Low Vision for the Private Practitioner:
It’s Easier Than You Think!
• 2017 OAO Symposium
• Friday, April 7th 2017
Shamrozé (Zay) Khan BSc, OD, FAAO
Clinical Assistant Professor,
UW School of Optometry and Vision
Science
[email protected]
Kate Baldry BSc, OD
Clinical Instructor, UW School of
Optometry and Vision Science
Associate OD, Bay St. Eyecare
[email protected]
• No Conflicts of Interest to Declare
LV = Standard of Care
• AAOph meeting 2016
• “Provision of, or referral to, vision
rehabilitation is now the standard of care
for all who experience vision loss”
• Low-vision patients are “those with visual
acuities less than 20/40, or scotomas, field
loss or contrast loss”
https://www.aao.org/low-vision-and-vision-rehab
– Bifocal adds
– Spectacle microscopes
•
•
•
•
•
Full field
Half-eye
Monocular
Binocular
Prism-corrected
– Hand magnifiers
• Pocket sized or larger
– Stand magnifiers
– Illuminated vs nonilluminated
– CCTVs
• Portable vs Desktop
– Refraction
– Eccentric viewing
– Image relocation with
prism (location of PRL)
– Miniature telescope
implantation
– Telescopes
• Handheld
• Spectacle- mounted
– Full-field
– Bioptic
• Monocular vs. binocular
Formula for LV Rehab
• “Your Head, Your Heart, Your Eyes”
– Spectrios Institute for Low Vision, Wheaton IL
Assistive Devices
-Low Tech
- High Tech
Rehabilitative
Strategies
-Non-optical Devices
-Adaptive Strategies
Counselling
Rule of Thumb
The worse a patient’s vision becomes (acuity
and field)
• The more devices they need
• The more complicated the devices become
• The more training the patient requires
i.e.
The 20/200 patient requires much more
intervention than e.g. the 20/70 patient.
20/40-20/70 patients
(mild visual impairments)
20/80-20/400 patients and beyond
(moderate to severe visual
impairments)
- Can be addressed
without separate LVAs
(during PC exams)
- Managed with a basic
range of devices
- Require separate LVA
- Managed with an
extensive range of
devices and services
1. The AMD1 patient who wants to read1
(20/40-20/70)
http://www.mirror.co.uk/news/uk-news/dame-judi-denchs-eyesight-battle-689976
Strategy for Management
• Identify who needs help
• “Are you happy with your vision?”
• Aim to address 4 categories:
• Distance
• Near
• Contrast/Glare
• “Other”
Strategy:
Distance
Distance
Near
Contrast
• Trial Frame Refraction for BCVA +/• Low-Powered Telescope
“Other”
• Calculation:
• 6/12 considered adequate VA for most vision
tasks
• e.g BCVA is 6/24
• Magnification required to get to 6/12 = 2x
TF Refraction Pearls
• Strongly recommended for VAs 20/100
and better
• Use autorefraction/ret as a guide
• e.g. 20/400, auto reads: - 025 -050 x 097
20/80 auto reads: -1.00 -1.50 x 097
• Cyl refinement at poor VA
•
•
•
•
e.g 20/400 patient JND = 4D
Highest JCC most trial lens sets +/-1D (total change of 2D)
If low cyl (<1D), just use ret/auto readings
If high cyl, rotate to blur for axis, trial with vs. without the cyl
for power
Strategy:
Near
Distance
Near
Contrast
• High Add (“spectacle microscope”) +/Low-powered hand or stand magnifier
“Other”
• Goal is functional 1M, and spot 0.4M
• Calculation: Use:
• Distance BCVA: Kestenbaum’s Rule: inverse of BCVA
gives dioptric power to see 1.0M;
OR
• Near BCVA: “Equivalent Viewing Power”: adjusts the
magnification the patient is already using to attain 1.0M
Near contd
– Kestenbaum’s Law
e.g. BCVA 6/24.
= 4D
Multiply x2 for reserve
= 8D
– EVP
e.g. BCVA 1.6M at 40cm
– 1.6M x 2.5D = 4D
1.0M
Multiply x2 for reserve
= 8D
Demonstrate 8D spectacle microscope
Demonstrate 8D hand magnifier
Stand magnifier: EVP/Pt’s add
e.g if wearing +250 add = 3.2x (“Transverse mag”)
Strategy:
Pearl: The EVP “Range”
Distance
Near
Contrast
“Other”
• Sometimes, particularly in early loss,
incorporating a reserve is not always
necessary
• Consider starting with an EVP range, as
opposed to a finite number
e.g.
