Lecture: Setting up Low Vision Clinics in the Present Scenario

DR PHANINDRA: So good morning, everybody. Thank you, first of all, for joining this webinar on setting up low vision clinics. I’m Phanindra from India. We have the resource person , Dr. Tanuja Britto. She’s actually from Orbis, and a consultant for low vision consulting and also a trainer and the director of the department of the Joseph Eye Hospital from Trichy, Tamil Nadu. So welcome to Dr. Tanuja. Thank you, Dr. Tanuja. Please go ahead.

DR BRITTO: Thank you very much, Dr. Penindra, and welcome, everybody. Good morning. For joining in. And thank you for this interest in low vision services. At the outset, I would like to thank CBM, and Dr. Sarah Madigan and Ravi for all their help in setting up this, and also I have to thank CBM for being where I am today. They trained me, and they helped set up our low vision services here in JEH. And I also want to thank Dr. Nelson, Director and Medical Superintendent of Joseph Eye Hospital, for his support to us. To me, especially, in this venture. In low vision. We started low vision in Joseph Eye Hospital in 1999, and ever since that, there’s been a gradual growth. So I would like to share about low vision. How to start low vision services, actually. Because now the need is increasing, and the interest is increasing. And there’s so much variety of inputs on this. So I would like to, at the outset, tell you how to set up, at a basic level. To start, what do you need? So you’re most welcome with your questions later, but what I’ll be saying is only an outline. So you are free to ask me at the end of this. We can go back to those slides. So thank you for patiently listening. So low vision clinic should provide appropriate, affordable, and accessible services. And the aim is to integrate a person with vision loss into the community, by enhancing residual vision. So for a person with a vision loss, they’ll be chartered into some isolated homes. But low vision is such that you put the person back into the community. So what are the basic components of low vision? The main thing about low vision is: People have some amount of residual vision. Although they have vision loss, they have some residual vision. So what we do is: We assess this residual vision, both clinically and functionally, just to quantify and qualify. Qualitatively measure it. And then once you’ll know how much they have, you’ll prescribe and provide interventions, train them in the use of prescribed interventions, and you refer them for other resources. And do a lot of follow-up. These are the basic components of any low vision service. So what is essential to low vision delivery? The main thing is: You need a modus operandi. That is a protocol. How do you go about it? Where do you start? Where do you end? What is the end? So you should have a protocol. How you do it. And then the second thing, most important, is trained Human Resources. You really need to train them in the right way. And then once they are trained, you need to have basic equipment. And infrastructure. What is infrastructure? These are the common questions that we are dealing with. And what are the other support services that you will need for a low vision clinic? So coming to the protocol, the first step is to identify if they are low vision or not. Because people with vision loss can be there, because they might need cataract surgery or a refractive error. So once that is then done, and then beyond that, everything is over, and then you’ve finished every medical intervention, and surgical intervention, and then they are still left with vision loss, then you do — that’s when you really identify them. So identification, positive identification, that these are low vision patients, is the first step. And once you identify them, what do you do? Once you identify them, you have to assess them. So assessment is two types. Clinical assessment, and then you don’t stop with that. Once you finish clinical assessment, then you do a functional and an educational assessment. Clinical assessment — we’ll be seeing that. It’s where you quantify how much vision they really have. And that also leads to your device prescription. Whereas functional and educational assessment is: How are they using this vision? Once you enhance it, how well are they using it? And functionally and educationally, how are they using it in everyday life? Are they able to use it in education? And how are they using it for their daily activities? And so on and so forth. So that is assessing. Once you are done with all your magnification, everything, then you have to, again, refer them or do this functional and educational assessment. So then you finalize your prescriptions, and so that is interventions. But one thing in interventions is: Low vision interventions — you have to do a lot of training to use them. Because there are some particular principles and calculations. So you have to train them how to use the interventions. For example, do they use it with or without the distance prescription? Do they use it with the bifocal? How are they supposed to hold the device? How are they — when are they supposed to use it? All this comes under your training part. And also, you will have to train them: How to read, write, do their daily activities, with the interventions