MANAGING LOW VISION When someone has low vision

Clare Gilbert Co-director, International Centre for Eye Health, London School of Hygiene and

Tropical Medicine, Keppel Street, Karin van Dijk London WC1E 7HT, UK; Clinical Advisor, Sightsavers.

Karin van Dijk CBM global advisor on low vision; low vision consultant to Light for the World Netherlands and to Kilimanjaro Centre for Community Ophthalmology. Grutto 21, 7423CZ Deventer, The Netherlands. [email protected]

As clinicians, being faced with a patient whose vision we cannot improve any further can make us feel like a failure. However, there are many ways to help such a person with low vision. Figure 1 shows the difficulties someone is likely to have, based on their distance visual acuity, and what support Teaching the use of an illuminated hand magnifier. PHILLIPINES they may be able to benefit from. These include optical devices, non-optical 2 Has all the medical, surgical, and optical Once you have established that the devices, advice on environmental modifi- treatment possible already been given? person does need low vision services, cations, and referral to rehabilitation and 3 Has the prognosis for vision been you can begin the low vision assessment. (special) educational services. confirmed by a medical professional? The following are the steps that In this article, we will show you how normally form part of a low vision If the answer to any of these questions is to assess a person with low vision and assessment: ‘no’, refer the person to the appropriate find out what it is they really want to be services, where possible. • Taking a history able to do. We will then outline the If we know the diagnosis, this will give • Explaining the eye condition interventions that are possible, and give us some idea of the likely impact on the • Determining the patient’s needs some guidelines. person’s visual function and thus on their • Performing an accurate refraction Before you start main visual needs (see page 2). • Assessing visual functions Ideally, people with low vision should • Magnification needed When you are faced with a person with poor have undergone refraction, and be • Designing a management plan vision, it is important to check that every- wearing their spectacles, before they are • Referral for further training and support thing possible has been done to improve given low vision support. In practice, and contacting educational or their vision, and that they really do need many eye care practitioners find it too rehabilitation services if needed. low vision services. Here is a checklist: challenging and/or time-consuming to • Selecting low vision devices and training 1 Has the person’s diagnosis been refract someone with low vision. This is the person in their use confirmed by an ophthalmologist or why refraction should always form part of • Suggesting non-optical interventions other eye care worker? a standard low vision assessment. and environmental modifications. Figure 1. How the type of assistance provided is influenced by distance visual acuity

Spectrum of distance visual acuity (ideally, with the person wearing the correct prescription) Can see 6/18 < 6/18; can see 6/60 <6/60; can see 3/60 <3/60; can see 0.1/60 < 0.1/60 Difficulties with activities of daily living: dressing, eating, walking around, recognising faces +/- + ++ +++ ++++++ Potential to benefit from optical devices such as magnifiers +/- + ++ ++ Highly unlikely Potential to benefit from making changes to the environment (see page 12) +/- + ++ ++ ++ Need for rehabilitation and special educational services +/- + ++ +++ ++++++

