Low Vision Service Provision by Optometrists: A Canadian Nationwide Survey

Norris Lam, OD, MSc, FAAO, Susan J. Leat, PhD, FCOptom, FAAO, and Alison Leung, OD

University of Waterloo School of Optometry and Vision Science, Waterloo, Ontario, Canada (all

authors)

Short title: Low Vision Optometric Service in Canada

2 tables; 4 figures; 1 appendix

Received: June 5, 2014; accepted October 10, 2014.

ABSTRACT

Purpose. To document the degree to which Canadian optometrists are involved in the provision

of low vision (LV) care and their referral patterns. To investigate the barriers to providing

optometric low vision services (LVS). Methods. Practicing optometrists across Canada were

randomly sampled and invited to participate in a questionnaire that included questions on

personal profile, primary practice profile, levels of LV care offered, patterns of referral and

barriers to provision of LV care. Questions included a combination of multiple choice and open-

ended formats, and included hypothetical cases. Results. 459 optometrists responded (response

rate = 24.8%). Optometrists estimated that 1% (range 0-100%) of their patients were LV patients

yet also estimated that 10% of their patients had acuity equal to or worse than 20/40.Thirty-five

percent of respondents indicated that their primary practice offered LV care, 75.6% would

manage a patient with minimum disability and simple goals themselves while 10.7% would

manage a patient with more than minimal visual disability who needed more specialized LV

devices (e.g. telescopes, electronic aids and custom-designed microscopes). 84.3% of

optometrists would assess for basic magnification and lighting in a hypothetical patient with

early ARMD, while 15% would undertake full LV rehabilitation in advanced ARMD.

Optometrists commonly referred to CNIB (formerly the Canadian National Institute for the

Blind), yet only 10.7% of respondents almost always received a written report after referral.

Those who would not undertake LV assessment stated that they lacked the knowledge,

equipment or experience, that LV assessment is too time consuming and the cost is too

prohibitive. Conclusions. This is the first comprehensive study of LVS provision by optometrists

in Canada. In order for optometrists to become more involved in LV services, there is a need for

more LV education, provincial health coverage of optometric LVS, and better collaboration and

communication between LV providers.

Key words: low vision, low vision services, visual impairment, rehabilitation, service provision,

barriers

The Canadian population is ageing. From 2006 to 2011, the rate of growth of Canadians aged 54

and older was more than double the 5.9% increase for the entire population.1 With an ageing

population, recent studies have documented a higher incidence of age-related vision loss in

Canada. The 2006 Participation and Activity Limitation Survey2 indicated that Canadians aged

75 plus were significantly more likely than the younger respondents aged 15 to 24 to have a

“severe seeing limitation” (30.5% vs. 16.7%). Similarly, the Canadian Community Health

Survey3 in 2003 found that while Canadians aged 65 and older made up 14% of the population,

they accounted for 23% of all people with vision problems. Similar trends are occurring in other

developed countries. The US Beaver Dam Eye Study, the only large-scale, population-based

study on the long-term incidence of vision loss, found that over a 15-year period, people aged 75

and older were 12.8 times more likely to develop low vision (LV) and 20.6 times more likely to

become legally blind compared with those younger than 75 years of age.4

Vision impairment has an adverse impact on social participation and is known to be a strong

predictor of self-reported difficulty with activities of daily living.5 It is associated with the risk of

falls6, hip fractures,6,7 and depression.8 The social, personal, economic and societal cost of vision

loss is tremendous.9 It is not clear that health care systems are prepared to deal with the increased

prevalence of people with vision loss.

According to the Canada Health Act,10 each Provincial and Territorial government has the

primary jurisdiction for the administration and delivery of health care. Consequently, there is no

systematic coverage for routine eye examinations. Most provinces only cover optometric routine

eye examination on an annual or biannual basis for those under 18 or 19 and/or ≥65 years, while

in some provinces there is no coverage.11 Neither is there any consistent provision or coverage

for low vision service (LVS). LVS may be provided by independent optometrists or

ophthalmologists, in hospital settings, within CNIB (formerly known as the Canadian National

Institute for the Blind) premises or within educational institutions. Remuneration for optometric

LVS also varies, ranging from no coverage to an inadequate or modest fee ($40.33 in British

Columbia,12 $55.21 in Alberta13 and $84 in Nova Scotia14 as of 2014). There is also variation in

provincial coverage for LVS provided by ophthalmologists, ranging from no coverage to a fee in

Ontario, Saskatchewan and Newfoundland. Coverage for low vision devices also varies among

provinces. For example, in Quebec, patients may receive LV devices on-loan free-of-charge

when examined within a government-run rehabilitation center.15 In Alberta, financial subsidy for

low vision aids is available only to patients who meet certain visual criteria and who are

registered clients of CNIB.16 In Ontario, the Assistive Devices Program17 partially covers the cost

of devices prescribed by a registered authoriser (who may be an optometrist, ophthalmologist or

CNIB low vision service provider).

