by Holly Bonner
As much as I hate to admit it, there are times when I’m just a blind, cynical New Yorker. I have a problem believing the hype when it comes to anything new to the realm of accessibility. When I came across a YouTube video for OrCam, a fledgling Israeli technology company and creators of a wearable camera for the blind; I’ll admit, I was intrigued. Intrigued, but not convinced. I shared the video on Blind Motherhood’s Facebook page [Blind Motherhood is my blog as well as a resource for individuals and families impacted by vision loss], and it appeared that many of my followers also knew very little about OrCam. Their technology had an almost myth-like reputation – the evasive unicorn of assistive technology. After researching the company’s website and watching several more of their YouTube videos; I knew I had to arrange for a demo of their product to “see for myself” (as the company says). So that’s where this journey begins for this blind mother of two – in this first installment of a two-part blog dedicated to all things OrCam.
I headed over to OrCam’s website in an attempt to make contact. Their site, though minimalistic in design, is filled with useful information and testimonial videos about their products. I filled out a brief, online contact form that also included a short "message" area. It was in this section that I noted I was not only a blind mother of two little girls, but also a blogger who wanted to share information about the device with my readers. Within two days, OrCam responded. First, with an email from Hannah, OrCam’s Community Manager, who also happens to be in charge of the company’s own blog page. Hannah introduced herself, describing her role and explaining she had forwarded my information to the sales team who would be contacting me via phone.
That same day, I received a voicemail response from Jonas of OrCam’s sales department. Jonas and I played phone tag for a day and a half – emailing each other in between. It seemed like every time he called me I was elbow deep in changing a diaper and when I tried calling him; he was on the other line. When we finally did connect, I discovered we were talking to each other on opposite ends of the world. Literally. Here I was on the island of Staten and he was sitting in Jerusalem, Israel. Despite the distance between us, I felt an instant connection with Jonas. His kind, professional demeanor made him extremely easy to talk to – even with two toddlers screaming for breakfast in the background.
Jonas explained we needed to spend about 20 – 25 minutes on the phone. The purpose of this initial OrCam phone consult is two fold. First, it gives its sales representatives the opportunity to provide a detailed product description, explaining both its capabilities and limitations. Secondly, it allows the company to conduct a short questionnaire with each potential buyer. They respectfully review every individual’s current vision status, ensuring they have no medical complications that could impede usage of the device.
What Is OrCam and What Does It Actually Do?
OrCam is a wearable, intuitive smart camera that attaches to the user’s glasses. The crux of this device revolves around text to speech technology, similar to programs like Zoom Text and several cell-phone apps on the market. OrCam reads, recognizes and can even remember people and products in the user’s life. Forget your audio books. Goodbye Close Circuit Televisions (electronic magnifiers). Adios hand-held magnifiers! OrCam helps people who are blind and visually impaired read newspapers, books, signs and labels. It can also read text from a computer screen or cell phone.
I’ll admit I got a little nervous when Jonas began describing what the device actually looked like. In my mind, I was picturing Arnold Schwarzenegger in those Terminator movies. As much as I wanted to try this technology, I still wanted to look like myself – not some robotic killer badass. Needless to say, my imagination may have gotten the better of me. OrCam is comprised of a head and base unit. The camera weighs ¾ of an ounce. It fits on the right side on your glasses and the ear piece sits just along the arm of your frames. The camera has a thin wire, easily hidden behind the ear, and connects to a rechargeable battery.
The battery is approximately the size of a cell phone or small remote control. If used consistently (meaning you’re OrCamming non-stop), the battery should last 3 full hours. If used intermittently throughout the day, the device should give you 12 full hours with one charge.
Also located on the base unit is the volume control, a trigger to activate the camera’s features, and settings to change the voice from male to female. You also have the option of listening to OrCam utilizing a headphone jack or portable speaker system. I’ll admit Jonas’ description made OrCam appear extremely versatile.
Finally, Jonas explained how OrCam combines a pointing gesture with its technology. The device’s camera is activated by gesturing the end joint of your index finger towards whatever you want to read. The user then hears two beeps prompting them to remove their finger. A shutter sound occurs. This gets the user comfortable with aligning their head with the text area they want to read.
Pictured: Holly wearing the OrCam device.
