Community Eye Health

JOURNALVOLUME 25 | ISSUE 77 Low vision: we can all do more Hasan Minto Regional Director for the Eastern Mediterranean, International Centre for

Eyecare Education. Karin van Dijk Clare Gilbert Co-director, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; Clinical Advisor, Sightsavers. Despite all the treatments, operations, and medication at our disposal, there is still a significant number of people whose sight we cannot fully restore. What happens to these patients once they leave our care? Without the neces- sary support, advice, and low vision devices, their remaining vision will not be very good; this can make life a struggle. Support may be difficult to find, as low vision services are often inadequate or Use real tasks to inaccessible in many low- and middle- assess near vision. income countries. Professionals, such as TANZANIA rehabilitation workers, ophthalmologists, mid-level eye care workers, optometrists/ and/or optical) have been given. The people’s lives. People with low vision may refractionists, and special education definition also emphasises the importance struggle to look after themselves without teachers, may not know what to do about of vision for day-to-day functioning. help. Having low vision affects their people with low vision, leaving them with People who may be able to benefit from status in the eyes of others and can make no-one else to turn to. low vision care will want to do a range of social situations difficult. It reduces the Individuals who can only see light or different things. In many low- and middle- ability of people to pursue an education, movement of large objects will need income countries, for example, many to look after their children, and to earn rehabilitation that focuses on non-visual people with low vision are aged over an income. People with low vision are also strategies for learning and daily tasks. 50 years and cannot read or write. They at greater risk of falls and death. However, there are many people who will have different needs, and require With our support, people with low have slightly better vision, but are still different services, compared to children vision can make better use of their sight classified as blind, who have the potential or adults in employment. to do the things they want and need to to use their sight. These people could Low vision has a significant impact on do. We hope this issue will show you how. benefit from low vision care, which may include refraction, provision of magnifiers, In this issue and/or environmental modifications. 1 Low vision: we can do more 16 Low vision services for children in The World Health Organization defines Hasan Minto and Clare Gilbert Tanzania a person who needs to be assessed for 2 Understanding low vision Paul Courtright and Elizabeth Kishiki low vision care as someone “who has Clare Gilbert 16 Comprehensive low vision services in Sri Lanka impairment of visual functioning even 3 Low vision: the patient’s perspective Sumrana Yasmin after treatment and/or standard refractive Karin van Dijk 11 PRACTICAL ADVICE correction, and has a visual acuity of less 4 When someone has low vision How to predict the near magnification than 6/18 down to and including light Clare Gilbert and Karin van Dijk needed perception, or a visual field of less than 12 Making life easier for someone with 15 USEFUL RESOURCES 10 degrees from the point of fixation, but low vision 17 FEEDBACK who uses, or is potentially able to use, vision Clare Gilbert From our readers for the planning and/or execution of task.” 13 How to make an eye clinic more 18 TRACHOMA UPDATE The important part of this definition is accessible for people with low vision Trachoma: the beginning of the end? that people should only be assessed for low Jaya Srivastava Danny Haddad vision interventions once all other treat- 14 Low vision care: who can help? 19 CPD: TEST YOURSELF: Picture quiz ments the person needs (surgical, medical Karin van Dijk 20 NEWS AND NOTICES © 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 1 use, distribution, and reproduction in any medium provided the original work is properly cited. Community Eye Health LOW VISION JOURNAL Supporting VISION 2020: The Right to Sight Understanding low vision

Volume 25 | Issue 77 Clare Gilbert Co-director, International Centre for Eye Health, Editor London School of Hygiene and Tropical Elmien Wolvaardt Ellison [email protected] Medicine, Keppel Street, London WC1E 7HT, Editorial committee UK; Clinical Advisor, Sightsavers. Nick Astbury Allen Foster Who is likely to have low vision? Clare Gilbert Ian Murdoch As a rule of thumb, the following people are GVS Murthy likely to need low vision services and must be Daksha Patel referred wherever possible: Figure 1. Blurred vision. People with Richard Wormald blurred vision (right) have difficulty David Yorston • All children who have undergone bilateral Serge Resnikoff seeing details, both at distance and cataract operations, both those with nearby; they often have problems with Consulting editors for Issue 77 pseudophakia and those with aphakia Karin van Dijk and Hasan Minto glare. Printed materials and colours • People with diabetic macular oedema whose might seem faded. Regional consultants vision remains poor despite laser treatment Sergey Branchevski (Russia) Miriam Cano (Paraguay) • People with age-related macular Professor Gordon Johnson (UK) degeneration Susan Lewallen (Tanzania) • Children with oculocutaneous albinism Wanjiku Mathenge (Kenya) Joseph Enyegue Oye (Francophone Africa) • People with optic atrophy, whatever the cause Babar Qureshi (Pakistan) • Any