Expanding Your Low Vision Care Team

BrightFocus Foundation
Expanding Your Low-Vision Care Team
July 27, 2016
Transcript of Teleconference with Ranjoo K. Prasad, OD
2:00–3:00 pm EDT

Please note: This Chat was edited for clarity and brevity.

MICHAEL BUCKLEY: Hello, I am Michael Buckley with BrightFocus Foundation. Welcome to today’s BrightFocus Chat, “Expanding Your Low-Vision Care Team.” Our speaker today is Dr. Ranjoo Prasad, and she is going to highlight some different types of low-vision practitioners and services that you may have access to.

If this is your first time joining us for BrightFocus Chat, welcome. Let me take a moment to tell you about BrightFocus and what we will do today. BrightFocus funds some of the top scientists in the world. We support research all around the world that is trying to find cures for macular degeneration, glaucoma, and Alzheimer’s. We share the latest news from these scientists with families impacted by these diseases. We have a number of free publications and plenty of materials on our website, www.BrightFocus.org. The BrightFocus Chats are another way of sharing this information with families.

Now let’s turn to today’s special guest, Dr. Prasad. Thank you for joining us today.

RANJOO PRASAD: Thank you for having me.

MICHAEL BUCKLEY: We invited to you to be a speaker on the call today because we regularly talk about the diagnosis and treatment of age-related macular degeneration and what we can expect from a retina specialist. We don’t always talk about what types of care or low-vision services someone can access outside of the clinic. First, I was wondering if you could tell us a bit about your background and professional experience. 

RANJOO PRASAD: Well, this year I was appointed as the director of the Penn Center for Low Vision Research and Rehabilitation at the Scheie Eye Institute Department of Ophthalmology of the University of Pennsylvania Health System in Philadelphia, Pennsylvania. I’ve been practicing for 18 years and have been at this department for over 15 years. I have extensive experience in low-vision management of both the most common and rarest ophthalmologic conditions which cause vision loss of both adults and children. I have a keen interest in international low vision and have spent time earlier in my career consulting overseas.

MICHAEL BUCKLEY: That’s great. Out of curiosity, what made you want to go into this line of work?

RANJOO PRASAD: When I was a student, I was an intern at a doctor’s office who provided low-vision rehabilitation, and when I observed her and watched what she did and how she was able to help people, I fell in love with it. I knew she was the one I wanted to be like; I wanted to be just like her and do what she did.

MICHAEL BUCKLEY: Wow, what a great experience.

RANJOO PRASAD: It’s a very rewarding career.

MICHAEL BUCKLEY: Thank you so much for doing that. I know that low vision and low-vision problems that are not corrected by glasses, or surgery, or another medical intervention—they affect people in different ways. I was wondering, what would the first step be for someone who is hoping to make the most out of their remaining vision? And is there some type of initial evaluation, or how should someone start when they have some concerns about their vision?

RANJOO PRASAD: The first step would be to immediately inform their functional difficulties to their present eye doctor or eye specialist. Almost every eye doctor would be well versed in knowing of local resources, and the first step for them could be a state agency for the blind—it all depends on where they are located.

If there’s an optometrist who specializes and practices in low-vision rehabilitation, then the individual may be referred to him or her. The initial evaluation with a low-vision optometrist would focus on your functional difficulties specific to the activities of daily living, and this may include reading, writing, seeing at distance, difficulties with getting around and navigating, along with many others. These are tasks that we do on a daily basis.

We also take into account the causes of vision loss and also look at psychosocial aspects. Many people for whom vision loss is relatively new, they do experience a lot of difficulties in, for example, their grieving, so we take that into account as well.
Our goal is to help the individual become more independent and improve their quality of life.

MICHAEL BUCKLEY: That’s great. If someone wanted to have the type of services that you and others provide, is that something that’s covered by Medicare, or does someone need a prescription or referral from the first eye care professional that they see?

RANJOO PRASAD: It’s typically covered by Medicare or their health insurance; however, the important thing is to make sure that who they are going to see is part of their panel. There are certain components of that exam that may not be covered by the health insurance, so for example, the refraction is typically not covered, and that refraction includes the finding of the prescription or determining your eye glass prescription.

