It’s a little over a month until graduation, and the reality of progressing from student to practicing optometrist is imminent. It’s a reality that encroaches on my clinical demeanor and decision-making process. When discussing cases with my preceptors, I’m constantly questioning myself and drawing from classroom knowledge and past clinical experiences to develop an optimal treatment strategy. I question my own decisions so that I know what studies and data support them, and ask my preceptors how they arrive at their own clinical decisions to learn what I should take away from each case. Being so close to graduation also makes me extremely grateful that I have been exposed to such diverse clinical experiences this year. Currently, my experiences in the Low Vision Clinic at the Buffalo VA Medical Center are introducing me to a patient base that I would not otherwise encounter in such depth. The VA, or Veteran’s Health Administration, is an extensive health care system in the U.S. that provides medical care and other services, including eye care, to former members of the military.
Low vision is an interesting branch of optometry, and one that most primary care optometrists encounter seldom in practice. A low vision exam differs greatly from a typical eye exam, and the philosophy of low vision optometry is directed toward rehabilitation and functionality rather than diagnosis and treatment. Of course, different low vision optometrists may utilize individualized techniques and structure their exams differently than the methods I have been introduced to through the VA. However, low vision’s uniqueness, in and of itself, is a reason for optometry students to familiarize themselves with its practice as much as possible; if we are able to become comfortable giving low vision exams as students, it will mean fewer referrals once we are practicing clinicians.
Low vision exams differ from comprehensive eye exams in several ways. Interestingly, a low vision exam typically takes place after a patient has already received a comprehensive eye exam by an eye care provider and a diagnosis and treatment plan for their specific needs has already been formulated. That way, the entirety of the exam can be devoted to assessing the patient’s visual needs and determining various methods of compensating for their vision loss. Unlike most comprehensive eye exams, taking a patient’s case history, rather than performing testing and examining the patient with various optometric devices, comprises the majority of the exam. I’m used to talking with a patient about their problems and history, which typically gives me a good idea of what I will be encountering in the exam and dictates my differential diagnoses, but after taking a thorough case history I rely primarily on objective testing and examination methods to rule out certain potential diagnoses and finalize a diagnosis and treatment plan. With low vision, it’s completely different—almost 100% of your information is gathered exclusively through talking to the patient.
This crucial difference between low vision exams and comprehensive eye exams can be jarring for students, but it’s also extremely advantageous. By talking to patients about their vision loss, you’re able to connect with them and better understand the issues they face in a way that simply isn’t possible from reading about it in a textbook. It’s one thing to read that patients with macular degeneration develop blind spots or distortion in their central vision, and another thing to have a patient describe to you the frustration he feels when he tries to read the mystery novels he loves. Low vision exams teach aspiring clinicians that the problems faced by patients aren’t always the ones that you would anticipate, and that solutions can vary with a patient’s abilities and motivation.
While I am learning at the VA to administer low vision exams as an optometrist, I have also been impressed by low vision’s focus on a team approach. To give a patient a successful low vision exam, you first need thorough examination and treatment by another optometrist or ophthalmologist at the VA. Then, after you, as the low vision optometrist, assess the patient’s visual functionality and needs, you rely on the rest of your low vision team to execute a specific rehabilitation treatment plan for the patient. At the VA, we work closely with a team of occupational therapists who specialize in vision and blind rehabilitation specialists to demonstrate various low vision devices to patients, and patients are able to receive home assessments and care catered to their daily lives. Low vision is a unique branch of optometry that allows a clinician to have a profound impact on a patient’s quality of life, and it is an excellent learning experience for both clinicians and patients alike.