person who still has difficulty performing BR Shamanna (India) their daily activities because of their vision, Professor Hugh Taylor (Australia) Min Wu (China) even after treatment and refraction. Andrea Zin (Brazil) What does low vision look like? Figure 2. Loss of central vision. “Is Advisors the man sitting down my husband, and Catherine Cross (Infrastructure and Technology) People with low vision are affected in different is there a seat for me?” Pak Sang Lee (Ophthalmic Equipment) ways. They may suffer from some or all of the Dianne Pickering (Ophthalmic Nursing) following: Editorial assistant Anita Shah Design Lance Bellers • Severely reduced visual acuity Proofreading Mike Geraghty • Blurred vision Printing Newman Thomson • Visual field loss: central or peripheral Online edition Sally Parsley • Loss of contrast sensitivity Email [email protected] • Increased light sensitivity. Exchange articles Anita Shah [email protected] Many people with low vision suffer from blurred vision (Figure 1), for example if they have Figure 3. Loss of peripheral vision. CEHJ online edition scarring on their corneas. “How many other people are there in Visit the Community Eye Health Journal online! the room?” All back issues are available as HTML and PDF. People with optic atrophy or age-related www.cehjournal.org macular degeneration will have loss of central To download our pictures, go to visual acuity (Figure 2), which means that tasks www.flickr.com/communityeyehealth requiring good central vision will be difficult. For How to subscribe example, reading, writing, threading a needle Readers working in low- and middle-income and sewing, putting on make-up, recognising countries get the journal free of charge. To people, seeing where their food is on the plate subscribe, send your name, occupation, and postal and whether they have finished eating, seeing if address to the address below. French, Spanish, and Chinese editions are available. their clothes are clean, finding their own pair of shoes. If they have a full field of peripheral Figure 4. Loss of contrast sensitivity. Yearly subscription/donation rates for high-income countries: UK £20 for your own vision then mobility will be less of a problem. With normal contrast sensitivity (left), subscription, or £40 for your subscription and to pay Someone with glaucoma or retinitis it is easy to recognise faces. With for four other eye care workers in low- and middle- pigmentosa will have constricted visual fields, reduced contrast sensitivity (right) income countries to receive the journal free of this becomes more difficult. charge. Send credit card details or an international i.e. loss of peripheral vision (Figure 3). This cheque/banker’s order payable to London School of makes it difficult to move around without Hygiene & Tropical Medicine to the address below. bumping into objects on the floor. People may Address for subscriptions have difficulty finding things they have dropped. Community Eye Health Journal, International Centre Reading may still be possible, but difficult. for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Loss of contrast sensitivity (Figure 4) can Tel +44 207 612 7964/72 have a very big impact on someone’s visual Fax +44 207 958 8317 function, making it difficult to recognise faces or Email [email protected] find food on a plate of similar colour. © International Centre for Eye Health, London Articles may be photocopied, reproduced or translated provided these Increased light sensitivity makes it very Figure 5. Increased light sensitivity. are not used for commercial or personal profit. Acknowledgements should be made to the author(s) and to Community Eye Health Journal. difficult for people to see detail or make sense This is how a street scene in bright Woodcut-style graphics by Victoria Francis. of what they see if they are in bright light, or sunlight would look to someone who ISSN 0953-6833 glare (Figure 5). has increased light sensitivity. © The author/s and Community Eye Health Journal 2012. This is an Open Access article distributed under 2 CEHJ | VOLUME 25 ISSUE 77 the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided the original work is properly cited. PATIENT PERSPECTIVES Low vision: the patient’s perspective For this issue on low vision, Impact the Community Eye Health Adults described how low vision Journal contacted low vision services had resulted in the Hari Bdr Thapa practitioners in India, Elizabeth Kishiki following: Tanzania, Nepal, and Peru to help gather the views of • Greater independence, eighteen people attending confidence, courage, hope, their low vision clinics. The and dignity people varied in age from 14 • A better understanding of the to 81, and suffered from a Damodar BC Mbaraka Omary reality of the visual loss. range of vision problems Nepal (22) Tanzania (18) “Society used to view me in a “I have really started living. Children talked about how the including nystagmus, retinitis negative way … I used to wonder With my glasses, I can recognise low vision service had helped pigmentosa, diabetic retin- how I would carry on my life. [But the faces of my friends and them with the following: opathy, and bilateral aphakia. now] there is a positive change in teachers. More importantly, I can The interviewees (or their which society views me. Most of watch football and see faces of • Starting school parents) described how their the time, I get to hear people my favourite stars. With my • Doing desired activities, such low vision had affected them say, ‘People with low vision can magnifier, I can read even the as reading print, even small before