The Association of Schools and Colleges of Optometry (ASCO) is the academic leadership organization committed to promoting excellence in optometric education. ASCO’s activities cover a wide range of educational issues related to optometry, including applicant development and diversity, faculty and executive development, advocacy, and communications.
ASCO also recognizes optometric student achievement through a number of annual awards, including the Student Award in Clinical Ethics, open to optometry students during any point in their educational programs at an ASCO-affiliated school or college of optometry in the United States, Puerto Rico, and Canada. To apply for the Clinical Ethics Award, a student must submit an essay that discusses any of the ethical theories and values that are involved in optometric patient care.
The 2016 Award Winner: A Low Vision Case Study
This year, the award recipient is Krystal Chee, O.D., from the School of Optometry, University of California, Berkeley, Class of 2016, for her essay that explores Rehabilitation of the Ethical Issues in Low Vision. In her essay, Dr. Chee explores the ethical issues she faced when working with a patient who came to the optometry clinic for a comprehensive eye exam, stating that she was “unable to see anything,” but whose exam results indicated that she did not meet the criteria for classification as legally blind.
The patient’s records documented a history of diabetic retinopathy, a macular hole, and macular scarring. Her medical history included type 2 diabetes and hypertension. At the conclusion of the exam, the patient requested a diagnosis of legal blindness and stated that she had received benefits through being legally blind in the past. She provided documentation of this diagnosis in the form of a letter from her previous ophthalmologist.
What Is Legal Blindness?
“Legal blindness” is a definition used by the United States government to determine eligibility for vocational training, rehabilitation, schooling, disability benefits, low vision devices, and tax exemption programs. It’s not a functional definition and doesn’t tell us very much at all about what a person can and cannot see.
Part 1 of the U.S. definition of legal blindness states this about visual acuity:
- A visual acuity of 20/200 or less in the better-seeing eye with best conventional correction (meaning with regular glasses or contact lenses).
- If you can only read line 1 (the big “E”) from 20 feet away while wearing your regular glasses or contact lenses, the doctor records your vision (or visual acuity) as 20/200 with best correction.
- In 2007, the Social Security Administration updated the criteria for measuring legal blindness when using newer low vision test charts with lines that can measure visual acuity between 20/100 and 20/200. Under the new criteria, if a person’s visual acuity is measured with one of the newer charts, and they cannot read any of the letters on the 20/100 line, they will qualify as legally blind, based on a visual acuity of 20/200 or less.
Part 2 of the U.S. definition of legal blindness states this about visual field:
- OR a visual field (the total area an individual can see without moving the eyes from side to side) of 20 degrees or less (also called tunnel vision) in the better-seeing eye.
This is a representation of a constricted visual field:
A living room viewed through a constricted visual field.
Source: Making Life More Livable. Used with permission.
You can read more about ways to classify vision at Low Vision and Legal Blindness Terms and Descriptions at VisionAware.org.
The Optometric Ethical Dilemma: Low Vision versus Legal Blindness
The following passage has been edited for clarity for non-medical readers and excerpted from Dr. Krystal Chee’s award-winning essay and case study, which you can read in its entirety at Rehabilitation of the Ethical Issues in Low Vision on the ASCO website.
The Exam Results
During the exam, her visual acuities were as follows: counting fingers at 40 cm [about 16 inches] in her right eye and 20/50 in her left eye. Pinhole and manifest refraction showed no improvement in visual acuities. [Editor’s note: In a manifest refraction, the doctor places lenses of various strengths in front of the patient’s eyes and asks “Which is better, lens A or lens B?”]
Visual field testing revealed constricted visual fields in both eyes. The right eye’s widest diameter of visual field was 15 degrees; the left eye’s visual field was constricted at the top (superior) and at the bottom (inferior), but was a full 54 degrees side to side (horizontally). We informed the patient that eyeglasses would not improve her vision and advised her to schedule an appointment to be seen in our low vision clinic.
The patient then requested a diagnosis of legal blindness and stated that she had received benefits through being legally blind in the past. She provided physical documentation of this diagnosis in the form of a letter from her previous ophthalmologist, which stated that she was legally blind. Although she desired the benefits she had previously received, it was clear that she did not qualify as “legally blind” per the U.S. Social Security Administration’s definition.