Getting to the Health Portion
Since I provided Jonas with a brief history of my vision loss and the current state of my residual vision, I was curious who exactly wouldn’t benefit from OrCam. Jonas explained because the technology is essentially a camera, people who have extreme light sensitivity would not be able to properly use the device. Cameras need light to see and being in a constant state of darkness would prevent OrCam from working to its full potential. Additionally, users with poor hearing may also find the OrCam problematic. Understandably, text to speech technology is useless if you can’t hear what the device is telling you. Finally, individuals who experience tremors or have persistent conditions such as Parkinson’s disease, may not be able to maintain the pointing gesture or necessary neck motion that work in conjunction with OrCam.
The Two Types of OrCams
OrCam has two versions of it’s technology. The “My Reader” ($2,500) only offers the text to speak option. OrCam’s "My Eye" ($3500) gives you the same text to speak technology, but also has the ability to store faces and products into its memory. Both devices come with a warranty and OrCam has financing options in the form of installments and a lease to own option. If you do choose to buy the product, the owner receives a complimentary one-on-one, two-hour training session by an OrCam certified trainer.
How I Wanted to Use OrCam
In the remaining few moments in my talk with Jonas, we discussed how thought I might be able to use OrCam. I talked about my two daughters (who I love more than anything in this world) and the difficulty I sometimes have searching for their favorite books and toys. I discussed how I wanted to be able to go to the pediatrician and not have to carry a portable magnifier or CCTV to fill out paperwork. Professionally, my current position has an extreme amount of paperwork that I spend hours reading via magnifier. My hope was OrCam would provide me with a kind of technological balance amidst my role as wife, mother, social worker and blogger. Jonas seemed very confident that OrCam could work for me. He assured me he would send my information to their NYC rep, Bryan.
Within a day Bryan had emailed me and we set up an appointment to demo the OrCam in my home – complete with two active toddlers and a “Mostly Wonderful” husband who got stuck working overtime. Tune in for Part II of my blog detailing my experience trying this technology first hand.
This post was published originally on my website, Blind Motherhood Part I Experiencing Orcam.
Additional Information about Orcam
by Neva Fairchild
Editor's note: During National Disability Employment Awareness Month, VisionAware is highlighting employment resources and strategies for people who are blind or visually impaired. A key piece of getting a job is the application process. Today that means applying online.
Applying Online: A Major Challenge for Older Workers
One challenge older workers experience when looking for employment is being able to apply for jobs online. Back in the day, you were able to walk into a company, get an application, fill it out, and know before you left if you got the job and when you were going to start. Nowadays, most applications are done online. You have to be able to find the job posting, upload your resume, and fill out application questions. Many job seekers wonder at the end of this process if the employer has actually received the application.
Using the Right Job Board
You can use job boards to find open positions when you are looking for a job online. If you have a good idea of what type of position you're interested in, you can narrow down your search results. For example, you might consider Monster.com if you are interested in a professional career. If you are looking for office, clerical, call center, or labor-based jobs, Indeed or Careerbuilder.com are the best options. If you're not sure of what you would like to do or which industry is best for you, try Indeed first. This site has a larger variety of job postings.
The Difference Between Monster.com and Indeed
The difference between the two sites is that Monster.com is charged per click. Employers are charged for every application they view, so rather than reviewing several applications, the employer might only review a few, find the one that is a good fit, and stop there even though the seventh or eighth application would have been a better fit. Indeed charges the employer a rate of about $250 for each posting, and they don't charge per resume that has been submitted. Therefore, employers who use Indeed are more likely to review a wider variety of applications. However, Monster.com is still a good place to upload your resume. An employer could search by keywords on a resume to find an appropriate applicant. Keywords can also be used as a recruiting technique on Indeed, but it is not as common as it was in the past.
If you're unsure of what position you're interested in, use general terms. For example, instead of "sales," you could use "customer service," or you could use "call center" instead of "collections inbound, outbound."
Checking Company Websites
It is expensive for companies to market job openings so many available positions are not listed on Indeed, Monster.com, or Careerbuilder.com. Spend some time thinking about all the companies that you would want to work for and then go to their websites to check available jobs.
Additional Job Search Tips
If you aren't comfortable using the computer and you don't have anyone to assist you to fill out online applications, there are other ways to find a job.
Networking with employers at career fairs is an excellent way to find job opportunities. Career or job fairs let you meet the hiring manager face-to-face and be able to have a conversation with them. Let them know exactly what you are looking for and that may give you an opportunity to negotiate any kind of accommodation or get a feel for the company environment and management style. It takes a while to be able to find what kind of management style works for you and even what type of duties you'll be doing. For instance, doing clerical work is going to be different than doing a sales job. Sometimes you don't realize what type of work you like or don't like until after you get into a position.