that you have prescribed. And once this is done, what happens? Most often, follow-up is a problem, because our patients, once they are done with one visit, then they feel everything is done. But as we know, low vision — vision loss is usually progressive. Or there are changes. Especially with age and other things. So follow-up is very important. So again, follow-up is mandated. You have to know: Is there any change in their disease status? Is there any change in their vision status? And how are their interventions? What do you offer them? So follow-up is a very, very necessary and mandatory part of low vision services. So this is the protocol that we follow here. Most of us follow. So with this many steps, what are the Human Resources that we need? We must understand from the beginning it’s a teamwork. Because not that I alone am able to do it, or I should do it. So coming to the team. Who are the team that we are looking at? So there are two types of teams. Sorry, members. One we may call as clinical. The others, I’ve named it as non-clinical, but usually they are called functional people. And then there are others who will be doing supportive work for us. So clinical people means we eyecare people. That’s what. Ophthalmologists, optometrists, refractionists, vision technicians. People like that. And non-clinical people can be anyone. The difference between a clinical and a non-clinical person is: A clinical person knows all about refraction and calculation. How to prescribe devices and such like. A non-clinical person is someone who does not know anything about refraction. That is the basic difference. And they are the people who will be doing your educational and functional assessment. And who will help out in the field. So I named them as non-clinical, but normally we call them as functional people or rehab people. So who are the people who will come under this? Rehab professionals, educators, special educators, everybody. Any type of social workers and any type of therapist, occupational therapist, physical therapist, anybody who we can train them to do this functional and educational assessment, and give us help with the patient. The other things that you will need in your team: I put it as admin workers. And accounts people. These are the people who will be helping you with other things, other than the assessment and interventions. And training. So let’s look at that. What is that job? So who does what? So finally, clinical people or eyecare people will be doing their clinical assessment. That means they will be evaluating, just like any other patient. Refraction, magnification, and then you prescribe distance and near, and then optical devices. And you also have to train them, how to use those aids. So follow-up always becomes necessary. So you’ll quantify the vision, just like any other ophthalmologic preparation. Like an ophthalmic patient — if you do a slit lamp examination, you do a fundus examination, and then refraction, distance correction, near correction, and then you try magnification, then you look at their contrast sensitivity, field, and how good is their near vision, and then you prescribe the distance, and like I said, the normal spectacles that they need, and then you go on for their optical devices that they need. And then you train them how to use these optical devices. The functional people, like I said: What are their roles? So primarily, they will be sitting and counseling the patients. We also will be counseling them. But they will take over and tell the patient how they can use these. What are the problems. They can actually help you, finding out: What are the day-to-day problems that these people have? What is it that they are — where is it that they are having some problems? So they will help not only in counseling, what to do, and all that, but also to find out: What are the needs that the patient has in everyday life? Because we are not dealing just with their diagnosis or vision loss. We are finding out: How are they handling this vision loss in their day-to-day work? So these functional people will help us by finding out in their day-to-day — how they are able to manage. So that’s what these people can do. Apart from what we do. And then a lot of counseling goes into this. Because they have to tell them how they can adapt in their situation. And they will do a functional assessment, in the sense: How much — it also includes your educational assessment. Are they able to read? Are they able to write? Are they able to move around? So all this. Are they able to do their daily activities? They assess that. And then, based on that, with optical devices, they do this, and then prescribe or recommend non-optical devices. Primarily non-opticals that we will be seeing later. What are the non-opticals. And then they also do a lot of training. How to work. How to read and write with a device given by their clinical people. Or eyecare people. And also a lot of guidance goes into this. Like where to go to school, what vocation to take up. Do they need any training? Or do they need even physiotherapy, especially in special children and all that. So all this sort of guidance, career guidance, everything. So a lot of counseling, again, is required. So these people will do that part of it. And we talked about supportive services