4 CEHJ | VOLUME 25 ISSUE 77 Taking a history CASE STUDY 1 This is an important part of the low vision This case study, and those that follow, are of actual people and demonstrate assessment and provides an opportunity practical low vision assessments and interventions. They show how the diagnosis for you and the patient to get to know and history can guide us in setting priorities for assessment and knowing which each other. interventions, especially non-optical, might benefit the person. Encourage the patient to talk about their problems. Asking open-ended 60-year old retired near vision was 1M (N8) at 15 cm. His questions will help; these are questions professor with age-related near acuity improved to 0.63M at 25 cm starting with words such as ‘when’, ‘what’, A macular degeneration complained with an add of +3.00D, a reading lamp, ‘how’, and ‘where’ – questions which that he could no longer read small text, and a reading slit. With these, he was don’t have ‘yes’ or ‘no’ as an answer. which had been an important part of his also able to read the newspaper and his Ask questions about: life. He also taught college students and writing was legible. • Their own eye health – how their vision worked extensively on the computer at The professor was advised to wear his is affected, what makes it worse or home. On further questioning, it became bifocal glasses constantly, to read with a better and how it has changed over time clear that he also had difficulties in table lamp and reading slit, and to use a • Their general medical history, their communicating with others. From the reading stand. A signature guide helped mobility, and their medications history, interview, and diagnosis, we knew him to sign cheques. • Their family’s eye health history that the man had central field loss and He was taught how to use eccentric • Their occupation and hobbies reduced contrast sensitivity, which would viewing (see page 8), which helped him • Any previous low vision assessments. require improved lighting and contrast. to recognise people more easily. This The low vision team assessed his best helped him socially. Here are examples of questions you can corrected distance and near visual The professor was advised about the ask about their eye health and vision: acuity, contrast sensitivity, reading and importance of explaining to his friends • When did you first notice a problem writing ability, and the extent of his field and family why he was not able to make with your vision? loss. direct eye contact. • What kinds of problems have you noticed? His visual acuity, tested on a logMAR He was also directed to the local • What problems do you have in the chart, was 6/36 (0.8 logMAR) in the government office to obtain a disability day? better eye, and with a +2.00D add his certificate and other paperwork. • What problems do you have at night? • What changes, if any, have you noticed in your vision? • Can you walk around in familiar places they want to be able to do. This will guide • What makes your vision worse? without assistance? the interventions you suggest. • What makes your vision better? Activities Ask for specific examples of what • Can you choose and find the clothes would help them to regain independence Explaining the eye condition you want to wear? or self esteem. For example: Some people with low vision will not have • Can you add the correct spices and • Regaining the ability to read their had their eye condition explained to them, herbs to the food while cooking? personal correspondence or they may not have understood the • Can you still do your hobby, e.g., • Helping to cook again instead of just explanation at the time. needlework or woodcarving? sitting around It is always worthwhile taking time to • Can you read religious texts, the • Learning to identify the correct explain the eye condition again, in terms newspaper, or utility bills? medication and taking it independently the person can understand. Even if patients Participation • Making a visit to a neighbour on their with low vision have heard it all before, • Do you attend family functions? own, whenever they feel like it. they will probably find it reassuring to have • Do you attend religious or other events? you explain it again, thereby confirming When discussing these topics, think • Are you still able to vote? what they have heard from others. about the following: Be positive. Emphasise that they have Check with relatives that this is what they • Do they need help with near and some residual vision and that you and have observed or experienced; sometimes intermediate vision, with distance your colleagues are committed to helping people feel embarrassed to acknowledge vision, or with all distances? them make the most of that vision. how dependent they have become. • Is the task long (reading) or short Reassure them that they cannot harm It is also important to find out what (looking at the oven temperature dial)? their residual vision by using it – they will kind of support they have at home. • Do they need to have one or both hands not ‘wear out’ their eyes! free? • Who do they live with, and is this person • What other visual functions might be able to provide help some of the time, affected and must be assessed? Determining the patient’s or all of the time? needs • Is providing this support having a Accurate refraction Start on a positive note by first asking negative effect on the family in any way? The importance of good refraction in a what they can still do, before going on to • What is the home like? Are there steps? low vision assessment cannot be ask what they may be struggling with. Where are the washing and sanitation overstated. Ask about their mobility, activities, and facilities? How is cooking done? Refracting people with low vision participation. Here are some examples. Having established broadly what support differs from refracting people whose Mobility they have at home, and what they can vision can be improved to normal (6/6 or • Can you walk beyond the house without and cannot do in relation to mobility, 20/20), as the person with low vision is assistance? activities, and participation, find out what Continues overleaf ➤