Social networking is also an important tool to use if you aren't sure of a specific career field. Reach out to your friends, old co-workers, or even use LinkedIn. Someone might know of a position that you were unaware of that would apply your specific skill set.
Volunteering is a great way to meet hiring managers, other employees, and someone down the line who might be able to help you find a job. Just meeting one person who might know somebody else could get you a job, especially now that many of the job postings are on company websites.
Keep Your Resume Updated
Always keep your resume updated. This means making sure that your resume is tailored to the application for which you are applying. If the job posting states that the company is looking for someone with five years of sales experience or two years of customer service, make sure that's reflected on your resume. Volunteer experience will also work. It is critical that employers know if your skills are current.
It is important to keep an open mind and not limit your search when you are looking for a job. Think about the odds. If you apply for ten positions a week your odds are higher than if you only apply for two jobs.
Interviewing Tips in Today's Job Market
- Always dress for the interview. Many people think that if it's a low skill job that they can show up in blue jeans and tennis shoes, but it just doesn't make the good impression employers are looking for.
- Be aware of the amount of space that you take up during the interview, including the size of any bags or other items you may carry.
- Be mindful of all the things that you bring to the interview. All of them need to have usefulness and a purpose and at the same time, you don't want to bring too much in and seem cluttered and disorganized.
- Ask questions during the interview, for example, ask what is considered being successful in the position that you are applying for.
- It's important to ask about dress code. You want to be able to fit into their company culture. When you ask the question, "what is the dress code," you are showing the employer that you are trying to visualize yourself working for that employer. That is what they want to see.
- Ask about expectations. What are characteristics and capabilities of employees they are looking for?
After the Interview
Showing an interest in the job and that you are thankful for the opportunity is always important. Some job seekers have had very positive results from sending out thank you letters.
You may also want to follow-up with a call to make sure the employer has everything he or she needs to make an informed decision.
by Priscilla Rogers
by Joe Baker, Medicare Rights Center staff
On October 15, open enrollment begins for Medicare recipients. This can be a very confusing time. You can get help from The Medicare Rights Center, a national, nonprofit consumer service organization. This organization works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs and public policy initiatives. The Center works tirelessly to ensure access to affordable health care for older adults and people with disabilities through its counseling and advocacy, educational programs, and public policy initiatives. Medicare Rights is the largest and most reliable independent source of Medicare information and assistance in the United States.
Medicare Rights has partnered with the American Foundation for the Blind (AFB) to make Medicare Interactive, its free online resource packed with hundreds of answers to Medicare questions, accessible directly from the AFB's VisionAware website. Medicare Interactive answers questions related to vision loss, including information on Medicare coverage of eye care services like glaucoma screenings – of which eighty percent is covered annually for people who are at high-risk for glaucoma – and eligibility for Medicare due to disability.
National Consumer Helpline
People with vision loss can also call the Medicare Rights’ National Consumer Helpline at 1-800-333-4114. One of its dedicated staff members or volunteers will counsel them about their Medicare coverage over the phone.
Example of Use of Medicare Rights Helpline by Person With Vision Loss
Ms. P, who is legally blind, called the Medicare Rights helpline at 800-333-4114 because she needed assistance affording her prescription medications when her Medicare Part D (prescription drug coverage) plan’s monthly premium increased dramatically. A Medicare Rights counselor also determined that her annual drug costs would exceed $5,000 on her current plan. The counselor guided Ms. P through selecting a new Part D plan, and also helped her enroll in New York’s income-based program that helps pay eligible individuals’ drug costs. Like New York, many states have a State Pharmaceutical Assistance Program to help people pay for their medications.
Ms. P is one of the thousands of people Medicare Rights assists on its helpline each year. Medicare Rights is dedicated to helping people with vision loss, and all people who are eligible for Medicare, navigate the complex world of health insurance. Be sure to check out their article on When Does Medicare Cover Eye Care.. Also, for more information, please call 1-800-333-4114 or go to the Medicare Rights website.
by Maureen Duffy
Alan R. Morse, J.D., Ph.D.
Alan R. Morse is President and Chief Executive Officer of the New York- and New York State-based Lighthouse Guild, which provides a full spectrum of integrated vision + healthcare services helping people with vision loss, including those with multiple disabilities or chronic medical conditions. His professional interests include the influence of vision loss on health care utilization, functional implications of vision loss, and communication issues in patient-centered care delivery.