MICHAEL BUCKLEY: When you say part of your panel, what does that mean?

RANJOO PRASAD: The panel means the providers who actually take that insurance. So not everybody is a Medicare provider, not everybody is a BlueCross BlueShield provider.
MICHAEL BUCKLEY: Certainly. I know that the field of Medicare and private insurance can be a little overwhelming for people. I think part of that is something like what the Marx Brothers said, “alphabet soup.” It seems like in the vision field there are so many of these alphabet soup specialties: I’ve heard of CLVT and CVRT and OT, among others. Can you tell us a little bit about these different specialties and how each one helps contribute to outcomes? Can you first start with CLVT and LVT? Tell us a little bit about what they are and how they are different and how they help people.

RANJOO PRASAD: The C in front of any those specialties stands for Certified. The certified is through the ACVREP, which is the Academy for Certification of Vision Rehabilitation and Educational Professionals. A CLVT is a certified low-vision therapist, and LVT is a low-vision therapist who is not certified.

A low-vision therapist evaluates an individual’s functional vision—by using different testing mechanisms—and its relation to vision and disability. They also look at their work and education, and activities of their daily living, etc., and train the individual with the devices that may have been prescribed by the optometrist. They use adaptive techniques to meet their goals.

There are other specialties as well: the CVRT, which is a Certified Vision Rehabilitation Therapist. They are the ones that evaluate and train the visually impaired individuals in their home environment or work environment. They actually go to the place. These therapists use compensatory skills and techniques and assistive technology and environmental adaptation. For example, they would teach adaptive grooming and bathing skills, they would teach adaptive kitchen skills like labeling and organizing. They are the ones that work with individuals with very low vision or who are blind.

MICHAEL BUCKLEY: Dr. Prasad, could you tell us a little bit about OTs, occupational therapists? 

RANJOO PRASAD: OTs are licensed providers, and they follow the medical model of rehabilitation and they perform full functional evaluations. An individual is referred for vision; the OTs will not only assess the vision component, but they will assess the cognition component and range of motion, upper body strength, and sensation, such as light touch. An example of a reason for light touch would be for someone who is diabetic and who has developed neuropathy of their fingers, they want to know that they can touch and feel things. They even evaluate balance, as well. They do require a prescription from a doctor, and they come up with a treatment plan, which is signed off by the doctor. The treatment plan has to objective, functional, and measurable, too.

MICHAEL BUCKLEY: We hear people talk about low-vision therapy and low-vision rehabilitation. Is there a difference? And, if so, what would the difference be?

RANJOO PRASAD: Low-vision rehabilitation is the umbrella, it includes all the team players—so, all of the team players that we mentioned above: the optometrist and the ophthalmologist, and therapy is actually the training. For example, someone who has macular degeneration, they usually have some good remaining central vision in certain areas, so a person who is undergoing low-vision therapy would likely be taught how to use that remaining vision, and that would fall under eccentric fixation training.

MICHAEL BUCKLEY: It seems like a lot of these vision challenges that older people face really affect their independence. Is there a type of specialist that would help us navigate our way through our daily lives, both inside and outside the home?

RANJOO PRASAD: Yes, and that specialist would be a COMS, which is a Certified Orientation Mobility Specialist. A COMS evaluates and trains the individual to determine their position and navigate safely in their own environment, and they do this by utilizing their other senses, such as hearing. For some individuals that may require training and using a cane. They also focus on safety. To summarize, an “orientation” refers to knowing your position in a setting; for example, when you walk into a large room with seating, you typically scan and see what seats are available, that’s considered orientation. Then when you find a seat, you walk over to the seat from where you are standing, and that is “mobility.”

MICHAEL BUCKLEY: That’s interesting, the range of new experiences that people and their extended families must have to navigate, and I think that one of the ones we hear a lot about at BrightFocus is driving. It’s such a core part of independence and lifestyle, and I’d like to ask you about that and mention to our listeners that BrightFocus has a number of materials that are available free of charge. One of them is a free brochure that is called Safety and the Older Driver, and that’s available free of charge at the BrightFocus website. So, Dr. Prasad, I was wondering, what do you think about some of the visual challenges with driving, and how do you address this in the patients that you see?