EVP 4D - 8D
Consider starting at the lower
end of the range for
microscopes (benefits working
distance by targeting
functional 1.0M acuity as
opposed to 0.5M
Consider starting at the
higher end for
magnifiers. Typically
guarantees the patient
fine print acuity (0.5M)
Refining Microscope Power
e.g. BCVA 6/24 1.
+4D
Starting range: 4D-8D
+4D
+4D OU over the
distance refraction in TF
Take near VA from top
of chart, ensure WD of
25cm
Pt attains 0.5M
https://www.medexsupply.com/snellen-chart--grid
Assess vision on target
material e.g. newspaper
Pt attains less than
0.5M
Increase + until best
possible acuity is achieved
Assess vision on target
material e.g. newspaper
Increase + to refine for
fluency and accuracy as
necessary
Final Power
Increase + to refine for
fluency and accuracy as
necessary
Example
•
•
•
•
LB, 74 yoF with diabetic retinopathy and CSME OU
BCVA OD: 20/70
OS: 20/60Starting range 3D-6D
Trial:+3.50D add OU = 1.0M- at 29cm on near card
+4.00D add OU = 1.0M+; slow but
accurate on newspaper
+4.50D add OU to see if we can increase reading
speed = no change in fluency, therefore +4D is the
most functional spectacle microscope power.
Spectacle Microscopes
• Non-illuminated tools where working distance is critical
• Success is limited by poor lighting, intolerance to close WD, poor
contrast sensitivity and large scotomata but patients always want
to try them
• If can’t get to 1.0M no matter what the add power:
• Suspect contrast, therefore requires much higher mag and
illumination (needs illum mags or CCTV)
• Patient’s near VA may be limited
• Don’t be tempted to Rx SV Distance
• See what patient gets with +400 add (aim for 1.6M, large
print)
• +250 add will always provide focus for countertops, seeing
food on a plate, etc.
Prescribing Spectacle Microscopes
• Powers ≤ 4D, consider bifocal
• Adds >4D: impact mobility; lose intermediate-40cm
• Powers 4-10D, consider binocular, prism-corrected
microscope
• Can design yourself
• Amount prism = Add +2
• e.g. 5D add needs 7BI in each eye (14BI total)
• - Prism helps with convergence and keeping one’s
place
• If finding a power >10D achieves fluent near, consider
monocular microscope
Strategy:
Contrast/Glare
Distance
Near
Contrast
“Other”
• Tints and Selective Transmission Filters
– Establish indoor vs. outdoor glare
– Consider Transitions
• Brown vs Grey
– Consider selective transmission fitovers
Strategy for Management
• Distance
• TF Refraction
• (Low-powered telescope)
• Near
• High add
• (Low-powered hand or stand magnifier)
• Contrast/Glare
• Transitions or fitovers
Suggested Inventory
• Distance
2.1x Max TV *
Max TV clip*
1.7x/2.2x Sightscope§
Larger TV
• Near
eReader
• Contrast/
Glare
10D pendant magnifierº*, 8D EasyPocket*, 10D Mobilux *
4D-8D prism readersº*, 12D Visolux*, 3x/12D MenasLux*
Transitions Brown
SolarShield fitovers*
Additional Considerations
• Near
Hand Mag, extended rangeº
Today: 16D Mobilux*
• Distance
• Contrast/
Glare
In the past: Stand mags*
Today: Portable CCTV e.g Smartlux*
1.7x of 2.2x Sightscope §, mounted
Chadwick medical filter wands ±
Device Vendors
• *Eschenbach http://www.eschenbach.com/
Mobilux hand magnifiers, Visolux, Smartlux portable CCTV, Max TV,
Max TV clip
• ºOptelec Canada http://ca.optelec.com/
Hand and stand magnifiers
• §Ocutech (USA) http://www.ocutech.com/
Sightscope
• ±Chadwick Optical (USA) http://www.chadwickoptical.com/
Filters
Strategy:
“Other”
Distance
Near
Contrast
• Non-optical strategies: “good ideas”“Other”
• Lighting
• “full-spectrum/natural” or LED
• Gooseneck, task-lighting
• Relative size mag
• Large labels
• Concept of contrast
• Sighted guide
• Particularly to well-meaning family members
“Other”
• Non-optical “devices”
• Adaptive writing tools
• bold, thick, black felt pen
• large-spaced, bolded foolscap
• Tactile adaptation
• 3D Fabric paint
• Large-print cheques
“Other”
• Resources (that make you look like a
hero)
• Transportation Resources
• Especially if revoking a license
• Every city/county has different Mobility transit guidelines
• E.g. “CNIB registration” vs. “Winter availability if visually impaired”
• http://www.accesstotravel.gc.ca/53.aspx?ProvinceCd=ON&lang=
en
• Vision Waiver Program for field loss
• Disability Tax Credit
• Full LVA referral
• Counseling
Case Ex. 1
• 80 year old Asian male; limited English
• Ocular Diagnoses:
– OD: Corectopia, phaco with PCO, extensive macular
atrophy following macular hole s/p vitrectomy and
possible retinal detachment
– OS: Phaco, possible myopic degeneration (previous
high myope)
• cc: Pain in eyes.