treatment, how their also do good deeds and can smallest letters. I have become print life changed after they work like normal people.’” a different person now.” • Increased independence, for received low vision care, example being able to read and what they felt they still the blackboard and learning needed. to write We hope that these experi- • Improving the attitudes of ences of people with low Elizabeth Kishiki peers and teachers “… who vision will highlight what is now see I can do many things.” important in a low vision service. • Better social interaction, for example “… recognising the Martiza Zuasnabar De la Cruz Before faces of my friends.” Before they received low vision Maribel Tomateo Falcon Abdi Kajembe What more is needed? care, the adults said they had Peru (27) Tanzania (9) been unable to do their Low vision services helped her Thanks to low vision services, • Some people still lacked the desired activities, such as to set realistic goals. “The visual school is now a lot easier for confidence to use their driving or reading. They were rehabilitation helped me a lot, him. “With my spectacles, optical devices in public worried about their vision and mostly to be aware of my I can sit at my front desk and • Most people also wanted to had negative feelings, limitations, to accept them read well on the blackboard be informed if there were new including stress, depression, and to know up to where I can and in books, and I can see technological developments, anger, and frustration. They develop and set my goals.” people well.” and hoped for lower prices for had also felt dependent on software and electronic low their family, and that they were vision devices of vision, provision of optical devices, and a burden to the family. The adults had • Some children did not know enough suggestion of environmental modifica- also struggled to accept their condition as about their condition and wanted tions. Specific interventions included: being irreversible. someone to explain it to them in terms School-age children and young adults • Changes such as sitting near the they could understand. said that they had been unable to attend window or using a lamp, sitting near the In our experience, it is helpful to keep in school, had to drop out, or had faced blackboard, using a stand for better touch with people who have been helped great difficulties in their schooling, such reading/writing position and more by low vision services. They can be excellent as being unable to take examinations. comfort, increasing contrast through advocates for the development of better Some of them had been treated as blind better light, using a reading slit, and services and may help to convince others and taught to use Braille. using a cap to reduce glare out of doors with low vision to seek help. These young people had also felt very • Giving advice about improving the Children who successfully use a low dependent on their families and had to environment through painting lines or vision device can also inspire other stay home much of the time. applying tape to improve contrast children who are still struggling. One of the biggest problems they had • Someone taking the time to clearly faced was the way society viewed them. explain the person’s eye problem and The interviews were arranged, They were victims of bullying, name- prognosis to him or her transcribed, and translated by: calling, and had been accused of • Counselling, particularly for adults who • Rosario Espinoza, Peru pretending to have a problem. were able to see before and have lost a • Hari Thapa, Nepal lot of their vision. This involved listening, • Elizabeth Kishiki, Tanzania Care provided discussing the implications of the vision • Joseph Eye Hospital LV team, India. The care provided to both children and loss and the effect on their life and adults consisted of training in better use emotions, and giving advice if needed. The article was written by Karin van Dijk. © 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 3 use, distribution, and reproduction in any medium provided the original work is properly cited. 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. ENVIRONMENTAL MODIFICATIONS Making life easier for people with low vision Clare Gilbert Figure 2. Using contrasting colours to improve visibility Co-director, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; Clinical Advisor, Sightsavers. Clare Gilbert/ICEH There are many things you can suggest that will help people with low vision make the most of their vision, whether they are able to benefit from magnification devices or not. If you are working at the community or at primary level, remember that these environmental modifications should never With normal vision, the rice is visible against all backgrounds. With low vision (right), be a substitute for referral: always refer the rice is much easier to see on the green banana leaf and red plate someone with low vison for an eye exami- nation, refraction and low vision services Figure 3. The effect of contrast on the legibility of text wherever possible. If you are working at district/secondary or tertiary level, refer your Once upon a time Once upon a time Once upon a time patient for vision rehabilitation. there was a man who there was a man who there was a man who The suggestions given here are a good lived at the top of a lived at the top of a lived at the top of a starting point, but some people may long, steep track long, steep track long, steep track require further support and training in order to make the most of their vision. Poor contrast Good contrast Best contrast A way of