«INTRODUCTION Assessment and management of patients with impaired vision has been part of the curricula at schools and colleges of optometry ...»
Entry-Level Competencies and Learning Objectives
In Visual Impairment and Low Vision Rehabilitation
Assessment and management of patients with impaired vision has been part of the curricula at
schools and colleges of optometry throughout North America for many decades. These low
vision curricula have evolved differently at the various schools and colleges, with varying depth
and breadth of classroom, laboratory, and clinical activities, but with all students held responsible for core low vision knowledge for National Board examinations. Nevertheless, concerns have arisen about the adequacy of current low vision education in meeting public health needs, primarily based on the observation that only a minority of practicing optometrists provide any low vision care1. Only 36% of optometrists responding to the 2006 AOA Scope of Practice Survey indicated that they provided some level of low vision services. However, nine out of ten (89.9%) ODs reported that they managed or co-managed patients with macular degeneration.2 More than four out of five (84.6%) reported referring low vision patients elsewhere for services, while only 25.4% indicated that they accepted low vision referrals from other practitioners.
There are a range of possible explanations for the modest clinical involvement of optometrists in low vision care, including referral patterns, start-up costs, reimbursement rates, and a range of perceptions about low vision practice. Some of these perceptions may stem from the low vision curricula provided by the schools and colleges of optometry. One such perception is that all aspects of clinical low vision rehabilitation fall within a specialized area of optometric practice that requires advanced training and credentialing, and are, therefore, not within the clinical scope of practice of primary care optometry. Optometrists, however, who have recognized the 6110 Executive Boulevard Suite 420 Rockville MD 20852 (301) 231-5944 Fax (301) 770-1828 www.opted.org significant need for low vision care, have responded to that need within a two-tiered approach to patient care. This approach has resulted in the delivery of low vision care not only by advanced care low vision rehabilitation programs, but also by primary care optometrists who choose to incorporate low vision care into their practices in order to address their patients’ basic low vision needs. Advanced care low vision practices and rehabilitation centers are typically staffed by optometrists who have had extensive experience in the field and have achieved formal recognition of low vision competency through completion of a residency program, certification by a state agency or completion of the Diplomate Program of the Low Vision Section of the American Academy of Optometry. These comprehensive low vision rehabilitation programs, however, are scarce and do not meet the geographic need for low vision rehabilitation services throughout the US, Canada and Puerto Rico. In order to address the low vision needs of their patients, private practitioners without extensive low vision rehabilitation experience, utilize their basic optometric training, clinical experience and informal post-graduate studies in the management of their patients’ low vision issues. Due to the variations in existing optometric low vision curricula, these doctors may not have the resources or knowledge base in order to offer more comprehensive low vision care. They may also not be aware of regional referral resources that would be able to address their patients’ more complex rehabilitative needs. The result is that patient needs may not be fully met, despite the optometrists’ best clinical efforts, and patients may not be adequately educated about appropriate resources that could address their unmet rehabilitation goals.
Optometric low vision educators have been eager to reduce barriers to low vision practice in order to meet public health demands and to enhance practice opportunities for graduates. Over twenty five years ago, there was a recommended plan for an educational program from ASCO that included a comprehensive curriculum plan for low vision rehabilitation.3 This thorough and ambitious model was not readily adopted by all of the schools and colleges of optometry,
optometric low vision educators have expressed a renewed commitment to ensuring that patients with low vision have access to services that will address all of their low vision issues.
The ASCO Low Vision Educators SIG was formed in 2006 and consists of representatives from every school and college of optometry in the United States, Canada and Puerto Rico. In order to meet public health needs and serve the profession, the ASCO Low Vision Educators Special Interest Group (LVE SIG) has focused on the development and standardization of specific competencies and learning objectives for both entry-level and advanced-level low vision care curricula.
The LVE SIG proposes that the development of competencies and learning objectives reflect the need for two tiers of optometric practice in low vision rehabilitation. The first tier, entry-level competency would focus on basic level low vision rehabilitation principles and clinical strategies appropriate for primary care practice. The patient population best served by these entry-level low vision rehabilitation strategies is comprised of individuals with mild to moderate levels of visual impairment. Functional visual goals addressed during a primary care low vision evaluation might include improved ability to read small print, watch television and to explore strategies for reducing glare. Achievement of the low vision competencies would be accomplished through coursework and clinical internships during the four year optometry curriculum. In addition to a specific low vision rehabilitation course, elements of the low vision curricula may also be integrated earlier in the four-year optometric program into existing basic science and clinical practice curricula. Early exposure to low vision related issues might foster the perception in optometric students that their patients’ low vision issues should be incorporated into primary care examination and clinical management strategies. Essential to that approach, however, is that primary low vision care must include an awareness of
concepts that highlight appropriate patient education and referral of patients for comprehensive care.
The second tier, advanced-level competency, would include advanced concepts in low vision rehabilitation that would be primarily learned in post-graduate education (e.g. low vision residency programs). The patient populations served by advanced-level low vision rehabilitation strategies would include individuals with severe and profound levels of visual impairment, individuals with moderate impairment who have special rehabilitative needs that cannot be addressed in primary care practice, as well as individuals who have both visual impairments and other physical or cognitive impairments, necessitating specialized examination and management strategies.