The Ethical Dilemma
As optometrists, we encounter situations in which we need to appropriately draw the line between patients with low vision and patients who can be defined as legally blind. The law defines legal blindness for public safety reasons (driving) as well as determining eligibility for disability benefits funded by the government.
In addition to monetary assistance, the government-funded programs for people with legal blindness (the Social Security Disability Insurance program and the Supplemental Security Income program) can also provide services including audio, large print, or braille resources. The Americans with Disabilities Act allows reasonable accommodations by employers to allow for equal employment opportunity, such as closed-circuit televisions and screen magnifiers.
What about Low Vision?
While these benefits are of great assistance to legally blind patients, there are many additional factors that factor into a patient’s visual functionality aside from visual acuity and visual field (e.g. contrast sensitivity). While a patient may not qualify under the United States Social Security Administration’s guidelines, use of their low vision can still be equally as challenging if these additional hindrances are present.
The Optometric Professional Code of Ethics: Considerations for Services
As stated in the American Optometric Association Code of Ethics, one of our duties is “to advance professional knowledge and proficiency to maintain and expand competence to benefit our patients.” Our job as optometrists is to ensure that patients who qualify for these services are diagnosed and directed to the appropriate resources that would allow for beneficial services, providing the highest quality of life possible.
According to An Optometrist’s Guide to Clinical Ethics, “optometrists must serve as patient advocates and help their patients receive the best available care.” This means we must be up-to-date with requirements through the United States Social Security Administration and how to direct patients towards receiving disability benefits. While we are to be advocates for the well-being of our patients, we must also recognize that these benefits are not to be abused.
We have an “obligation to protect the health and welfare of society,” including appropriate allocation of resources to those who are in serious need. Patients may desire the benefits of being classified as legally blind, especially if they have been granted these benefits in the past – as with the patient in this case report. While one of our ethical principles is to help others (beneficence), it is necessary to be truthful of our exam findings in order to uphold the code of ethics.
Additionally, we should consider rehabilitation of these patients in the way of low vision services and low vision devices. If we do not have the means to provide these services ourselves, we must follow the Code of Ethics which states our responsibility to “advise our patients whenever consultation with, or referral to another optometrist or other health professional is appropriate.”
This goes along with being an advocate for our low vision patients, especially those who feel overwhelmed or helpless in their daily functioning because of their reduced vision. The United States Social Security Administration states that even if a patient is not “legally blind” per their definition, a visual impairment may still make them eligible for Social Security benefits on the basis of disability. For these cases, directing our patients to a Social Security Disability attorney or advocate may be the best option to help them benefit from necessary services.
The Resolution of This Case
Considering that this patient’s visual acuity and the extent of visual field were both better than the definition of legal blindness per the United States Social Security Administration, we determined that we could not diagnose her with legal blindness, despite her previous documentation and receipt of benefits. We consulted thoroughly with our patient and advised her of all of her options for low vision rehabilitation.
Another aspect of our Code of Ethics is to strive to ensure that all patients have access to eye and vision care, regardless of transportation or financial limitations. We connected her to the local Department of Rehabilitation, which would be able to help set her up with services through our low vision clinic. We also advised her that despite not qualifying as legally blind, her visual impairment could still allow her to gain services through the Social Security Administration and that an advocate could help her determine the appropriate options.
After discussing at length the potential benefits of low vision services to improve her employment opportunities and quality of life, our patient was greatly thankful for our advocacy and was optimistic about maximizing functionality of her vision.
Readers: It’s Your Turn
What is your reaction to Dr. Krystal Chee’s award-winning essay? Please feel free to discuss your reactions in the comments section. We want to hear from you!
- Working Life: Working-Age Adults with Blindness or Low Vision
- There is Hope; There is Help: Part 1 in a Series on Low Vision and Low Vision Services by Bryan Gerritsen, CLVT
- Understanding Low Vision Care and Low Vision Devices: Part 2 in a Series on Low Vision and Low Vision Services by Bryan Gerritsen, CLVT