remembering environmental other family members’ shoes At meal times, people with low vision modifications is to think about: • Mark the bottle of medication that is to can sit near the window or doorway so • Making things bigger and bolder be taken in the morning with a big they can see what they are eating and • Using colour and contrast yellow circle (to represent sunrise) and when they have finished. • Improving lighting, using lines, and the evening bottle with a big black circle Lines. Many people with low vision find it trying to lift what you want to look at. (to represent night). hard to follow a row of text: they may not be able to scan the words easily, they Bigger and bolder Contrast makes things easier to see. For example, a black pen on white paper is may find it hard to know when they have Bringing things closer to our eyes makes easier to read than pencil. White writing got to the end of a row of text, or they them appear bigger. This mainly helps on a black background gives the greatest may struggle to find the beginning of the young people and children who have very contrast and hence is easier to read, but next line. Partly blanking out the lines good accommodation. this can usually only be generated on a above and below the line being read, for People (including children) who have computer screen (Figure 3). example, using a reading slit (see page 10), had cataract surgery and those with makes the visible line of print easier to presbyopia will need a near add (a plus Lighting, lines, and lift read. A reading slit can be made of black lens) to bring things into focus if they Lighting is perhaps the best way to card with a rectangle cut out of it. bring them nearer. improve contrast, so if someone wants to Lines can help with mobility and Use charcoal or a felt pen to write read make sure the page is well lit. safety. For example, paint the edge of bolder messages, and write with larger stairs in a contrasting colour, or put white Ideally, the light should shine directly onto letters than usual (Figure 1). Keep it short paint on the top of stones which mark the the page, but without producing glare. It and simple! Put it somewhere visible and path to a neighbour’s home. should not shine in their eyes. Good write on a bright piece of paper if you want lighting in darker areas of the home is Lift. Figure 4 shows a locally made, to attract the person’s attention. important, particularly where the person foldable reading stand, lifts the page Enlarging photocopiers and computer may be nervous, e.g., going up and down closer to the eyes and makes reading less screens are also ways that print and stairs or going to an outside latrine. tiring, particularly if magnifiers are used. other images can be made bigger and hence easier for the person with low Figure 1. Bigger and bolder (right) Figure 4. Reading stand with angled lamp vision to see. Colour and contrast Colour can be used in many ways to help someone in their home. For example: Clare Gilbert/ICEH Clare Gilbert/ICEH • Use brightly coloured plates (Figure 2) • Put red tape around light switches • Use paint or red nail varnish to put spots of red to help the person line up the “off” buttons on the gas cooker • Stand the person’s shoes on a brightly Small writing (left) is not as easy to read coloured mat to distinguish them from as big, bold writing. Shorter is better. © The author/s and Community Eye Health Journal 2012. This is an Open Access article distributed under 12 CEHJ | VOLUME 25 ISSUE 77 the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided the original work is properly cited. How to make an eye clinic more accessible for people with low vision

Jaya Srivastava lettering on a black or Low Vision Consultant, Spectrum Eye dark background Care, Prasad Chambers, 169, Peters Before you make any Road, Gopalapuram, Chennai, Tamil changes, make sure Nadu, India 600086. people with low vision Good patient flow can read the signs! • The unit should be laid out in such a • In the waiting area, way that it is easy for patients to go use brightly coloured from one part of the unit to another chairs, or paint them • Some hospitals paint coloured lines on in a contrasting the floor which patients can follow. For colour compared to Figure 1 Figure 2 example, a brightly coloured line may the walls and floor. lead straight from registration to the This will help people first waiting area with low vision to find them and paint the door a different colour • Remove obstacles that people with see the ones that are empty (Figure 2). low vision may fall over or collide with. • Use tape or paint to apply a thick line to the edges of steps to make them Staff assisting someone with Use of colour, contrast, and more visible. Use ramps with a low vision lighting handrail instead of stairs, if possible • Be patient: people with low vision may • Use large, clear letters for all the signs • White hand basins and toilets against have visited many eye units or in the department. Ensure there is white tiles can make bathrooms very professionals already, and have told good overall illumination and avoid difficult to use. Change the colour of their stories many times before creating glare, which could be caused the walls and/or floor to improve • Be kind: people may initially be angry by using shiny white tiles on the floor contrast when they are told they have and walls. For signs, use colours with • If there are lifts, put a brightly coloured untreatable visual loss. Listen and be high contrast, e.g., white or yellow arrow or ring around the call button, or supportive, but do not give false hope.