Dr. Morse is an Adjunct Professor in the Department of Ophthalmology, College of Physicians and Surgeons of Columbia University; a trustee of the Healthcare Association of New York State; and a member of the Advisory Panel on Addressing Disparities of the Patient-Centered Outcomes Research Institute. He serves on the Editorial Board of Ophthalmology, the journal of the American Academy of Ophthalmology, and recently has been appointed to the Academy's Vision Rehabilitation Committee.
He is an ad hoc peer reviewer for more than a dozen publications, a current or past director of numerous healthcare organizations, and a regular participant on government panels, work groups, and committees. Dr. Morse received his B.A. from Franklin College, M.S. from Indiana University, J.D. from Pace University and Ph.D. from Fordham University.
Maureen Duffy: Hello Dr. Morse. Thank you very much for agreeing to speak with our VisionAware readers. To begin, can you tell us about your background? I'm interested to learn more about where you grew up, your schooling, what you studied, and how you got to this point in your life.
Alan Morse: I grew up in New York, in Wantagh, on Long Island. I went to Levittown Public Schools and from there I went on a little detour. I ended up at Franklin College in Indiana where I studied psychology. From Franklin, I went to Indiana University to study rehabilitation counseling on a federal grant. After finishing at Indiana, I came to New York to work at the former Jewish Guild for the Blind for two years, again on a federal grant. I ended up staying at the Jewish Guild, and finished my Ph.D. in counseling at Fordham University, also in New York. A few years later, I went to law school at night. I've been at The Guild, now Lighthouse Guild, ever since then.
[Editor's note: In 2013, Jewish Guild Healthcare and Lighthouse International announced plans to combine as one organization. In 2014, the combined organization, called Lighthouse Guild, officially launched. You can read more about the long and distinguished histories of both organizations at Our History on the Lighthouse Guild website.]
MD: What drew you to study psychology?
AM: Well, I was debating between psychology and law. And I was going back and forth about it. Pre-law wasn't really a defined major, not nearly as well defined as pre-med. And you could major in almost anything and call it pre-law. While I was looking for a major, I wasn't particularly fascinated by history, and political science – both common pre-law majors – didn't really intrigue me.
Philosophy had some interest for me, but I wasn't sure I was smart enough to do that, so I ended up in psychology. Later on, my daughter was a philosophy major and used to call me up with arcane questions and I thought, Boy, I'm glad I didn't major in philosophy!
MD: What about law? How does that fit into the whole picture for you? When I saw you had a law degree, I found that to be very interesting.
AM: That was really by chance. My work at the Guild involved a lot of law – a lot of contracts and negotiations – so I was reading an awful lot of documents. In the middle of one of our negotiations, we were using outside counsel. I asked him a question and he said, "Well, you wouldn't understand because you're not a lawyer." And that's all it took for me to decide to go to law school. Now I use it all the time in my work. It's great preparation and provides great discipline.
MD: Speaking about planning (or not planning) things, what did you know about blindness when you first came to the Jewish Guild?
AM: I didn't know anything about blindness when I came to the Jewish Guild. It was a work assignment. My only experience with anyone blind was with a fellow grad student at Indiana University and I didn't have a lot to do with him because he was always in study groups with other people who were blind. So my first real experience was when I came here. I hadn't read anything about blindness, other than the textbook chapter I read in my Medical Aspects of Disability course. I had to learn very quickly on the job.
MD: I'm interested to know more about your innovative work in identifying and treating depression at Lighthouse Guild. In the July 18, 2016 issue of Mental Health Weekly, Dr. Goldie Dersh, Vice-President of Behavioral Health Services, was interviewed about your Behavioral Health programs at Lighthouse Guild. I thought the article's opening paragraph was perceptive and very true:
"The grief that often accompanies a considerable loss of vision can result in depression and a host of other problems. When the individual also has to address another serious medical issue, it becomes critically important to provide comprehensive and coordinated care. Few mental health provider organizations ever encounter a sufficient number of visually impaired patients to develop an expertise in meeting their needs."
In the interview, Dr. Dersh says this: "Vision loss is often experienced as a loss of part of one's self. These life changes are permanent. [People] experience difficulty doing the things they did in the past and often feel worthless." I think many of our readers can relate to her observations. Can you tell us more about the Lighthouse Guild Behavioral Health program?
