Models of Low Vision Rehabilitation and a 

Multidisciplinary/Interdisciplinary
Approach to Low Vision Rehabilitation

Susan J. Leat, PhD, FCOptom, FAAO

Professor
School of Optometry and Vision Science
University of Waterloo

©Copyright: Susan J. Leat

LV rehabilitation in Canada
• Very variable among the Provinces
• QC – most comprehensive
• 14 government-funded MDCs
• ON
• A few MDCs
• 10 CCTV assessment centres
• OD/MDs in solo practice or with VLRO (CNIB)
• AB
• One MDC in Calgary and one travelling LV clinic for
children
• Services by VLRC (CNIB) working with Optoms in
their offices
• SK
• 2 clinics with OD/MD passing onto VLRC
• MB
• 2 fairly complete MDCs offered by VLRC
• BC, NS, PEI, NB, NL – no MDCs
• ODs → devices → refer to VLRC
• PEI – have to travel out of province
• Most provinces have some OD/MDs
providing LV assessment and devices

• Communication not ideal between our

professions

Lam, Leat, Leung. (2015) Optom Vis Sci 92:365‐74.

• Funding for low vision assessments very
variable also.
• BC, NS & AB – ODs can bill a modest LV
assessment fee
• Balance billing is allowed in BC
Other provinces – for restricted category
of patients (e.g. age, veterans) or
dependent on location of service or no fee
at all
• ON – no fee for ODs doing LV
assessment. There is a fee for MDs

• Yet the ideal is for LV rehabilitation to

start with refraction, updated glasses,
good functional assessment (VA, CS, fields
etc), determination of magnification and
trial of simple devices (if applicable).
• Also very variable funding for devices

• ON – ADP
• AB – funding through VLRC (STEP program)
• SK – SAIL program for those with VA≤6/45 or
fields <20⁰ and who have had an assessment
through one of the LV Clinics
• QC – devices free on loan when patient
evaluated through an MDC
• Other provinces – no or very patchy coverage
EHCO (Eye Health Council of Ontario)
report
• Fragmented model for delivery
• Difficult for patient to navigate the
system/repetition of visits
• Estimated 23-26 months for typical patient to
get all their needs met
• Limited and patchy cover for providers
• Redundancy – repetition of assessment
• Still not enough patients being referred for LV
rehab Low Vision Services in Ontario: Current Status, Gaps and Recommendations 
for Change. Low Vision Rehabilitation Sub‐committee Sept 2015
What is needed?
• Visual rehabilitation should be recognized
as a medical necessity similar to other
rehabilitation? E.g. stroke, neurological
diseases, orthopedic?
• And funded appropriately
• A consistent model across the Province
• Cost effective
What model should we adopt? What is
the evidence?
• There is evidence that full MDC LVR is
effective (LOVIT)
• No strong evidence that the full MDC is
significantly better than solo optometric
services or other community services
overall

Stelmack et al (2008) Arch Ophthalmol 126:608‐17, Reeves et al (2004) Br J Ophthalmol 88:1443-9

La Grow and Daye (2005) Int Cong Ser 1282:187, De Boer et al. (2006) Ophthal Physiol Opt 26:535-44.
Two or three tier system
• Growing interest in this concept

• Welsh model
• Local optoms provide LV services (refraction,
devices, tints, lighting)
• Link with community resources → some
level of multi-disciplinary support
• Shown to be as effective as the LOVIT rehab.
• Patients were seen quicker and more locally

Ryan et al (2010) Ophth Physiol Opt 30:358-64. Court et al. (2011) Br J Ophthalmol 95:178‐84

• Australia discussing a similar model.

• Wales and Australia have isolated

communities, like Canada

Bentley et al (2014) Clin Exp Optom 97:214‐20

 WHO recommends a 3 tier model
Three tiered model

1. Primary Screening, awareness, Primary health/eye Referral into

Care/Commu referral, care, teachers appropriate
nity-based
level of LVS
2. Secondary Refraction, low vision Optometrist
assessment, prescription Ophthalmologist Estimated that
of basic LVDs with training Orthoptist
80% of LV
patients can be
3. Tertiary Comprehensive LVS, Optometrist managed at this
more complex and high- Ophthalmologist
level
powered LVDs, skills Orthoptist
training, MDCs Rehabilitation
specialists
MDCs

WHO. Asia Pacific Regional Low Vision Workshop.