people. And apart from this, we have — these are the two primary areas. But out of this, we also need a lot of what I put as others. What other activities? Once you do all the assessment and all that, record keeping. Recording is so important. So you have to record. You have to be very meticulous in recording what are the devices, at what distance, how are they able to — even their day-to-day, their activity. Are they good with light or without light. All that sort of thing. So record keeping is so important, and recording is so important. So keeping these things, especially files, are very important. Now we have computers. So even then, those are the other activities of recording. Then billing. So how are you going to bill them? What are you going to look at? It’s all about finances. So I said accounts. Are you going to give them free of cost, are you going to give a subsidy, or people are going to pay for it, how are you going to manage this? Are you going to look for sponsors? All of that comes under the finances and billing and all that. Then again, scheduling appointments. Follow-up. This is mainly follow-up. Or contacting the low vision people. Finding out where they are and what are they doing. Why they have not come, and all that sort of thing. And also, communication. In the sense… If you’re going to do some placement and all that, you have to be… You have to know people who can take this child in their school, or in the business, or whatever. So a lot of communications. Around it, you have so many activities. Which have to be also looked into, or you need a person to do that. The functional people actually can do that also. They can do all this. But I would say all this guidance, counseling, and all that, you can add all the other activities with that. So with so many activities, and so many people, we would be wondering — so many stages of the protocol — how many people we really need. How many we really need. Anybody would like to offer? Let’s see if we have… So this is the WHO recommendation. An ophthalmologist and a special educator or a rehab person. That means one eyecare person and a non-eyecare person. These are two people who are sufficient to run a low vision clinic, to provide the diagnosis and services, care for 10 cases, 10 to 15 cases per day, and care for a population of 5 million. This is the WHO recommendation. So you can go up and down on this. But definitely you need two people in the team. An eyecare person and a non-eyecare person. Who will help your functional work. So the non-eyecare person is really necessary. A special educator. If it’s a hospital or a clinic. Then you can always train an ophthalmic nurse or a general nurse, who does not know — you see, the thing is, they should not be forced to do — they should not be doing refraction. They can be anybody who does not know refraction. But who can help or who can be trained to do this. Could be a counselor. Or anybody, for that matter. With a little bit of education. And education also — you don’t need a masters degree in social work or anything. Class 2 passed, in rural areas, more than sufficient. If you want it to be a little bit higher, maybe a person — excuse me — with a science background, preferably a graduate, is more than sufficient to train them. You can train them. Provide all that. And help them too. Helping patients. And normally, these people are — as we progress, they are very supportive and very good for us. So that’s one thing. So what I’m trying to say — why I’m saying this — is: You must understand that low vision is teamwork, and it’s not all about eyecare. It’s not all about low vision devices. Clinical assessment and devices. There are other things involved in it. That’s all. So then let’s come to the equipment. What is the equipment? What I call basic diagnostic equipment, equipment for clinical assessment, and equipment for functional assessment. So let’s look at that. So basic diagnostic is like your slit lamp, your refraction set, retinoscope, everything. And your vision charts. Fundus examination. All that goes with that. So in this, I want to add something. Many of your patients, your refractometer does not work. You have to be very sure of your refraction. That’s very important. So a refraction set — especially those with the big aperture lenses — are very good. So the big aperture lenses are the best in this. So otherwise it’s just your slit lamp, your fundus lamp examination, and all that. Then your vision assessment. For vision assessment, you have the different charts. Mostly LogMAR charts. And then you have your functional assessment kit. Your magnification set, all the devices, optical devices, and your other interventions. So we will see that. So what is this assessment kit? Anterior and posterior segment instruments, like I said. Refraction set and fixation targets that you can use. There are multiple ones. The ones with the smileys and things like that. And then LogMAR vision charts for distance and near. I can show you some of these. So this is a 3 meter chart. It’s a simple chart. We could actually hang it, and I hope everybody can see it. This is a 3 meter chart. This is a 4 meter chart. This is a 4 meter chart. Okay. You can’t see it. This is a 4 meter chart. And then we have a target that you will use. This is a target