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Welcome to UAB MedCast, a continuing education podcast for medical professionals, bringing knowledge to your world. Here's Melanie Cole.

Melanie: Welcome to UAB MedCast. I'm Melanie Cole and I invite you to listen as we discuss low vision awareness. Joining me in this panel discussion today is Dr. Dawn DeCarlo, she's the Director of the Center for Low Vision Rehabilitation at UAB Medicine; and Dr. Marissa Locy, she's an optometrist at UAB Medicine; and Jason Vice, he's a low vision occupational therapist with UAB Medicine.

Thank you all for joining us today. What a great topic. So Dr. DeCarlo, let's start with you. Tell us a little bit about the types of low vision that you deal with that come to the clinic. What qualifies as low vision?

Dr Dawn DeCarlo: So people have many different definitions for low vision. Some of which, you know, the World Health Organization tends to use less than 20/60. Some people use 2040. It's really not, to us, an acuity-based definition. Basically, somebody who's having difficulty with everyday activities because of decreased vision qualifies for low vision rehabilitation services.

Typically, we want all of our patients to already be having their eye health addressed, and those conditions treated as much as they're able to be. But some conditions like glaucoma and macular degeneration, diabetic retinopathy lead to permanently impaired vision that cannot be corrected medically or surgically. And that's where we come in to find ways to help people do the things they need and want to do.

Melanie: Dr. Locy, in relation to COVID-19, discuss how your patients have been relying on low vision aids, as many of them are older or have been isolating at home. How have delays to get patients in for treatment impacted their vision in a measurable way? What are some of the challenges you've run into with this pandemic?

Dr Marissa Locy: I think one of my patients said that actually the best. He was a return patient who came about a year later now, and his vision really hadn't changed, but he felt that he was more limited. Since he's not getting out and visiting with friends and family and doing activities outside of the house, he's trying to find more things that he can do at home, like reading and arts and crafts type things and all really fine-detailed vision. And he's kind of realized that his vision isn't what it used to be and it's more prominent now that he's at home trying to do those tasks. So he came back to me, now interested in looking at low vision devices and aids to help him with those daily activities at home to help keep him happy and doing hobbies that he enjoys.

Jason Vice: I just wanted to add that there is also a significant impact on the low vision population who are particularly already at risk for depression. So the impact on their mental health and dealing with low vision and the lack of participation in the activities they want to do has been pretty significant.

Melanie: Jason, I'd like you to expand on that because I was going to ask you that question anyway. So tell us a little bit about the emotional impact the pandemic has had on patients with vision issues. Really what have you been seeing and how have you been able to help them with these kinds of emotional, psychosocial, mental health issues?

Jason Vice: So the pandemic of course has been a challenge for everyone and particularly the low vision population as we've quarantined ourselves and isolated ourselves from one another for a good reason to practice good social distancing and hygiene. It's really been impactful for those individuals who already aren't able to participate in community mobility, their ability to get from one place to another is limited because they can't drive many times. So these are typically older individuals who maybe live alone. They can't get out into the community already, that they're limited because of their vision. And now, the ability of their family members to come visit them has also decreased.

There's also been a significant impact on their ability to participate in activities of daily living. So their ability to care for themselves, to do things like prepare a meal, or to manage their finances or even leisure activities like read a book, it's already significantly impacted. And so how they cope with the pandemic is different than how we may cope with the pandemic just that they can't do every day enjoyable tasks that we are able to do within our own homes. They have nothing to turn to because of their vision.

Melanie: It certainly has encouraged healthcare and really the healthcare community to be more innovative in delivering that kind of emotional support for patients during this. So, Dr. DeCarlo, why don't you give us an overview of the UAB Center for Low Vision Rehabilitation? How did it come about? Tell us about some of the services that you offer.

Dr Dawn DeCarlo: So the center itself was formed back in 2002 as a joint effort between the School of Optometry and the School of Medicine. It was created because the Eyesight Foundation of Alabama, which was at the time known as the Alabama Eyesight Foundation, conducted needs survey. And that needs survey show that the biggest unmet eyecare need in Alabama was for low vision rehabilitation services.

So they were invested in helping us getting going. And so the center has been in existence for 18 or so years. It's really important to us that we have a multidisciplinary approach to the care. So initially a patient is seen by an optometrist. We have had ophthalmologists that specialize in vision rehabilitation, but ophthalmologists are surgically trained and most of them do not want to do this non-surgical sub-specialty. So it's mostly optometrists that provide this care. So we have optometrists, we also have occupational therapists and we work with different state agencies and the state agencies that work with providing services to people who are blind or visually impaired vary pretty greatly throughout the country.