The CNIB is a nationwide charity that also offers low vision assessment, in addition to emotional

and wellness support, mobility training, independent living services, assistive technology

services and an accessible library.18 CNIB Low Vision Specialists may perform low vision

assessments independently,11 or in collaboration with an optometrist or ophthalmologist.15,19 To

become a Low Vision Specialist, one must fulfil the requirements of an in-house training

program, which “includes self-study, completion of the Johns Hopkins LV Training Program,

practicum, one-year mentorship and final exam”.19 When this survey was undertaken, people

with any level of vision loss who were experiencing visual disability could gain access to CNIB

through self-referral or referral by an eye care professional. While services are “free-of-charge”

to eligible clients, program delivery and availability varies locally and financial support is

dependent on public donation and government funding.20 In conclusion, provision of LVS across

Canada is highly variable. Canadians who suffer from vision loss deserve to receive higher

quality and more effective LVS. There is a tremendous need to build an effective model for

vision rehabilitation in Canada.

A first step is to determine a more accurate picture of the current provision of LVS by each type

of provider. The purpose of this present study is a survey of the extent of provision of LVS

offered by optometrists, their referral patterns and their perception of the quality of LVS in their

local communities and the barriers to providing more LVS.

METHODS

The study was approved and received ethics clearance through the Office of Research Ethics at

the University of Waterloo and adhered to the tenets of the Declaration of Helsinki. The survey

was designed after a careful review of previous literature of provision of LVS by eye care

professionals.21-23 The 30-item questionnaire included information in the following sections: A.

personal profile; B. primary practice profile; C. level of LVS offered and barriers to provision of

low vision care; and D. referral patterns. For comparisons, some questions were adopted from

previously published LV surveys.22-24 A unique aspect of our questionnaire was the use of three

hypothetical clinical cases (C5-C7) and two open-ended questions that allowed respondents to

comment on LV education and the current provision of LVS. Six practicing optometrists were

asked to complete the draft survey. As a result of their feedback, questions were adjusted in cases

where they thought there was ambiguity. A summary of the final questionnaire can be seen in the

Appendix (available at [LWW insert link]).

A complete list of practicing optometrists (n=4608) was obtained from each provincial

regulatory body of optometrists. Due to the absence of a directory for practicing optometrists in

the Canadian Territories, we were not able to include these optometrists. Optometrists to be

invited were randomly selected from each list. The sampling rate was lowered to 30% for the

more populated provinces (Ontario, Quebec, Alberta and British Columbia) but was 100% for

the less populated provinces (Manitoba, Saskatchewan and the Eastern Provinces) to give more

equal final numbers of responses, allowing for statistical comparisons between different regions

in a subsequent part of this study (Table 1).

In October 2010, the selected optometrists were invited to participate either by email (if

available) or by regular mail, with a cover letter and an enclosed postage-paid return envelope.

Only an English version of the questionnaire was sent. We faxed follow-up letters with the

original questionnaire approximately six weeks after initial contact to increase response rate. It

was noticed that the email questionnaire generated few responses. Therefore, additional paper

questionnaires were mailed to optometrists in provinces where the response rate was below 20%

and who had initially received only the email version of the survey. By January 2011, the

questionnaire collection had been completed.

Data analysis: Descriptive statistics were used with non-parametric statistics to determine

medians for the multiple-choice questions. A modification of quantitative analysis was used for

the open ended questions. In Questions C11, C12 and C14, respondents were asked to select only

the answers that apply and rank in order of importance of the answers. However, many

respondents only selected the applicable answers by checking the box beside the multiple choice

instead of ranking their choices. Therefore, ranking was discarded and instead, the frequency of

choices was counted.

RESULTS

Of the 1851 optometrists sampled, 459 (24.8%) responded. Table 1 provides an overview of the

responses by province and region. The proportion of female respondents was 48.8%. The years

of practice of the respondents followed a bimodal distribution with one peak (25%) at 0-5 years

and another at 26 or more years (25%). The modal city population of their primary practice was

500,000+ (25% of respondents). The most frequent type of practice for optometrists was private

group practice or cost-sharing practice (56%), with one being the modal number of optometrists

practising in the respondent’s primary practice at one time (40%). In a typical week, the modal

response (37%) was that ≥120 patients would be seen in their primary practice.

When asked to estimate the percentage of LV patients seen in their primary practice, the mode

and median were 1%. In contrast, Canadian optometrists estimated that a modal value of 10% of

their patients had best corrected visual acuity (BCVA) in the better eye of 6/12 and poorer while

90% of their patients had BCVA of better than 6/12 (Figure 1).