– Mentions difficulty with walking, has fallen
– Right eye “cannot see”
– Wearing SV Distance and removing them to read or
using a storebought magnifier (did not bring)
Case Ex. 1
Distance Visual Acuity
OD: -275DS
OS: -300DS
Near Visual Acuity
Without glasses (habitual)
OU: 1.25M at 40cm
Retinoscopy
OD:-150-375x035
OS:-400-100x090
NI
6/21
Refraction
Trial Frame
OD:------------------OS:-400 -075x090
6/18
Near Assessment
LP
6/30
EVP: +300D (6D with
reserve)
+300D  0.8M
+350D  0.63M
+400D  Too close,
doesn’t like; besides, 1.0M
is the smallest print patient
reads (we asked!)
Case Ex. 1
• Low Vision Rehab plan as follows:
– Distance
• Update distance Rx
– Near
• +3.50add bifocals for reading
– Consider using them for reading only and not walking
first since gait an issue, first-time bifocal wearer
– Contrast
• Regular clip-ons or sunwear
– “Other”
• Not necessary, counsel on LV clinic if VA gets worse
Case Ex. 2
• 92 yoM with mild bilateral cataract, dry
AMD and R-side homonymous
hemianopia
• cc: Annual 406. “No complaints.”
• BCVAs
• OD: -050 -175 x 087
OS: pl -225 x 084
20/70
20/60+
• Are you happy with your vision?
– Can’t read unless the lighting’s good
– Hard to focus after coming inside from outside
• BCVA 20/60+
Distance
Mag caclulation is 1.5x
Could show low-powered telescope
Near
Starting range is 3D-6D
3D add – 0.8M on near VA chart
Trial on newspaper – fluent!
8D Easypocket – 0.5M, hesitant
10D Esch HMag – 0.4M – really likes!
Contrast/Glare
Trial yellow SolarShields – “everything
looks sharp!”
“Other”
Discuss adaptive lighting
Tips for Success
• If it’s not working initially, don’t give up… it’s
not you!
• Proficiency takes time (6 months to refine your
protocols and “scripts”)
• Psychological state of patient
• Limited by a diseased eye
Device Demonstration
• Hand magnifiers
• Hold down on page, then lift up
• Fixed magnifier-to-print distance
• Field of view increased by holding whole system
closer to eye
• Stand magnifiers
• Sit on reading material
• Need add or accommodation to focus
Device Demonstration
• Portable CCTV
• Sits on page
• Take VA on lowest mag setting
• Struggling? Adjust contrast first, reattempt VA,
add mag last
• Telescopes
•
•
•
•
•
Focus telescope at distance for patient
Patient views target
Hand patient telescope
Patient holds telescope to eye WHILE viewing target
Take VA
• If not 20/40, teach focusing first
Device Demonstration
• Tints
• Trial and Error
• Consider indoors vs outdoor trial
• Demonstration Pearl
• Explain pros and cons of devices as you demonstrate
• Ask for patient’s preference
• e.g.