© 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 use, distribution, and reproduction in any medium provided the original work is properly cited. Useful resources for low vision

Low vision devices articles, mainly aimed at ophthalmologists. Community Eye Health Journal Hong Kong Society for the Blind back issues www.mdfoundation.com.au – practical For visual assessment charts, refraction These back issues are available online guides (PDF format) for patients and their equipment, training materials, and low (www.cehjournal.org – click on ‘Past carers, with a focus on macular degener- vision devices. Visit www.hksb.org.hk issues’) and on the Community Eye Health ation. Look in “Fact Sheets & Update CD which was sent out with Issue ICEE Global Resource Centre Publications”. 76: Instruments and Consumables. For low-cost spectacles, frames, lenses, Please let us know if you have not yet www.afb.org – advice on living with vision and low vision devices. Prices for low vision received a copy. New subscribers: an loss. aids start from US $2.50. Contact Vivasan updated CD will be sent to you in 2013. Pillay at [email protected] www.svrc.vic.edu.au – for people with low vision who are in education. or +27 312023811. Vol. 20 No. 62, 2007. The visually impaired child http://www.ski.org/Colenbrander/ Internet browsing support Vol. 17 No. 49, 2004. Low vision care: TM Images/Low_Vision_Exam.pdf – LowBrowse the need to maximise visual potential practical guidance on performing a low is a free Vol. 16 No. 45, 2003. Helping the blind vision assessment, aimed at trained low add-on to the and visually impaired vision practitioners. Mozilla Firefox web browser, For information on testing near vision: which is also Rènée du Toit. How to prescribe Low vision courses free. It lets spectacles for presbyopia. Community Kilimanjaro Centre for Community users read all Eye Health J 2006;19(57): 12-13. Ophthalmology, Tanzania text in web For information, contact Genes pages in a special reading frame at the Online resources for low vision Mng’anya, KCCO, Good Samaritan top of the screen. The frame presents text http://bit.ly/L2Y5VS – article on assistive Foundation, PO Box 2254 Moshi, in a single line and users can change the technology by someone with low vision. Tanzania. Tel: +255 27 275 3547. size, font, colour contrast, and letter PDF (1.6MB) Email: [email protected] or visit spacing without having to zoom in and out. It www.lowvisiononline.unimelb.edu.au www.kcco.net has a speech option which reads the text. – a guided learning resource for eye care October 17–26: Training in clinical low workers who want to learn more about vision care. Basic and advanced clinical LowBrowse: https://addons.mozilla.org/ working with patients with low vision. low vision care. Aimed at optometrists. en-US/firefox/addon/lowbrowse/ Available in English, Chinese, and French. (123.5 kB) October 29–30: Population-based www.lighthouse.org/for-professionals/ approach to establishing a low Mozilla Firefox: www.mozilla.org (32 MB) practice-management – a collection of vision service

CEHJ | VOLUME 25 ISSUE 77 13 PLANNING SERVICES

Low vision care: who can help?