AM: Sure. First, let me expand all these quotes a little bit. One thing that often gives us problems is that many professionals have the impression that we at Lighthouse Guild regard mental health disability as something that occurs with blindness. We don't think that. And we also don't want to give the impression that we believe people have deep-seated, serious mental health problems because they are blind. That's also not true. But for many people, loss of vision is accompanied by loss, sometimes by feelings of inadequacy or loss of self-sufficiency, and sometimes by depression. Having vision loss doesn't mean you can't also have other issues.
So we want other professionals who work with people with vision loss to be aware that when you have a patient with low vision – in an ophthalmologist's or optometrist's chair, for example – it's not inappropriate to have some discussion back and forth, such as "How are you?" and "How are you doing?" This is normal "small talk" that people often have when they are at the doctor. And the doctor should be alert to indications that maybe this person could be feeling depressed or have other issues. We certainly don't want – or expect – the doctor to deal directly with depression or other mental health issues. They are usually not equipped to do that. But the doctor should know how to refer the person to appropriate services.
Back in the 1950s, when the clinic here began, it was originally a full psychiatric unit. That's how long the Jewish Guild has had its behavioral health interest. It was staffed, much as it is now, by psychiatrists, psychologists, and social workers. And people from other departments at the Guild were involved if the person had, or was perceived as having, related medical or rehabilitation issues.
As our practice and our clinic evolved and became wider in scope and more outward looking, we began encountering people – even people who were congenitally blind – who hadn't been exposed to many other blindness services and training. Professionals from other departments within the Guild now had a chance to see something, to identify something, and to make referrals to behavioral health. We consider the behavioral health program to be integral to our offerings here. When people in our other programs, such as Vision Rehabilitation, Medical Services, or Education, have issues, we have a way to deal with them without having to look outside the organization for services.
MD: I'm not sure that all physicians are completely comfortable with that, though – with even asking the question.
AM: They're not comfortable, but they need to be. It's no longer appropriate anywhere in medicine, or anywhere in health care, to be talking about a patient as a disease entity. It has never been appropriate, but many physicians do it and have done it. Rather than talking about the nice man in Room 452 with a gall bladder problem, they'll talk about the gall bladder in 452. That happens with blindness and vision loss also.
Oftentimes, when people who have vision loss are seen in health care, they are not recognized as being the same as, or similar to, other patients because vision loss is seen as a different kind of problem. Frankly, it's something that the health care community has not dealt with very well, but needs to deal with well, because if they understand the implications of vision loss on what they are doing, it will give them better access to their patients, allow them to provide better care and, surprisingly, will find that better care will end up costing less.
MD: I agree with you. What are your thoughts on how to change this thinking and physician training?
AM: I have been invited to sit on a number of boards, work groups, and committees, and have had other professional opportunities, such as joining the editorial board of the journal Ophthalmology and the advisory panel on disparities of the Patient-Centered Outcomes Research Institute, so I get a chance to share these viewpoints with people who are far more expert than I am in a lot of things. They are ophthalmologists, physicians, specialists in other areas of healthcare, for the most part.
But they don't deal with patients in the same kind of environment, in the same kind of setting that we do at Lighthouse Guild, so their viewpoints are quite different. They tend to see patients for a brief period of time for episodic care – every six months or every year or every other month for treatment. They don't want to, they don't have the time, and they don't have the skill set, frankly, to start going beyond that. And that's the reason why our behavioral health services are so important.
Also, we are working with the ophthalmology residency programs on a training program in vision rehabilitation that will be available across the country. The learning modules will include a range of topics, from how to tell your patients they shouldn't be driving any longer, to identifying depression, to helping ophthalmologists understand what a low vision device or low vision assistive equipment is. We also want to help them understand state agencies and services and how that system works. In other words, we want to make them more knowledgeable about the world of blindness, not just the world of eye disease.
We expect to have the modules done in the next few months. We have the learning platform up and we are now starting to populate that. Certainly by this time next year it should be on the web and accessible to ophthalmology residents. What we hope is that when they have a patient with vision loss, they no longer have to say, "There's nothing more I can do. I'll see you in six months."
MD: Here's a final question for you as we wrap up our discussion. Could you talk about the importance of integrating vision and health care services? I know that integration of these services is a concept you support strongly and I'd like our readers to learn more about your thoughts on this.