Vs
• “Building a toolkit”
The Assistive Devices Program (ADP)
• MOHLTC government funding program
• Ontario only
• Subsidizes 75% (up to a maximum) of cost of
assistive devices
– 100% (up to a maximum) for patients on
OW/ODSP/ACSD
• 19 categories
– Eg. Wheelchairs/mobility devices, Hearing Aids,
Oxygen Delivery Equipment, Visual Aids
Patient Eligibility
• Any age
• Functional visual disability of 6 months or longer
• “The Applicant’s visual functioning is reduced to such a level
that he/she is unable to perform common, regular, everyday,
age-related visual tasks. The Applicant must have long-term
low vision or blindness that can not be corrected medically,
surgically or with ordinary eyeglasses or contact lenses (e.g.
corrected vision in the better eye is in the range of 20/70 or
less).”
• TAKE HOME: Patient can see 20/40 and still be ADPeligible
from Applicant Eligibility Criteria for Visual Aids – ADP Visual Aids Policy/Admin Manual
The ADP Process
Prescriber – recognizes patient could benefit from devices. Refers to an
authorizer or is an authorizer
OPTOMETRIST
ADP authorizer – provides a clinical assessment and
makes device recommendations
ADP Application for
Funding Form
OPTOMETRIST
ADP vendor – is the site that sells
the device to the patient
OPTOMETRY PRACTICE
ADP assesses claim and, if approved, requests invoice
from vendor.
ADP pays vendor remaining balance.
Patient pays for their
portion and receives
device. Vendor mails
completed ADP
application form to
ADP Toronto.
Devices Eligible for ADP-funding
Optometrists CAN authorize for and vend:
Low Tech Optical Aids
Non-spectacle and spectacle-mounted magnifiers, telescopes,
Prescription and non-prescription specialized lenses (e.g. adds >4D,
filters), Field enhancement devices, Contact Lenses. As of 2014:
Portable Video Magnifiers (i.e. portable CCTVs).
They DO NOT authorize or vend
- Audio playback machines, braillers, white canes
- High Tech Visual Aids i.e. desktop CCTVs, Computer Hardware and
Software, Sight Substitution Resources
ADP-designated Regional Assessment Centres (UW, 5 CNIB
sites, OCAD Toronto),Vision Institute (CCTV only), W Ross
MacDonald School for the Blind (Sight Substitution only)
Patients can use ADP for:
3 Optical Aids in a 5 year period (one near, one
intermediate, one distance)
Re-eligible within 5 years if:
• Condition changes
• Body size changes (growth or atrophy)
• Replacement needed and warranty expired or
expensive to fix
AND
1 Computer in a 5 year period
AND
either 1 CCTV OR 1 Daisy Player in a 5 year
period
Prism reader, your cost
Markup
Total cost
=
=
=
$200.00
$200.00
$400.00
ADP category
=
Binocular microscope
If ODSP/OW/ACSD
=
If not on assistance “other” =
ADP pays 100% of total up to the approved price
ADP pays 75% of total up to 75% of approved price
(75% of $666.67 = $500 maximum in this case)
In this example,
• ODSP/OW/ACSD patient =
• “Other”
=
Device is covered in full by ADP
ADP pays $300
Px pays $100
NOTE: Total cost can be > ADP approved price.
ADP approved price is NOT the max price at which device can be sold for low
tech optical aids.
Useful ADP Links – Setting Up
• Main landing page (with contact information and link for HealthCare
Professionals)
http://www.health.gov.on.ca/en/pro/programs/adp/vendor_registration.
aspx#
• Visual Aids Coordinator
Mr. George Smolinski Tel: 1 416 326 6474, [email protected]
• Application to become an Authorizer
http://www.health.gov.on.ca/en/pro/programs/adp/authorizer_registrati
on.aspx
• Application to become a Vendor (main requirements are a permanent
physical address and insurance information, bank deposit information)
http://www.health.gov.on.ca/en/pro/programs/adp/vendor_registration.