Provision of Low Vision Services

Thirty-five percent (161/459) of respondents indicated that there was an optometrist(s) within

their primary practice who offered LV care. The most common type of LVS available within a

day’s travel for respondent’s patients was CNIB (n=402), followed by local optometrists (n=309)

and multi-disciplinary clinics (n=178). In the “others” option (n=17), respondents indicated that

other LVS included the respondent’s clinic itself offering LVS (n=4), hospital (n=4), opticians

(n=2), private nurse (n=2), orthoptist (n=1), “low vision clinic close by” (n=1), “independent LV

consultant” (n=1) and vision aid store (n=1).

In the three hypothetical case scenarios, we asked how the respondent would manage a

hypothetical patient with early macular degeneration (Figure 2A), advanced macular

degeneration (Figure 2B) and homonymous hemianopia (Figure 2C) with specific visual

disability(s). When dealing with a patient with early macular degeneration, most optometrists

(84.3%) stated that they would undertake vision rehabilitation themselves (i.e. assessing for

lighting and magnification). The responses become more diversified when dealing with a patient

with multiple visual goals and a diagnosis of advanced macular degeneration or hemianopia. For

the patient with advanced macular degeneration, 15% of optometrists would undertake the full

LV rehabilitation themselves. Notably for the patient with hemianopia, over 25% of optometrists

would provide information about reading techniques, appearing not to address the mobility

difficulties. However, further analysis showed that only 5.2% (n=24) of these respondents did

not check off another response (i.e. referral to specialized LVS); i.e. they are mostly giving

information plus another management.

The level(s) of LVS respondents would provide is depicted in Fig 3 (Question C10). Most

respondents (90.6%) would recognize a LV case. Of those who did not checked off this choice,

the majority of them (32/43) did check off a higher level(s) of LVS, implying that these

respondents must be recognizing a LV case. Thus we may assume that only 2.4% would not

recognise or provide LV rehabilitation for a patient with LV. Fewer would assess for visual

disability (58.2%). The percentage of optometrists who would manage a patient who has more

than minimum visual disabilities with more specialized devices (i.e. telescope, electronic LV

aids, and custom-designed microscopes) was fewer still (10.7%). Only 3.5% of the respondents

would manage a patient with complex goals (i.e. vocational, requiring multiple interventions).

Regarding availability of low vision equipment and devices, 55.4% of respondents had either a

logMAR or Feinbloom distance visual acuity chart and 37.1% had the Lighthouse continuous

text card or equivalent for near visual acuity. 38% had either a computer generated contrast

sensitivity chart (24.7%) or the Pelli-Robson or other paper contrast sensitivity chart (14%). The

range of LV devices that respondents had available in their practice can be seen in Table 2,

together with the results of Lim et al.24

If the respondents did not manage many patients with minimal amount of visual disability and

simple goals using high powered additions and lighting (Level D) or simple optical devices such

as magnifiers and filter lenses (Level E) in Question C10 (shown in Figure 3), they were asked to

indicate the reasons for not providing this level of management (Figure 4A). We chose to explore

these levels further, as these are the levels of LV care which can be provided in the optometrists’

offices and may be deemed primary care low vision services.25,26 The most common three reasons

were the lack of LV devices (75.3%), the lack of LV equipment (70.7%) and the lack of

experience (58.2%). If they responded that their reason for not providing LV was lack of

equipment or devices, they were asked their reasons for not acquiring LV equipment or devices

(Figure 4B). The most common three reasons included financial non-viability (60.5%), the lack

of demand (58.2%) and the respondent’s lack of interest (45.0%). They were then asked what

needs to change for them to be willing to manage more patients with LV and the results are

shown in Figure 4C. The most common reason was more equipment (64.6%), followed by a fee

for LVS (55.6%), more education on LV (48.2%) and funding for devices (47.1%).

Referral Patterns

Most optometrists referred to CNIB (81.9%) while the proportions who referred to local

optometrists and ophthalmologists (30.7%) and to multi-disciplinary LVS (30.1%) were almost

equal. A small proportion of optometrists did not refer at all (2.0%). The respondents generally

rated the availability (40.7% and 27.2%) and quality (41.2 and 23.2%) of LVS as good or fair

respectively. However, the frequency of receiving a report back after referral was low. Only

23.6% of respondents almost always or often received a written report from these agencies or

individuals while 37.1% of respondents almost never or rarely received one.