CEHJ | VOLUME 25 ISSUE 77 5 MANAGING LOW VISION Continued

Assessing residual vision Using the bracketing The support we provide depends on having a thorough understanding of the technique person’s overall visual function. For Because patients with poor visual example, people with poor contrast sensi- acuity may have difficulty in deter- tivity may require more magnification than mining small changes in lens power suggested by their near visual acuity and clarity, it is often necessary to alone. make large power changes. When assessing someone with low A bracketing technique can be vision we therefore need to have a better useful. For example, use a +2.00DS idea of their overall visual function, trial lens and compare this with a including: −2.00DS trial lens. If the patient is Figure 2. A logMAR chart has an equal • Distance visual acuity able to differentiate between the number of letters in every line, regular • Near visual acuity two, the lens giving the better vision spacing between lines and letters, and a • Contrast sensitivity can be added and the technique uniform progression in letter size • Visual fields repeated using, say, a +1.00DS and • Light sensitivity a −1.00DS lens, etc. It may be less sensitive to small changes in the • Colour vision necessary to refract the patient with power of trial lenses and may respond the chart placed at 3 m or less. If this much more slowly. Patience is essential, If you work in a setting with limited is done, the result is over-plussed and using the bracketing technique (see resources, the improvement of distance (the chart at 3 m acts as a near panel) can help. and near visual acuity can be empha- object and therefore adds a vergence Fatigue and frustration can negatively sised; the other visual functions can be of about −0.30D in the plane of the influence the outcome of the refraction. tested functionally, as suggested here. trial lens) and a correction should be Ensure the person is seated comfortably If you work at a large eye hospital, use made according to the test distance. and give them time to recover from any the appropriate tests and equipment. signs of stress or tiredness. Adapted from: Subjective Refraction: Principles and Techniques for the Correction of Spherical While doing refraction, the test chart Distance visual acuity Ametropia, Andrew Franlin http://www.banjoben. should be at a distance where the patient We are used to testing distance visual com/low_vision_refraction.htm can see at least the top line of letters. Full acuity using standard Snellen charts at aperture trial lenses should be used to only two distances: six metres (20 feet) Near visual acuity allow the patient to move their head or or three metres. However, when testing It is very important to test everyone’s eyes in order to fixate eccentrically (see someone with low vision, we should near vision, not just those who can read panel on page 8). preferably use logMAR charts as they and write, as good near vision is needed Assess the near addition (lens) needed give better measures of acuity. If the for a very wide range of other activities. and measure the working distance with person cannot see the letters at three We must also know the near visual acuity which the patient is comfortable. Record metres, we must also test at other test so that we can prescribe low vision their best corrected near and distance distances, such as two metres, one magnifiers for near tasks, if needed. visual acuity. metre, etc. Near visual acuity can be tested using CASE STUDY 2 logMAR charts (Figure 2) similar to those used for testing distance visual acuity. It 45 year-old man with against a dark background. Mobility was is important that comparable tests for glaucoma, who drove himself tested in different lighting conditions by both are used. The choice of test depends to work in a factory, was referred going for a short walk with the client. His A on age, development level, and literacy to the low vision clinic. He was married distance visual acuity was 6/24 of the client, e.g., tumbling Es or with two school-age children, and was (0.60 logMAR) with his myopic glasses Landolt rings. the main breadwinner in the family. of -4.00D. He could read 1M (N8) It may be useful to assess near vision The man said that he had problems without his glasses at 20 cm. at a distance of 25 cm (see article on with driving and working in the evenings, A 6D hand-held magnifier was page 9). Note that people with presbyopia and had difficulty navigating inside the prescribed to make reading the may need an appropriate addition in order factory. These difficulties were the result newspaper and small print on the to read at this distance. In addition to of loss of peripheral field and reduced machinery more comfortable, and he near vision, reading and writing contrast sensitivity related to the was advised to wear a cap with a visor to performance should be assessed among glaucoma. He also had difficulty in reduce glare when in bright sunlight. those who are literate. This is because crossing roads, identifying curb edges, After consultation with his employer, reading requires other functions that are walking in shaded places, and identi- levels of illumination in the factory were not assessed in acuity testing, for fying landmarks. These findings increased. This improved contrast, example, locating the next line of print. If suggested a need for better illumination enabling him to navigate doorways and near acuity only is measured, difficulties in the evenings and in situations of concrete pillars more easily. This with reading may be missed. poor lighting. improved his mobility, working efficiency The best way to assess reading is to The low vision assessment included and confidence. He was advised to use printed text from a newspaper or book distance and near visual acuity with best travel to work using public transport or and to ask the person to read it aloud. correction, visual field testing by share rides with co-workers. The need Reading aloud allows the assessor to confrontation, and contrast sensitivity for regular review and continued use of hear mistakes and observe the person’s testing using light-coloured objects glaucoma medication was explained. visual skills.

