The number of people who are visually impaired and blind in the United States is estimated to be roughly 5 million, and is expected to rise because of the aging of the “Baby Boomer” generation, and may double by 2030. Macular degeneration is the major cause of impaired vision in the older population. Diabetic eye disease and glaucoma are also more common in the elderly. Retinitis pigmentosa, various congenital diseases, stroke, trauma and many other causes of vision loss continue unabated.

Most persons who are recently visually impaired will benefit from utilizing services that provide examination, counseling, home visits, demonstration and provision of low vision aids and instruction in modified daily activities. Those born with impaired vision and the student with low vision can benefit from services to achieve their goals for independence and hopefully employment.

Providers of services for individuals who are blind and visually impaired are diverse and unevenly scattered about the United States. Urban areas have more services and options. All states have a Department of Vocational Rehabilitation Services (VRS) that provides assistance to those with disabilities seeking careers, education and employment. The American Foundation for the Blind (www.afb.org) has a directory on their website that lists all kinds of services in each state as well as national programs such as the National Library Service for the Blind and Physically Handicapped which will deliver audio books to your home at no cost.

Types of Low Vision Service Providers

In order to have the best possible functional vision, a person will want to have a low vision examination by an ophthalmologist or optometrist specializing in low vision. The purpose of this examination is to go beyond glasses and contact lenses, and see what optical and non-optical devices can help enhance the individual’s ability to use their vision for daily needs. This is an extra step beyond a regular eye examination and may be provided in another location by trained professionals.

1) Ophthalmology and Optometry Training Programs

Many medical university training programs for Ophthalmologists and Schools of Optometry have low vision rehabilitation clinics, with medical professionals such as ophthalmologists, optometrists, occupational therapists and others participating. They provide comprehensive evaluation of each individual, and usually have Occupational Therapists helping with training and home visits. These are almost always of high quality and engaged in research. Currently, they are not present in all university training programs, but may be in the future due to recent emphasis on vision rehabilitation by the leadership of the American Academy of Ophthalmology. As they are primarily in large metropolitan areas they may not be readily accessible to many in remote rural areas.

2) Private Non-Profit Organizations for the Blind and Visually Impaired

There are private non-profit organizations which specialize in serving individuals with vision loss scattered throughout the United States. In their Low Vision Clinics, most provide an initial functional evaluation by an ophthalmologist or optometrist, followed by a wide gamut of services including adjustment counseling, adapted independent living methods, communication skills training, orientation & mobility services, and instruction and use of assistive technology.

Home and center based functional vision assessments are also done by qualified field staff such as Occupational Therapists, (OTs) and Certified Vision Rehabilitation Therapists (CVRTs). Most have an inventory of adaptive devices, magnifiers, lighting devices, and non-optical aids for demonstration and provide instruction in their use. In addition, Certified Orientation & Mobility Specialists (COMS) provide assessment and instruction to assist in daily travel.

There are over 150 different private organizations such as the Carroll Center for the Blind (Newton, Massachusetts), the Center for the Visually Impaired (Atlanta, GA), the Braille Institute (Los Angeles, CA) and Community Services for Vision Rehabilitation (Mobile, AL). Some of these organizations are known as Lighthouses for the Blind and are found in major cities – such as the Lighthouse Guild in New York, Chicago Lighthouse, New Orleans Lighthouse, San Antonio Lighthouse, San Francisco Lighthouse, etc.

There is an association of private non-profits known as the VisionServe Alliance which has a list of member organizations on their website at http://www.visionservealliance.org . This list includes most of these organizations.

3) Private for-profit Low Vision Services

Private for-profit low vision services and clinics provided by an Optometrist or Ophthalmologist as part of an individual general optometry or ophthalmology practice vary greatly in the types of services they provide. Some only provide a limited number of available magnifiers, and others have a wide variety of low vision products. Typically they do not provide counseling, training in adaptations and/or home visits unless they have a Certified Vision Rehabilitation Therapist, Certified Low Vision Therapist or Occupational Therapist on staff.

4) Veterans Administration (VA).

Veterans may be eligible for care for any eye problem, even if non-service connected, such as macular degeneration. Although some services may be dependent on the veteran’s income, these qualifications may be waived if the veteran is legally blind. There are special counselors (VIST Coordinators) who deal only with veterans who are blind and visually impaired. There are 10 special Blind Rehabilitation Centers scattered throughout the US. These are inpatient facilities offering the best rehabilitation care available. Any veteran with any degree of vision loss should consider availing themselves of help from the VA.

5) State Vocational Rehabilitation Agencies

State Vocational Rehabilitation Services (VRS) agencies are the largest providers of care to the visually impaired and blind in the US. They are either general agencies serving all disabilities or specialized agencies serving only those with vision impairments.

They are funded by the U. S. Department of Education’s Rehabilitation Services Administration (RSA). RSA has a budget of $3.2 billion that is granted to the states. Grant applications are made by each state individually, and matching funds (about 20%) must be provided by the state. The amount granted per state depends on the population of the state and the amount requested and matched.