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. Innocent Emereuwa [email protected]

We know that, in many low- and middle- income countries, low vision services are limited to tertiary or teaching hospitals, which means that most people are not able to access them. If this is the case, who can those with low vision turn to for help? People with low vision do not fit comfortably within the job descriptions of most health and education professionals. • They are not blind, so rehabilitation workers may not feel able to help them • Clinicians (ophthalmologists, An older child’s colour vision is tested during an outreach clinic. NIGERIA ophthalmic nurses, and other mid-level One of the most important things we first point of contact for the person personnel) feel there is nothing more can do, whatever our own role, is to be with low vision, or their last hope for they can do aware of what other services may help help. Whatever the case, it is our • Optometrists and refractionists can the person with low vision and refer responsibility to find out whether the improve their vision, but cannot help them. And we must communicate people who come to us have received them to see ‘normally’ with the person, the family, and our clinical and refractive error care. If they • Special education teachers are usually colleagues in these other services about have not, it is essential that we refer trained just to work with children who the care the person needs, in clear and them. If they have, we must find out are blind, and may not have the simple language. what other support they might need and additional training needed to help refer them. children use low vision devices and Importance of referral But it is not enough to just refer – it is advise them about where to sit and the People with low vision may need clinical also our responsibility to make contact importance of using their vision. care, refraction, and rehabilitation with our colleagues in local community In fact, the services of all of these people support, and children and others in rehabilitation and educational support are vital to ensure that the person with full-time education will also require services. Refer people as appropriate, low vision can live a full life. educational support. We may be the and share information with these Providing a basic low vision service at district level: what is the minimum we need? The Low Vision Working Group of VISION Ophthalmic equipment • Four hand-held magnifiers (non- 2020 has endorsed a Standard List for • Streak retinoscope illuminated) from 5D to 20D. For low vision services.1 However, it may not • Direct ophthalmoscope example, one of 6D, one of 10D, one always be possible to purchase all the • An ordinary trial lens set; a full aperture of 15D, and one of 20D items on the Standard List. trial set is preferable • Non-illuminated stand magnifiers from We have put together a list of the • Universal trial frames 10D to 25D. For example, one of 12D, minimum equipment and devices you • At least one pair of paediatric trial frames one of 16D, one of 24D would need to offer a basic low vision • Pen torch and measuring tape. • Use a variety of locally available service at district level. This list is based sunglasses in different shades if filters Vision assessment equipment on our experience in the field, and we hope are not available • Distant LogMAR test charts: at least it will help you to start providing low vision have tumbling Es Non-optical devices support where no other service is available. • Near vision tests: at least have • Reading/writing stand: locally made Keep accurate records of who you see tumbling Es • Reading slit, signature guide, and and how they have been helped. Collect • Reading acuity test. This can be writing guide: all locally produced. quotes from patients saying how they created on computer using N or M have benefited, and use these and your Further reading sizes. records to ask for further training, 1 Standard list of low vision services. Comm Eye Health J 2004; 17(49): 8. increased funding, and better equipment Optical low vision devices 2 Hasan Minto. Establishing low vision services at for your low vision clinic. Always refer • Spectacle magnifiers: locally made secondary level. Comm Eye Health J 2004;17(49): 5. Both available on the Community Eye Health people with complex needs for services high positive add spectacles, from Update CD and online: www.cehjournal.org/ at a higher level. +4D to +12D, in steps of 2D. journal.html

14 CEHJ | VOLUME 25 ISSUE 77 colleagues about any changes in the who want to access print or perform tasks • Ensure regular follow-up of adults and needs and vision-related abilities of the that require good near vision. The panel children who were seen at tertiary level. person with low vision. on page 14 lists the minimum equipment Tertiary level or teaching hospital you will need to start a low vision service Well-trained, dedicated low vision staff at secondary or district level. Different levels of can provide the following: low vision care At this level, optometrists and mid-level eye care workers can be trained Primary/community level • Complex assessment tests to give basic low vision services appro- Nurses, ophthalmic nurses, community- • Refraction of people with complex priate to their skills and experience. based workers, and other mid-level problems They should have good communication personnel can do the following: • Provision of a wide range of devices, skills and be able to do the following: • Be alert and identify people who might including electronic devices have low vision • Test distance and near visual acuity • Good links to education and • Refer them for diagnosis, prognosis, (ideally also in younger children) rehabilitation services and good refraction • Perform objective and subjective • Training the use of low vision devices. • Refer older children and adults who refraction have useful vision to low vision services • Perform minimum essential low vision Beyond the clinic at secondary or district level assessments (page 4 onwards) There will be many more people with low • Refer young children and adults with • Prescribe essential low to medium vision in the community who need our complex needs to tertiary level magnification devices for near and services. • After diagnosis, refraction, and referral distance, with training in their use Think about how you can reach out to for low vision