RANJOO PRASAD: I address this quite often, very often. I think it’s one of the most difficult things to address, as well. For almost everyone, driving equates to independence. So if you take away their ability to drive, then they lose their independence. However what I try to reiterate is, first and foremost, I’m not taking their license away, it’s not me, and I have to follow what the state regulations are. Every state has different requirements for driving, so wherever that individual is living, they should familiarize themselves or ask the doctor what the legal requirements for driving is.

MICHAEL BUCKLEY: Are their specialists or occupational therapists or others that can help on this?

RANJOO PRASAD: For example, there are individuals who are within legal limits to drive, and they find that they aren’t as confident on the road, or they may have had an additional condition such as a stroke, or they may have fallen, so yes, there are driver rehabilitation services that are available. They are mostly available in the larger rehab setting and are handled by an occupational therapist.

MICHAEL BUCKLEY: I can imagine that this is an extremely sensitive conversation for families to have; do you have advice for families that are facing this or think that it’s going to be happening to them soon?

RANJOO PRASAD: If there is any question, the families should bring them to their eye doctor and voice the concern and also reiterate that it’s about protecting themselves, not only is it about protecting other people, it’s also about protecting themselves.
I’ve had to address it a number of times, and I’ve had to tell the individual that if something were to happen, even though it wasn’t your fault they may still come after you, and if you turn out to be liable then you have a lot of things at risk to lose, a lot. It’s about protecting yourself first and foremost.

MICHAEL BUCKLEY: I’m sure a popular human trait is denial. What do you say to people who think everything is great and can’t even imagine where you are coming from on this, on the driving?

RANJOO PRASAD: I actually go to the DMV site and print out their statutes and I give them written documentation. I show them their visual fields, if it’s a peripheral vision issue, which you’ll find with glaucoma and retinitis pigmentosa, and even point out on the chart where they should be seeing and what they are seeing. In the state of Pennsylvania we are required to inform the state of a driver’s condition if they do not meet the legal requirements, but not every state has that.

MICHAEL BUCKLEY: Where you practice in the Philadelphia area, are there the type of services that you recommend to people when they are no longer able to drive, since it will affect them emotionally and affect their access to food and other services? Are there resources that can help families?

RANJOO PRASAD: There are a number of resources. The first resource is a state agency, which is the Bureau of Blindness and Visual Services. Every state has an agency that provides resources and sometimes money for devices for individuals. That’s the first place I go. In Philadelphia, there is the Associated Services for the Blind.

MICHAEL BUCKLEY: This is good to know. Related to that, we just received a question from a gentleman in Maryland, how do you expand your care team? I’m going to add to that question, how does somebody keep track of all this? Do you have their information sheets that might be at a doctor’s office? In terms of all these different services, how do you as a physician make sure that they are integrated?

RANJOO PRASAD: We have the information at our fingertips. One of the greatest inventions that we have is the internet. We almost never keep copies, so I’ll always have it at my fingertips to look at their site and print out that information. We are also in the process for us to have all these resources available at our website, so that’s still in the process; we are working on that. It’s just a matter of when you see the doctor, or when the patient sees me, and we have a conversation to know what the patient’s difficulties are, I will know where to go.

For me it’s through our continued education, I’m learning more and I have a lot of colleagues, I work with a lot of occupational therapists. I also have contacts in different states, so they are all there. I work in a tertiary care setting, so I have all of the medical knowledge at my fingertips if I have any questions.

MICHAEL BUCKLEY: On the patient side of it, what can a patient and her or his family do to help? If someone brings a friend or family member, what can that accompanying person do to help make sure that they are getting the services that they need and understanding the differentiations that you talked about?

RANJOO PRASAD: Just being informed and educated, I think, just by asking questions. I’ve had a lot of individuals who have been proactive and found out a lot of things before they came into the office. They are able to say this is what they need and just to follow up with them and to know exactly what the patients know. I’ve also found that depending on where they are emotionally—we’ve had people come in who are angry, they will be in denial, and they won’t be as receptive, but those who are more accepting and want to improve their quality of life are the ones that will be easier to take care of and to help.