that you will use. And that everybody knows. And these are grating patterns. So the near vision charts like this, which we call flip charts, you can use these charts, they’re supposed to be held at different distances, and LogMAR charts (inaudible). You have near vision charts. So these are the different near vision charts that we can use. And (inaudible). Then you’ll have your contrast sensitivity chart. I want to say something about the contrast sensitivity chart. Don’t go in for the Pelli-Robson. Most of the low vision patients will not be able to cooperate for your Pelli-Robson. The simple ones are adding a double layer, and then you will have the grating charts. And actually even your Cardiff is based on contrast sensitivity. And color and field testing. Field testing, again, I want to caution you that HFA fields cannot be done, most often because of the contrast problems. And then, for the reading, writing, and all that, you need to have some schoolbooks and magazines. And you need measuring tapes and your records. Records means where you wrote down all that. So measuring tape — you have to be very specific about what distance you are testing them. So that’s very important. So that’s why I put that there. And then your interventions that are optical, I’ve put down some intervention devices, optical and non-optical. The near devices — you have near and distant devices. So near devices are magnifying glasses, hand and stand magnifiers, telescopes. And then field expanders are reverse telescopes. They have a field button. The size of the object becomes small. CCTV, and Fresnel prisms. Fresnel prisms are available freely to be inserted. But again, patients have to get used to Fresnel prisms. And glare controls are tinted glasses and filters. Let me show you some of them. So this is a stand magnifier. Again, I hope everybody is able to see. This is a stand magnifier. And this is a hand magnifier that everybody has seen. This is another type of hand magnifier. That has a two-power lens. So you can see this. This is a dome magnifier. Excuse me. This is a stand magnifier. Another model. And you know about the CCTV. Everybody has got this. It’s very expensive, but it’s good for distance vision. And this is the spectacle mounted telescope that you use like this. For classroom reading. And this is a handheld telescope. And this is another type of hand magnifier. And of course, everybody knows this sheet magnifier. Which is easy for older people especially. So this is that. Yeah. These are… This is a loupe, where the patient takes their money — this is money magnification. This is a tightness pull, where a person puts it on their reading material and reads in a single line. This is a writing guide, where you write in between the lines. So the person is writing straight lines. This is a signature guide. So older people, they are able to just cover it like this. And they can sign checks and all that. These are the different types of filters. Filters — they are very expensive. But now they’re available. Only certain colors are available. These are common ones which CBM got for me. We have a stand here. We can see… So if you can see, this is the reading stand. So this is actually… I bought it on Amazon. It’s funny. Because in those days, we were — in the early years of my practice, we had to run around for this, make it ourselves, and things like that. But now this is available online, and this lamp is also very useful. It’s very portable. And this can be used — you can even control the emission of this. So this is very useful. This is how you can do it. And of course, a cane is useful for mobility purposes. And a cap to avoid glare. Then, since things are locked up, I’m showing you — this is a video magnifier, portable. And this is what we have already. This is a CCTV, with a mouse model. So these are the latest assistive devices, that are more software. Like magic software, JAWS software. There are two types of software. Screen reading and screen magnifying. So these are the things that are available. Now let’s come to infrastructure. Excuse me. Coming to infrastructure. So when you plan your low vision services, you have to decide about enhanced accessibility. Patients should be able to find their way in and out. So there has to be a lot of attention given to color contrast, lighting, and glare. So especially the reflective glare tiles cannot be used. Paint has to be matte finish. These sorts of simple changes that you need to make. And patients should be able — not much of all these lamps and things like that. As preferably possible. Make it smooth from the opening to your department, or as close as possible, for patients and everybody. Be very careful that the floors are not slippery. And they don’t have glare. So these are all very important. And you also want to have controlled lighting, where you can increase or decrease, according to the — that’s why this whole place is so lighted up. And you can reduce the number of lights, or you have this control. So with that, you can diminish or increase the light. One thing is: Low vision is always not about bright lights. So we need to know the patient’s preference. And then facilities that you will need: You will just need a room. It could be 8 to 10 square meters. That’s sufficient. You don’t need a very big space. You just need that. And one corner can be for clinical assessment, and the other corner — it has to be very non-clinical, or shall I say non-hospital, where there are some toys and books and other things. So we have some books that we see how they do things with, and then we have a blackboard also, where patients can write on the blackboard. It’s a simple blackboard. You can actually paint the wall. Or paint anything. One side of the wall, you can check how they are doing with their device. When you are giving a telescope, you have to check the blackboard reading and all of that. So I believe that 8 to 10 square meters — that would be about — because you need a full 6 meters to measure the vision. You can’t just do it as the return on the 3 meters. 