AM: I think one of the things that so often happens – and this is not because of vision loss, it just happens in health care – is that it's become so specialized. My view of the world tends to be through a health care lens, whereas other people's might be through an education lens or a rehabilitation lens. So my health care lens very much shapes my thinking about this topic.
Here's one example of how medical specialization affects integration of services. If I were in a car accident and had some broken bones and a brain injury that resulted in vision loss, my doctors would deal with the brain injury and the broken bones. But they would send me someplace else for vision rehabilitation to treat my vision loss. Why?
Why does it take an organization like Lighthouse Guild to provide that needed vision rehabilitation service when we're only a few blocks away from many world-class hospitals, all of which have outpatient rehabilitation departments and all of which are working with people who have had strokes, for example? Thirty percent of stroke patients have vision loss, but these outpatient rehabilitation departments don't see them as vision loss patients; instead, they see them as stroke patients.
In New York State we have about 18 full-service agencies for individuals with vision loss. There are many times that number of hospitals. Wouldn't it be nice if every one of those hospitals could provide vision rehabilitation? People sometimes say that I'm "medicalizing" vision loss – but it's just that most blindness or vision loss comes from a medical or health care condition. Something caused it, so you're going to have interaction with the health care delivery system at some point. It would be good if that system could address your needs in a more medically comprehensive way. It can be done!
MD: Dr. Morse, I've very much enjoyed talking with you and learning more about your point of view. We thank you for your support of VisionAware, your innovative work, and your longstanding research and practice on behalf of blind and visually persons worldwide. It has been a pleasure to speak with you.
More Helpful Information
- Meet Rebecca Sheffield, Ph.D., Senior Policy Researcher, American Foundation for Blind Public Policy Center
- Meet Doug Anzlovar and the New "Low Vision Focus @ Hadley" Program at The Hadley School for the Blind
- Meet Dr. Gislin Dagnelie and Dr. Duane Geruschat: Pioneers in the Study of Restored and Prosthetic Vision
African-American Patients: Highest Risk for Diabetic Retinopathy and Lowest Rates for Follow-Up Eye Care – What Kind of Education Is Needed?Posted on 9/27/2016
by Maureen Duffy
A retina with
An emerging body of diabetes, vision, and health care research indicates that significant disparities in the quality and equity of eye care exist throughout the United States, more specifically within the African American and Latino patient communities.
This research includes an evaluation of the disparities in screening rates for diabetic retinopathy among minority patients, an examination of the rates of vision loss of African-American patients with diabetes, and the Los Angeles Latino Eye Study, which examined macular degeneration and related quality of life.
Most recently, The National Academies of Sciences, Engineering, and Medicine (NASEM) released a comprehensive and powerful report that proposes an all-encompassing framework "to guide action and coordination among various—and sometimes competing—stakeholders in pursuit of improved eye and vision health and health equity in the United States."
Now, new diabetes and diabetic retinopathy research from the University of Alabama at Birmingham and Wills Eye Hospital in Philadelphia has added to this growing body of knowledge. According to the researchers, "The public health success of diabetic retinopathy screening programs depends on patients' adherence to the timetable of follow-up eye care. African-Americans are among those at highest risk for diabetic retinopathy and have one of the lowest rates of eye care use."
The Research from JAMA Ophthalmology
The research, entitled Patients' Adherence to Recommended Follow-up Eye Care after Diabetic Retinopathy Screening in a Publicly Funded County Clinic and Factors Associated with Follow-up Eye Care Use, has been published "online first" in the September 15, 2016 edition of JAMA Ophthalmology, an international peer-reviewed journal published monthly by the American Medical Association.
The authors are Zachary Keenum, BS; Gerald McGwin Jr., PhD; C. Douglas Witherspoon, MD; Julia A. Haller, MD; Mark E. Clark; and Cynthia Owsley, PhD, who represent the University of Alabama at Birmingham and Wills Eye Hospital, Philadelphia, Pennsylvania.
About the Research
The prevalence of type 1 and type 2 diabetes in the United States is 9.3 percent and expected to increase, along with complications associated with diabetes that include diabetic retinopathy (DR), the leading cause of new cases of blindness among adults ages 20 to 74 in the United States. Yet many patients do not adhere to their physicians' eye care recommendations.
[Researchers at the] University of Alabama at Birmingham … are trying to find answers to the extent county clinic patients with diabetes in a DR screening program adhere to the timetable of recommended follow-up eye examinations.
