Guest case study: Making a difference – a low-vision case

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Nabill Jacob, Clinical Relationship Manager for Vision Australia, which was one of the fundraising partners at the 2019 Specsavers Partnership Seminar, presents an example low-vision case that demonstrates the difference optometrists can make with a simple referral.  

As the clinical face of eye health, you review and help different people get the most out of their vision every day, and often refer to other specialists in the circle of care. Most of the time, this is routine. However, sometimes a simple conversation with your patient can set off alarm bells. Some patients with low vision are reluctant to admit they are struggling with the most basic tasks, such as cooking, shopping or socialising as they once did. Here is a case study that is typical, yet often missed.

History

Your patient:

  • 70-year-old female
  • Retired lawyer
  • Husband has dementia, lives in a nursing home
  • Lives alone in family home
  • Has a son, married, living in Cairns

General health: Slightly elevated cholesterol, 1 x Crestor PO tablet daily. Otherwise healthy.

Eye health history: Age-related macular degeneration diagnosed 10 years ago. Anti-VEGF drugs ceased being effective 2 years ago. Current shared care with an ophthalmologist.

Clinical Assessment

Rx: R -0.50 DS     L -1.00 DS     Near +3.00 Add

Visual acuity:
At diagnosis: BCVA – R 6/9     L 6/9
Currently: BCVA – R 6/18     L 6/24

IOP: R 16 mmHg     L 18mmHg

While examining the patient, she seems a little apprehensive and tells you she is having a few problems which have been getting worse, namely:

  • Reading the paper is almost impossible
  • Watching TV is difficult
  • Cooking is difficult
  • Can’t see to put on make-up properly
  • Shopping and socialising is difficult
  • Feeling isolated and depressed
  • Scared of bumping into things or falling.

The patient tells you she understands intervention from an optometrist or an ophthalmologist can no longer help improve her vision but is afraid of losing any more of her sight. She says she wants to stay in her own home and be independent but is also scared she’ll end up in a nursing home.

Management

Thinking of your patient’s case from a holistic perspective (i.e. beyond clinical / optical care), your primary optometric concerns for the patient at this stage should include:

  • Falls risk – mobility issues
  • Mental health issues – depression.

Action to take: Your care and concern for the patient lead you into conversation with her about available options. You recommend a referral to Vision Australia and reassure her they can help and will be able to address her and your concerns via their full suite of low-vision and blindness services.

Vision Australia assessment: Upon assessment at Vision Australia, the patient is asked what she would like to be able to achieve and about the tasks she’d like to be able to do that have become difficult because of her low vision.

The orthoptist performs a baseline functional vision assessment to help clarify which services and aids may be of most benefit, and to ensure no significant changes in vision have occurred since her last optical examination with you, which is noted in her referral information. (Should any changes or concerns be noted, the patient would be immediately referred back to you.)

Subsequently, the following goals for the patient are identified:

  • “I would like to have a dog guide or white cane to be able to go out into the community.”
  • “I would love to be able to keep reading novels and newspapers.”
  • “I would like to feel safe at home and continue to cook.”
  • “To be able to see the price, ingredients and use-by date of items at the supermarket.”
  • “To socialise at the local club and learn new skills and not so feel isolated and useless.”

Outcome

A few months post your referral to Vision Australia, for assessment and intervention, the following outcomes are successfully achieved:

  • Seeing Eye Dog allocated, as well as orientation and mobility training using a white cane. Able to walk to shops and club safely, and use public transport safely and confidently. The patient can now even visit her son in Cairns with confidence, knowing Vision Australia has an office there should she need help.
  • Joined Vision Australia Library and now has access to more than 40,000 publications in talking book and large-print formats. Has been introduced to Vision Australia Radio.
  • Occupational therapist has assessed the patient’s home. Re-arranged the kitchen and bathroom and organised slight home modifications. Introduced her to aids and equipment to suit people with low vision. The patient is able to successfully self-manage.
  • The orthoptist has prescribed and instructed the patient on the use of handheld and portable electronic magnifiers. Adjusted home lighting.
  • Vision Australia woodwork and day programs have been introduced to ensure socialisation.

Your referral to Vision Australia has helped the patient achieve her goals.

Learnings

  • The expanding role of optometry means patient welfare sometimes extends beyond clinical and optical care.
  • A holistic view needs to be taken of each patient and their individual needs.
  • Vision Australia are devoted to working with you and your patient. Their comprehensive services will meet your low-vision and blind patients’ needs and are also a natural extension of the shared and continuum of care model.
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