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Low-vision care: ophthalmology's rehabilitaton subspecialty


The current definition of vision impairment is vision not satisfactory to the individual or that person's significant other.

Toronto-Shifting population demographics and expanding research efforts have brought low-vision rehabilitation to the forefront as a new subspecialty in ophthalmology.

"Every ophthalmologist can and has to become involved in low-vision care at some level," said Dr. Markowitz, assistant professor of ophthalmology, and director, low vision program, department of ophthalmology and vision sciences, University of Toronto, Ontario, Canada. "The SmartSight program was designed to introduce a new pattern of practice where this can be part and parcel of daily practice for every ophthalmologist regardless of current professional focus."

Dr. Markowitz explained that the place of vision rehabilitation as a distinct subspecialty in ophthalmology has been driven in part by the aging of the baby boomer generation, and the need for these services is accelerating. However, the concepts of what constitutes low vision have changed over the last few decades. Consequently, the elements of vision rehabilitation in the current era contrast sharply with those of the original model.

"Vision rehabilitation was originally intended to meet the needs of visually impaired persons who were born with severe low vision and needed to develop skills for life or who were returning veterans who lost sight as a result of field injuries," Dr. Markowitz said. "Today, we have a generation of maturing adults with less severe vision loss as measured by visual acuity standards, but who are in good physical health and devastated by the functional impairment resulting from their low vision. The size of this population is already huge and is rapidly growing."

The current definition of vision impairment is vision not satisfactory to the individual or that person's significant other. It applies to persons with vision impairment who have exhausted medical and surgical options, and can include anyone with acuity less than 20/40, a scotoma, field loss, or loss of contrast sensitivity.

"Some would argue that 20/50 is still a good level of visual function, but the focus should be on functional vision because of its impact on quality of life," Dr. Markowitz said. "If a person is experiencing difficulty reading, working, performing activities of daily living, or participating in recreational activities because of vision, it is a problem."

Unfortunately, neither the public nor the majority of ophthalmologists is aware of the numerous strategies available for low-vision rehabilitation. SmartSight was developed as a multipronged effort in order to educate the ophthalmology community about its essence (see "Academy initiative aims to involve all practitioners in low-vision care").

Dr. Markowitz is a member of AAO's Vision Rehabilitation Committee that developed and rolled out the SmartSight initiative in the United States in 2005. Currently, he is working with several Canadian colleagues to introduce the program in his own country.

Members of the Vision Rehabilitation Committee are also reaching out to medical schools to increase education of ophthalmologists-in-training, supporting research and publications in this area, introducing programs to raise public awareness, and working in other ways to inform ophthalmologists in the community and encourage them to integrate some level of low-vision rehabilitation care into their practice.

Gaining support, involvement

The support given to the SmartSight model by the AAO Board of Trustees is one indication that low-vision rehabilitation is gaining the recognition it deserves. Statistics showing that a growing proportion of ophthalmologists are providing some form of low-vision rehabilitation services are also good news to Dr. Markowitz and his colleagues.

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