Gregory Goodrich, Ph.D.Gregory Goodrich, Ph.D.

VA Palo Alto Health Care SystemVA Palo Alto Health Care System

Low Vision Low Vision Services:Services:

Evolution Evolution In A Time Of In A Time Of Revolution?Revolution?

My GoalsMy Goals

Starting point was Krister IndeStarting point was Krister Inde’’s reference to s reference to Darwin and what hasnDarwin and what hasn’’t worked:t worked: What forces drive low vision? Are these evolutionary What forces drive low vision? Are these evolutionary

or revolutionary?or revolutionary? Are we in the midst of an evolutionary response to a Are we in the midst of an evolutionary response to a

revolutionary change?revolutionary change? I am trying to be controversial and precipitate I am trying to be controversial and precipitate

discussion so my hypothesis is that we are governed discussion so my hypothesis is that we are governed by evolutionary change in a time when we need to by evolutionary change in a time when we need to instigate revolutionary change (that is; evolution is too instigate revolutionary change (that is; evolution is too slow and the dinosaurs need to change more rapidly slow and the dinosaurs need to change more rapidly or the mammals will take over).or the mammals will take over).

The QuestionThe Question In low vision are we seeing a In low vision are we seeing a

gradual change from common gradual change from common ‘‘ancestryancestry’’ that has led to a that has led to a continuation of successful low continuation of successful low vision services?vision services?

Or, are we seeing a dramatic Or, are we seeing a dramatic change with abrupt departures change with abrupt departures from the past that threaten from the past that threaten quality services for all who need quality services for all who need them?them?

Its a Matter of Perspective Its a Matter of Perspective (or can we tell the difference?)(or can we tell the difference?)

EvolutionEvolution Change over Change over

successive successive generationsgenerations

Minimal or substantialMinimal or substantial Enhances survival Enhances survival

and/or reproductive and/or reproductive successsuccess

Implies some Implies some predictabilitypredictability

RevolutionRevolution Turning pointTurning point Overthrow of idea or Overthrow of idea or

governmentgovernment Sudden or momentous Sudden or momentous

change in a situationchange in a situation Implies lack of controlImplies lack of control

Why do we care?Why do we care?

Evolutionary changes are usually those Evolutionary changes are usually those that can be relatively easily adjusted to, that can be relatively easily adjusted to, and change can be incorporated into our and change can be incorporated into our standard of care over a period of timestandard of care over a period of time

Revolutionary changes may happen so Revolutionary changes may happen so quickly and responses need to be of such quickly and responses need to be of such magnitude that the standard of care is no magnitude that the standard of care is no longer adequate and must be radically longer adequate and must be radically redefined. redefined. ““Do we need a revolution?Do we need a revolution?””

Some Perspectives On:Some Perspectives On:

Patients/clientsPatients/clients Low vision devicesLow vision devices Low vision knowledge baseLow vision knowledge base Service deliveryService delivery Professional servicesProfessional services Medical advancesMedical advances

The Changing PopulationThe Changing Population

ChildrenChildren Number remaining about constantNumber remaining about constant Increase in percent of children with multiple Increase in percent of children with multiple

disabilities (CVI)disabilities (CVI) Working AgeWorking Age

Transition from youth to adults about the sameTransition from youth to adults about the same Iraq/Afghanistan; polytrauma and TBI increasingIraq/Afghanistan; polytrauma and TBI increasing

SeniorsSeniors ““Epidemic growthEpidemic growth”” in age-related disease in age-related disease Lack of attention to Stroke/TBI (may exceed the Lack of attention to Stroke/TBI (may exceed the

visually impaired population in size)visually impaired population in size)

The The ““simplesimple”” numbers numbers ~200,000 new cases of macular ~200,000 new cases of macular

disease/yr.disease/yr. ~250,000 new cases of visual ~250,000 new cases of visual

impairment/yr.impairment/yr. Un-served populationsUn-served populations

~20% to ~40% of all stroke/TBI ~20% to ~40% of all stroke/TBI patientspatients

• <about 15% in VA TBI population<about 15% in VA TBI population• ~60,000+ cases of field lose from ~60,000+ cases of field lose from

stroke/TBI/yr.stroke/TBI/yr. If caused by a virus these numbers If caused by a virus these numbers

of new cases would be labeled an of new cases would be labeled an epidemic and medical funding epidemic and medical funding made availablemade available

The population numbers suggest a The population numbers suggest a revolution is needed!revolution is needed!

History - Low Vision DevicesHistory - Low Vision Devices• 19101910 Telescopic DevicesTelescopic Devices

• 19301930 Practical TelescopesPractical Telescopes

• 19501950 Magnifiers More Magnifiers More AvailableAvailable

• 19591959 CCTV First Described CCTV First Described

• 19701970 CCTV First Marketed CCTV First Marketed

• 19801980 Computers/Reading Computers/Reading MachinesMachines

• 1990 Head Mounted LV Devices1990 Head Mounted LV Devices

• 20002000 to present - Continued to present - Continued Trend to Evolve Better DevicesTrend to Evolve Better Devices

• Feinbloom LV Practice/Optical Feinbloom LV Practice/Optical DesignDesign

• First Low Vision ServiceFirst Low Vision Service

• Spectacles/lenses evolveSpectacles/lenses evolve

• Magnifiers evolveMagnifiers evolve

• Electronic devices evolveElectronic devices evolve

• Internet, communication, Internet, communication, electronic books, accessibility electronic books, accessibility evolvesevolves

Darwin’s happy – its evolution!