There is a substantial need for practitioners skilled in the care of patients with mild or moderate levels of visual impairment whose needs may be met through entry-level vision rehabilitation strategies. In a small pilot study of the recruitment potential of low vision clinical trial sites, Kammer and Jones reported on the patient characteristics of six optometric low vision clinics over a thirty day period. The study found that approximately 78% of all patients (n=163) considered to have “low vision” met the ICD9 classification for moderate visual impairment or better, based on visual acuity that was better than 20/200. More specifically, 36% of patients had acuity better than 20/70.4 This suggests that a significant number of patients seen in optometric practices may in fact need only entry-level low vision care, and that this need could be met by training optometrists to address a large segment of the visually impaired population.
Education about the role of comprehensive low vision rehabilitation services and clearly defined referral criteria are critical for appropriate care of patients who may fall outside the scope of entry-level practice.
through the efforts of the Vision Rehabilitation Committee of the American Academy of Ophthalmology. The committee’s SmartSight vision rehabilitation initiative seeks to specify how vision rehabilitation fits within a continuum of ophthalmic care, using a model with three levels of training.5 The International Council of Ophthalmology also supports three levels of training or competency, using low vision rehabilitation curricula with basic, standard and advanced-level goals. The first two levels include a more comprehensive low vision evaluation, treatment and management approach, including the introduction of various low vision devices for field enhancement as well as for central vision loss. These two levels also include driving assessments. The third level includes prescribing of the most complex optical devices, rehabilitative therapies and field enhancement strategies.6 During LVE SIG meetings that were held in conjunction with the 2006 and 2007 meetings of the American Academy of Optometry (AAO), a common theme surfaced repeatedly. The educators thought that there was a need for a body of competencies and learning objectives that would serve as a foundation for instructors charged with creating or maintaining the low vision rehabilitation curricula in the schools and colleges of optometry. While there was agreement that competencies and learning objectives were needed both for entry-level and advanced practice, the LVE SIG agreed that the logical starting point would be to develop entrylevel competencies and learning objectives. These competencies and learning objectives were developed and finalized during LVE SIG meetings held in 2008, 2009 and 2010. The future utilization of these competencies in the development of low vision curricula will give evidence of their value to optometric education.
For details regarding the process of developing the competencies and learning objectives, refer to the Addendum. (ADD LINK) 6110 Executive Blvd., Suite 420, Rockville, MD 20852 301-231-5944 301-770-1828 (Fax) http://www.opted.org Carlson AM, Hinkley SB. The status of low vision rehabilitation and certification in the state of Michigan. In press: Optometry, 2011 AOA scope of practice survey, 2006.
A plan for an educational program in rehabilitative optometry. Conducted by the Association of Schools and Colleges of Optometry 1980.
Kammer R, Jones L. Study of Low Vision Recruitment Potential. Optom Vis Sci. 2006; 83 (suppl).
American Academy of Ophthalmology. Vision Rehabilitation for Adults Preferred Practice Pattern. San Francisco CA: American Academy of Ophthalmology; 2006.
International Task Force on Resident and Specialist Education in Ophthalmology on behalf of the International Council of Ophthalmology (ICO).. Principles and Guidelines of a Curriculum for Education of the Ophthalmic Specialist.Chapter 15. Low Vision Rehabilitation. Klinische Monatsblätter für Augenheilkunde. 2006.223:S1-S48.
Visual Impairment and Low Vision Rehabilitation: Entry-Level Competencies and Learning Objectives Competency 1. Epidemiology Be able to apply epidemiologic aspects of visual impairment, appropriate terminology and classifications of visual impairment in order to communicate with patients, the public and other health care providers.
Objective 1A Identify leading causes of visual impairment in specific populations (as defined by key demographic factors).
Objective 1B Use current terminology in blindness and visual impairment classification.
Objective 1C Adapt explanations of this terminology for communicating with patients, the public and other health care providers.
Competency 2. Case History In addition to performing a standard case history, be able to ask basic questions about symptoms, functional difficulties, and rehabilitation goals to anticipate the level of care that patients with visual impairment may require.
Objective 2A Identify and document patient’s knowledge and understanding of his/her disorder and prognosis.
Objective 2B Customize case history questions to address task performance and safety issues.
Objective 2C Elicit specific rehabilitation goals of a patient with impaired vision.
Objective 2D Develop initial impressions about the range of rehabilitation services that may be required based on information collected in the case history.
Competency 3. Implications of ocular disorders Be able to recognize functional implications, hereditary factors, and prognoses of common causes of visual impairment and explain them in language understandable to patients, families and other care providers.
6110 Executive Blvd., Suite 420, Rockville, MD 20852 301-231-5944 301-770-1828 (Fax) http://www.opted.org Objective 3A Describe vision changes associated with common causes of visual impairment and their functional implications, such as task performance, comfort, and safety.
Objective 3B Recognize common genetically based causes of visual impairment and provide patient education and referral, as indicated.
Objective 3C Identify natural history and typical clinical course of common causes of visual impairment.
Objective 3D Use plain, clear and individualized language when advising patients, families and care providers about the implication of common causes of visual impairment.
Competency 4. Psychological issues Be able to recognize psychological factors (e.g. depression, grief, motivation) that may affect adjustment to vision loss and the potential for rehabilitation.
Objective 4A Identify patient psychological signs and symptoms that may affect adjustment to vision impairment and outcomes of rehabilitation.
Objective 4B Identify visually impaired patients in need of psychological support and refer them to appropriate care providers.
Competency 5. Social issues Be able to recognize pertinent social factors (e.g. social support system, education level, vocation, physical environment) and how they may influence the rehabilitation plan and process.
Objective 5A Identify social factors that may affect rehabilitation outcomes and adjustment to vision impairment.
Objective 5B Identify visually impaired patients in need of social support and refer them to appropriate care providers.