6 CEHJ | VOLUME 25 ISSUE 77 Contrast sensitivity CASE STUDY 3 Contrast sensitivity is the measure of the eye’s ability to detect differences in iabetic retinopathy made a The interventions recommended greyness and background, or small 75-year-old woman unsure of focused on improving her near visual changes in brightness. Most of our world Dher bearings at home, even acuity and included an 8 dioptre illumi- is in moderate to poor contrast. Visual though she had undergone cataract nated stand magnifier, which enabled her acuity charts are one of the few things in surgery with intra-ocular lens implan- to read 1M print, using a reading stand to high contrast! tation. She was unable to identify help her read more comfortably. She Reduced contrast sensitivity can be different utensils and other items, such could also use the magnifier to identify assessed functionally by asking questions as spices, in the kitchen. She also could money. such as: not see the knobs on the gas cooker. She was trained in the use of She was keen to do her own cooking, eccentric viewing to assist in daily activ- • Do you find it more difficult to walk gardening, reading, and shopping. ities and was shown how to fold paper around in very bright sunlight, or at Pseudophakia is accompanied by loss money in different ways so she could tell dawn and dusk? of accommodation, while diabetic retin- which amount they were for. • Can you see the white light switch on opathy can result in sensitivity to light, To help in the kitchen she was the light-coloured wall in your house? patchy field loss, with reduced contrast advised to use different coloured labels • Can you read your bills (which are often sensitivity and color discrimination. for different pots and to use containers on grayish paper, with poor contrast)? These visual functions were all of varying shapes or sizes for her spices. There are several ways of testing contrast assessed. Her best corrected distance She was also advised to remove all sensitivity clinically, such as the Pelli visual acuity was 6/60 (1.0 logMAR) with unnecessary furniture in the living areas. Robson chart, but these charts are astigmatic correction. Other non-optical interventions she liked expensive and require that the person With a near add of +4.00D, she were a signature guide for banking, and with low vision is literate. A less expensive could read 1.6M at 20 cm. extra illumination for near work. alternative is the Lea low-contrast flip chart (see page 13 for ordering details), objects or people can become very You can determine the best lighting which is suitable for those who are not difficult. conditions for particular tasks, such as literate, including children. Low contrast People with reduced light sensitivity reading or sewing, by letting the person may explain why a person with a visual also struggle to see, and will often also try out different types of lamps in the acuity of 6/36 can manage many tasks have reduced contrast sensitivity. clinic. well, but struggles in poor light. People with increased light sensitivity Light: tips for daily activities Contrast: tips for daily activities could wear tinted glasses, sunglasses, or Getting the amount of light right is the key It is not easy to translate these findings to a cap outdoors to help with glare. intervention in this situation. Ask what the impact on daily activities. In general, Filters (Figure 3) can help people with person is struggling with, such as seeing moderate contrast sensitivity might have both contrast and/or light sensitivity by at night (reduced light sensitivity) or an impact on reading, whereas very poor minimising glare and increasing contrast. seeing outside in bright sunlight or when contrast sensitivity might indicate the Filters look like safety glasses and are the light reflects off the blackboard need for visual rehabilitation and mobility available at low cost (see page 13 for (increased light sensitivity). training. ordering details). Many different colours For people with reduced light sensi- You can help people with low contrast and shades are available, such as yellow, tivity, recommend that they sit near a sensitivity by advising them how to brown, grey, red, etc. window or try different lamps. increase contrast in their environment. People may need two different shades There are two main ways: of a particular filter: one for indoor use (light) and one for outdoor use (dark). 1 Use better lighting. For example, sit by the window to read or sew, or use a Ving Fai Chan Ving Fai Visual fields lamp. Be aware: very bright light, Ideally, the clinician making the diagnosis including direct sunlight, can reduce will have assessed the patient’s visual contrast. fields as part of their clinical assessment. 2 Make adaptations in the If not, questions can help. environment. For example, use paint Patients may realise that they cannot or coloured tape to create contrasting see detail clearly but can see well enough strips on steps or around light switches. to walk around. This suggests central visual field loss; this is often due to Light sensitivity macular degeneration. Both too little light, and too much light Someone with peripheral field loss (glare), can affect what someone with low from glaucoma or retinitis pigmentosa vision is able to see. can see detail but will bump into furniture People with increased light sensi- or fall over things on the floor. tivity struggle to see in the presence of There are a range of tests available, bright light (for example, light reflected including confrontation (face-to-face) by a shiny blackboard or table top). This testing, static tests (e.g. Friedmann visual is a common problem for people with Figure 3. A red filter has helped this man field analyser), and dynamic tests (e.g. low vision. with achromatopsia (a rare form of colour tangent screen or Goldmann tests). In the presence of such bright light, or blindness causing extreme light glare, contrast is reduced and recognising sensitivity) to see in daylight Continues overleaf ➤

