The Journey

By Shivan Sivakumaran

Reflecting on Low Vision Optometry

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Reflecting on Low Vision Optometry
By Shivan Sivakumaran • Issue #59 • View online
Kia ora e hoa,
I want to share my experience as a Low Vision (LV) optometrist working for LightHouse Trust and the Canterbury District Health Board. I’ve been working in this role for about a year.
I am still working as a community optometrist and I am at my LV role once a fortnight.
In this newsletter, I will outline how my perception of an optometrist has changed. What LV means to me and my roles as an LV optometrist.
What is Low Vision?
I was confused when I first heard about LV. My understanding is optometrists improve eyesight.
My ignorance was early in my degree. I thought the only solution to poor eyesight was glasses — and sadly this is a major belief held by the public.
Now that I’m enlightened: how is LV different? Two reasons exist for reduced vision. One is lack of focus easily corrected with glasses and contact lenses. Second, and more difficult, is an eye disease.
Some eye diseases are cured through medication and surgery (e.g. cataracts). On the other hand, a large number of eye diseases hold no remedy (e.g. macula degeneration).
LV focuses on the latter. Low vision employs a variety of techniques and strategies to rehabilitate someone with reduced vision so they can live close to a normal life.
Why become a Low Vision Optometrist?
We all have differing motivations. My one for this role was a move towards more career variety. For a number of years now, I had only worked in a retail setting. Working in LV once a fortnight has given me some respite from Groundhog day.
Another motivation stems from my perception of an optometrist. Coming from an academic background, my value in a skilled optometrist was through the grades, how well one can recall eye pathology, and who got the best refraction in the shortest space of time. The more years I worked as an optometrist, the more I realised that these skills, though useful, are not the most important.
Valuable skills are in the art of communication and how you make a patient feel. What we really want is the best outcome for patients, and the ensure they leave feeling positive. Not only does our knowledge and refraction have to be on point but we must also be good at listening to the patient, understanding their needs, and communicating a solution in a way that they understand.
For example, if a contact lens is going to take a long time to arrive, it is important to let the patient know what the expect.
If a temple breaks on the frame, we need to deal with it in the quickest way possible.
If a patient has macula degeneration, this may equate to complete blindness in their mind. But we know that peripheral vision is preserved and this is what we need the patient to start learning how to utilise.
When I ask my fellow optometrists about LV, they feel their skills are lacking in this area. And the skills they are probably thinking about are how to calculate the required magnification. However, the skills important are the ones we develop while working in LV, which come from experience on the job rather than a classroom or textbook.
The Job
The job is best explained through the patient’s experience. Patients are booked in one-hour slots. First, they are seen by the Occupational Therapist (OT). Fortunately, the OT makes life a lot easier and asks the bulk of the questions about lifestyle, challenges the patients are having, and what the patient would like to achieve.
Next, the patient will see me. The OT has already laid out what the patient will be needing. Generally, this may need an introduction to a magnifier, or a CCTV, but primarily reiterating and explaining the eye disease.
Despite the vision loss being inevitable with current technology, our attempt is the come up with strategies to still live a life close to normal.
Since most patients have had a thorough assessment from an optometrist or ophthalmologist, there is less emphasis on refraction and ocular health checks that are normally done in community settings. There is more time to explain in detail what is going on with their vision to both patient and any attending family members.
Additionally, the OT will perform a home visit if necessary to ensure the home set-up is adequate for their vision. This could be a recommendation for how to improve lighting to tactile dots on the oven.
Our role is important not only in communicating with patients and family but also with other health staff: other referring occupational therapists, eye specialists, general practitioners, and optometrists too. This involves writing letters — which fortunately we can dictate and it will be written by a hard-working office administrator.
I’m grateful for the team that I’m working within making this job easy and enjoyable.
The Patients and the Outcomes
LV patients vary in all ages. They can be very elderly, working-age, or children.
To me, these people are the most inspiring. There is a lot of fear of losing eyesight. With the loss of independence, quality of life and freedoms that we all take for granted, these individuals are living that reality.
Generally, patient success in treatment is visual acuity. We hope to at least maintain visual acuity or improve it. LV can be a bit unusual in this scenario because visual acuity is almost a lost cause.
Reducing vision is what we have to accept, so too does the patient.
Remember the goal is that we want to maintain life even with this decline in vision. This is where we need to attempt strategies that can be frustrating for the patient.
As a practitioner, this can be depressing as we may not get the outcomes that we desire.
What makes this incredibly difficult is if someone has significantly reduced vision and it’s their first appointment at the LV clinic. Significantly reduced vision correlates highly with low mood. Low mood makes it difficult to adopt new strategies such as using magnifiers or eccentric fixation.
This is why it is important to refer patients early. A 6/9 (one line better than the driving standard) may not have immediate problems right now, but a referral to an LV clinic will let them know that there is something that can be done about their reducing vision — in a case of macula degeneration.
This makes it easier for individuals to adapt, knowing that there is something that can be done if the vision does get worse.
Conclusion
Working in LV has improved my understanding of this role. The prerequisite is simply a willingness to learn. LV offers some career diversity, where communicating with patients is key.
I am blessed to be working in this area and I hope you have gained some insight into the role.
Did you find this useful? If you did, please forward this on to family and friends so they can find it useful too.
Thanks for reading and all the best for the week ahead.
Ngā mihi nui,
Shivan :)

My Favourite Things
  1. Video AlphaGo - The Movie | Full award-winning documentary This is an excellent documentary on AlphaGo — artificial intelligence designed by DeepMind to out game the best Go player, Lee Sedol. This story is both emotional and inspiring.
  2. PodcastThe Tim Ferriss Show: #524: Ramit Sethi on How Couples Can Talk about Money In this podcast, Sethi and Ferris talk about couples and money. My takehome is that couples need to have an aligning ‘north star’. It’s not possible to bring someone else up if they don’t share your vision.
  3. Video Māori Data Sovereignty - A revised Definition Karaitiana Taiuru provides insights into how we manage data concerning Tangata Whenua.
Kindle Highlight of the Week
The person that you want to be is the person that you really are
Prof Steve Peters, The Chimp Paradox
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Shivan Sivakumaran

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