African-Americans are at higher risk for the ocular complications of diabetes than are other segments of the population. Some research has suggested that the quality of their medical care for diabetes is lower than for other groups. African-Americans' lower rates of eye care are believed to stem from less access and more barriers to care, fewer eye care providers with practices situated in their communities, and a lack of awareness of their high-risk status for vision loss and how routine preventive care could reduce that risk.
For the study, screenings were performed at Cooper Green Mercy Health Services' internal medicine clinic in Birmingham. Data from the Jefferson County Health System's administrative database pertaining to eye care utilization for the patients screened were obtained from January 2012 through May 2015.
When the follow-up eye care utilization data were examined, only 29.9 percent of patients adhered to recommendations to have an eye examination within indicated time frames, even though cost and accessibility were minimized as barriers. Two years after the initial screening, 50.9 percent still had not undergone an eye examination.
[Study co-author] Dr. Cynthia Owsley says strategies for developing and implementing effective education at DR screenings should be carried out as next steps. "The education would focus on communicating the importance of seeking the eye care that is recommended following the screening, and also on communicating how to avoid barriers to care."
More about Diabetic Eye Disease
Although people with diabetes are more likely to develop cataracts at a younger age and are twice as likely to develop glaucoma as people who do not have diabetes, the primary vision problem caused by diabetes is diabetic retinopathy, the leading cause of new cases of blindness and low vision in adults aged 20-65:
What a person with
diabetic retinopathy sees
- "Retinopathy" is a general term that describes damage to the retina.
- The retina is a thin, light-sensitive tissue that lines the inside surface of the eye. Nerve cells in the retina convert incoming light into electrical impulses. These electrical impulses are carried by the optic nerve to the brain, which interprets them as visual images.
- Diabetic retinopathy occurs when there is damage to the small blood vessels that nourish tissue and nerve cells in the retina.
- "Proliferative" is a general term that means to grow or increase at a rapid rate by producing new tissue or cells. When the term "proliferative" is used in relation to diabetic retinopathy, it describes the growth, or proliferation, of abnormal new blood vessels in the retina. "Non-proliferative" indicates that this process is not yet occurring.
- Proliferative diabetic retinopathy affects approximately 1 in 20 individuals with the disease.
Four Stages of Diabetic Retinopathy
According to the National Eye Institute, diabetic retinopathy has four stages:
- Mild non-proliferative retinopathy: At this early stage, small areas of balloon-like swelling occur in the retina's tiny blood vessels.
- Moderate non-proliferative retinopathy: As the disease progresses, some blood vessels that nourish the retina become blocked.
- Severe non-proliferative retinopathy: Many more blood vessels become blocked, which disrupts the blood supply that nourishes the retina. The damaged retina then signals the body to produce new blood vessels.
- Proliferative retinopathy: At this advanced stage, signals sent by the retina trigger the development of new blood vessels that grow (or proliferate) in the retina and the vitreous, which is a transparent gel that fills the interior of the eye. Because these new blood vessels are abnormal, they can rupture and bleed, causing hemorrhages in the retina or vitreous. Scar tissue can develop and can tug at the retina, causing further damage or even retinal detachment.
What Is a Vision Screening?
A vision screening is a relatively short examination that can indicate the presence of a vision problem, such as diabetic retinopathy, or a potential vision problem. A vision screening cannot diagnose exactly what is wrong with your eyes; instead, it can indicate that you should make an appointment with an ophthalmologist or optometrist for a more comprehensive dilated eye examination.
What Is a Comprehensive Dilated Eye Examination?
A comprehensive dilated eye examination generally lasts between 30 and 60 minutes, and is performed by an ophthalmologist or optometrist. It should include the following components:
A Health and Medication History
- Your overall health and that of your immediate family
- The medications you are taking (both prescription and over-the-counter)
- Questions about high blood pressure (hypertension), diabetes, smoking, and sun exposure.
A Vision History
- How well you can see at present, including any recent changes in your vision
- Eye diseases that you or your family members have had, including macular degeneration and glaucoma
- Previous eye treatments, surgeries, or injuries
- The date of your last eye examination
An Eye Health Evaluation
- An examination of the external parts of your eyes: the whites of the eyes, the iris, pupil, eyelids, and eyelashes.
- A dilated internal eye examination: Special eye drops will dilate, or open, your pupil, which allows the doctor to observe the inner parts of your eye, such as the retina and optic nerve. This can help to detect subtle changes of the optic nerve in persons without any visual symptoms and potentially lead to early detection of disease, including diabetic retinopathy.
