Managing low vision candidates has changed dramatically as this case study shows.
The majority of low vision patients present with a loss of visual acuity with dense central scotoma in both eyes. In this group, the most common diagnosis has been wet age-related macular degeneration (AMD). With the advent of better treatment regimens””in particular, anti-vascular endothelial growth factor (VEGF)””the management of these patients has dramatically changed. The following case report highlights many of these changes.
|Abnormal slit lamp results signal ocular disease.|
A 78-year-old female came into our office with multiple ophthalmic problems and surgical interventions. She has a 20-year history of primary open angle glaucoma that has been aggressively managed, initially on topical medicine and then with trabeculectomies in both eyes followed by a tube shunt in the left. This aggressive approach has resulted in only minimal field loss. She has also had cataract/IOL procedures in both eyes.
To complicate matters, she was recently diagnosed with wet AMD in both eyes and went through a series of anti-VEGF injections every six weeks for eight months. She is now considered stable with occasional injections in the left eye.
Her chief concern was a gradual decrease in vision over the past three years. She is unable to drive or read comfortably, even with her closed circuit television (CCTV) magnifier, telescopic glasses, and new prescription glasses from another doctor.
Entering visual acuity, measured at 10 ft. with her new glasses was 10/60 in the right eye and 10/80 in the left. Near acuity was 1.6M in the right eye and 1.2M in the left; both measured at 30cm.
Lensometry: OD -0.50 +0.75 x 180 OS -1.00 +1.00 x 180 with a +3.00D add in a progressive multifocal.
Manual Keratometry: OD 41.50 at 110 x 46.75 at 20 with slightly blurred and distorted mires; OS 40.00 at 75 x 47.00 x 165 with moderately blurred and distorted mires.
Trial Frame Refraction at 10 ft. showed: OD -2.50 +3.00 x 23 OS -2.75 +4.00 x 165.
Distance acuity improved to OD 10/15 OD and OS 10/20; with a +4.00D add, near acuity improved to .5M.
Ocular health exam was consistent for a patient with bilateral trabeculectomies and a tube shunt in the left eye. The posterior chamber IOLs were well placed with clear capsules. The intraocular pressure was 10mm in each eye. Dilated fundus exam showed asymmetric cupping of the optic nerves with the right at .6 and the left at .8. There were diffuse pigment changes in a macula with moderate drusen with mild geographic atrophy.
The patient was given new glasses as follows:
OD -2.50 +3.00 x 23
OS -2.75 +4.00 x 165
ADD +4.00 FT Bifocal
With increased cylinder in her spectacles, the patient has maintained good acuity in follow-up exams of 20/40 in the right eye and 20/50 in the left with 20/30-2 OU. Her near acuity is .5M OU and she is able to read comfortably with a good light source. The CCTV and the telescopes were donated to The Lions Club.
As technology continues to advance providing more options for patients with vision loss, vision rehabilitation often begins with an accurate refraction. Using a trial frame provides a more realistic approach compared to using a phoropter. A basic hand magnifier set (+5.00D, +10.00D, and +20.00D) and a handheld telescope of 2.5x to 4.0x are all we require for most testing.
Scott A. Edmonds is in private practice in Philadelphia, PA.