aspx
• Policy and Administration Manual – Visual Aids (lots of little but
important stipulations)
http://www.health.gov.on.ca/en/pro/programs/adp/publications.aspx
Useful ADP Links – Post-Setup
•
Visual Aids Fact Sheet (to be given to each patient using ADP)
http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetFileAttach/0
14-4824-67E~3/$File/4824-67E_info.pdf
•
Application for Funding
http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/FormDetail?Ope
nForm&ACT=RDR&TAB=PROFILE&SRCH=&ENV=WWE&TIT=4823&NO=0144824-67E
•
Vendor Invoice Template
http://www.health.gov.on.ca/en/pro/programs/adp/.../adp_vendor_invoice_tem
plate.doc
•
Product Manual – Visual aids (gives funding amounts per device)
http://www.health.gov.on.ca/en/pro/programs/adp/product_manuals/product_
manuals.aspx
•
List of Registered Vendors – Visual Aids (to be offered to every patient)
https://www.ontario.ca/page/visual-aids#section-3 (towards bottom of page)
•
Release of Information about Previous Funding (in case patient received
devices elsewhere, you want to know what and when)
http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetFileAttach/01
4-2045-67~6/$File/2045-67E.pdf
Useful ADP Links - Bonus
• Overall ADP Policy and Procedures Manual
http://www.health.gov.on.ca/en/pro/programs/adp/update_vendor_ag
reements/docs/pp_adp_manual.pdf
• Conflict of Interest Policy (since ophthalmologists/optometrists can
be ADP prescriber, authorizer and vendor for the same patient)
http://www.health.gov.on.ca/en/pro/programs/adp/publications/confli
ct_of_interest.aspx
ADP – Important Things to Know
• Patient must get ADP Visual Aids Fact Sheet, list of Vendors
• Conflict of Interest Policy relevant to Optometrists
• Frames for specialized lenses do not count as a device (e.g. can
get magnifier, specialized lens, frame for specialized lens and
telescope; counts as 3 devices, not 4)
• Patient must be able to return device within 30days
• Average time to claim approval: 4-6 weeks from seeing patient.
Average time to payment to vendor: 1 month.
• Must follow-up with patient after patient gets a device (no
specifications for how or when, therefore can do phone call?)
2. The Patient who Would Benefit
from the CNIB
http://www.cnib.ca/en/news/Pages/20130130_More-awareness-needed-on-significance-of-white-cane-in-Nova-Scotia.aspx
• Registered charity supporting the blind and
visually impaired
• 26 “local offices” spread throughout Ontario
• 5 Regional Assessment Centres
– CNIB Toronto, CNIB Hamilton, CNIB Ottawa, CNIB
Sudbury, CNIB Thunder Bay (CCTV only)
• Rehabilitative services now rebranded as:
– Vision Loss Rehabilitation Canada
Vision Loss Rehabilitation Ontario
Services
• Low Vision Services
• Basic LVA
• Conducted by a “Low Vision Therapist”
• Daily Living Skills
• Provided by “Vision Rehabilitation Therapist”
• Can be in community, patient’s home, CNIB office
• Focus on adaptive strategies to attain goals; safety
• Mobility Instruction
• Provided by certified “Orientation and Mobility” instructor
• Orientation and Mobility training (real-life environments)
• White canes
• Assistive Technology Services
• 5 RACs for CCTV, computer, high-tech assessments
Sister CNIB Services
• Picture ID Card if Legally Blind
• i.e. VA equal to/worse than 20/200, or VF ≤ 20 degrees
• Recognized by many businesses and services
• Shop CNIB (Online + Print Catalogue)
• Better living products (e.g. talking watch,
• large print playing cards, large print keyboards)
• CELA-member Library
• Audio and Braille format books,
• magazines, newspapers, materials
http://extranet.greyhound.com/revsup/cpfsm/sec03sn.html
Sister CNIB Services
• Emotional Wellness Support
• Support groups
• No DIRECT counselling (i.e. on-staff counsellor), but may be
connected with counsellors in the community
• Career Connect Canada
• Services for Children and Families
• Youth Summer Programs
• Braille preparation, tactile learning sessions, access to
intervenors
• Education and support for parents
The VLR Process
http://www.huffingto
npost.com/2015/02/
23/judi-denchrudest-wordretirement_n_6736
030.html
VLR main office,
uploaded to VLR
system
Service
Coordinator
calls patient;
phone intake to
establish
patient’s needs
https://www.visionlossrehab.ca/Documents/REHAB_DrReferral_FORM-1_pager-Rev.pdf
e.g. Training with O&M
instructor in patient’s
most traveled locations
Co-ordination
of services
e.g. LV Assessment
with Vision Rehab
Worker
e.g. Referral to closest RAC for CCTV
assessment (UW or CNIB Hamilton)
VLR: Common Misconceptions
• “Offers Full-spectrum LV care”
• Vision rehab workers not allowed to authorize spectaclemounted devices
• Refraction NOT part of the LVA
vs.