- A test of the fluid pressure within your eyes to check for the possibility of glaucoma.
A Refraction, or Visual Acuity Testing
A refraction helps determine the sharpness or clarity of both your near (reading) and distance vision.
This includes testing your vision with different lenses (sometimes contained in a machine called a phoropter, pictured at right) to determine if your vision can be improved or corrected with regular glasses or contact lenses.
Visual Field Testing
Visual field testing helps determine how much side (or peripheral) vision you have and how much surrounding area you can see.
The most common type of visual field test in a comprehensive eye exam is called a confrontation field test, in which the doctor briefly flashes several fingers in each of the four quadrants (above, below, right, and left) of your visual field while seated opposite you.
In some cases, your doctor may also want to perform a more precise visual field measurement, using a computerized visual field analyzer, such as the Humphrey Field Analyzer (pictured at left).
Your Examination Results
The doctor will be able to determine if the visual problems you are experiencing are normal age-related changes or are disease-related, and if additional testing, referral to another doctor or specialist, or treatments are needed.
More about the Study from JAMA Ophthalmology
Excerpted from the study abstract:
Importance: The public health success of diabetic retinopathy (DR) screening programs depends on patients' adherence to the timetable of follow-up eye care recommended by the screening program. African Americans are among those at highest risk for DR and have one of the lowest rates of eye care use.
Objectives: To assess the rate of adhering to recommended follow-up eye care in a DR screening program administered in a safety-net health care facility and to examine factors associated with follow-up eye care use.
[Editor's note: The "health care safety net" is a term that defines the array of clinical sites that provide health care opportunities for those who otherwise would have barriers to accessing quality health services. These barriers include lack of coverage, geographic isolation, language and culture, mental illness, and homelessness.]
Design, Setting, and Participants: Prospective follow-up study of persons with type 1 or type 2 diabetes. The setting was an internal medicine clinic of a publicly funded health system in Alabama, serving a population that was largely uninsured and African American, that had implemented a DR screening program using a non-mydriatic camera for ocular imaging and remote reading centers for evaluation of images.
[Editor's note: A prospective study measures a group of individuals over time and follows up with the study subjects in the future. A non-mydriatic camera is one that will take a picture of the retina, without the need for bright lighting and eye drops that dilate, or open up, the pupil. This can make the exam proceed more quickly by eliminating wait times for (a) the pupil to dilate and (b) the eye to adjust following the light flash that accompanies the retinal photo.]
Patients with physician appointments between January 26 and July 24, 2012, were eligible for screening if they had a diagnosis of type 1 or type 2 diabetes and were 19 years or older. Data from the county health system's administrative database were obtained from January 26, 2012 (date of first enrollee), through May 1, 2015, to establish participants' eye care use in the ophthalmology clinic after screening.
Results: Diabetic retinopathy screening was completed in 949 adults with diabetes, of whom 84.5% were African American, 64.5% were women, and 71.7% lacked health insurance. Participants ranged in age from 21 to 95 years, and their mean age was 53.9 years. The mean age at diabetes diagnosis was 44.3 years, and the mean duration of diabetes was 9.6 years. 29.9% adhered to obtaining comprehensive follow-up eye care within the recommended time frame.
Two years after a participant's screening date, 50.9% had no record of having received eye care. Factors associated with adhering to interval appointments were having an advanced age and knowing one's glycated hemoglobin level. Agreeing to assistance in making a follow-up eye care appointment was associated with nonadherence.
[Editor's note: The glycated hemoglobin test, also known as the A1c blood test, hemoglobin A1c, and HbA1c, is the primary tool used to diagnose diabetes and pre-diabetes and to monitor blood glucose control in people with type 1 and type 2 diabetes. This test enables health care providers to diagnose diabetes and treat it before complications occur and to diagnose pre-diabetes to prevent or delay the development of type 2 diabetes. You can read more about the established A1c levels used to diagnose diabetes and pre-diabetes at Diabetes and the Significance of the A1c Test on the VisionAware blog.]
Conclusions and Relevance: After a DR screening program in a public clinic largely serving an African American population, only one-third of participants adhered to interval recommendations for follow-up eye appointments, even though cost and accessibility were minimized as barriers to care. Our findings suggest that DR screening programs are not likely to meet their public health goals without incorporation of eye health education initiatives successfully promoting adherence to recommended comprehensive eye care for preventing vision loss.
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