MICHAEL BUCKLEY: Good advice for people in a lot of situations. You mentioned when a family member or a friend comes in who has done some of their research, I think it’s interesting the intersection between the internet and the practice of medicine, and so when someone makes the effort to do some research and they read things about low-vision microscopes or other devices, what do you usually say when people mention some type of product like microscopes or devices that they’ve been hearing about?

RANJOO PRASAD: That happens to me all the time. I obviously ask more about what they’re asking about, and see if it would relate to the patient and show them, “This is what you’re looking at, this is the device we have, this may work for you or not.” We’ve had people who have decent vision, and what the family member found was something that was electronic and too strong, and it’s not something that the patient would need at that time. It’s great that they are educated, because they know that these are available for them.

MICHAEL BUCKLEY: That’s good to know. In general, if its people’s research or emotional reactions, is there sort of a common message that you like to give to your patients or a common misperception that you feel that you need to correct on a regular basis with your patients?

RANJOO PRASAD: I have one: when individuals and patients come in and tell me that nothing can be done, that “I can’t do this anymore.” I try to tell people that you can’t do it anymore in the same way that you probably used to. I try to reassure them and try to be as encouraging as possible and then give examples of others who have been successful.

MICHAEL BUCKLEY: We have a question, Lorraine from New Hampshire is wondering about assistive technology, CATIS? Could you tell folks what that is?

RANJOO PRASAD: C-A-T-I-S. That is a certified assistive technology instructional specialist. These individuals were certified by the ACVREP, as I mentioned earlier. They are highly trained experts who specialize in working with the visually impaired in the areas of assistive technology: so it will include hardware, software, mobile devices, tablets, or any other form of technology in almost any setting. So these are highly skilled people.

MICHAEL BUCKLEY: Around the home, I know that vision is a major cause of falls around the house, and then falls around the house becomes a major reason you can’t live at home anymore, so it could seem like a downward spiral. Do you have advice for people around the home, what they can do to keep their house a safer place so people can stay in homes longer?

RANJOO PRASAD: So the first and foremost is to keep it as clutter-free as possible. To keep things off the table, anything glass, keep the walkways pretty open and keep it very well lit. A lot of the times what I’ve done is after suggesting this, I will refer them to the state to have a CVRT possibly come to the home and help them with that, as well.

MICHAEL BUCKLEY: It seems like that is a real challenge. For example, in the kitchen, I know people want to be able to still cook and be active there, what can folks do in that area?

RANJOO PRASAD: The kitchen can be a very touchy and dangerous area, especially with using knives. I try to tell people who’ve lost their vision or have some extensive vision loss to wait until they are properly trained with that.

In the kitchen, it’s more dangerous to have a gas stove, an electric stove is better. What we tell people is to try not to get up close to the dials to look at where the stove settings are. We recommend marking the stove dials with a raised paint, so they will know different temperatures.

MICHAEL BUCKLEY: Ed from Pennsylvania is wondering, if somebody has blind spots in their vision, are there strategies from specialists that can help navigate blind spots in their vision?

RANJOO PRASAD: That’s where a low-vision therapist, a CLVT, can help with eccentric fixation. Within those blind spots, there is probably one area where you are probably seeing a little bit better. There are training techniques to help you utilize that and focus on that area.

MICHAEL BUCKLEY: Alice from Maryland has a question about support groups; do they exist for low-vision issues, and what can they help with, and how does one find low-vision support groups?

RANJOO PRASAD: There are a number of support groups, it all varies based on where you live. The main way to look is to go to the state agency and they will have counselors that will know. Typically a low-vision doctor would know of support groups and what’s available. There are also disease-specific, or condition-specific, support groups, too, so even websites that will have different organizations for the different conditions would have knowledge of support groups in different areas.

MICHAEL BUCKLEY: So Dr. Prasad, for our final few minutes, I was wondering if you had any final thoughts or any specific suggestions for people living with low vision. Any points that we didn’t get to address today?