CEHJ | VOLUME 25 ISSUE 77 7 MANAGING LOW VISION Continued

The Amsler grid test is used to plot Figure 4. Increasing magnification reduces the field of view (right) areas of significant visual loss within the central 20° of the visual field (the area of the retina providing fine detail). The Janet Silver Janet Silver person is tested while wearing their reading glasses or bifocals, if appropriate. For perimetry, e.g. Humphrey perimetry, a new hand-held perimeter is available from the Low Vision Resource Centre (see page 13). It is quick to use and provides reliable and repeatable results. Visual fields: tips for daily activities Low magnification Moderate magnification For people with central visual field loss: whether the person can see or match the electronic readers, the same limitations 1 Provide high magnification primary colours, e.g. red, green, and blue. do not apply. However, these devices are 2 Show them how to use eccentric This can be tested using pencils or pieces a lot more expensive than lenses. viewing (see panel below). of coloured fabric, for example, and Remember: to maximise the benefit asking the person what colour they see. of magnifiers, it is important that people For peripheral visual field loss, the best However, clinical colour vision testing wear an up-to-date pair of distance advice is to keep pathways clear and to can be valuable to make the correct correction spectacles when testing avoid moving furniture in the house. A diagnosis concerning the cause of a magnifiers and that they wear their cane for walking around outside may be person’s decreased vision. reading spectacles with stand magnifiers. very useful. For suggestions on predicting the level Colour: tips for daily activities of near magnification someone will Colour vision People with a colour vision deficiency or require, see the article opposite. It is rare for a person to be completely with blurred vision may find it difficult to colour-blind, but reduced colour vision distinguish between two colours that are Designing a occurs more often in people with low similar. Suggest the following: management plan vision. This can be assessed by asking • Arrange the food cupboard so tins or Develop a management plan based on all questions such as: do you have difficulty foods of contrasting colours are next to the information you have gathered about when trying to find clothes of matching or each other the person with low vision. similar colours? Have you noticed any • Ask someone to help label clothes or to Ask yourself: what does the person problems when discriminating shades of put matching outfits together ahead of need? This depends on their history, their colours? time (on the same hanger/shelf) physical capabilities, the nature of their There are formal methods for colour • Use other senses (touch and smell) to residual vision, and what they want to do. vision testing, such as Ishihara plates and find out which fruit are ripe. You may suggest some or all of the the Farnsworth dichotomous test (D-15), following: which involves colour arrangement. In Magnification needed practice, it is usually sufficient to see • Optical low vision devices: for near or Many people with low vision can benefit distance vision Eccentric viewing from magnification: using lenses to • Non-optical interventions, such as caps make objects appear bigger. However, for glare, a reading stand to reduce It is likely that people with loss of magnification has its limitations. It is fatigue, a reading guide, various lamps, central vision (often associated with important to understand these limita- filters, sunglasses, etc. See the ‘tips’ macular degeneration) will need to tions and explain them to the people you given on pages 7 and 8; the case develop an eccentric viewing technique, are helping so they have realistic expec- studies also contain useful ideas. in which they use their peripheral vision tations about what is possible. • Environmental modifications, such as instead of their central vision. They • Stronger magnifiers have smaller painting lines on stairs or using might find it easier to see things if they lenses. You cannot have a strong contrasting colours around the home do not look directly at them, but rather magnifier that has a big lens! (see page 12 and the case studies in to one side or the other. • Stronger magnifiers have more this article). Eccentric viewing can be difficult to distortion around the edge of the lens, teach, and to learn. However, you Think about when the person should which means you can see clearly come back to see you again. Make an could start by encouraging the through the centre of the lens only. person to try finding the best area for appointment if possible. viewing for themselves, starting with So, although the object or word looks This is also the point during the low real objects, then faces, and later on bigger, only a few letters or a small part of vision assessment where you consider with larger letters or words. The the object can be seen at any one time what other support the person will need, person will eventually learn to control (see Figure 4). This reduces reading or for example, educational support and/or their eye movements. working speed. visual rehabilitation and mobility training. If you have internet access, you can Therefore, we recommend you Write the necessary letters or notes visit http://www.mdsupport.org/ prescribe the lowest possible power of and ensure the person knows where to go. evtraining.html for a guided magnifier that can be used comfortably If possible, follow up with the referral introduction in how to use eccentric for a long time (if needed). service to check whether your patient has viewing. With electronic devices such as taken up the referral. If not, why not? closed-circuit television cameras and Continues on page 10 ➤

8 CEHJ | VOLUME 25 ISSUE 77 Figure 5. Examples of optical low vision devices (left to right): stand magnifiers, hand-held magnifiers, and spectacle magnifiers Hong Kong Society for the Blind Hong Kong Society for the Blind Hong Kong Society for the Blind Hong Kong

