Dr. Greene to Lead The Vision Council’s Low Vision Division

Ocutech co-founder and President, Henry Greene, OD, FAAO, has been elected in-coming chair of the Low Vision Division of The Vision Council (sponsor of Vision Expo East and West). His 2-year term begins in late January 2022. 

“I am honored to have been chosen to lead the Low Vision Division during what promises to be a very exciting time for the vision rehabilitation specialty.  I take over the reins from outgoing chair, Richard Tapping, who has lead the division during the many challenges posed by the COVID pandemic.”

As the first optometrist to take on this role, Dr. Greene plans to address issues that he feels will be helpful for all members of the low vision care community. 

One of the most common refrains that low vision providers hear is ‘How come no one has told me about low vision care until now?’

Addressing this lack of awareness will guide our efforts during Dr. Greene’s term in office.  Specifically the LVD goals will include:

  • Increasing awareness of low vision care on a national basis
  • Creating a national directory of low vision care providers
  • Improving and facilitating methods for the referral of patients for low vision care

To stay updated on the LVD initiatives and to express your potential interest to join a national directory of low vision care providers click here.

“The Vision Council is thrilled to welcome Dr. Greene into the Chair role for the Low Vision Division. From fostering a high level of engagement between members and division leadership to raising awareness of low vision rehabilitation among eyecare providers as well as visually impaired consumers and their caregivers, Dr. Greene will play a key role in moving the division forward,” said Ashley Mills, CEO of The Vision Council.

The Importance of Ocular Dominance in Low Vision Care

By Henry Greene, OD, FAAO

Over the years experienced practitioners tend to ‘go where the action is.’  What this means to me is that we refine our testing methods to do the tests that are most instructive in managing the patient and stop doing tests that don’t tell us much.

One such test that I have found very helpful is testing for ocular dominance. I’ve written a short blog post about Ocular Dominance and I’ve shared it here.

All of us have a dominant eye, just as we do a dominant hand and foot. Some of us have a very strong dominance while others can easily switch between eyes. I have a very strongly dominant right eye.  I can barely localize when looking through a monocular telescope with my left eye, and it took forever for me to learn to use my left eye with my handheld ophthalmoscope (dating myself, aren’t I?)

As we know, the dominant eye superimposes over the non-dominant eye. If the non-dominant eye is the only eye with reduced acuity, the patient might not even notice it.  However, if the dominant eye has the reduced acuity, they’ll be on the phone to us immediately. 

Whenever I have a patient with markedly different acuity between the eyes, I always have them cover the poorer-seeing eye.  If they report that they see better with that eye closed, than the covered eye is likely the dominant eye and this will impact all my prescribing decisions both distance and near.  When the poorer-seeing eye is the dominant eye and it drags down binocular vision I call it a “dominancy conflict.”

Most individuals find that sighting and localizing through a monocular telescope is much easier when using the dominant eye. In fact, many individuals are unable to aim or sight through a telescope with the non-dominant eye (like me!).  As a result, the ability for the patient to localize through a bioptic telescope will be much more natural if they are using their dominant eye.

Another easy way to determine the dominant eye is to ask the patient to look through a monocular handheld telescope without suggesting which eye to use. (I use a handheld 2.2x Galilean for BCVA of 20/100 and better, or a 4×12 Keplerian pre-focused for the chart distance for 20/125 and less.) They will usually bring it to their dominant reflexively.  And, since I already know which is the better seeing eye, I’m keeping my fingers crossed (behind my back) that they bring it to the better-seeing and hence dominant eye!

 If they ask which eye they should use, I suggest they bring it to whichever eye seems more natural.  On occasion, patients will show no ocular preference and can sight equally well with either eye, for which I send up a prayer of thanks, however this is less common.

When thinking about bioptic telescopes, if I have a dominancy conflict I will try to prescribe a binocular system in lower powers or if I need a monocular device, I would often prefer to prescribe a higher power to the dominant eye so long as I can get the acuity through telescope that I seek.  If I have to prescribe to the non-dominant eye, I might consider a sector occluder so when the patient dips their head to sight through the bioptic the fellow eye is covered.  However, even with occluders and/or lots of training I have usually found that these folks have a bit more of a challenge thriving with their bioptic and I will warn them about that right away.

Hope this little tidbit helps you as much as it has helped me.

Henry Greene to lead The Vision Council’s Low Vision Division

Ocutech co-founder and President, Henry Greene, OD, FAAO, has been elected in-coming chair of the Low Vision Division of The Vision Council (sponsor of Vision Expo East and West). His 2-year term begins in late January 2022. 

“I am honored to have been chosen to lead the Low Vision Division during what promises to be a very exciting time for the vision rehabilitation specialty.  I take over the reins from outgoing chair, Richard Tapping, who has lead the division during the many challenges posed by the COVID pandemic.”

As the first optometrist to take on this role, Dr. Greene plans to address issues that he feels will be helpful for all members of the low vision care community. 

One of the most common refrains that low vision providers hear is ‘How come no one has told me about low vision care until now?’

Addressing this lack of awareness will guide our efforts during Dr. Greene’s term in office.  Specifically the LVD goals will include:

  • Increasing awareness of low vision care on a national basis
  • Creating a national directory of low vision care providers
  • Improving and facilitating methods for the referral of patients for low vision care

To stay updated on the LVD initiatives and to express your potential interest to join a national directory of low vision care providers click here.

https://thevisioncouncil.org/members/low-vision-prescriber-network

“The Vision Council is thrilled to welcome Dr. Greene into the Chair role for the Low Vision Division. From fostering a high level of engagement between members and division leadership to raising awareness of low vision rehabilitation among eyecare providers as well as visually impaired consumers and their caregivers, Dr. Greene will play a key role in moving the division forward,” said Ashley Mills, CEO of The Vision Council.