The money obtained is then administered by each state individually. Almost all are called “Department of Rehabilitation Services (DSR)” or “Department of Vocational Rehabilitation Services (VRS)” and may be under the state Departments of Labor, Education or Health & Human Services. The funds obtained are for the rehabilitation of persons with all disabilities, not just for vision impairment. Hearing loss, loss of an arm or leg, stroke, mental illness and other disabilities are also included.

Goal of Vocational Rehabilitation Services

The goal of vocational rehabilitation services is primarily to help people with disabilities enter and/or remain in the work force. Thus, emphasis is placed on job training, use of adaptive aids, workplace modifications and working with employers. The career development of young people who are in transition from high school to post-secondary education or employment is also a priority for VRS. Education Services from kindergarten through high school graduation are provided in local schools or residential schools for the blind separate from VRS in most states.

Rehabilitation Counselors are the coordinators/case managers who provide help for the working age group. They generally have a Master’s degree in rehabilitation counseling. They assist individuals in developing a plan to learn adaptive skills, provide career counseling, provide vocational training opportunities and assist with job placement. Their priority is to help people get to work.

No upper age limit on working assistance

Employment and job retention services through VRS are available starting at age 16, or slightly younger in some states. There is no upper age limit for both job employment and job retention services. If the individual with a documented disability is motivated to work, can benefit from services, and there is feasibility of successful employment, they are eligible for vocational rehabilitation services. This might include provision of adaptive aids and devices, adaptive skills training, training in assistive technology, orientation & mobility, low vision services, or job assistance.

6) State Senior Services

Independent Living for Older Individuals who are Blind (OIB)
Although the major thrust of state VRS is toward education and employment, a secondary goal is to help non-working seniors with visual impairments maintain or regain their independence and “age in place” – in their own homes. Some of the federal money granted to and administered by each state VRS is allocated to services for seniors. The age of a senior is defined as 55 or older, although most who benefit from these programs are above 65.

Who actually administers the Senior Programs?

The funds for senior programs is an additional allocation to each state by RSA and is administered through the designated state VRS program. In some states, help for seniors is kept within the state VRS program or “in house”, but it may be contracted out to non-profits. The model of service delivery in each state is determined through the VRS program administration of that state.

What is provided for the seniors?

Emphasis is placed on safe, independent functioning for the senior who lives with vision loss. Based on individual need, service provision includes Center based or home visits by a cadre of qualified professionals including Certified Vision Rehabilitation Therapists (CVRTs) also known in some states as Rehabilitation Teachers (RTs), Occupational Therapists (OT), Certified Orientation & Mobility Specialists (COMS) and Certified Low Vision Therapists (CLVT). The CVRT or OT will begin with an assessment of the home for safety issues (loose throw rugs, poor lighting, lack of hand rails, etc.) to prevent falls and work with the individual to determine what types of instruction or additional services might be needed. Instruction in daily activities such as cooking, laundering, hygiene, financial management, communication, and other daily activities. Often, magnifiers, talking watches, timers, and simple, inexpensive aids are provided. In many states, expensive electronic magnifiers or eyeglasses are not usually provided.

Visual eligibility for services vary by state. In some states, VRS assistance is limited to those who are legally blind (visual acuity of 20/200 or worse, or restriction of visual field to less than 20 degrees). As difficulty with routine activities begins at much lower levels of impairment, individuals may seek services before that point. In some areas services can be provided by private non-profit organizations or qualified Occupational Therapists or you may need to travel to a more urban location to find the services you need.

Are these services available everywhere in every state?

As with health care in general in the United States, there is considerable variation from state to state and within different regions of the state. Theoretically every state provides some assistance to all visually impaired people over the entire area of the state. However, there may be remote rural areas that can be visited only infrequently. Trials of interactive internet services, called “Telehealth” or “Telerehabilitation” are ongoing in an effort to fill this need.

For a list of state VR agencies see http://www.ntac.blind.msstate.edu/information-and-resources/ncsab/

Finding help near you

a) Ask your own eye doctor. He/she should be able to advise you depending on your own individual problems and needs and what is available locally.

b) Go to the Vision Aware “Vision Connect” web site at http://www.afb.org/directory or

c) The VisionServe Alliance lists many private non-profits and Lighthouses at http://www.visionservealliance.org

d) You can find a list of state and territorial VR programs at http://www.ntac.blind.msstate.edu/information-and-resources/ncsab/

e) Information and direction is available at the American Academy of Ophthalmology’ “Smart Sight” at http://www.aao.org/low-vision

f) For veterans, call 1-877-222-8387 or go to http://www2.va.gov/directory/guide/home.asp

Conclusion:

For people of any age, in every state of the Union, help, education and assistance is available. Seek and ye shall find.

Joe Fontenot MD, CLVT
Medical Director, Community Services for Vision Rehabilitation, Mobile Alabama

B. J. LeJeune, CRC, CVRT
Director of the Older Individuals who are Blind Training and Technical Assistance Center (OIB-TAC), National Research and Training Center on Blindness and Low Vision, Mississippi State University