PRACTICAL ADVICE How to predict the near magnification needed It is possible to use a simple formula to • Use a reading chart with sentences. Ask 8 dioptres (D) is needed: 2 x 4 = 8D predict the amount of near magnification them to hold the chart at 25 cm • If you do not know the dioptres, check if a person might need. • If needed, particularly in older people, the box of the device gives the ‘x’ (e.g., The actual amount of magnification add positive lenses (from +1DS to 2x) magnification. This is often given for needed will vary according to the person’s +4DS) to both eyes, to enable them to a reference distance of 25 cm, which is visual needs, environment, and the low accommodate at 25 cm the same distance used in this section. • Ask the person to read aloud vision device chosen. However, this is a Table 1. Text sizes in M notation (at both • The smallest size the person can read useful starting point when selecting low 25 and 40 cm) and in N notation vision devices to try out. with comfort and good speed gives their M M N Usual type In this article, we use the testing near acuity at 25 cm (Note: this is not (40 cm) (25 cm) text size distance of 25 cm, rather than the usual the smallest size they can see!) • Write down the near acuity achieved 40 cm, for two reasons: 2.0 3.2 16 Large print at 25 cm, whether in M or N notation. 1 Bringing objects closer makes them 1.6 2.5 12 Children’s books easier to see and improves contrast, Note: M sizes differ depending on the 1.25 2.0 10 Magazine print important for people with low vision. testing distance used. Table 1 shows the 1.0 1.6 8 Newspaper print 2 If we know the magnification needed at M sizes of different types of text at both 25 cm, it is easy to calculate the 25 cm and 40 cm. The latter is more 0.8 1.25 6 Paperback print dioptres needed to provide this. familiar to most people. For our purposes, 0.6 1.0 4 Footnotes it doesn’t matter which you use, provided Finding the magnification you use the same notation throughout. Magnification for tasks needed for reading other than reading The formula we use is given below. It lets Step 2. Find the required near acuity at 25 cm Magnification is useful for many other us predict the amount of magnification tasks, not just reading. For example, the person will need (2x, 6x, etc.). • Ask what they want to be able to read • Determine the text size and record the sewing, sorting seeds, and drawing. Near acuity achieved required near acuity at 25 cm, in the For people who cannot read, test their Magnification at 25cm same notation. near vision using an E chart and record = the size they can very easily see at 25 cm needed Required near acuity Note: Don’t aim to record the smallest (Step 1). It is much easier to see the at 25cm size a person can see. Recording the size directions of just five ‘E’ letters than it is to Step 1. Find the near acuity the person can read with comfort and speed read sentences, so the tester must resist achieved at 25 cm in Step 2 ensures that you will be able to the temptation to ask the client to read • Make sure the person is wearing their choose the right amount of magnification. smaller and smaller sizes. Stop early! distance prescription, if any Step 3. Use the formula to calculate Estimate a size of text equivalent to the the magnification needed level of detail they would require for their • Divide the near acuity achieved at 25 cm activity (Step 2). You can now predict the by the required near acuity at 25 cm. This near magnification required (Step 3). gives the amount of magnification required. Use the actual activity they want to For example: near acuity achieved is perform to try out the different magnifying 2M, required near acuity is 1M: 2x devices, so keep sewing thread and magnification is needed to achieve this needles, or seeds for sorting, etc., in the • Now that we know the magnification clinic; or ask the person to bring their needed, we can calculate which dioptre materials. Advise them on different ways of holding their work and the magnifier, lenses can provide this level of and give advice on lighting. If they need magnification at 25 cm. two hands free for their activity, spectacle David de Wit Dioptres at 25 cm = Magnification x 4 magnifiers are the best device to use. Use a reading chart with sentences (or an E chart for people who cannot read). • So to provide 2x magnification at With thanks to Karin van Dijk, Caroline Hold it 25cm from the face. VIETNAM 25 cm (see example above), a device of Clarke, Mark Esbester, and Renee du Toit.

