Vision Rehabilitation at The Indiana Eye Clinic (formerly known as Low Vision)
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Transcript of Vision Rehabilitation at The Indiana Eye Clinic (formerly known as Low Vision)
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Vision Rehabilitation at The Indiana Eye Clinic
(formerly known as Low Vision)
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The Big Picture
• To provide low vision devices and training for patients in need (magnifiers, CCTV’s, etc.)
• To educate them about and direct them to other resources for vision rehabilitation.
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Patient Flow
• Patient recommended by M.D. or O.D. for vision rehab. (VR) because of reduced acuity, visual field loss or poor contrast sensitivity.
• Patient given info sheet by scribe or head tech that explains scheduling, fees, etc.
• Acuity 20/60 or better in better eye? Level 1 - regular schedule at GW or PF.
• Acuity 20/70 or worse in better eye or VF defect?
Level 2 – Thurs. AM in GW.
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Flow continued:
• Technician: VR workup (more later)• Dr. F:
– expands history, refracts, counsels, educates, makes material recommendations and may discuss other resources available.
– Optical: Demo/educate materials
• Patients purchase desired items. • Some patients referred to
Crossroads/Bosma/IRCIL.
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Fun Fact #1
Number of people in the “middle class” in the world today:
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500,000,000
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Coding for Vision Rehab.
• Refraction fees: • $20-65.00 based on complexity. • E&M codes:
– In VR, based on time the doctor spends with the patient (not including the refraction time) if at least ½ of the time was spent counseling and educating the patient.
• Level 1 - E&M code based on time:– If documented visual field defect – Amsler Grid– Eye/E&M codes if medical eval.
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Coding continued:
• Level 2: – Refraction usually $30.00 -$65.00– Because of acuity level or vf defect, can
automatically use time-based E&M.– Primary diagnoses: level of vision impairment– Secondary diagnoses: medical (amd, etc.)– Eye codes if medical eval.
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Coding cont:
• Medicare: No coverage for VR devices.– Can cover VR services performed by
physical/occupational therapists.
• Patients can obtain funds for VR devices from organizations like IRCIL (Indianapolis Resource Center for Independent Living)
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Fun Fact #2
Percentage of Americans who say they would have cosmetic surgery if they could afford it:
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Work-up: history
• Record medical eye status:-e.g., advanced dry amd O.U.,
homon. hemi, etc. as in normal work-up.
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History Cont:
– Record visual symptoms:
Allow patient to elaborate on specific difficulties
e.g., “I can’t see to dial a telephone, pay my bills, read a book, identify a person, see the bird feeder, deal with glare, etc.
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History Cont.
• Ask about desired visual activities:– “what would you like to be able to do?”
Reading, cooking, watching T.V., etc.
– Explore interest in rehab services:• Do you want in-home ADL training?
» Orientation and Mobility training?» Assistive technology
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Fun Fact # 3
Percentage of British elementary-school students who think Issac Newton discovered fire:
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Magnification basics
• Three ways to achieve magnification:1) Relative size magnification (making the object bigger) – CCTV’s, large print books, etc.
2) Relative distance magnification – moving the object closer to make its image on the retina larger.
3) Angular magnification – Magnification produced by an optical system that’s not from relative size or distance) e.g., telescopes.
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Relative Distance Magnification• Bringing an object twice as close makes its retinal image twice as
large, so that results in “2X relative distance magnification” and so on.
• At near, mag compared to object at 25 cm.• Formula: diopters/4 = mag at near. e.g., 12D lens provide 3X mag.• Plus lenses – allow closer working distance without accom.• High powered and microscopic spectacles:
– 4-48D plus powered lenses• 4D lens – 25 cm working distance (1X mag)• 10D lens – 10 cm working distance (2.5X mag)• 16D lens – 6.25 cm working distance (4X mag)• 20D lens – 5 cm working distance (5X mag)
• Up to 10-12D, base-in prism for binocularity ?how much prism?: 4D add = 6 base in each eye
6D add = 8 base in each eye, etc
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Hand/Stand Magnifiers
• Conceptually same as taking a microscopic spectacle lens and moving it farther away while keeping object at focal length of lens.
• As magnifier moves farther away, RDM decreases, angular mag increases but total remains unchanged.
• Same mag formula (power/4 = mag). A 3X magnifier is a 12D lens.
