Special Needs Report

By Alee Dutell

For my special needs patient, I choose Rosa D., a woman who is legally blind in both

eyes due to open-angle glaucoma. Open Angle is the most common glaucoma diagnosed in the

United States (American Optometric Association, 2022). This causes her vision to be limited to

blurry shapes and outlines, multiple black spots, and extremely poor depth perception. This

disability requires Rosa to need special accommodations such as a driver and a personal reader.

She has been considered legally blind for the past fifteen years.

John Hopkins Medicine defines glaucoma as, “A chronic, progressive eye disease caused

by damage to the optic nerve, which leads to visual field blindness. The most major risk factor is

eye pressure” (John Hopkins Medicine, 2023). This is the specific cause in Rosas’s case. When

She began experiencing blurry vision in her left eye and reoccurring headaches, she went to see

an ophthalmologist. This doctor informed Rosa that she had mild glaucoma and would need to

take eye drops daily to keep the pressure down in her eye. He also told her she was a great

candidate for Ocular Photodynamic Therapy laser surgery. This procedure is typically intended

for age-related macular degeneration, but he was confident this would work well in Rosa’s case.

This doctor ensured her that this surgery would help her glaucoma from progressing by

reducing the pressure in her eye due to blood vessel growth. Ocular Photodynamic Therapy is a

laser surgery, “That involves the infusion of an intravenous, photosensitizing drug followed by

exposure to a laser. The drug seeks out the abnormal vessels that are characteristic of AMD.
The doctor then targets the vessels with a laser that activates the drug, setting in motion a

chemical reaction that seals off the vessels and causes them to regress” (UCLA Health,2023).

Unfortunately for Rosa, this treatment ended up worsening her vision in her left eye and

a few short months later she developed glaucoma in the right eye, leaving her considered

legally blind. She is able to keep her glaucoma stable for the time being by using medicines to

keep the pressure in her eye low enough that it does not cause further damage to the Optic

nerve. These include the eye drops timolol maleate and latanoprost. Rosa takes additional

medications such as metformin for her type II diabetes, lisinopril for her blood pressure, and

Eliquis for blood thinning as an adjunct to her heart ablation procedure. Because her eye drops

have been successful at keeping Rosa’s eye pressure low for many years, she has a relatively

good prognosis. Her ophthalmologist has though informed her that it is not uncommon for

these drugs to lose their efficacy over time so she must monitor this closely.

Before I began treatment one obstacle I knew I would face would be teaching Rosa

homecare. I could not do my usual routine of handing over a mirror and showing her what to

do. I decided I would adapt this by using the sensory cue of feeling instead of seeing. I would

first start by demonstrating the proper technique on her and then asking her if she could feel

what I was doing. I would then ask her to try and replicate that feeling and evaluate if she was

able to perform the technique effectively. I would basically turn our traditional tell-show-do

into tell-feel-do.

Another modification I anticipated making is how I would explain to her the severity of

her periodontal disease without the use of her X-rays. I wasn’t sure how this would go but I
decided I would use something she could physically feel and knew the look of well. I decided I

would use her pointer finger to try and model a tooth.

During treatment, Rosa took to learning homecare by feeling very well. When teaching

sulcular brushing I told her to visualize the angle of the brush at 45 degrees going under the

gumline. I then modeled this for her and ask her if she could feel the way the bristles were

positioned. She was able to correctly insert the brush at the proper angle on her own and took

to the circular motion well. I was also able to successfully teach her how to use the rubber tip

gum stimulator under her many crowns. I once again started with her feeling the position of the

tool and then had her replicate it. I then told her to trace the crown using an erasing motion,

which she had no problem replicating.

When it came to explaining to her the severity of her stage III periodontitis, I think that

using her own finger ended up being a good visual for her. I started by telling her to imagine her

pointer finger as a tooth. Her crown should end just slightly before her first knuckle, and in

health, the bone surrounding it should be right at the first knuckle. Then I explained that in her

case her bone level was all the way down to just above her second knuckle giving her about

33% bone loss. All and all I think this was a good visual for her, but I don’t think I was able to

adequately express to her the seriousness of this bone loss as I would have been able to if she

could see the radiographs. Although I did explain that she has a lot of roots exposed and this

could lead to further tooth loss, I think that actually seeing roots and furcations showing would

have evoked a more intense response.

One modification I was not prepared for was how much talking I would need to do to

keep her understanding what was going on. Typically, with my patient, I perform a step and
then write my note on the said step. The patient can see that I am using the computer and they

sort of accept that as part of the process and my job. With her every time I stepped away, I felt

the need to inform her that now I would be writing a note on what we just did. Her treatment

also involved a lot of explaining what I was setting up and why. She once asked me why I kept

getting into the cabinet, and that’s when I realized she had no idea how frequently I was

changing my gloves. It was little things like that, that involved a lot more care on my part. When

I stopped to grab an assessment paper, I literally had to vocalize that to her so she would

understand.

These were the modifications I was not prepared for but made me stop and think about

the way I conduct myself with patients. Should I be more vocal about what I am doing with all

my patients? Am I making the mistake of assuming they understand what I am doing because

they can use their eyes to see it? These are the modifications that I think I will take with me in

practice for even my able-bodied clients. I am curious to see if this way of communicating could

change the way my patients respond to and interact with me as a whole.

 AMERICAN OPTOMETRIC ASSOCIATION. (n.d.). Glaucoma. AOA.org. Retrieved

 Glaucoma. Glaucoma | Johns Hopkins Medicine. (n.d.). Retrieved January 26, 2023,
from https://www.hopkinsmedicine.org/health/conditions-and-diseases/glaucoma

 Photodynamic therapy. UCLA Health System. (n.d.). Retrieved January 26, 2023, from
https://www.uclahealth.org/medical-services/ophthalmology/surgical-treatments/
photodynamic-therapy