CEHJ | VOLUME 25 ISSUE 77 9 MANAGING LOW VISION Continued

Selecting a low vision the person’s hands tremble, a device hand-held magnifier is not useful and a ICEH spectacle magnifier would be better. Start by thinking about the following: Other considerations include: • The person’s visual abilities: can both eyes be used? Think about refractive • The availability of the device error, ability to accommodate, and age • How acceptable it is • The task the person wants to do: can • How much it costs one or both hands be free? • How much the person has to learn to • The time for the task: short (such as use the device. Will the person come checking a medicine label) or long back if the device is difficult to use? (reading a story)? For a short task, a At the first appointment, try to focus on hand-held magnifier is fine, but for long providing just one low vision device. A reading guide or reading slit helps to periods of reading, dome, stand, or Choose the easiest problem to solve, or improve contrast, and it may reduce the spectacle magnifiers would be better the one that is most urgent for the amount of magnification needed. • The physical condition of the person. If patient. It takes time to learn how to use a new low vision device; learning one device FROM THE FIELD successfully builds the person’s confi- dence and they will be more likely to How to train people to use come back for further support. Depending on the task the person low vision devices wants to do, demonstrate one or more Iow vision devices that will provide the Ving Fai Chan is 2 Try to explain that there are things magnification they need. Allow them time an optometrist they can and cannot do as a result to try the devices for themselves to see who works for the of their decreased vision, even with International Centre which work best. for Eye Care the help of the low vision devices. If Where possible, let them do something Education (ICEE). that is not made clear, patients will similar to what they would like to do at He is a lecturer at the have unrealistic expectations and home, work, or school. Check the ease Asmara College of Health Sciences in Eritrea will be disappointed with the results with which they are able to use the and is the only person providing low vision – which means they may give up services in that country. different devices and suggest modifica- learning how to use the device. tions as needed. For example: add a The first time I tried to drive a car, my 3 Give clear and step-by-step instruc- reading guide, provide a reading stand, or dad was sitting beside me, expecting tions. People with low vision increase available light. me to do it right the first time. When I usually respond well to verbal struggled, I was extremely disappointed instructions. You can also give Adapting the magnification and felt I would never drive again. written instructions if the person or to fit the person It is the same when people with a family member is literate. Use The magnification you predict a person low vision try to use a device for the first good contrast and bigger letters will need (see page 9) is merely a starting time. We, as low vision practitioners, where possible. point. Consider increasing the magnifi- may expect them to know ‘Follow up 4 Provide regular, routine cation by the smallest step possible for how to use the low vision training. Teach your the following factors: devices perfectly, without your patients. patients new skills only • Poor light: if there is no electricity or the giving them any encourage- after they have mastered light is dim and cannot be improved ment or training. We think Everyone loves the previous ones. Giving • Tasks done for a longer time, such as that, as long as the person to be cared for’ too much information at reading or studying has achieved his or her once will make your • Poor contrast, such as bills or other desired vision in the clinic, patients feel stressed. printed matter with poor contrast our job is done. Far from it! 5 Follow up your patients. Everyone • A longer working distance needed, for Using low vision devices involves the loves to be cared for. Encourage example, if the person is physically development of completely new skills, them and praise them when they unable to hold reading materials closer. often involving complex hand-eye have done well. Try to build their coordination. And this requires confidence and listen to their Demonstrate one or more devices that practice. What seems natural and easy challenges. Sometimes it is better will provide the magnification the person to us, such as focusing a telescope, to listen than to talk. needs to do their chosen tasks, and let feels quite unnatural to a patient the 6 Help them to solve their challenges them choose which one works best. first time. The only way to solve this one at a time. Sometimes meeting It is important to listen to the person: problem is to support and encourage someone else with low vision can what is comfortable for them? What can our patients continuously. show patients that it is possible to they physically manage? There is no point Here are some basic steps: overcome their problems. in giving someone a magnifier which they don’t enjoy using. 1 Always explain to patients that it is Whenever my patients come back with fine if they are unable to perform the a problem, providing support and With thanks to Tanuja Britto (ophthalmol- task the first time. Emphasise that encouragement is always the best way I ogist) and Anitha Jayan (rehabilitation this is normal. can help them. professional), Joseph Eye Hospital, Tiruchirapally, India