3 meters is not sufficient. So 6 meters are definitely required. I gave a margin of 8. Another 2 square meters. So that’s what we need. And it has to be comfortable and clutter-free, please. You cannot put everything where the patient can crash against or dash against. All of this has to be very — you have to be very careful about these people. So you have to make them comfortable. Otherwise, they’re not going to come to you. The other thing is clutter-free. This is very important for the low vision patient. Then what are the other things that we have to put our mind to? Record keeping. This is very, very, very important. Not for legal purposes alone, but just for your follow-up. Because if you test a patient today, and then you don’t have any records, and they come back, you will be redoing this whole protocol that we saw, which is a waste of time. And so you must know where they were, when you saw the person. So that helps you to also monitor your progress and all that. And you need a stock and inventory. So you can’t just — these devices are not available outside. And even if they’re available, they’re not made on optical principles. So you need to keep a stock, which you can sell on the spot. And your glasses, magnification glasses, you can do them at any and all optical shops. Yeah. This is a +20 with a pediatric insert. This is ready made, but you need an assessment before this. And then you also keep some ready. Which you can sell on the spot. So you need to maintain stock and keep a stock of devices. Because most of the time, our patients cannot afford them in the beginning. So you need to keep a stock and inventory. And then ask them to — you can sell it on the spot. So this takes us to accounting and finances. So finance burden — you have to think about: What are you going to do? How are you going to do that? Also, low vision doesn’t end with you in the clinic. It also spills over to the community. So community interaction — for example, you need to be aware that you have to do a lot of community interaction. And then we see what we do. And it becomes a question of sustainability. I want to tell you: At the outset, in the beginning, we did not even talk about this. But accounting and sustainability — you have to decide whether you’re going to give it all free, all paid, or a subsidy, and how much subsidy and things like that. That depends on you. So what is a subsidy? 10%, 20%, 30%, whatever. So you have to remember all this, when you are in your accounting. So that’s why I put that. And sustainability. In the beginning, you cannot even talk about sustainability. But later on, we can move into that. Since now we have more indigenous devices available. Normally the Indian ones are less than the imported ones. So just because they’re imported does not mean they are good. You have to verify. You have to use them and see. So the optics are very important. So you have to find out which are your vendors. Don’t just take one company and say this is good. Try others also. So you have to decide about all that. So I can then — I talked about community interaction. So networking is very important. So why must we do networking? Mainly, case detection. You train people, you have infrastructure, you have everything, and then you don’t have cases? Then layoffs. It’s bad. So you have to find — you can’t just say only those who are coming to the OPD. So case deduction. You can network with all the NGOs in this field. And you will get a lot of cases. And then supportive therapy. If a patient needs occupational therapy or if he needs physiotherapy, whatever it is. But that — you have to network. You have to know the cases. The patient can be sent and followed up. You have to have a good rapport with them. And then socio-economic resources. In this, government plays a major role. Because our patients may not be able to afford the rehabilitation services of every state and the government of India. Social welfare. Family and social welfare has a lot of this help. So you have to send them for socio-economic resources. Like: Can they get some free subsidies? Can they get some support for scholarships or for setting up a business? All that. So you must know the people in the government sector. Like the local district rehabilitation officer and things like that. You need to know the people who are there, who can help, and also for placement. You can’t just leave them and say they’re good. They have to find out schools which are able to take them, and give them education, which allows them to build their skills with