When should I be considering an Ocutech Bioptic for my patient?

I’m frequently asked what makes me consider a bioptic for an individual patient. So, I’ve written a short blog post to describe my approach. There are several factors to explore when considering the appropriateness of an Ocutech bioptic for an individual. Here’s a list of factors you may choose to consider.

1. Vision

a. BCVA in the better-seeing eye (hopefully the dominant eye) is 20/300 or better

b. Field of view of at least 40 degrees diameter with regular glasses if used

c. Absence of hemianopsia

2. The prospective patient seeks to improve their distance and/or midrange vision for activities that might include:

a. Independent travel

b. Classroom

c. Signage

d. Shopping

e. Social engagement

f. Table/desk activities

g. Computer screens

h. Driving

i. Music

j. Theater/movies

k. Museums/galleries

l. Hiking

m. Gardening

3. They have promising manual dexterity and cognitive status

4. They have a need for hands-free visual support

5. Focusing options are based upon working distance considerations

a. Fixed focus (perhaps with reading caps) or Manual focus if their needs are at fixed distances  with minimal need to refocus the device

b. Autofocusing bioptic if they have a range of varying and continuous working distances

An alternate approach to defining vision. The Visual Radius and the Social Range

Quite often patients will ask what 20/20 means.  The explanation of the Snellen visual acuity fraction doesn’t often satisfy their need to understand.  A patient once mentioned that with her reduced vision from macular degeneration, the furthest she could see was to the end of her arm.  Having just received a 4 power bioptic telescope, she remarked that it in effect it made her arm 4 times longer.  She no longer needed to walk up so close to see her friends and family, read signs, watch TV, and shop at the supermarket. 

Her experience suggests an alternate way to define distance vision—the furthest distance one can see an object of regard, which we can call the “Visual Radius.”  There is also a range of distances in which we engage in our normal day-to-day activities, often from 3-20 feet, which we can call the “Social Range.”  Getting closer than 3 feet to recognize an individual is considered socially aggressive behavior—we’re invading their personal space. They don’t feel comfortable having it done to them, and we don’t feel comfortable doing it.  Rooms are rarely bigger than 20 feet, so if we can see to the far end of a room, we can pretty much see what we need to see to be socially engaged.

So, for many situations, the goal in prescribing telescopic low vision aids for better distance seeing might be to extend the “Visual Radius” far enough in to the “Social Range” to be helpful for the individual.  If, for instance, we can only see faces as far as 4 feet away, a 4 power telescope will extend the distance to 16 feet, far enough into the social range to be helpful.  If, in another example, one can only see a face from 1 foot away, a 4x telescope would only extend the “Visual Radius” to 4 feet– insufficient to see far enough into the “Social Range” to provide a functional benefit.

So, knowing the distance at which an individual can normally see well, can offer a method for us to describe visual acuity in functional terms in a way that the patient can appreciate.  It can also be helpful in determining the proper telescope power needed to be helpful to an individual.

Bioptic Driving: The challenge of dealing with the state’s driver licensing office

By Henry A Greene, OD, FAAO

One of the great motivators for individuals to pursue bioptics is that they may become eligible to drive. 

In 2013 the State of North Carolina, my home state, passed its bioptic driving law that would enable some visually impaired individuals to be eligible to obtain a driver’s license.  Soon afterward I was invited to make a presentation to the state’s DMV Medical Board to explain what bioptics were all about and how they are used for driving (seems kind of backwards, doesn’t it?).  While I had expected to give a 30 minute presentation, the meeting lasted 2 hours and discussions explored a range of subjects related to vision and driving.

Soon after, I was invited to join the DMV Medical Review Board where I became involved not only in reviewing and ruling on DMV actions regarding individuals who were deemed inappropriate for licensure based upon a range of issues including vision, diabetic control, seizure disorders, substance abuse, cognitive status, behavioral issues and high accident rate.  In fact, the majority of the cases I was involved in reviewing were not vision-related at all.

In addition to my roll examining the cases of individual drivers, I became involved in reviewing and revising the DMV’s vision guidelines including developing the process for licensing bioptic drivers. After several months of exploring the range of options, including meetings with stakeholders, we developed the methods and process that would be used for evaluating drivers. These were boiled down to be as easily administrable as possible. But there are 100 counties in the state, and many hundreds of DMV examiners, and more often than not, the examiner was unlikely to have previously encountered a bioptic driver. In addition, feedback I received from my own patients when they pursued their bioptic driver’s license, was that the DMV examiner had little idea how to perform vision tests on these individuals nor how to evaluate their on-road driving skills.

As a result of these issues, and as part of my role on the DMV Medical Board, I wrote a whitepaper backgrounder both for my NC Medical Board colleagues (one of whom was an ophthalmologist, while the others were neurologists, geriatricians, and a physiatrist) and for the DMV examiners in the field. I wrote two versions of this backgrounder to share:

In addition, as part of my role at Ocutech, I created several information brochures including:

I’m pleased to share this information with the low vision provider community.  I hope that this information is helpful and I invite you to share it as you see fit to help promote an effective understanding of how bioptics may enable visually impaired individuals to drive. If you should have any questions, please email us at bioptics@Ocutech.com.

Understanding “Galilean” vs. “Keplerian” and “Wide Angle” vs. “Expanded Field” telescopes

I thought that this discussion might shed some light on how bioptic telescopes are named and what the names represent.

As is well known, bioptic telescopes are available in two optical designs—Galilean and Keplerian. Each has its distinct characteristics and attributes. We prescribe them, of course, to support our patients’ range of distance-seeing needs and activities, not just for bioptic driving.

Read more