• “Is completely free”
• Services are free, devices are not and are marked up before
ADP is applied (retail model)
VLR: Issues
• Concerns:
• Phone intakes can be tough!
• Service coordinator may be paid staff, not therapist
• Move by VLR to have LVTs and VRTs all certified by
2018
• LVT is not an optometrist
• No refraction, but mag has to be based on BCVA
• Subtleties of measurements e.g. VA can be
missed
• Currently no reports sent back
• Use “20/70” as criteria for ADP-eligibility
Current Delivery of LV Services
Patient:
http://www.huffingtonpost.com/2015/02/23/judi-dench-rudest-word-retirement_n_6736030.html
Needs and Choices:
Assistive Devices
Low Tech
Optometrist
VLRO*
Ophthalmologist*
High Tech
Regional Assessment
Centres
i.e 5 CNIB centres
UW
OCAD Toronto
Vision Institute*
W Ross MacDonald School*
Rehabilitative
Strategies
VLRO
Optometrist*
Counselling
VLRO*
Family Doctor
Local Counselling
Services
* = partial services
MORAL: No one source offers all solutions.
Low Vision Rehabilitation is a Collaborative
Effort.
Accessing VLR Ontario
• How to refer:
• Online form: https://on.visionlossrehab.ca/en/referral
• OR
• - Keep referral forms in office (fax to 416-480-7700)
• Locate nearest CNIB office:
•
- http://www.cnib.ca/en/about/Pages/Find-AnOffice.aspx
•
- Connect with office low vision therapist
• Identify nearest Regional Assessment Centre
(know where your patient would need to travel
for a CCTV/Computer)
Use comments sections
on the VLR referral
forms to:
-Target services
-State patient is still ADPeligible even if they see better
than 20/70
https://www.visionlossrehab.ca/Documents/REHAB_DrReferral_FORM-1_pager-Rev.pdf
Case Examples
• 94 yo male, geog atrophy, BCVA 20/200, still
living independently; cooks and buys groceries
himself
– VLR referral: kitchen safety, marking up kitchen
appliances, Orientation and Mobility evaluation for
getting to grocery store, ID Card
• 77 yo male, wet AMD BCVA 20/50, 5D add gets
1.0M size maximum but wants to read
newspaper hands-free
– VLR referral for desktop CCTV assessment
3. The Patient with Field Loss
Ontario Regulation 340/94:
“ Class G, G1, G2, M1, or M2 driver:
- Horizontal visual field of at least 120 continuous degrees along the horizontal
meridian
- at least 15 continuous degrees above and below fixation, with both eyes open
and examined together”
- must include central visual fixation point at its centre, and be continuous
Does this field pass?
50º
70º
Options?
• Visual Aids
– Regulation 340/90
• “No extraordinary visual aids”
– No telescopes or prism
http://www.bostonmagazine.com/health/blog/2013
/11/11/local-doctor-invents-revolutionary-prismglasses/
https://www.ocutech.com/product/inst
amount/#
Vision Waiver Program
• http://www.mto.gov.on.ca/english/dandv/driver/medicalreview/standards.shtml
• Est. May 2005
• G class drivers only
• “allows individuals unable to meet the horizontal visual
field requirement the opportunity to demonstrate
through a driving evaluation, whether they can
compensate for the defect and drive safely”1
http://www.gettyimages.ca/pictures/norm-couture-is-back-behind-thewheel-after-10-years-news-photo-165451036#norm-couture-is-backbehind-the-wheel-after-10-years-news-photo-id165451036
Vision Waiver Application Process
• License has to be revoked first
• Patient contacts MTO
•
•
•
•
Medical Review Section
Tel: (416) 235-1773 or 1 (800) 268-1481
Email: [email protected]
Pt requests Vision Waiver application package
Application Requirements
1.
2.
3.
4.