Nearly a quarter (22.5%) of respondents would not refer a patient until the BCVA was worse

than 6/60 with the majority referring when BCVA was 6/21 to better than 6/60. Fewer

optometrists answered the question regarding referral for visual field loss (n=398) compared with

the question regarding referral criteria for BCVA (n=436). Of those who did answer, 13.1%

would initiate a referral for a LVS only when their patients had a total visual field diameter of

less than 20°, although the modal value for referral was when the field was between 35-49°

(38.9%).

Written Comments

There were 192 written comments to Question 13 which asked whether the respondent felt that

they would benefit from more education on LV, and if so what topics and format would be best.

While 30% said they were simply not interested, approximately 70% (n=134) of respondents

were opened to more education and/or made comments about what format such education might

take. Optometrists disclosed that training had been/could be done through local LV sales

representatives. One optometrist mentioned that he and his colleagues “do LV seminars in [their]

city”. Many respondents suggested a practical approach, which may include training/workshops

with actual LV devices, labs about “real cases” and working a day at a multi-disciplinary LV

clinic. The overwhelming themes of the training were practicality and feasibility of providing all

or part of the LV optometric service. Optometrists were interested in topics ranging from how to

set-up a LV clinic, what equipment would be the most useful to patients at a reasonable cost, and

how to perform LV assessment in a timely and cost-efficient manner. Respondents were curious

to learn about the latest devices (including high tech devices). They also suggested a refresher

course on general optical principles and dispensing techniques. Topics of how to manage the

psychological aspect of LV and patients’ expectations were also suggested.

There were 113 written comments to the open-ended question about the provision of LV

services. These comments provided the respondent’s insight to the topics of accessibility, inter-

professional collaboration and fee coverage. Almost one-third (n=7) of comments on good

accessibility were made by respondents from Quebec, who complimented government-run LVS.

Optometrists who commented on poor accessibility noted that even when there was a LVS

available within one or two hour’s travel time, the patient “often cannot drive and has difficulty

finding someone to go with them” (Quebec optometrist) and that it is still “too far for seniors”

(Ontario optometrist). Accessibility was also hindered due to “long drive over difficult roads…

in the winter months” (British Columbia [BC] optometrist) and a long waitlist at the local CNIB

(Ontario optometrist).

The comments on inter-professional collaborations were wide-ranging. Collaborations appeared

to occur between optometrists and CNIB in BC and Manitoba, where CNIB would come to their

primary practice area and do LV exams and equipment demonstration. Other respondents in BC

mentioned referrals to an ex-worker of CNIB after CNIB had closed down and referrals to LV

companies “who accept referrals and have a variety of devices available”.

Despite no specific request for comments on CNIB, it was mentioned in 38% (n=43) of all

additional written comments on the provision of LVS. These comments were evenly split

between the positive and negative and were generally related to issues regarding local

accessibility, inter-professional collaboration, quality and availability of low vision services.

There were also comments on fees and device coverage, especially on the (lack of) provincial

coverage in most provinces and challenges associated with charging a reasonable fee for service

that would be “proportional to chair time”. One respondent who was experienced in LV

commented that “out of the 20 ODs in my area, I am the only one offering intermediate-level

services… usually with elderly patients on limited income, we take a financial hit to perform

these services” (Ontario optometrist).

DISCUSSION

This is the first survey of LV practice among optometrists in Canada. It is also one of the most

extensive optometric surveys on LV conducted thus far in any country. The total response rate of

25% in this current study is comparable to similar studies conducted in the past (response rates

range from 6.7% to 36%).21-24

Estimate of the Need for LVS

The estimated proportion of patients with best corrected visual acuities of 6/12 and worse (10%)

in this current survey was higher than that found in population-based studies.5,27 In the Salisbury

Eye Evaluation study,5 6.9% of study population (aged 65 to 84) had a binocular presenting

visual acuity of worse than 6/12. In the most recent population-based study27 in the City of

Brantford, Ontario, Canada, the weighted prevalence of people aged 40+ years with presenting

visual acuity of worse than 6/12 in the better eye was 2.7%. This difference may have arisen

from the following factors: (i) people with poorer vision would be more inclined to seek

optometric care; (ii) different age groups in the study; (iii) different VA ranges included (6/12

and worse versus worse than 6/12; and (iv) inaccurate estimation by the respondents in the

present study.

