VisionAware

Dr. Joseph Fontenot is a medical doctor, Certified Low Vision Therapist, and Medical Director of Community Services for Vision Rehabilitation (CSVR), with offices in Alabama and Mississippi.

He is also the current Chair of the American Academy of Ophthalmology’s Vision Rehabilitation Committee. In that role, he commissioned and led the production of There Is Something Else You Can Do, a newly-released six-minute video that emphasizes the impact of vision loss on the individual and the responsibility of the ophthalmologist to refer to, or provide, appropriate vision rehabilitation services.

Dr. Fontenot has low vision himself, and understands the problems and needs of people with vision impairment. He began his career as a medical doctor almost 50 years ago. After working as a cardiologist for many years, he made the decision to transition into the low vision field as a result of his first-hand experience with vision loss, caused by macular degeneration.

“I became visually impaired at age 50, but I continued to work as a cardiologist for 14 years,” Dr. Fontenot explains. “I could do that because I was able to access all of the low vision and access technology that I now try to make people aware of. When I was about to turn 65, I decided to go into this field. I realized that most people who have vision loss didn’t know this technology was available, so I decided to start Community Services for Vision Rehabilitation (CSVR). Our mission is to provide help and assistance to those with low vision.”

Maureen Duffy: Hello Dr. Fontenot. Thank you very much for speaking with us. To begin, how would you describe low vision for our readers? Is it more than a numerical definition?

Dr. Joseph Fontenot: Simply put, low vision is impaired vision that interferes with a person’s normal everyday activities. It cannot be corrected by usual eye care or glasses or surgery. For instance, if a person has myopia (nearsightedness), they can go to the eye doctor who can provide a prescription for the proper glasses and they will be able to see well. That’s not low vision; that’s what’s called a refractive error, which can be corrected. Or say the person has cataracts. They can go to the eye doctor, have cataract surgery, and then probably see well again after the surgery.

When we talk about low vision, though, what we’re talking about is impaired vision that cannot be corrected by simply having the proper glasses or by having some medication or surgery. Low vision is anything that impairs the person’s function. Say, for instance, a person uses a computer at work. If they have low vision, they might have great difficulty doing certain work-related computer tasks. It’s going to interfere with their function and they might lose their job. Say they can’t drive a car; that certainly, in almost any country in the world now, impairs your ability to get a job and get around to many places independently. When we’re talking about vision that impairs your everyday function, that is low vision.

With low vision, you could also have contrast sensitivity loss. Contrast sensitivity is the ability to tell objects apart which are similar in shape or color, such as a blue napkin on a table that’s a lighter shade of blue. If you lose that ability, you’re going to have trouble doing all sorts of visual tasks. You could also have loss of color perception.

You could have visual field defects, or “tunnel vision,” which you can get with glaucoma, retinitis pigmentosa, or a stroke. A normal visual field is around 150-160 degrees. The world around us is 360 degrees, so if your visual field is smaller than 20 degrees, that is a very small window on the world.

You could also have a scotoma, which is a central blind spot or central visual field loss, which you can get with macular degeneration or diabetic eye disease.

But numerical measurements, meaning those that define “legal blindness,” are necessary, because you do have to have some kind of objective measurement, and not just a subjective statement saying “Vision impairs my function.” You need it for many purposes, including disability benefits and tax exemptions. But legal blindness is not a functional low vision definition and doesn’t tell you very much about what a person can and can’t see.

[Editor’s note: You can learn more about the definitions of legal blindness, including visual acuity and visual field measurements, at Visual Acuity and Low Vision, A Functional Definition of Low Vision, and Low Vision vs. Legal Blindness on the VisionAware website.]

MD: What you’re saying, then, is that it’s important to look for an eye doctor who specializes in, and understands, low vision.

JF: Yes. Anyone who has impaired vision should see a low vision specialist. Usually the low vision specialist works in a low vision rehabilitation clinic or practice and you would be examined there. They can determine how severe your vision loss is, what your contrast sensitivity is, and whether you have blind spots or field defects.

The low vision specialist also asks you a lot of questions about your own particular goals and needs. For example, a person who is transitioning from high school to college has a different set of needs from those of a retired person. It’s a matter of determining your own capabilities and goals and then determining what would be helpful to you in achieving those goals – what sort of training, what kinds of aids and devices would help you get there? That’s what visual rehabilitation is about: helping a person achieve the goals they want or need to do.

MD: What is the best way to find a good low vision specialist?

JF: The best way to do it, I think, is to ask your own eye doctor, who should know what low vision services are available in your area. They should also know about the ethical standards of those clinics and the type of services they provide. You could also give your doctor information about the new video There Is Something Else You Can Do, which was created specifically to help eye doctors understand and locate low vision services.

You should look for a clinic of the highest quality. Generally speaking, the best quality low vision clinics would be at, near, or affiliated with a university or medical school. If you have one of those in your area, you should probably go to that. An alternative would be a non-profit clinic located in an organization that is serves the needs of blind and visually impaired persons.