care, advise on non-optical (pages 9–10) tell them about what you offer. Plan interventions and environmental • Advise patients on non-optical outreach clinics, or link with others modifications (pages 7,8, and 12) and interventions and environmental working in the community. refer for educational support and modifications (page 12) Visit schools for the blind – perhaps community-based rehabilitation if needed. • Refer people to the most appropriate there are children who will be able to use person or organisation for further their remaining vision if they receive low Secondary or district level training, financial help, and education vision support. At secondary or district level, services are • Refer young children and those with Low vision work may be challenging, aimed mainly at adults and older children complex needs to the tertiary level but it is immensely rewarding! © 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 use, distribution, and reproduction in any medium provided the original work is properly cited. Improving access to low vision services

Peggy Pei-Chia Chiang care, a trained vision technician could • Non-governmental organisations must Postdoctoral research fellow, Singapore do these tasks. work together with the private sector Eye Research Institute; Centre for Eye • Build on the skills of existing staff. For and government to support and fund Research Australia (CERA). low vision services. However, for this to Email: [email protected] example, in areas where there are no ophthalmologists or optometrists, work in the long term, the government Jill E Keeffe refractionists, ophthalmic nurses, and must take the lead and take ownership Director, World Health Organization opticians can be trained to take on of programmes and services. Collaborating Centre for Prevention of additional low vision tasks appropriate Blindness at CERA. Advocacy to their skills and experience. We recommend two strategies: 1,2 Our recent survey found that low vision Sustainability 1 Use strong research evidence on services were often inaccessible to large Strengthen community-based rehabili- which to formulate policy. numbers of people in low- and middle- tation and outreach services. 2 Encourage NGOs and all stakeholders income countries. • During outreach, you could explain or with an interest in low vision to come Based on the findings of this research, show how the home environment can together under one umbrella organi- we suggest three areas for action: human be adapted and make timely referrals to sation, i.e. a national VISION 2020 or resources, sustainability of services, and district level care. Through outreach, prevention of blindness committee. advocacy. However, it is important to keep people can be followed up to ensure The group can then deliver the policy in mind that these strategies must be they are still able to use their low vision message with one clear voice. adapted to suit your situation. devices, and you can give refresher Once advocacy and lobbying have started, Human resources lessons to those who need it. In more detailed planning must be done at • Integrate low vision into existing addition, children with poor vision can the implementation level. For instance, ophthalmic and optometric curricula be detected and supported early. encourage local government and policy and include it in the practical training of • Outreach services should be carried out makers to include low vision in their education and rehabilitation workers on a regular basis, although the district VISION 2020 or eye care plans. • Offer informal low vision workshops and frequency may vary, depending on courses for eye care workers who have need. References 1 Chiang PPC, O’Connor, P., Le Mesurier, R.T., Keeffe, J.E. not received formal training. • Integrate low vision services into existing A Global Survey of Low Vision Service Provision Ophthal • Delegate tasks to less specialised health education, rehabilitation, and eye care Epidemiol 2011;18(3):109-121. workers where possible. For instance, systems. Establish appropriate and 2 Chiang P, Xie J, Keeffe JE. Identifying the Critical Success Factors in the Coverage of Low Vision Services Using the instead of the optometrist doing the healthy collaborations between the Classification Analysis and Regression Tree Methodology. simple refraction and basic low vision government and the private sector. Invest Ophth & Vis Sci 2011;52(5):2790-2795. © 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 15 use, distribution, and reproduction in any medium provided the original work is properly cited. RAPID-FIRE CASE REPORTS Low vision services for children in Tanzania Elizabeth Kishiki Meetings were held to improve collaboration Childhood Blindness and Low Vision between government, non-governmental Co-ordinator, Kilimanjaro Centre for organisations, and private stakeholders in Community Ophthalmology both education and eye care. This national Paul Courtright Elizabeth Kishiki consensus had to be translated into action Director, Kilimanjaro Centre for at the regional/district and local level, mainly Community Ophthalmology, through training of education and eye care PO Box 2254, Moshi, Tanzania workers. The Kilimanjaro Centre for Community Follow-up was crucial. SMS reminders Ophthalmology (KCCO) has been involved were used to ensure that children had in a five-year pilot project to improve low clinical follow-ups on an annual basis. The vision services for children in Tanzania.Low co-ordinator made regular calls to the Many children have benefited from the vision services were limited to a few tertiary optometrists, and they would visit schools to low vision programme. TANZANIA hospitals and were accessible to only a few troubleshoot as needed. children. key factors in the success of the The training of district special needs Children with low vision were usually programme was the appointment of a education officers, who are responsible for enrolled in schools for the blind, most of Childhood Blindness and Low Vision annual budgeting, has in some districts led them without having received an eye exami- Co-ordinator (Elizabeth Kishiki) to them to include low vision assessments, nation or refraction. In these schools, many co-ordinate, plan, and teach. Each trained optical devices, spectacles, and non-optical teachers believe that reading “destroys optometrist was also given the lead role in devices in their district budgets. your vision” and that children with low his or her region with a strong report-back While at the start of the programme, only vision should learn to use Braille; they also mechanism. 