There were some disparities in the responses around the frequency of need for LVS. The

percentage of patients that was considered to have LV was 1% (Question B5) while the

percentage of patients with an estimated best corrected visual acuity of 6/12 or worse was 10%

(Question C4). Yet disabilities can start to manifest themselves at a visual acuity of 6/12.28 The

discrepancy between these percentages could be due to several reasons. First, a mild visual

acuity loss may not automatically translate to visual disability. A visual disability would exist

only when the individual could not to perform his/her visual goals because of a visual

impairment. Second, optometrists may not consider basic magnification and information about

lighting as LV rehabilitation i.e. they are performing LV rehabilitation without defining it as

such. This is illustrated by the response to the hypothetical early AMD patient and a visual acuity

of 6/12 (Question C5). When a reading disability was explicitly presented in this case, 86% of

respondents would provide basic low vision intervention (i.e. assessment of basic magnification

and lighting requirement). This high percentage is in contrast to the 35% of respondents who

indicated that there was an optometrist in the practice who would provide LVS and also indicates

that optometrists may not think of this basic level of intervention as “LVS”. Third, respondents

may not think of visual acuity in the realm of 6/12 as being LV and therefore may not ask about

disabilities and offer LV rehabilitation. Fourth, the definition of LV usually includes the

assumption that an individual has exhausted all conventional treatment methods. This conception

may lead some eye care providers to postpone offering LVS/referral while they are being treated

medically. The patient him or herself may not expect any help. It is well-established in the

literature that non-users of LVS are often not aware of the services available to them.29-31 One

way of overcoming a patient’s non-awareness would be for all eye care practitioners to initiate a

conversation about vision rehabilitation even when the patient’s vision impairment is minimal. In

1999, Leat et al25 proposed a definition of visual disability as best corrected visual acuity of

<6/12 or contrast sensitivity of <1.05 by considering the level of visual measures which result in

measurable or reportable disability. Lovie-Kitchin et al32 recommended referral for mobility

assessment when a patient’s binocular visual field diameter is reduced to between 31 to 52

degrees.

Encouragingly, the percentage of optometrists whose primary practice offers LVS (Question B9)

was 35.1%. This is comparable to the results of the 2008 American Optometric Association

Scope of Practice Survey, which found that 44.4% of optometrists provided some LVS to their

patients33. It is also comparable the 39% found in a Quebec survey by Renaud et al,34 even

though only 2.7% of respondents in the Quebec survey worked in specialized LV centers. When

asked about the level of LVS they, themselves would provide, most respondents would manage

patients with a high reading add and give lighting advice. A dip was evident, however, in the

proportion of respondents who assess for visual disability (Fig 3). The responses outlined in the

levels of LVS provision (Question C10) were intended to be in sequence (i.e. assessing for

disability comes before managing with high reading additions, etc.). Some respondents seemed

to have misunderstood this intention or understood the wording “disability” differently.

However, it is encouraging that 73% state that they would undertake simple LV with high

additions and lighting and as many as 42% would assess for simple optical devices.

In the case of advanced ARMD and hemianopia, rather than simply referring a patient, more than

40% of respondents chose to provide some low vision intervention, indicating that many

respondents would undertake as much LVS as possible within their practice constraints. CNIB,

being the most accessible LVS provider and being one who can offer services “free-of-charge”,

was logically the most popular choice among all types of LV service providers. Similar to Lovie-

Kitchin et al’s study,23 receiving a written report after referral to other LVS providers is

uncommon. Receiving reliable feedback from the LVS provider encourages the referral of other

patients by health care providers.35 Without feedback, it would be difficult for optometrists to

learn about appropriateness of referrals, to gain insight into the scope and depth of LVS provided

by the referred entity, and to judge the quality of LVS provided other than from the feedback

from returning patients.

Barriers to Providing LVS

Fewer optometrists stocked optical devices than in Lim et al’s study24 and only 7.0% (n=32) of

respondents’ primary practices were equipped with some form of high-tech magnifying aids. Yet

paradoxically, lack of devices was the most common reason mentioned for not undertaking LVS

(75%). Although high-tech devices offer more utility value compared with conventional LV aids

due to enhanced contrast function, multiple magnification power, and ease of use, the high cost

and lack of provincial coverage in many provinces (except for Quebec and Ontario) likely deter

many optometrists from supplying them. Even in Ontario, the Assistive Devices Program, “has

fallen far behind with respect to coverage of new device technologies”.36 The program “has also

been criticised for failing to keep abreast of real market pricing of eligible devices”.36 These

barriers to providing LV care within the office seem to be interrelated and to some extent

circular. Lack of funding in most provinces for devices decreases the likelihood that patients will

purchase the recommended devices, and so optometrists have less incentive to stock equipment

(70.7% stated that lack of equipment was a barrier to them provided more extensive LVS). Lack

of equipment and devices will deter an optometrist from undertaking LV services (and indeed,

appropriate equipment is necessary to provide more than the very basics), which results in no

development of experience or knowledge. Alternatively, lack of knowledge/experience may be

another reason leading to the reluctance to purchase equipment. The perceived lack of demand

for LVS, which discourages the provision of LVS, may be reflected the lack of awareness,

recognition and involvement of optometric LVS in the public health system.