[Editor’s note: You can use the VisionAware Directory of Services and the American Foundation for the Blind VisionConnect™ App to locate a clinic or an organization that provides these services in your area.]

You should also ask if the clinic has a comprehensive program that offers more than simply walking in, having an eye examination, being sold a magnifier, and then walking out. It should be an organization that provides a full range of vision rehabilitation services. You don’t want to be restricted to just one device or service. If you encounter any organization or clinic that is trying to get you to buy only one type of low vision device, that’s probably not the best place for you to go.

It’s also important to find out ahead of time if you can return a low vision device if it doesn’t work out for you. Most reputable clinics will offer a trial period that can be as short as 1-2 weeks or as long as 30 days. This allows you to try out the low vision device in your own home. If the device doesn’t work for you, you want to have the option to return it. Some items might not fit into this category, such as less expensive devices or prescription glasses, but for any expensive device, you should make sure that you can return it within a reasonable amount of time.

MD: Some low vision practices ask prospective patients to call ahead for a pre-appointment discussion. Is it a good idea to do this before going to an appointment?

JF: If a clinic offers to have a telephone consultation by an eye doctor prior to your appointment, that’s usually a telltale sign that it might not be a clinic you want to go to – particularly if they say you’ll have to pay a certain amount of money up front that is above and beyond your normal insurance co-pay.

Unfortunately, there are some clinics and organizations that are not working for the best interests of the patient. They will try and push expensive glasses or devices that they can make quite a nice profit from. And be careful when clinics state that their one device is going to solve all of your problems. It’s probably not going to work and almost certainly it’s going to be very expensive.

MD: Prospective patients should also know what a true comprehensive low vision examination includes. Can you tell us more about the different components of a low vision exam?

JF: The first thing to know is that it’s different from a standard eye exam by a regular eye doctor. There are no drops put in the eyes to dilate the pupil, so the person won’t have to wear dark glasses after the examination.

I start the examination by doing a history to find out when the person first started having symptoms. When did they first notice that their vision was not good? Then I’ll ask when they stopped doing certain activities. When did you stop driving? When were you not able to read small print, like newsprint? When did you start having trouble using your computer? We try to reach people as early as possible and ask these questions to get a history of the events and steps occurring in the person’s vision loss.

And there are three additional questions we always ask. The first is about depression, the second is about macular degeneration, and the third is about Charles Bonnet syndrome.

Depression: We ask the patient about their mood and also observe if they are exhibiting any signs of depression or anxiety. Depression is very common in people who have lost their vision. Losing your vision is a life-changing event. It is similar to loss of a spouse or child and it is very common for people to become depressed. Sometimes they will work through this depression, but sometimes they do not, and it will take some time to get over the loss of vision. We believe that helping the person function better will prevent most of the depression that can, and frequently does, occur because of vision loss.

Macular degeneration: If a patient has typical macular degeneration, we always say, “Do you know it’s very unlikely you’ll become totally blind?” Usually, the patient will say, “No, I was worried about that. I thought I was going to go blind.” We then tell the patient, “If all you have is macular degeneration, it’s extremely rare that you would ever go totally blind. Your central vision likely will get worse, but it’s very rare to get to the point where you’ll be blind.

Most patients are very relieved to hear this and some say, “My doctor didn’t tell me that.” Nowadays, however, many more say “My doctor did tell me that,” which is good – good for the patient and good for the doctor. However, you can’t say that to someone with glaucoma or diabetic eye disease or retinitis pigmentosa. But since a majority of people in the United States who have vision loss have macular degeneration, it’s something that should be done.

Charles Bonnet syndrome: Many low vision specialists also ask about Charles Bonnet syndrome (CBS) and routinely ask the patient whether they have the visual hallucinations associated with it. We reassure them that this is a normal event that, by some estimates, affects 20-30% of adults with vision loss.

[Editor’s note: Charles Bonnet syndrome (CBS) is a condition that causes vivid, complex, recurring visual hallucinations, usually in older adults with later-life vision loss. The visual hallucinations associated with CBS can range from animated, colorful, dreamlike images to less complex visions of people, animals, vehicles, houses, and similar everyday images. You can learn more about CBS at Charles Bonnet Syndrome: Why Am I Having These Visual Hallucinations? on the VisionAware website.]

After we ask questions and get a history, then we’ll do a visual acuity test. For this test, we do not use a standard letter chart. Everybody knows there’s an E up top and there’s only one letter there, so it’s not good for evaluating people who have significant vision loss. We use a different chart, called the ETDRS chart, which stands for the Early Treatment of Diabetic Retinopathy Study.

In addition to the visual acuity test, which gives us a numerical measurement, such as 20/40 or 20/200, we routinely do several other tests.

One is a reading test, with the person reading a chart that contains sentences of different size print, going from very large to very small. This gives us information about near vision and the person’s reading ability.