your help. And vocational placement. That’s very important. I have done this very often. Education — I have to talk to the colleges and schools. So our patient placement — you can suggest to them actually — you must have a list of where these people can be placed. For training, as well as for their livelihood. That’s very important. So this also brings us to the question of advocacy. This is very important. In our hospital, for any hospital, you have an HR department, you have a marketing department. So you can use these people actually for this work. You don’t need a separate person. Then a few pointers in planning. What are the necessities in planning? So evaluate the need in your catchment area. How much is it? What are the people? So just find out the need in the community. Then you will know what services are required. You don’t just start with the tertiary level. You don’t think about the tertiary level with all this rehabilitation. It’s not necessarily, absolutely. You can build it up later. So in the beginning, that’s why I said it’s basically vision services. So determine what level of services are required for your program, project, or study. And then constant networking. If there are things not available, start networking. Just because you don’t have a functional person or rehab person, you can get one later. You network with someone. Send them somewhere they can get that information and bring it back to you. So we do a lot of networking like that. We send them for IQ evaluation and different types of evaluations. So networking is very important, when you’re thinking about the level of services. Then analyze your financial commitment. How much are you going to be able to invest in this? My thing is that you would need only 2 to 3 lakhs in the beginning. You don’t need more than that. You really don’t need more than that. If you’re starting small and you don’t have the basic things. You don’t need much. And then determine how to incorporate this into your existing organizations, institutions, frameworks. You have to — this is a very important one — that you have to try and incorporate — not demand. This has to be there. And something like that. But you have to incorporate into especially the timings. So in the beginning, consider timing for your people. Once you pick up, like in our hospital, we don’t separate them. When the patient comes, we do them and we manage — the general OPD, special OPD, everything together. So you have to find how you can work within your existing framework. So caution in planning. As I was saying, there are three things that you have to keep in mind. There are a few things which are — many things which are necessary to have. Okay? So the basic stuff that I told you. Then there are some things which are good to have. Like all these assistive devices right there. And there are some things which are nice to have. But at the outset, I would say stop with what is necessary. Don’t plan for — that’s why my version is very small. Two to three lakhs. So what is necessary? It fits right into that. It good to have — in your services, expand — when you are going up, when you are expanding your services, your level of services, then you can think of these good things. Keeping your computer training and all your software, all these assistive devices. Some of these assistive devices are 2 lakhs and 3 lakhs, which is not really necessary right now. So that’s good to have. And nice to have is — I don’t know. Nice you to have. Even though we are a tertiary level eyecare, especially in low vision, we are a center of excellence, still there are many nice things which I still don’t have, and I don’t think it’s necessary. Because our thing is to reach out to the patient, the person concerned, and see that they are okay. They are back in the community, living their lives. So that’s the caution in planning. And that’s why my finance — you might think my finances budget is very low. But I think that’s more than sufficient. If you want, you can stretch it up to 5 lakhs. So to conclude service delivery to those with vision loss, which is towards community integration, by establishing these clinics, should have: If you’ve been listening, it’s a holistic approach. You can’t just see the clinical part or the eyecare part and then send them. You have to do a holistic approach. Where the patient’s livelihood and his economic status, everything comes into play, and you have to at least coordinate for them. Even though you may not do it for them. Coordinate and see that they are — and again, the service delivery should be in a phased manner. So low vision clinics can start small, and then you can keep adding things. There is support for everything. And I also find that as you move on, many things become obsolete. What was necessary has become obsolete. Because of technology. Equipment. Again, don’t go in for too much of technology. Because most of it, most of our patients are from the lower status of society or in the rural areas. They may not have all those. So with all these gadgets coming up, your smartphones, you have softwares which can be used on smartphones, so many things — that’s why it’s better in a phased manner. Thank you. I want to thank Dr. Nelson for his support for me, in all these years. And thank you all for patient listening.