For low vision specialists and those who consult them
Local or centralised – which is the best model for low vision care?
January 26, 2010Posted by on
Would you rather have a low vision clinic near your house which sees a handful of people with visual impairment every year, or would you prefer to travel many miles to attend a clinic which sees dozens of people every week?
This interesting point of debate came up whilst I was examining a PhD thesis last week. The thesis was in part describing the new community low vision service in Wales (see here for more information) where optometrists in the community receive extra training in low vision and are able to prescribe and dispense low vision aids locally. The scheme has dramatically reduced waiting lists and travel time to low vision appointments, but does mean that people with low vision are seeing practitioners who, whilst trained, are not as experienced as their colleagues in hospital departments who may see low vision patients exclusively.
Travel can be arduous for people with visual impairment, and older people in particular may not be enthusiastic about travelling into a large city where bigger low vision clinics are often located. Having a service in a local area – possibly within walking distance – is extremely useful and may well allow people who will not travel into a specialist centre to be seen.
As long as people are trained, does it matter if they don’t see many patients? There is very little evidence in the low vision field which addresses this topic apart from more specialist techniques (such as the prescription of Peli prisms which are more successful in centres which see more patients). In other areas of medicine, paediatric cardiac surgery is known to have a better outcome with a more experienced surgeon, but there are not clear documented benefits in other areas. Of course this may well be because of the ethical and logistical difficulties in constructing a study to evaluate this.
So would I suggest to a close friend with visual impairment that they see a local optometrist with less experience in low vision, or a city-centre specialist centre where they will see people with more experience in low vision? Of course, I am biased because I work in probably the largest low vision clinic in the world, but my answer would be that it would depend on what my friend’s needs were. If they just needed refractive correction and conventional hand or stand magnifiers I would definitely suggest the local service. However, if they needed spectacle mounted telescopes, field expansion devices, minifiers, or other complicated devices, or if they were a child or had specific employment difficulties, I would suggest they were seen in a larger clinic.
I think it is true that ‘the more the better’ applies when referring to low vision services: we really need more people providing services and easier access for patients to our clinics. The ideal model would involve local “basic” low vision care with onward referral to regional specialist centres for more advanced care. I think the Welsh scheme is pretty close to optimal.