We also routinely test contrast sensitivity and color perception and do a visual field test, which tells us if the person has blind spots or other visual field-related difficulties. These problems may not be obvious from doing simple visual acuity testing.

After doing all these tests, we have a very good idea of what the patient is actually seeing, and a good idea of what the patient needs to be able to see better.

[Editor’s note: You can learn more about the components of a comprehensive low vision examination, including an eye health evaluation; the Amsler grid test for macular degeneration; visual field testing; tests for color perception and contrast sensitivity; a lighting evaluation; and examples of specialized low vision eye charts at Components of the Low Vision Examination on the VisionAware website.]

MD: Many people say they just want “a pair of glasses” to help them see “like they used to” before they had low vision. However, people might not understand that they may need more than one device to carry out different everyday tasks. Can you talk about that?

JF: A comprehensive low vision clinic offers many alternative forms of vision enhancement. Most people who go to a low vision clinic do so because they have an idea that all they need is a “better pair of glasses” and so they very commonly come in and say “Doc, all I want is a pair of glasses that I’ll be able to see with.”

But unfortunately, standard glasses only work up to a certain point and although stronger glasses are available, they might not be adequate for all the needs of a person who has truly significant vision loss.

Stronger glasses have some disadvantages. They are more difficult to use than normal glasses, they require a much closer viewing distance, and they are harder to focus. They do require some practice and experience in using them. And there are often much better alternatives than simply stronger glasses.

All low vision clinics offer stronger glasses and sometimes these glasses are the best alternative. But the person needs to understand that a very strong pair of glasses is not easy to use and they’re not necessarily going to help the person to sit back and read a long novel comfortably. Stronger glasses might be good for “spot reading” or “spot viewing” where you just need to, say, look at a thermostat or read a medication label.

MD: What you’re saying, then, is that a person doesn’t always need to spend $1,000-$3,000 for a custom-made pair of strong glasses.

JF: That’s right. There may be better alternatives to stronger glasses. There are different kinds of magnifiers, both with and without built-in lights. There are electronic magnifiers, which are like video cameras that project an enlarged image onto a monitor screen. And there are more alternatives, too, such as audio output devices and braille output devices.

Smart phones and tablets have recently become very useful for people with low vision. They have many built-in accessibility features and many apps designed specifically for users who have low vision.

A fully-stocked low vision rehabilitation clinic will have easily a thousand different items available to achieve the result the patient wants and needs. It’s usually not a matter of only “getting a better pair of glasses.”

Proper lighting is also very important. People who have loss of contrast sensitivity will invariably need more light. The type of light they need is usually more “white,” instead of “blue-ish” or “yellow-ish.” Whiter light maximizes the contrast between different colors and different shades of color.

MD: What about paying for low vision devices? They can be very expensive.

JF: At Community Services for Vision Rehabilitation, we serve people with any eye condition, of any age, and with or without insurance coverage. Generally speaking, though, low vision devices are not covered by insurance or Medicare. I’ve been doing this for almost 15 years now, and I’ve had just one patient who actually got their insurance company to pay for a device. He was the most persistent man I’ve ever known. I think they finally paid for something just to get him off their backs, but it took him years.

Some devices, particularly electronic magnifiers and magnifying systems, are expensive, but there are plenty of low-cost devices that are available, too. For example, a person who has macular degeneration and a visual acuity of 20/200 would probably be able to read normal-sized print with a hand-held magnifier that costs $60-$70, or an electronic magnifying device for $150 that connects to a standard television screen.

You can also buy used equipment. And we let people lease equipment from us. If a patient wants to try an electronic video magnifier, or CCTV, we let them take it home for a month or two. We can give them a used one, let them pay $10-$20 a month, let them try it out at home, and if they don’t like it they can bring it back.

Remember that it’s a matter of your own needs and choices – not just what is being offered to you. Aids and devices have become much more sophisticated and are actually less expensive than they were 20-30 years ago. There is much greater variety now, in terms of both capability and expense.

I always recommend going to a reputable, comprehensive low vision clinic that has a full array of optical and electronic devices. As I always say to my patients, it’s a matter of “buyer beware.” Be an informed and proactive consumer.

MD: Dr. Fontenot, I’ve very much enjoyed talking with you. We thank you for your support of VisionAware and your longstanding commitment to blind and visually impaired persons everywhere.

More Helpful Information

• You can view the new American Academy of Ophthalmology video There is Something Else You Can Do at www.aao.org/low-vision-video.
• Meet Donald C. Fletcher, M.D., Internationally Recognized Authority on Low Vision Rehabilitation
• There is Hope; There is Help: Part 1 in a Series on Low Vision and Low Vision Services by Bryan Gerritsen, CLVT
• Understanding Low Vision Care and Low Vision Devices: Part 2 in a Series on Low Vision and Low Vision Services by Bryan Gerritsen, CLVT