Medical Report (completed by GP)
Vision Report (completed by OD or OMD)
Driving record requirements
Functional assessment from an approved Functional Assessment
Centre (http://www.mto.gov.on.ca/english/safety/functional-assessment-centres.shtml):
Barrie (x2)
Kingston
Pembroke
St. Thomas
Toronto
(North York)
Burlington
London
Peterborough
Smiths Falls
Toronto (York)
Collingwood
Ottawa
Sault Ste. Marie
Sudbury
Hamilton
Ottawa Hospital
(French)
St. Catharines
Thunder Bay
WindsorTecumseh
5. Patient cost:
- Minimum $600 (vision testing fees (NOT OHIP-INSURED),
report fees, assessment fee, extra driver’s training)
If Successful:
Annual renewal report completed by an
optometrist or ophthalmologist:
1. Visual acuity measurement
2. Visual field measurement
3. Has the visual condition remained stable?
4. In your opinion, has the individual adjusted well to
the visual condition?
5. Do you believe patient is eligible to be considered
for vision waiver?
Licensing Considerations: OD
Perspective
• Professional obligation
– Submit vision report to MTO
• Medico-legal ramifications
– Who saw the patient last?
• Ethical obligations
– Protecting other drivers, pedestrians and
cyclists
Patient Perspective
• Health and wellness impact
– Loss of independence2, Reduced mobility3,
Decreased health-related quality of life4, Social
isolation, Clinically significant depression5
• “Safest” amount of VF still not known6
• Patients adjust their driving habits
subconsciously6
• Patients learn to compensate (e.g. scan)
Binocular Visual Field Ex. 1
Binocular Visual Field Ex. 2
• Visual Fields: Binocular
References
References
1) Owsley C, McGwin G, Lee PP, Wasserman N, Searcey K. Characteristics of LowVision Rehabilitation Services in the United States. Arch Ophthalmol.
2009;127(5):681-689. doi:10.1001/archophthalmol.2009.55
2) Government of Ontario. (December 21, 2010). Medical review section. Retrieved 07/20,
2016, from http://www.mto.gov.on.ca/english/dandv/driver/medicalreview/optometrists.shtml
3) Johnson C. A., Keltner J. L. (1983). Incidence of visual field loss in 20,000 eyes and its
relationship to driving performance. Arch Ophthalmol, 101,371–375.
4) Yassuda, M. S., Wilson, J. J., & von Mering, O. (1997). Driving cessation: The perspective
of senior drivers. Education Gerontology, 23(6), 525-538.
5) Windsor, T. D., & Anstey, T. J. (2006). Interventions to reduce the adverse psychosocial
impact of driving cessation on older adults. Clinical Interventions in Aging, 1(3), 205-211.
6) Owsley, C., & McGwin Jr., G. (2010). Review: Vision and driving. Vision Research, 50,
2348-2361.
7) Marottoli, R. A., Mendes de Leon, C. F., Glass, T. A., Williams, C. S., Cooney Jr, L. M.,
Berkman, L. F., et al. (1997). Driving cessation and increased depressive symptoms:
Prospective evidence from the new haven EPESE. Journal of the American Geriatrics
Society, 45(2), 202-206.
8) Peli E. (2008) Driving with low vision: who, where, when, and why. In: Albert and Jokobiec's
Principles and Practice of Ophthalmology, Robert Massof, editor, 3rd Ed. Vol.4 Elsevier pp.
5369-5376, 2008.
Appendix
• Add Calculation on Pre-Presbyopes
Add Calculation on Pre-Presbyopes
• i.e Children to age 40
– Indicated to relieve visual fatigue, headache,
decreased attention span
– Based on working distance demands and
minimum amplitude of accommodation
•
•
•
•
e.g. 30 year old patient, reads 0.6M at 10cm
Min AoA = 15 – ¼ (30) = 7.5D
Accommodative demand at 10cm = 10D
Half of accomm amp can be used comfortably = 3.75D
– Patient therefore needs 6.25D of accomm assistance
Add Calculation on Pre-Presbyopes
• Trialing the add
– Have patient hold near reading card and look
at smallest print that was read (or at smallest
print that patient reads on daily basis)
– Add calculated add to the trial frame
• If add is too much, patient will comment that text
just blurred
• If add is helping, patient will either comment that
print got bigger, or they will immediately relax WD
– Increase or decrease add in +/- 1.00D steps to
refine. Prescribe as bifocal or SVN.