http://whqlibdoc.who.int/Hq/2002/WHO_PBL_02.87.pdf
 Level 1: Screening/Recognition of a potential low vision patient.
All optometrists should be involved at this level.
Patient should be referred to Level 2 OR Level 3 based on patient’s vision and their visual
demands
Patient Characteristics:
• Best corrected VA (better eye or binocular) poorer than 6/12 (20/40)
• Or visual fields <70 degrees (circular diameter or equivalent) or significant central or parcentral
scotomas
• Or log CS <1.40
• Or any patient with a measurable visual impairment who has visual disabilities
Optometrist actions:
• Knowledge of diagnosis and likelihood of vision impairment
• Refraction
• Visual assessment (VA, central or peripheral visual fields as indicated by diagnosis, contrast
sensitivity measurement)
• Determination of patient’s disabilities and goals
• Discussion with patient of low vision intervention and its effectiveness and benefits
• Triage/referral
Additional equipment required by optometrist: Standard optometric equipment plus contrast sensitivity
charts

Level 2. Management of the patient with minimum
visual impairment/disability.
Optometrists may choose to be involved at this level.
Patient Characteristics:
• VA between <6/12 (20/40) and 6/21 (20/70)
• and CS between <1.40 and >1.00,
• but with visual fields better than 70° solid angle and no
significant or large paracentral scotomas.
Optometrist actions:
• Assessment of patient’s disabilities and goals
• Assessment for magnification for near
• Discussion and demonstration of lighting, filters and
the built-in accessibility of modern electronic devices
• Discussion of tasks such as TV and driving
Additional equipment required by optometrist: Continuous
text reading cards (Colenbrander, MNRead, Radner or
Lighthouse)
Range of low-powered hand and stand magnifiers, half-
eyes
Filters (450, 511, 527) or similar
Level 3: Comprehensive low vision rehabilitation for
patients with more vision loss and greater
disabilities.
Optometrists may choose to be involved at this
level.
Patient Characteristics:
• VA <6/21 (20/70 )
• or visual fields <70° diameter
• or CS <1.00
• or some combination that results in an equivalent
impairment
Optometrist actions:
• Full service low vision rehabilitation, in multi-
disciplinary clinic or in close collaboration and
communication with low vision therapists
Additional equipment required by optometrist:
• Full range of optical magnifiers, telescopes and
telemicroscopes, filters
• Electronic magnification
• Fresnel prisms for Peli or sector prisms

Leat SJ, Optom Vis Sci. 2016, 93(1) 77-84

• This model is similar to the Canadian
SmartSight model for ophthalmology.

• Basic concept adopted by EHCO

Jackson ML. Can J Ophthalmol 2006;41:355-361.

Level 1. Absolute minimum
Recognise
Assess
Goal setting
Attempt a higher add (up to
4D)
Refer
 Level 1: Screening/Recognition of a potential low vision patient.
Should all optometrists should be involved at this level?
Patient should be referred to Level 2 OR Level 3 based on patient’s vision and their visual
demands
Level 2. Management Patient
of the patient with
Characteristics:
minimum visual impairment/disability.
• Best corrected VA (better eye or binocular) poorer than 6/12 (20/40)
• Or visual fields <70 degrees (circular diameter or equivalent) or significant central or parcentral
scotomas
• Or log CS <1.40
Optometrists may choose to be involved at this
• Or any patient with a measurable visual impairment who has visual disabilities

level Optometrist actions:

• Knowledge of diagnosis and likelihood of vision impairment
Patient Characteristics: •
•
Refraction
Visual assessment (VA, central or peripheral visual fields as indicated by diagnosis, contrast
• VA between <6/12 (20/40) and 6/21 (20/70)
sensitivity measurement)
• Determination of patient’s disabilities and goals
• and CS between <1.40 • and >1.00, Discussion with patient of low vision intervention and its effectiveness and benefits
• Triage/referral
• but with visual fields better than 70° solid angle
Additional equipment required by optometrist: Standard optometric equipment plus contrast sensitivity
and no significant or large
charts paracentral scotomas.

Optometrist actions: Level 3: Comprehensive low vision rehabilitation for

patients with more vision loss and greater
• Assessment of patient’s disabilities and goals disabilities.
• Assessment for magnification for near Should all optometrists to be involved at this level?
• Discussion and demonstration of lighting, filters Patient Characteristics:
• VA <6/21 (20/70 )
and the built-in accessibility of modern electronic • or visual fields <70° diameter
devices • or CS <1.00
• or some combination that results in an equivalent
• Discussion of tasks such as TV and driving impairment
Optometrist actions:
Additional equipment required by optometrist: • Full service low vision rehabilitation, in multi-
disciplinary clinic or in close collaboration and
Continuous text reading cards (Colenbrander, communication with low vision therapists
MNRead, Radner or Lighthouse) Additional equipment required by optometrist:
Range of low-powered hand and stand magnifiers, • Full range of optical magnifiers, telescopes and
telemicroscopes, filters
half-eyes • Electronic magnification
• Fresnel prisms for Peli or sector prisms
Filters (450, 511, 527) or similar
Leat SJ, Optom Vis Sci. 2016, 93(1) 77-84
• Level 2. What can be done at this level?
• higher reading additions, prism half eyes and/or basic hand
and stand magnifiers
• 68% of primary aids were simple aids
• 57% of patients to a LVC in Wales required only simple devices
• 72% needed magnification of 4x or less
• discussion of issues such as loss of driving license
• accessibility functions of computers, tablets and other
electronic devices
• demonstration of lighting and advice about use of light at
home
• demonstration of commonly preferred filters for glare