Growth in Knowledge BaseGrowth in Knowledge Base

1910 1920 1930 1940 1950 1960 1970 1980 1990

Decade Ending

0

1000

2000

3000

4000N

um

be

r o

f P

ub

lica

tio

ns

Knowledge BaseKnowledge Base

Rapid growthRapid growth SpecializationSpecialization

Children/Education; Adults; Devices; Children/Education; Adults; Devices; Services/Training; etc.Services/Training; etc.

More professional disciplines recognize impactMore professional disciplines recognize impact

Need documented (numbers, cost)Need documented (numbers, cost) Few positive outcome studies – limits growth of Few positive outcome studies – limits growth of

servicesservices Over-all growth is revolutionaryOver-all growth is revolutionary

Service DeliveryService Delivery

Currently there are highly trained professionals, Currently there are highly trained professionals, however too fewhowever too few Optometrists & OphthalmologistsOptometrists & Ophthalmologists Special Ed, Rehabilitation, OT, etc.Special Ed, Rehabilitation, OT, etc. Support servicesSupport services

Appear to be few opportunities to increase Appear to be few opportunities to increase growth in professionsgrowth in professions

Services often outside medical profession and Services often outside medical profession and this limits growth through traditional medical this limits growth through traditional medical funding sourcesfunding sources

Service DeliveryService Delivery

No widely accepted or applied standard of No widely accepted or applied standard of clinical careclinical care

InternationallyInternationally Vision 2020Vision 2020 Low Vision Resource Center, Hong KongLow Vision Resource Center, Hong Kong

Service Delivery appears to be Service Delivery appears to be evolutionary although there may be a evolutionary although there may be a revolution going on in some parts of the revolution going on in some parts of the worldworld

Medical AdvancesMedical Advances

Improved treatmentImproved treatment Lucentis and Avastin Lucentis and Avastin Laser surgery for Laser surgery for

diabetic retinopathydiabetic retinopathy

Significant advancesSignificant advances Reduce severityReduce severity Prosthetic visionProsthetic vision Long term gain?Long term gain?

More to come??More to come?? Undoubtedly, but…Undoubtedly, but…

Medical AdvancesMedical Advances(illustration from the Artificial Retina Project)(illustration from the Artificial Retina Project)

Two companies in Stage Two companies in Stage III Clinical TrialsIII Clinical Trials

In next 12 to 24 months In next 12 to 24 months perhaps 100 to 200 perhaps 100 to 200 people will use one of people will use one of these implantsthese implants

Rehabilitation Needs? Rehabilitation Needs? Will this reduce the blind Will this reduce the blind

population & increase low population & increase low vision population?vision population?

Effect on low vision Effect on low vision services…services…

EvolutionEvolution or or RevolutionRevolution??

Patients/clients - Patients/clients - RevolutionRevolution Low vision devices - Low vision devices - EvolutionEvolution Low vision knowledge base – Low vision knowledge base – Revolution?Revolution? Service delivery – Service delivery – Evolution? Evolution? Revolution?Revolution? Medical advances - Medical advances - EvolutionEvolution

ConclusionsConclusions

It appears that the population and our It appears that the population and our knowledge base are in the midst of a knowledge base are in the midst of a revolution.revolution.

Our development of devices and medical Our development of devices and medical advances are evolutionaryadvances are evolutionary

Service delivery change is (in many Service delivery change is (in many countries) evolutionary but some parts of countries) evolutionary but some parts of the world are having a revolutionthe world are having a revolution

ImplicationsImplications More patients/clients will More patients/clients will ““trumptrump”” other other

processesprocesses No substantive increases in professional No substantive increases in professional

providers or servicesproviders or services Limited by lack of 3Limited by lack of 3rdrd party funding, separation from party funding, separation from

medical model, failure to integrate into mainstream medical model, failure to integrate into mainstream care, professional apathy, professional care, professional apathy, professional ““turfturf”” (we don (we don’’t t ““play well with othersplay well with others””), conflicting/apathetic consumer ), conflicting/apathetic consumer inputinput

In short, we may be in the midst of a revolution In short, we may be in the midst of a revolution with response that will leave too many with response that will leave too many un/underserved!un/underserved!

The Result…The Result…

No agreed upon No agreed upon ““gold standardgold standard”” of care or of care or even even ““minimum standardminimum standard”” of care of care

Majority of clients/patients faced with no Majority of clients/patients faced with no available services or services that many available services or services that many would consider to be less than effectivewould consider to be less than effective

Low vision professionals replaced by more Low vision professionals replaced by more numerous but less qualified opportunists?numerous but less qualified opportunists?

Thank you for your attention…Thank you for your attention…

Please feel free to publicly voice your Please feel free to publicly voice your disagreement or agreement!disagreement or agreement!

And feel free to try to change the status And feel free to try to change the status quo (for the better, of course)!quo (for the better, of course)!

My contact information:My contact information:

Gregory.Goodrich@va.govGregory.Goodrich@va.gov