Since LVS services are needed with the aging of the population, the question becomes “how to

break this cycle”. The most common barriers mentioned are external to the optometrist

themselves: more education, a fee for services and funding for devices. These barriers were also

mentioned in a recent study by the Low Vision Working Group of Optometrists Association

Australia.37 Unfortunately, many patients with LV are particularly vulnerable to out-of-pocket

expenses that are not covered by provincial health plans. Gold et al’s study found that the

primary source of income for the working age group of people with LV (n=200) was provincial

disability benefits (42%) and federal pension (26%).38

Patients’ ability to afford access to optometric LVS and LV devices is thus a cause for concern.

The remuneration for providing LVS should compensate for the chair time, staff training and the

associated administrative work. With regards to education, the optometrists were generally open

to opportunities to learn more about LV, but wanted this instruction to be practical and hands-on.

Limitations of the Study

There are some limitations of the study. Like all surveys, the results may be biased towards the

characteristics of those who have an interest or feel strongly about this issue, in this case LV.

Thus, the proportion of optometrists who provide LVS may be overestimated. The survey may

also be biased towards those who are able and/or are willing to communicate in English. The

research protocol did not track the demographic characteristics of respondents versus non-

respondents.

The term “low vision” was not explicitly defined in the questionnaire. However, if the term was

defined explicitly, it would have changed the nature of the questionnaire, and inadvertently

influenced respondents’ answers to certain questions. Considering that these questions are

important elements in achieving the objectives of this study, the level of uncertainty regarding

“low vision” may be acceptable.

CONCLUSIONS

This study is encouraging as 35% of optometrists stated that there was an optometrist within the

office who provides low vision services and as many as 86% of respondents would provide basic

low vision intervention for a case of early age-related macular degeneration. As expected, fewer

would undertake full LV rehabilitation in a case of advanced AMD or hemianopia, choosing to

refer to other local services when they are available. Although not all optometrists are willing to

be involved in the provision of LVS, many are open to working with these patients. There are,

however, clear barriers. Although optometrists are the primary healthcare providers of LVS,

there is a lack of/inadequate fee to remunerate optometrists for LV services and a lack of

coverage of the cost of devices in most provinces. On the side of the optometrists, many feel they

have a lack of education and experience, equipment and devices. Another issue that was clearly

identified in this study was the lack of communication in the form of reports received back by a

referring optometrist.

The way forward to improve LVS in Canada may be complicated, due to the various agencies

and professions involved. It is clear that optometrists should have a major role. They are often

the first to detect eye disease in the general population and should play a pivotal role in actively

identifying patients who may suffer from visual disability and therefore influence entry into the

LVS system. They also have a key skill set required in the assessment and management of

patients with low vision and it would seem advantageous to work towards eliminating barriers to

their involvement and creating a more integrated system for LVS in Canada. Bentley et al34 list

some goals to improve optometrists’ involvement in LVS in Australia and many of these would

seem appropriate for the Canadian situation also. Moving forward, more studies are needed to

evaluate how better to improve collaboration and communication, eliminate service redundancy

and optimise services for people with visual impairment.

ACKNOWLEDGMENTS

This work was funded by the Canadian Optometric Education Trust Fund. The authors are

grateful for the involvement of optometrists who responded to our survey. The authors would

like to acknowledge the provincial colleges and associations of optometrists for providing the

contact information of the practising optometrists. The contents of this manuscript were

presented as a poster at the American Academy of Optometry meeting in Boston, MA in October

12, 2011.

APPENDIX

The appendix, a summary of the final questionnaire, is available at [LWW insert link].

REFERENCES

1. Statistics Canada. Population by broad age groups and sex, 2011 counts for both sexes, for

Canada, provinces and territories. Available at: http://www12.statcan.gc.ca/census-

recensement/2011/dp-pd/hlt-fst/as-sa/Pages/highlight.cfm?

TabID=1&Lang=E&Asc=1&PRCode=01&OrderBy=999&Sex=1&View=1&tableID=21&

queryID=1. Accessed July 22, 2012.

2. Statistics Canada. Facts on Seeing Limitations. Available at:

http://www.statcan.gc.ca/pub/89-628-x/2009013/fs-fi/fs-fi-eng.htm. Accessed March 4,

2013.

3. Millar WJ. Vision problems among seniors.

http://www.statcan.gc.ca/pub/82-003-x/2004001/article/7041-eng.pdf. Accessed March 5,

2013.

4. Klein R, Klein BE, Linton KL, De Mets DL. The Beaver Dam Eye Study: visual acuity.

Ophthalmology 1991;98:1310-5.

5. West SK, Munoz B, Rubin GS, Schein OD, Bandeen-Roche K, Zeger S, German S, Fried

LP. Function and visual impairment in a population-based study of older adults. The SEE

project. Salisbury Eye Evaluation. Invest Ophthalmol Vis Sci 1997;38:72-82.