Leat and Rumney (1990) Ophthal Physiol Opt 10, 8-15

• Still access other resources as necessary
• Additional factors that may require
involvement/referral to other resources at
Level 2.
• E.g. person with falls risk, person who wishes
to continue driving, employment or academic
issues
 Level 1: Screening/Recognition of a potential low vision patient.
Should all optometrists should be involved at this level?
Patient should be referred to Level 2 OR Level 3 based on patient’s vision and their visual
demands

Level 3: Comprehensive low vision rehabilitation

Patient Characteristics:
• Best corrected VA (better eye or binocular) poorer than 6/12 (20/40)

for patients with more vision loss and greater

• Or visual fields <70 degrees (circular diameter or equivalent) or significant central or parcentral
scotomas

disabilities.
• Or log CS <1.40
• Or any patient with a measurable visual impairment who has visual disabilities
Optometrist actions:
• Optometrists may choose to be involved at this
Knowledge of diagnosis and likelihood of vision impairment
• Refraction
• level
Visual assessment (VA, central or peripheral visual fields as indicated by diagnosis, contrast
sensitivity measurement)
•
•
Patient Characteristics:
Determination of patient’s disabilities and goals
Discussion with patient of low vision intervention and its effectiveness and benefits
• • VA <6/21 (20/70 )
Triage/referral
Additional equipment required by optometrist: Standard optometric equipment plus contrast sensitivity
charts • or visual fields <70° diameter

• or CS <1.00
Level 2. Management of the patient with minimum
• or some combination that results in an equivalent
visual impairment/disability.

impairment
Should all optometrists be involved at this level?
Patient Characteristics:
• VA between Optometrist
<6/12 (20/40) and 6/21actions:
(20/70)
• and CS between <1.40 and >1.00,
• but with visual• Full service
fields better low
than 70° solid anglevision
and no rehabilitation, in multi-
significant or large paracentral scotomas.
Optometrist actions:
disciplinary clinic or in close collaboration and
communication with low vision therapists
• Assessment of patient’s disabilities and goals
• Assessment for magnification for near
• Discussion and demonstration of lighting, filters and
the built-in Additional equipment
accessibility of modern electronic devices required by optometrist:
• Discussion of tasks such as TV and driving
• Full range of optical magnifiers, telescopes and
Additional equipment required by optometrist: Continuous
telemicroscopes, filters
text reading cards (Colenbrander, MNRead, Radner or
Lighthouse)
• Electronic magnification
Range of low-powered hand and stand magnifiers, half-
eyes
• Fresnel prisms for Peli or sector prisms
Filters (450, 511, 527) or similar

Leat SJ, Optom Vis Sci. 2016, 93(1) 77-84

 Level 3 – comprehensive LV rehabilitation
The Ideal – MDC (IDC) 2nd option 3rd option
Rehabilitation
ODs/MDs, vision A smaller combination OD/MD provides initial
therapists, OTs, opticians, of professionals work assessment (refraction, VA,
O&M trainers, hi-tech together e.g. OD/MD CS, fields) and provision of
assessment specialists, with vision therapist. devices, prisms, training with
counsellors work together Assessments are devices and EV assessment,
in the same location and undertaken in and advice (lighting).
time. collaboration.
Refer to other VR
Create rehabilitation plan, Other assessments professionals and support
assess for and prescribe planned as required groups.
devices, address
environmental concerns, Patient may enter VR through
undertake training, another professional.
including sight substitution Request report from OD/MD
and refer for devices
Full range service
Reports and communication
are VITAL
• MDCs (IDCs) are the ideal for those with more
severe vision loss and for urban centres

• But not all patients may require these services

• Or be able to travel to them

• Accounts for Canada’s geographic size and sparse

population in some regions

• This multi-level model is cost-effective

• Work towards improving our model of
delivery
• More consistent model the basis of policy
decisions, education and collaboration.
• Requirement for this model to work
• Consistent funding for low vision assessment,
rehab and devices
• Communicate