes
No
Yes
No
Yes
No
13. Specialized diagnostic procedures:
angiography, ultrasound,
electrophysiology
Yes
No
Yes
No
Yes
No
14. Culture for conjunctivitis
Yes
No
Yes
No
Yes
No
15. Corneal scraping for culture, corneal
biopsy
Yes
No
Yes
No
Yes
No
16. Optical correction
Yes
No
Yes
No
Yes
No
17. Occlusion, defocusing, defogging
(for amblyopia)
Yes
No
Yes
No
Yes
No
18. Topical treatment for infections
Yes
No
Yes
No
Yes
No
19. Topical treatment for reduction of
corneal edema and of intra ocular
pressure
Yes
No
Yes
No
Yes
No
20. Keratorefractive surgery
Yes
No
Yes
No
Yes
No
21. Cataract removal
Yes
No
Yes
No
Yes
No
22. Corneal transplant
Yes
No
Yes
No
Yes
No
23. Other incisional ophthalmologic
surgery (glaucoma, eye muscle,
eyelid)
Yes
No
Yes
No
Yes
No
County to Which
You Typically
Make or Receive
Referrals
Diagnostic Services
Treatment Services
69
SERVICE
Routinely
Provide
Routinely
Receive
Referrals
Routinely
Make
Referrals
24. Assessment of functional disability
and adaptation skills
Yes
No
Yes
No
Yes
No
25. Low vision exam
Yes
No
Yes
No
Yes
No
26. Training in use of magnification,
lighting and contrast enhancement,
maximizing residual vision
Yes
No
Yes
No
Yes
No
27. Training in adaptations for activities
of daily living
Yes
No
Yes
No
Yes
No
28. Counseling on the impact of low
vision (e.g., vocational, mobility, job
placement, adaptive equipment)
Yes
No
Yes
No
Yes
No
County to Which
You Typically
Make or Receive
Referrals
Rehabilitation Services
For each general eye service area (preventive, diagnostic, treatment and rehabilitation), please identify the
particular services that are the most difficult to make referrals?
Service Area
Particular Service with Referral Difficulty
29. Preventive Services
30. Diagnostic Services
31. Treatment Services
32. Rehabilitative Services
Which three eye care services, if any, are most difficult for people in your community to obtain? For each service
please identify the major reason for this difficulty.
Services
Cost or
Ability to Pay
Travel
Distance
Lack of
Providers
Lack of
Social
Support
Other
33.
34.
35.
70
36. What are the greatest unmet eye care needs in your community?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
37. What single action by a private foundation (such as the Alabama Eye
Institute, Inc.) would make the greatest
improvement in eye care in your
community? Please explain why?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Thank you.
71
Survey of Rehabilitation
and Support Service
Providers
72
ALABAMA EYE INSTITUTE, INC.
November 22, 1999
Dear Colleague:
The Alabama Eye Institute, Inc., a non-profit foundation formed with the proceeds of the
sale of the Eye Foundation Hospital in Birmingham, wants to help you and other
organizations throughout Alabama in your efforts to serve the eye care and vision needs
of the citizens of our state.
The AEI board consists of independent business, medical and community leaders in
Alabama. Our mission is to promote research, education and indigent care related to
the human eye. In order to meet this mission, we are conducting a comprehensive
needs assessment of the state of eye care in Alabama. The attached survey is an
important part of this study.
Please take a moment to fill out this brief survey. As a member of Alabama’s eye care
community, your knowledge and experience with services for people with eye and vision
problems will provide us with important information. The more responses we receive to
this questionnaire, the more likely we are to gain a complete picture of eye care and
vision services in the state, and a better understanding of where the needs are greatest.
As you will see in the survey, we are interested in information about both direct eyerelated services that your organization provides (such as eye screenings, transportation
to and from appointments, training or rehabilitation services) and support for eye-related
services (such as referrals or financial assistance for exams, eye glasses, medications
or surgical procedures).
Also, some of the information from this questionnaire will be included in a
comprehensive statewide directory of eye care and vision services to be made available
throughout Alabama as a public service of AEI. We would like to include your
organization and programs in this publication and would appreciate receiving
your completed survey as soon as possible. Please return it to the AEI by fax205/325-8532, or by mail-700 South 18th Street, Suite 601, Birmingham, AL 35233.
Thank you so much for your help. If you have any questions, please call Ms. Torrey
Smitherman in Birmingham at 205/325-8508.
Sincerely,
Torrey Smitherman
Executive Director
Hartwell Davis, Jr.
Chairman, Board of Trustees
Attachment
700 SOUTH 18TH STREET - SUITE 601 - BIRMINGHAM, ALABAMA 35233
73
Alabama Eye Institute, Inc.
Survey of Alabama Eye Care and Vision Services Providers
Name of
Organization____________________________________________________________
Contact
Person________________________________________________________________
Address________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Phone_________________Fax_______________E-mail_________________________
Direct Services
Does your organization provide direct eye-related services, such as eye exams,
transport, equipment, training, rehabilitation services? _____Yes _____No
If yes, please list any and all services. __________________________________
________________________________________________________________
________________________________________________________________
What population do your direct services reach? (For example, children, visually
impaired adults, people with multiple disabilities.) Please list.
________________________________________________________________
________________________________________________________________
________________________________________________________________
Where are your direct services located?
________________________________________________________________
________________________________________________________________
What geographic area do your direct services reach?
________________________________________________________________
________________________________________________________________
74
Are your direct services limited to low-income individuals? _____Yes _____No
If yes, how does your organization define low-income?
________________________________________________________________
________________________________________________________________
________________________________________________________________
What is the number of direct clients your organization serves per year?
________________________________________________________________
Please list the major sources of funds for your direct services.
________________________________________________________________
________________________________________________________________
________________________________________________________________
Support Services
Does your organization provide support for eye related services, such as
financial assistance or referrals? _____Yes _____No
If yes, please list any and all services.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
What population do your support services reach? (For example, children, visually
impaired adults, people with multiple disabilities.) Please list.
________________________________________________________________
________________________________________________________________
Where are your support services located?
________________________________________________________________
What geographic area do your support services reach?
________________________________________________________________
Are your support services limited to low-income individuals? ____Yes ____No
If yes, how does your organization define low-income?
________________________________________________________________
________________________________________________________________
________________________________________________________________
75
What is the number of support clients your organization serves per year?
________________________________________________________________
________________________________________________________________
Please list the major sources of funds for your support services.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Is your organization affiliated with any other Alabama organizations? ____Yes ____No
If yes, please list
.______________________________________________________________________
______________________________________________________________________
Is your organization affiliated with any other national organizations? ____Yes ____No
If yes, please list.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
What are the greatest unmet eye care needs in your service area?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
76
What single action by a private foundation (such as AEI, Inc.) would make the greatest
improvement in eye care in your service area? Why?
_____________________________________________________________________
______________________________________________________________________
_____________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Thank you.
Please return the questionnaire by December 10, 1999, to:
Ms. Torrey Smitherman
Executive Director
Alabama Eye Institute, Inc.
700 South 18th Street, Suite 601
Birmingham, AL 35233
77
78