6. Steinman BA, Allen SM. Self-reported vision impairment and its contribution to disability

among older adults. J Aging Health 2012;24:307-22.

7. Klein BE, Klein R, Lee KE, Cruickshanks KJ. Performance-based and self-assessed

measures of visual function as related to history of falls, hip fractures, and measured gait

time. The Beaver Dam Eye Study. Ophthalmology 1998;105:160-4.

8. Rovner BW, Ganguli M. Depression and disability associated with impaired vision: the

MoVies Project. J Am Geriatr Soc 1998;46:617-9.

9. Cruess AF, Gordon KD, Bellan L, Mitchell S, Pezzullo ML. The cost of vision loss in

Canada. 2. Results. Can J Ophthalmol 2011;46:315-8.

10. Health Canada. Canada Health Act annual report 2012-2013. Available at: http://www.hc-

sc.gc.ca/hcs-sss/alt_formats/pdf/pubs/cha-ics/2013-cha-lcs-ar-ra-eng.pdf. Accessed Aug 10,

2014.

11. National Coalition for Vision Health. Foundations for a Canadian Vision Health Strategy:

Towards Preventing Avoidable Blindness and Promoting Vision Health. Available at:

http://www.visionhealth.ca/projects/documents/Foundations-For-A-Canadian-Vision-

Health-Strategy.pdf. Accessed July 22, 2012.

12. British Columbia Ministry of Health. Optometry payment schedule; April 1, 2008.

Available at: http://www.health.gov.bc.ca/msp/infoprac/suppbilling/Opt-Pmt-Schedule-

April-1-08.pdf. Accessed July 26, 2014.

13. Alberta Health Website. Optometric price list - as of 01 October 2013. Available at:

http://www.health.alberta.ca/documents/Allied-Opto-Price-2013-10.pdf. Accessed July 26,

2014.

14. Government of Nova Scotia. Insured Optometric Services Tariff Regulations. Available at:

http://www.novascotia.ca/just/regulations/regs/hsioptometric.htm. Accessed August 29,

2014.

15. Robillard N, Overbury O. Quebec model for low vision rehabilitation. Can J Ophthalmol

2006;41:362-6.

16. Canadian National Institute for the Blind (CNIB). Specialized Technical Equipment

Program Manual. Available at http://www.health.alberta.ca/documents/AADL-Manual-

CNIB-STEP.pdf. Accessed July 26, 2014.

17. Ministry of Health and Long-term Care. Assistive devices program: Visual Aids Policy and

Administration Manual. Available at:

http://www.health.gov.on.ca/en/pro/programs/adp/policies_procedures_manuals/docs/

visual_aids_manual.pdf. Accessed November 9, 2013.

18. Canadian National Institute for the Blind (CNIB). Our Range of Services. Available at:

http://www.cnib.ca/en/services/vision-support/range/Pages/default.aspx. Accessed July 27,

2014.

19. Gilmour GR. Low vision rehabilitation services: the Saskatchewan experience. Can J

Ophthalmol 2006;41:370-2.

20. Canadian National Institute for the Blind (CNIB). We’re here every step of the way: Annual

Review 2012-2013. Available at: http://www.cnib.ca/en/about/Publications/Corporate-

Reports/Documents/CNIB_Annual_Review-2012-2013.pdf. Accessed October 15, 2013.

21. Kammer R, Sell C, Jamara RJ, Kollbaum E. Survey of optometric low vision rehabilitation

training methods for the moderately visually impaired. Optometry 2009;80:185-92.

22. Keeffe JE, Lovie-Kitchin JE, Taylor HR. Referral to low vision services by

ophthalmologists. Aust N Z J Ophthalmol 1996;24:207-14.

23. Lovie-Kitchin JE, Keeffe JE, Taylor HR. Referral to low vision services by optometrists.

Clin Exp Optom 1996;79:227-33.

24. Lim HY, O'Connor PM, Keeffe JE. Low vision services provided by optometrists in

Victoria, Australia. Clin Exp Optom 2008;91:177-82.

25. Leat SJ, Rumney NJ. The experience of a university-based low vision clinic. Ophthalmic

Physiol Opt 1990;10:8-15.

26. Ryan B. Models of low vision care: past, present and future. Clin Exp Optom 2014;97:209-

13.

27. Robinson B, Feng Y, Woods CA, Fonn D, Gold D, Gordon K. Prevalence of visual

impairment and uncorrected refractive error - report from a Canadian urban population-

based study. Ophthalmic Epidemiol 2013;20:123-30.

28. Leat SJ, Legge GE, Bullimore MA. What is low vision? A re-evaluation of definitions.

Optom Vis Sci 1999;76:198-211.