RANJOO PRASAD: The one thing that I tell everyone that I see is, “Don’t give up, use your vision, and always use your vision.” I’ve had people who, just because they can’t read the way they used to, don’t read at all. I always tell them, if you have vision, read the headlines, and watch TV. Always use it.

MICHAEL BUCKLEY: BrightFocus funds a lot of research on treatments and cures. We hear a lot from our researchers about those effects of isolation or less activity. Do you see this a lot in your patients? 

RANJOO PRASAD: I do, I do. Fortunately, I get patients very early on in their disease process, so I can work with them at a very early stage. I get them motivated. For example, I’ll see people with vision that’s not that bad and I’ll just say, “You don’t need these yet, but we are here and we have all of these options available, so don’t give up.”

MICHAEL BUCKLEY: How do people react, if you’re able to tell them that they are at the earlier stage of something? I could see some people maybe bristling at that—what is your experience when you give the warning shot?

RANJOO PRASAD: They are actually pretty receptive because a lot of the times, they say I hope it never gets that way and I say, “I hope so, too, I don’t want you to lose hope, we hope that we will never get to this, but everything is available right here at my fingertips.” The other thing is, I don’t typically follow them back; I will wait until their doctor sends them back to me or they feel that they have—not for everybody—if there is a time that they are having difficulties functioning, they will come back. So they like that I’m not a necessity at all times.

MICHAEL BUCKLEY: It’s fascinating, the role of motivation and how you connect with people.

Well, I think you’ve done a fantastic job today doing that, and hopefully our listeners have found a few specific takeaways and we certainly appreciate your walking us through the alphabet soup of the professional field that you’re in.

For our listeners, a few housekeeping things: First, our next Chat will be August 31, 2016. The topic is going to be, “What’s New in Macular Degeneration Research?” We encourage folks to call us to register, and we will be sending you a reminder email on that.

Lastly, you can call us request copies of the transcript of this call for you to share with someone who might be interested, you can receive free publications from BrightFocus—the Safety and the Older Driver publication we mentioned earlier—and Amsler grids and other resources. We have materials on treatments, and we have a popular card that fits in a purse or a pocket called The Top Five Questions to Ask Your Eye Doctor. We have a lot of materials to help you. Those are at www.BrightFocus.org, or anytime you can call us at (800) 437-2423.
Dr. Prasad, I just want to thank you so much. You’ve been very helpful and very positive, and thank you from all of us at BrightFocus.

RANJOO PRASAD: You’re welcome, it was my pleasure. Thank you for having me.

MICHAEL BUCKLEY: Thank you Dr. Prasad, and thank you to our listeners. We will talk to you soon. Thanks.

BrightFocus Foundation: (800) 437-2423 or visit us at www.BrightFocus.org. Available resources include:

• Information on research funded by BrightFocus
• Amsler grid
• The Essential Facts of Macular Degeneration
• Safety and the Older Driver
• The Top Five Questions to Ask Your Eye Doctor
• Service providers:
  • CLVT: Certified Low-Vision Therapist—Evaluates an individual’s functional vision and its relation to vision and disability; certified through the ACVREP
  • LVT: Low-Vision Therapist—Evaluates an individual’s functional vision and its relation to vision and disability; not certified through the ACVREP
  • CVRT: Certified Vision Rehabilitation Therapist—Evaluates and trains the visually impaired individuals in their home environment or work environment; certified through the ACVREP
  • VRT: Vision Rehabilitation Therapist—Evaluates and trains the visually impaired individuals in their home environment or work environment; not certified through the ACVREP
  • COMS: Certified Orientation Mobility Specialist—Evaluates and trains the individual to determine their position and navigate safely in their own environment
  • CATIS: Certified Assistive Technology Instructional Specialist—Highly trained experts who specialize in working with the visually impaired in the areas of assistive technology; certified through the ACVREP
  • OT: Occupational Therapist—Licensed provider who follows the medical model of rehabilitation; performs full functional evaluations

The information provided in this transcription is a public service of BrightFocus Foundation and is not intended to constitute medical advice. Please consult your physician for personalized medical, dietary, and/or exercise advice. Any medications or supplements should be taken only under medical supervision. BrightFocus Foundation does not endorse any medical products or therapies.