In our state, we work very closely with those providers who are located throughout our state. And we work with other resources like the National Library of Congress has free talking books that can be sent to patients, which think has been a godsend for some of our patients during the pandemic.

We also, in our department, have a group that works on looking at psychosocial aspects and they have a support group, which is going to start meeting virtually. I think they were hoping to get back to in person, but since we don't know when that's going to be now, they've started virtual meetings. So we work with them and we refer patients to their licensed clinical therapist.

So we have all three of those components and we do work with ages. The youngest I've seen is about a two-week old baby whose parents knew the child was visually impaired and they needed the assurance that that child was going to be okay. And I had 104-year-old patient earlier this month. So we really work with the gamut of age and we try to work within the constructs of the medical system to make sure that we're enhancing the quality of life of the patient, but also the safety of the patient. And I think occupational therapy is really key for that.

We have a lot of patients with diabetic retinopathy and the occupational therapist can help them, despite their vision loss, be able to measure their blood sugar, be able to be sure they're getting the right insulin dose, things like that. So it's not just about leisure activities. It's about things that are really essential to their health and wellbeing mentally and physically.

Melanie: Jason. I'd like to find out what the role of OT is as a part of this care team at the center and Dr. DeCarlo just mentioned the importance of this multidisciplinary approach. Tell us your role in this.

Jason Vice: Absolutely. I think a lot of the individuals who come into the low vision clinic have been told over the years how poor their vision is or how much vision they've lost. We really focus on teaching individuals to maximize their remaining vision, the use of the remaining vision. And if they're not able to do that, how to engage in activities using other means whether that's through assistive technology or adaptive equipment, whether it's learning to do a different task a different way.

From occupational therapy standpoint, we really address low vision from a functional perspective. We think about participation, what can we do to help this person safely engage in an occupation? Which that word, a lot of individuals is confusing because they think of their paid occupation or what they did for a living. But really what we mean is just everything that most of us want to or need to do everyday could be considered an occupation. So as Dr. DeCarlo mentioned medication management, all the way to meal preparation, being able to operate appliances in their home, financial management, reading, writing, all the way really up to driving a car.

So our goal is to focus on what the patient is really most interested in and what they want to get back to doing and developing a patient-centered plan of care to help them get back to those activities.

Dr Dawn DeCarlo: The other thing I want to add is that because low vision rehabilitation really is rehabilitation, we do spend more time with our patients than your typical doctor. And if you have vision loss, it can be very intimidating and daunting. And so you're in your retina surgeon's office, and he's saying, "I'm going to give you intravitreal injection of Avastin" and all of a sudden you're here and "I'm getting a needle in my eye." That can be frightening. And you may not be thinking about the questions you want to ask about the diagnosis and the prognosis and things like that. And then that retina surgeon has to see a lot more patients a day than somebody who specializes in rehabilitation does.

So by sending patients to rehabilitation specialists, the doctors providing the treatment of the underlying disease are really getting an extra bang for their buck in terms of what they're doing for their patients. That takes them less time, lets them be more efficient in their delivery of care that's so needed and lets us spend the time explaining to them and that helps patients accept their vision loss when we are able to explain those things to them and moving through those stages of   acceptance to vision loss is really important in being able to do the things that are important to those patients.

Melanie: What a great point. And Dr. Locy, what's exciting in the field right now? Tell us about some of the latest technology for visual aids and low vision.

Dr Marissa Locy: So a lot of new technologies, as far as wearable low vision aids. A lot of it in the past has been more desktop or portable devices. These are things that you wear like glasses. They can change the contrast. They can change the size. They have a lot of cool inputs where you can connect with things, so you can even watch your Netflix right there on your low vision aid. So especially for those who are really tech savvy, there are a lot of cool new wearable devices.

There are a lot of devices that are also looking at optical character recognition and they will have cameras attached there that can read print and it's for patients who have very little vision remaining, they can read their mail again. They can read their newspaper. They can read their prescription labels.

For those with smartphones, there are a lot of new apps on the smartphones also. Some that do some of those same things with OCR, optical character recognition. There are other things where you can connect with a volunteer via your smartphone, and that volunteer might be, you know, miles away, but they can help you read the label on your food package, how long do you have to put it in the microwave, things like that. So we have a lot of really cool technology that we can work with patients one-on-one. A lot of it is just tailoring it to what their needs are and what their goals are.