10 CEHJ | VOLUME 25 ISSUE 77 PRACTICAL ADVICE

H ow to work with children and older people It might take time and creativity to assess Working with older people a young child, but with patience and ICEE With older people, one should remember appropriate tests distance and near visual that most of them will have had good acuity can be measured. Other visual vision for most of their life and will have functions such as contrast sensitivity can lived independently. be assessed by asking the child and/or the As people get older, it is harder to parents. The following are also important: change habits and to learn new things. Patience and encouragement are very • Children are more adaptable than adults important. We must also be alert to the and learn fast. They may be able to fact that older people are likely to have manage a range of devices for a range of other impairments or conditions which activities, with some being used at school can impact on the assessment as well as while others are used at home for play. Teaching a young person with low vision what is advised and the frequency of • Explain to parents it is good to use the how to use a telescope. SOUTH AFRICA follow-up. The following may be present: remaining vision, even if the child sees child with oculocutaneous albinism less well than other children or only very • Orthopaedic problems, such as an need protection from the sun as it is little. Parents need to understand that inability to bend fingers due to arthritis. very sensitive to light. Clear explanations spectacles and devices help the child to This may make it difficult to use a will help those who care for the child see better and use their vision better, hand-held magnifier use the interventions recommended and that these will not “weaken” their • Neurological problems, such as • The meaning of the distance and near sight or damage their child’s eyes. weakness of one arm, or tremors. These visual acuity. For example, say: “Your • It is useful to find out what beliefs people may also make hand-held magnifiers child can now see 6/24 with the new have about eye conditions in the local difficult to use spectacles. This means she can now community so that eye care workers • Loss of hearing means that the read the blackboard from the front row know what to ask about. For example, individual will feel very isolated, and that in her classroom” people might believe that children with the assessment, explanations, and • Demonstrate to parents and teachers albinism should not be touched, or that counselling may take longer what the child struggled to do before the use of spectacles is a sign that vision • Neurological problems, such as receiving low vision interventions; use is deteriorating, or that children who are dementia, may cause people to forget real activities such as reading from a born with poor vision cannot be helped. that they have a magnifier, or how to school book. Show what they are able to • Many children with low vision have use it do now that they are sitting near the had poor vision since birth and will • Mental health problems such as window (for example) and have received have developed their own way of anxiety or depression are common in spectacles and/or magnification. This learning. They need support to explain older people and may be made worse will show parents and teachers the to others, especially their peers, why by a loss of vision. Such people may be importance of following advice about they cannot see everything, what they too pre-occupied to explain what their lighting, wearing spectacles, and using can and cannot do easily using their problems are, or to concentrate and any devices prescribed vision, and why they might need to use listen to what is being said to them. • Explain any simple interventions that devices such as magnifiers or can help the child to use their vision Older people may have to take a range of telescopes. One of the reasons better, e.g., sitting near the window, medications. Ask about this when children with low vision do not do well using a reading stand, ensuring there assessing them. Try to find ways to help in school is that they fear the negative are contrasting lines on the stairs them label bottles to ensure they take reactions of peers and/or teachers. • Explain how and when the child should their medication as prescribed. Children with low vision should ideally be use the magnifying device(s) prescribed If transport is not an obstacle, do the re-assessed at least every year. Ensuring and how to explain to peers how this assessment, prescribing, advice, and they come for follow-up is an important task device is helping them counselling in several separate visits. of the low vision service. This is because: • Most important: emphasise the need Suggest that they are accompanied by for regular follow-up! a younger relative or a carer. • The demand on vision increases as they get older (e.g., the size of text in books CASE STUDY 4 becomes smaller in higher grades) his 14-year-old boy came with vision spectacles. A 14D stand • As children grow, they will need bigger complaints of struggling to see the magnifier along with a table lamp and spectacle frames; their prescription is small print in his school textbook, reading stand helped him to read and do also likely to change every year T which had reduced his reading speed near work. He was also advised to use a • Children are more likely to break, considerably. He said that he was torch at night and a cap to control glare scratch, or lose their spectacles. unable to find and pick up anything he during the day, and to use a dark- Give a written summary of all findings and dropped or misplaced. He also reported coloured lunch box to improve contrast. recommendations to the parents and having difficulty in moving in unfamiliar At a follow-up visit, he reported that staff at school. In addition, explain the areas and was not able to play with his the magnifier was comfortable for following in clear and simple language: friends in school. He had difficulty in reading and that he could now read identifying food and eating neatly. faster. Simple environmental modifica- • The practical implications of the eye After a complete low vision tions (the cap, lunch box, extra light, disease causing the visual problem: for assessment, he was given distance etc.) had improved his independence. example, the eyes and the skin of a © The author/s and Community Eye Health Journal 2012. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial CEHJ | VOLUME 25 ISSUE 77 11 use, distribution, and reproduction in any medium provided the original work is properly cited.