August 2020
By Errol Rummel, OD, FAAO, FNORA, FCOVD and Richard Shuldiner, OD, FAAO, Chief Clinical Editor
Most people who seek low vision care enter our offices with a mix of psychological and/or cognitive issues ranging from anxiety and trepidation to fear, distrust, and/or depression. To no avail, they have tried over-the-counter reading glasses, a variety of routine eyeglass prescriptions, handheld magnifiers, retinal treatments and AREDS vitamins. Their vision is not getting better, and they have been told by more than one primary eye care practitioner that “nothing more can be done”. Of course, those doctors mean “medically”. Hopefully, a relative, friend, significant other, or a knowledgeable eye doctor has recommended low vision care. Usually the patient is willing, with some skepticism, to give it one more try.
In addition to myself as the examining low vision optometrist, and the patient, the next most important person in the exam room, is the “third person in the exam room”. Experience shows that it is essential for the patient to have a support person in the room to improve the potential for a successful visual outcome. It is best if the person is a significant other, spouse, partner, adult child or other involved person, rather than just a driver. Even an aide or caregiver can be that “third person”. In fact, in my office I emphasize that necessity to the patient.
There are many reasons for having that third person in the room. If nothing else the familiarity helps calm the patients’ anxieties. More importantly, even when the memory of the patient is intact, they rarely remember all the suggestions and recommendations I discuss. But most important is the “listening” of the patient.
Patients come in listening for something, and they don’t often tell you what they are actually listening for! I call this their “listening filter”. It might show up as an attitude, point of view, or an opinion, or an emotion such as anger. It might show up as a concern or an outlook, or agitation. Some are listening for a cure, even though they have been told there is none. Some are listening for the doctor to say “yes, I can help you”. Others are listening for the cost, how the low vision aids will look, how long the help will last, and a multitude of other issues. The point here is this, while they are listening for what they are listening for, they will NOT hear what I do say. Having the third person in the room increases the odds of someone hearing what I say.
We must remember that the third person also comes in with their own particular listening. Sometimes, the third person is a distraction, but fortunately, that happens rarely. As an example, a female sitting in my exam chair wanted the bioptic telescope glasses I demonstrated, to help with driving. Her husband, the third person, had questions, all of which had to do with his concern for the cost. He said to his wife, “perhaps you should go talk to the retina doctor again before we go ahead”. It was his attempt to get her out of the office without purchasing. I looked directly at her and said, “What do you want?” Her answer? “I want to see! Order the glasses”.
Other times, the third person has self interest in mind. The husband of an elderly macular degeneration patient actually began sobbing during my evaluation of her. I stopped and asked him what was going on. “We’ve lost all our friends”, he said. “We live in a retirement community and our social life revolved around playing bridge. Now she can’t see the cards, so we’ve lost our social life”. I almost cried myself. Fortunately, she was able to return to bridge with custom designed low vision glasses.
Other important reasons for the third person are the pre-exam medical-legal history issues to be discussed, plus bits and pieces of a patient’s visual needs and wants that are often not mentioned by the patient. I have also noted that the elderly with hearing impairment can better hear and understand that significant person in the room, whose voice they are familiar with, than when speaking with me.
Many times, the “third person” has not been in previous eye exam rooms with the patient and is not at all knowledgeable about the level of the patients’ vision loss. I find that they are either dismayed at how poor the patient’s vision is during eye chart testing, or they are elated to find out the patient who was told they are “legally blind” elsewhere does in fact have usable vision that we can enhance with low vision glasses. That third person can act as a cheerleader, encouraging the patient to attend to the eye chart, and try one more line, through a visual system that has not been stimulated for months, if not years. They help to praise the patient as better vision is noted at distance through telescope glasses, or to voice amazement of the small size of print the patient can read with a microscopic lens at a given focal distance from their face.
That other person is the one who, at home, will encourage and remind the patient to follow the instructions on the use of the low vision aids. For example, making sure they are holding material at the correct reading distance and situating the placement of the brighter desk lamp for maximum benefit. They will be the conduit to the rest of the family who want to know how the patient did at the exam.
In summary, it is my firm opinion that the third person in the exam room is absolutely essential to a good outcome when vision improvement is possible. And when the patient’s vision improvement through low vision care does not or cannot meet the patient’s visual wants and needs, that third person serves as a psychological sounding board to get the patient through that reality. When they leave the office, most patients are satisfied with the low vision visit, even if they cannot be helped, when they know the low vision doctor explored anything and everything to get the person to see better. But disappointment may show up later, as displaced anger at the doctor. The third person, having been there with the patient, can serve as a buffer and reminder that everything possible was done.