Jason Vice: So that's the great thing about having this clinic located here in a major urban setting. These individuals see that these products exist sometime on television or through media ads. You know, we have a lot of those devices here on site and our low vision eye doctors can evaluate them, see if these devices are appropriate for them. And if they are, then we can provide additional training for them on how to use the device and how to use it for everyday activities before they invest in some pretty expensive equipment that may or may not work for them.

Melanie: I'd like to give you each a chance for final thoughts. So Jason, I'd like to start with you as this pandemic has affected so much of the country and the challenges we've discussed a little bit, how have you been utilizing telemedicine? Have you been utilizing it? And how are your patients liking it from rural areas, being able to maybe, you know, have an appointment with you? Tell us how you're utilizing it and what you see happening in the future. Do you think that you will still utilize this technology after the pandemic has cleared?

Jason Vice: That's a great question. And I think that this has been sort of a game changer in terms of telemedicine and telehealth. I believe that after the pandemic, it's going to be really no looking back in terms of virtual visits. Again, you know, we're from Alabama, it is a relatively rural state. So it's difficult for individuals from the corners of our state to make it centrally to Birmingham where we're located and particularly true in the pandemic with some of our patients have been a little more uneasy about getting out into the community.

The way I've adapted is for those individuals who maybe aren't as comfortable coming as frequently to therapy, I've been able to do e-visits with those individuals, whether it's by phone or a virtual platform to check in with them between our sessions, I've been able to do initial evaluations and treatments via telehealth. UAB has a portal that we utilize. So for those individuals who aren't able to come in directly, we're able to work with them from their homes.

And so I think that the insurance agencies are going to see the value in this and that we're able to get care out to more people who wouldn't be able to make it in otherwise. And I think you'll see much more utilization of tele and e-visits in the future.

Melanie: Dr. Locy, next to you, what would you like to tell other providers about the clinic? What's unique, what you do to go above and beyond, and the importance of this multidisciplinary approach that you have at the UAB Center for Low Vision Rehabilitation?

Dr Marissa Locy: I think it's important for providers just to understand that if they have patients who are not where their goals are, as far as vision, if they're struggling to do any kind of daily activity because of their vision, that they should refer to a Low Vision Rehabilitation Center. We often spend, as Dr. DeCarlo alluded to, an hour or so with a patient. So we take a lot of time with each patient to really make sure that they're able to do the things that they need to do and they're safe and it's a lot of hands-on time with these patients.

Melanie: Dr. DeCarlo, last word to you. Expand a little on referral criteria for the Center for Low Vision Rehabilitation at UAB Medicine, what you'd like other providers to know about your team and the exciting work that you're doing there.

Dr Dawn DeCarlo: So our referral requirements are very, very loose. We don't restrict. Basically, if the patient feels that their vision is not adequate, we are happy to see them. That does mean that occasionally we see people who would have been just as well served going and getting glasses somewhere else, but those are pretty few and far between. But what we tell the providers that refer patients to us is that if your patient's not able to do the things they need or want to do, go ahead and refer them.

Sometimes patients, especially patients receiving the anti-VEGF medications for wet macular degeneration will have good acuity on an eye chart and you look and you go, "Well, you know, they're reading really well on that eye chart, but they're complaining." People with macular degeneration can have scotomas in their central vision that interfere with their function, despite good performance on a high contrast acuity card. They can also have impaired contrast sensitivity, which severely impacts their ability to read. And we have time to delve into how central scotomas are impacting things, how contrast sensitivity is impacting things. And we know the recommendations to make, to help people get by, and not just get by, but excel at what they want to do.

And when we need to, we get them into occupational therapy. So it really should be guided by what the doctor is hearing from their patient. We also accept self-referrals because sometimes patients will end up talking to each other and say, "Well, have you gone to the Low Vision Center yet?" "No, I haven't heard of that." And I think that because low vision services are not as widely available as everybody would like them to be, not every physician is trained that this is an option. But if you think about what happens after somebody has a stroke, do they get rehabilitation? If they have any functional deficits, the answer should be a hundred percent and that's fairly true, I believe.

In vision rehabilitation, people can have a lot of vision loss and yet somehow people will say, "Well, I'm sorry. There's nothing more I can do," and that's just not an acceptable answer anymore. And we have contacts all over the country. We are all very active on the national level and even the international level. So if a physician reached out to us and they were from another state, we would be happy to try to contact them with a reputable low vision provider in their area.

Melanie: That's great information. Thank you all for joining us today and telling us about the UAB Center for Low Vision Rehabilitation. It's really, really an important center. And thank you for all the great work that you're doing.

A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST.

That concludes this episode of UAB MedCast. For more information on resources available at UAB Medicine, please visit our website at UABMedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB medicine podcasts. I'm Melanie Cole.