29. Spafford MM, Rudman DL, Leipert BD, Klinger L, Huot S. When self-presentation trumps

access: why older adults with low vision go without low-vision services. J Appl Gerontol

2010;29:579-602.

30. Pollard TL, Simpson JA, Lamoureux EL, Keeffe JE. Barriers to accessing low vision

services. Ophthalmic Physiol Opt 2003;23:321-7.

31. Southall K, Wittich W. Barriers to low vision rehabilitation: a qualitative approach. J Visual

Impair Blin 2012;106:261-74.

32. Lovie-Kitchin JE, Soong GP, Hassan SE, Woods RL. Visual field size criteria for mobility

rehabilitation referral. Optom Vis Sci 2010;87:948-57.

33. Edlow RC, Marcus GR. Highlights: 2008 American Optometric Association Scope of

Practice Survey. Optometry 2009;80:267-70.

34. Renaud J, Baudry E, Gresset J. Optometrists' attitudes toward visually impaired patients in

the province of Quebec. Int Congr Ser 2005;1282:283-7.

35. O'Connor PM, Mu LC, Keeffe JE. Access and utilization of a new low-vision rehabilitation

service. Clin Experiment Ophthalmol 2008;36:547-52.

36. Strong JG. Principles and Practices of Low Vision Rehabilitation: The Assistive Devices

Program (ADP). Available at: http://www.pplvr.com/pplvr/article/assistive-devices-

program-adp. Accessed Nov 7, 2013.

37. Bentley SA, Jackson AJ, Johnston AW, Napper GA, Hodgson M, Soong GP, Oberstein SL,

Chong MF, Baggoley G, Optometrists Association Australia Low Vision Working G.

Advancing low vision services: a plan for Australian optometry. Clin Exp Optom

2014;97:214-20.

38. Gold D, Simson H. Identifying the needs of people in Canada who are blind or visually

impaired: preliminary results of a nation-wide study. Int Congr Ser 2005;1282:139-142.

Corresponding author:

Norris Lam100 – 200 University Ave EToronto, ON M5H 3C6CANADAe-mail: nhylam@uwaterloo.ca

Table 1. Breakdown of responses by provinces and regions.

Geographic Region Province # All ODs listed in regulating body

Sampling rate (%)

# Actual responses

Response rate

Total actual # response

Eastern provinces Newfoundland & Labrador 47 100 12 25.5%

72Prince Edward Island 16 100 4 25.0%

Nova Scotia 105 100 26 24.7%New Brunswick 112 100 30 26.7%

Quebec Quebec 1346 30 71 17.6% 71Ontario Ontario 2012 30 157 26.0% 157Western provinces Manitoba 118 100 19 16.1%

150Saskatchewan 126 100 21 16.7%Alberta 194 30 43 29.1%British Columbia 532 30 67 41.9%

Province not stated 9 9Overall 4608 459 459

OD = optometrist.

Table 2. Type of LV devices available in optometric practices in comparison with Lim et al13

Current study ntotal=459 Lim et al96 (2007) ntotal= 97Hand magnifier 207 (45.1%) 61 (62.9%)Stand magnifier 159 (34.3%) 51 (52.6%)Telescope 89 (19.4%) 30 (30.9%)Head-borne magnifier device 159 (34.6%)* 47 (50.5%)**High-tech magnifying aids (including CCTV)

32 (7.0%) n/a

CCTV 25 (5.4%) 12 (12.4%)Selective transmission tints 23.8% n/a

*prism half eyes (22.2%) and microscopes (12.4%) were considered to be in our current study as head-borne magnifier device

**“magnifying glasses” in Lim et al’s study were considered to be head-borne magnifier devices. CCTV = closed circuit TV.

FIGURE LEGENDS

Figure 1. Median estimated percentage of patients according to their best corrected visual acuity

(BCVA) in the better eye.

Figure 2. Percentage of optometrists indicating each course of action for managing a

hypothetical patient. (A) Patient with early ARMD, with a BCVA of 6/12 and a main goal of

reading. (B) Patient with advanced ARMD, with a BCVA of 6/60 and goals of reading,

watching television and writing. (C) Patient with hemianopia and complex needs (reading

and mobility). OD = optometrist, LV= low vision

Figure 3. Provision of Low Vision Service by Respondents. VA = visual acuity, CS – contrast

sensitivity, VF = visual field, HM = hand magnifier, SM = stand magnifier

Figure 4. (A) Reasons for not providing LVS at Levels D or E (in Figure 3); (B) Reasons for not

acquiring low vision equipment or devices; (C) Factors that needs to change for respondents

to provide LVS at Levels D or E (in Figure 3)