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Hand/Stand Continued:
• Light from hand magnifier emerges parallel (as if at distance), so view through distance part of glasses (if object held at focal length).
• Light from stand magnifiers is divergent, so view with add.
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Field of View
• Field of view is widest with microscopic spectacles, as lens moves farther away – field decreases.
• As power increases, field of view decreases.
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For increased working distance:
• Use a telemicroscope. A distance telescope with a “reading cap” to allow focus at a closer distance.
• Formula:– Pt. with 20/400 vision wants to read at 25cm.
• 400 x 25/2000 = angular mag needed; use 4D cap for 25 cm working distance. Thus 5X telescope with 4D reading cap.
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For far distances (angular mag):
• Reverse acuity fraction to get mag needed for 1M acuity.– 20/400 = 400/20 = 20X
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Fun Fact #4
Number of U.S. states in which it is legal for first cousins to marry:
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So what does M mean ?
• 1M-size letters held at 1 meter (1/1M) form an image on the retina that’s the same size as 20/20 size letters at 20 feet (5 minutes of arc).
• 1M print is half as big as 2M print, etc.• Phone book = 1M, newspaper = 1.2M, large print = 3m.• A patient reading 4M at a certain distance would need 4x
magnification to read 1M at that distance.• The M fractions are equivalent to Snellen fractions, e.g.
20/200 = 1/10M = 2/20M = .25/2.5M and so on.• Record the test distance in meters over the M size print
read (the ETDRS chart is usually at 2 meters but can be anywhere); the near card distance is often 25cm = 0.25 meters) .
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Advantages of “M” for Vision Rehab:
• Since 2M is twice as large as 1M print, etc, easier to conceptualize than using Snellen fractions (20/70 vs. 20/20)
• More elegant acuity measurements at near (.25/4M is “better” than “reads 20/20 line at 40 cm”).
• Acuity describes mag needed at that distance for 1M vision:– Distance acuity of 1/12M needs 12x– Near acuity of .25/3 needs 3x (with 12D lens or 3x
magnifier).
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How to calculate the add:
• To determine the power needed to read 1M print at near, use Kestenbaum’s formula:
• If the acuity is 20/240 (which equals 1/12M), flip the fraction and divide: 240/20 = 12. – A 12D lens in the spectacle plane would allow the
user to hold the material at 8.33 cm, which is 12 times closer than the material at one meter (12X) or 3 times closer than the material at 25 cm.
– Or, use a 12/4 = 3x magnifier and hold the material farther away, as long as the magnifier is 8.33 cm from the print.
– Or, use a 3x telemicroscope with a 4D reading cap.
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Simplified Formulas
• Mag at distance for 1M vision: flip the ratio and divide. 20/240 (1/12) becomes 240/20 = 12X mag needed for distance.
• Mag at near for 1M vision using dist. mag: divide distance mag by 4. 12/4 = 3X.
• Mag at near for 1M vision using near va:– Flip near va and multiply by .25.
near va .4/4.8 becomes 4.8/.4 times .25 = 3X
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A summary
• Measure the distance acuity at 2 meters using the ETDRS chart. Record it as 2/the M line read, e.g., 2/12M (which equals 20/120).
• Measure the near acuity by having the patient hold the print at the clearest distance. If the patient reads 1.5M at 25cm, record it as .25/1.5M (that also equals 20/120).
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Fun Fact #5
Earthworms travel in herds.
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So what materials do we provide?
• Stronger than usual (3-4D add) single vision reading glasses (usually level 1)
• Much stronger reading glasses (+4 to +48D) reading glasses (lower powers with base-in prism for binocularity)
• Small and large CCTV’s (the Pebble, Onyx)• Hand-held, clip-on monocular and binocular telescopes.• Illuminated hand-held and stand magnifiers• Filter options.• An assortment of near magnifier styles.• High-intensity reading lamps.
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And beyond?
• Patients can be referred to:– Bosma Enterprises (ADL, O&M, Assistive tech., office
and in-home)– Indianapolis Resource Center for Independent Living
(IRCIL) – ADL , office and in-home)– Crossroads (ADL, office and in-home)– Vocational rehab
Activities of daily living, orientation and mobility training, other forms of visual rehab – covered by Medicare if provided by OT or PT.