When I was a Georgia Tech student, I encountered an elderly woman needing assistance. She was using a white cane trying to find the Center for the Visually Impaired (CVI). Once I helped her find the office, I asked the front desk if they had any volunteer opportunities. The experience that followed opened the door to a new perspective and appreciation for the realm of vision impairments and accommodations.
Importance of addressing low vision
My first interaction was tutoring a middle schooler with math homework. In front of him was the enlarged print paper with a large font size. Then I saw him get 2 inches from the paper to read the prompt for a pythagorean theorem question. It was the first time I got a truly powerful understanding of the necessity of accommodations for the low vision population.
“Taking time to address accommodations required by our visually impaired patients is crucial to being a compassionate physician as well as a well-rounded eyecare professional.”
Laws surrounding special accommodations
The Americans with Disabilities Act (ADA) broadly defines disability as an “impairment that substantially limits a major life activity.” According to the U.S. Equal Employment Opportunity Commission, it can be a physical or mental condition affecting walking, talking, seeing, hearing, or learning. With these guidelines in mind, the degrees and type of visual dysfunction varies and certain limitations are task-specific.
Legal blindness is considered a BCVA of 20/200 or less in the better eye or if the field of vision is less than 20 degrees. However, the overarching term is visual impairment, which encompasses various functional disabilities as well as total blindness.1
Functional Vision Impairment
| Functional Vision Impairment | |
|---|---|
| Moderate | 20/70 to 20/160 |
| Severe | 20/200 to 20/400 |
| OR | |
| Visual field of 20 degrees or less | |
| Profound | 20/500 to 20/1000 |
| OR | |
| Visual field of 10 degrees or less | |
| Near-Total | 20/1000 to LP |
| Total | NLP |
Essentially the employer needs to determine if the employee can safely perform under the job description, as well as distinguish if and how they can support reasonable accommodations.2 Additional inquiries may be made or medical documentation may be requested.
Functional limitations of low vision patients
It can be very apparent when ocular pathologies impact a patient’s day-to-day activities, especially with significantly reduced BCVA or peripheral fields. Regardless of the underlying low vision condition, optometrists are able to understand and uncover bothersome visual constraints that emerge on many different platforms including:
- Academic
- Occupational
- Personal/Leisure
- Social
- Daily activities
- Mental health
Whether a patient’s low vision is partial or total blindness, limitations are unavoidable. Spatial awareness can be affected with central or peripheral defects. Other visual disruptions can cause diminished acuity or distorted contrast and color vision. Upon clinical exam, these findings can be corroborated with special testing and a comprehensive eye exam. You can download the low vision guide and clinical cheat sheet HERE.
Determining need of additional assistance
Degree of vision loss and area of scotoma are the most significant factors in vision impairment. The effect on performance depends on different task demands, especially more strenuous or complex tasks.
If indicated, low vision rehabilitation allows patients to best utilize the patient’s residual vision. Along with refractive correction, other optical aids include magnifying devices and prism. Non-optical aids are also available, as lighting adjustments or filters can also be beneficial.
Suggestions for appropriate accommodations
Beyond the vision and ocular health assessment in the exam chair, is how the patient utilizes their best corrected vision in everyday life. Certain levels of vision impairment may call for unique, creative accommodations. For instance, low vision patients can use tactile labels around new environments.
| Vision Impairment Accommodations | |
|---|---|
| Moderate to Severe Vision Impairment | Additional task time |
| Proper lighting | |
| Large font and paper size | |
| Large monitor | |
| Magnification devices | |
| Assistive technology | |
| Visual field of 10 degrees or less | |
| Near-Total | 20/1000 to LP |
| Total | NLP |
Simple modifications such as lighting or low vision devices are impactful. Handheld, stand or dome magnifiers may be useful desk tools. A clip-on or bioptic telescope may be practical for conference meetings or classrooms. Other wearable aids are also available. Larger paper or screen size can alleviate some adversities as well.
There is also a range of evolving assistive technology devices and apps for patients.4 Closed circuit television systems (CCTV) can magnify print material, and conversely, optical scanners will convert print work into electronic documents. Screen reading programs can provide larger text size and auditory feedback. In this sense, a digital recorder can be a great tool as well, even for customized training or audio instructions.
Special accommodations may be needed
For accessibilities to low vision resources, patients may bring documents required by the company or employer, which may or may not include additional testing forms.
I have had a patient who was 20/50 OD and NLP OS due to multiple retinal detachments and subsequent cataracts. After starting her new job, she and her employer noticed that the peripheral movement demands and difficulty with reading postage timely was limiting her production rate. When requesting additional time to perform tasks through her employer, she received company forms I needed to complete for her.
Even younger patients with retinal dystrophies have requested additional accommodations for standardized admissions testing. Occasionally, there is a requirement for an accommodation letter from an eye care physician.
Classroom assistance for vision impairment
In the academic world, Individualized Educational Plans (IEPs) were pushed as a development through the Supreme Court to ensure appropriate services and guidelines that align with the child’s disability. As optometrists, we can fill out a specific form that reviews testing completed and allows for recommendations that can benefit the patient.3
Comparatively, 504 Plans do not have special instruction as IEPs and do not fall under Individuals with Disabilities Education Act (3). Despite those factors, this education service does allow for large print textbooks, specific lighting or extended testing periods.
Documenting patient difficulties
Asking about consistent, frustrating obstacles can make a profound impact by allowing us to offer novel options. Including these possible hurdles in the patient chart is a useful clinical tip. In some cases, the value of low vision referral is critical. Note that you advocated for optometric low vision services to build social and independent skill sets, especially as they focus on orientation and mobility measures.
Template for low vision accommodation letter
The first time a low vision accommodation letter was requested of me, I tried to look for resources. Unable to find direct guidance, I put together a template. It incorporates key subjects to include, such as severity, length, and type of vision impairment, its pertinent vision limitations, and possible accommodations.
Download our Low Vision Accommodation Letter Template.
HIPAA and confidentiality considerations
We know that the confidentiality component of this sensitive exchange of communication is indisputable. The same applies to an employer’s confidentiality of learning disclosed medical information.
After completing your accommodation letter, it is imperative to send it directly to who it is required for. Applying it to a proper letterhead and including a HIPAA cover sheet would also be suitable protocol.
Takeaways
Vision is our most impactful sense, providing our brain with feedback to make suitable impressions and interpretations of our surroundings. Each person has different daily activities and individual experiences that can be impeded due to chronic and progressive vision loss. As optometric physicians, we can understand the subsequent consequences first hand.
By suggesting appropriate accommodations we can provide proven, substantial methods to support our patients, even recommending creative solutions to low vision challenges.
Maybe you discover the patient is using accessible alternative transportation for your appointment. If required, it may be a reasonable recommendation to suggest a modified work schedule that takes special transportation into account, or possibly work-from-home options. Understanding these personalized difficulties can leave room for us to reduce hardships for our patients.
Regardless of the particular limitations the irreversible blindness entails, it is our job to counsel about the ocular disease implications. This goes hand in hand with proposing low vision rehabilitation when applicable. (If you are interested in adding this specialty in your practice, here are ten ways to get started with low vision rehabilitation.)
It allows us to enable our patients to achieve their goals with simple adjustments that can enhance quality of life. Changes in desk setup may benefit sensory efficiency for functional skills like organization and time management. Moreover, considerations for assistive technology would be advantageous for magnification or auditory support.
While volunteering at CVI in Atlanta, I learned the importance of allowing the visually impaired population to achieve independence and to develop proficient skills and self confidence to comfortably fulfill lifestyle functions. As well rounded eyecare physicians, we have the ability to help low vision patients better adapt to complex activities with visual rehabilitation options, recommended accommodations, and professional guidance.
References
- What is legal blindness? VisionAware. https://visionaware.org/your-eye-condition/what-is-legal-blindness/. Published April 23, 2021. Accessed February 10, 2022.
- Issuing Authority This technical assistance document was issued upon approval of the Chair of the U.S. Equal Employment Opportunity Commission., This technical assistance document was issued upon approval of the Chair of the U.S. Equal Employment Opportunity Commission. Blindness and vision impairments in the workplace and the ADA. Blindness and Vision Impairments in the Workplace and the ADA | U.S. Equal Employment Opportunity Commission. https://www.eeoc.gov/laws/guidance/blindness-and-vision-impairments-workplace-and-ada. Accessed February 10, 2022.
- Walker CAC. Blind Students and the IEP Process. Blind students and the IEP Process. https://nfb.org//sites/default/files/images/nfb/publications/fr/fr36/2/fr360202.htm. Accessed February 1, 2022.
- Agarwal R, Tripathi A. Current modalities for low vision rehabilitation. Cureus. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8396411/. Published July 22, 2021. Accessed February 10, 2022.