13% of children at annexes had been believe that all visually impaired children To improve linkages between education assessed by an eye care professional before “will lose their sight in the long run.” and health services, teachers were trained admission, after four years, 82% had been To address this, better provision of low in the need for regular low vision care and assessed and were provided services. Some vision services and better linkages between assessment as well as the use of print challenges remain, particularly because so education and eye care were needed. To (rather than Braille), when appropriate. many people and services have to improve provision of low vision services, it Combining some of the training sessions to co-operate to make low vision services work, was decided to integrate low vision into include both teachers and optometrists but the benefits have made it worth doing. existing district and regional eye care improved co-operation and collaboration. services, and to train the many optometrists To ensure sustainability, low vision training With thanks to Light for the World already working at regional or district was included in special education teacher Netherlands, Seva Canada, and Light for (population about 1 million) level. One of the training at the training college in Arusha. the World Austria. © 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 use, distribution, and reproduction in any medium provided the original work is properly cited. An integrated low vision service: Sri Lanka Sumrana Yasmin linkages with education, rehabilitation, level, with their salary paid for by govern- Programmes Manager: South East Asia and social services could also be estab- ment. Their availability, experience, and & Eastern Mediterranean, International lished. existing refraction skills made them the Centre for Eye Care Education, Pakistan Implementation started in 2008 and ideal group to train for this task. Unusually for a low- or middle-income the first priority was to strengthen the Significant progress has already been country, Sri Lanka provides free health three clinics at tertiary level so they could made. By 2010, nearly 8,000 people services through government hospitals provide visual skills training, orientation (10% of which were children) had been and other outlets. and mobility training, and counselling helped, five times as many as in the Before, services for the estimated services for people with low vision. previous three years. 140,000 people with low vision in Sri Ten secondary level clinics, with strong The next step is to extend low vision Lanka were provided by just three low referral links to the three tertiary clinics, services through community-based vision clinics at tertiary hospitals; this were then established within existing rehabilitation (CBR) services in order to meant that few people received the help district hospitals. These are easily acces- reach under-served areas and groups; they needed. sible to most people, and offer compre- this will form part of existing CBR projects. When a national eye care plan was hensive low vision assessment, pre- Programme planning and implemen- developed in 2007, international scription and dispensing of low vision tation is driven by the National Focal non-governmental organisations (INGOs) devices, and training in the use of low Person for Low Vision, Dr Saman such as Sightsavers and the International vision devices. People with complicated Senanayake, who works in consultation Centre for Eye Care Education were able needs are referred to the nearest tertiary with the ministry of health and INGOs. The to make a strong case for including low low vision clinic for further management. expansion of the programme has been vision. As a result, and thanks to the Ophthalmic technologists provide the achieved through co-ordinated national support of the ministry of health, low services in the ten new secondary level planning, advocacy, human resource vision was part of the national eye care clinics. These eye care practitioners were development, and the availability of plan from the outset. The necessary already working in the eye units at district affordable and low cost equipment. © The author/s and Community Eye Health Journal 2012. This is an Open Access article distributed under 16 CEHJ | VOLUME 25 ISSUE 77 the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided the original work is properly cited. FEEDBACK From our readers

Thank you to all our readers who wrote in to share stories and experiences around low vision.

QUESTIONS FROM MADAGASCAR VIEW FROM NIGERIA We received several questions by Lala Jaona Iandrinirina and Verohanitra Enechi Gilbert, National Raharimamonjy of the Centre National de Formation en Santé Oculaire Communautaire Secretary of the Low Vision and in Madagascar. The answers are by Clare Gilbert, Karin van Dijk, and Sumrana Yasmin. Rehabilitation Society of Nigeria How can we persuade ophthalmologists tasks the child is interested in, such as (LVRSN), wrote to say that there and parents that it is important to looking at a flower or a family photo, and is still a big gap between the refer children for low vision services? which they would now struggle to do need for low vision services and • During the eye examination, show without magnification the country’s ability to provide parents what their child can currently see, • Show the child that they can do the same them, in large part because of a and what they are likely to be able to see activities as their peers, such as reading lack of low vision professionals. after refraction and low vision support. on their own, if they use a device He feels all eye care workers For example, reading a poster on the wall • Provide good training, both for the child should take responsibility for or text in a school book and the family: first in private so the child low vision: “Every eye care • Include simulation of low vision (for can practise without fear of teasing; later, professional should be able to at example, looking through a plastic sheet) in a variety of settings least detect and then diagnose, when training eye care practitioners • Organise a meeting with a child who manage, or refer (in accordance • Find children with low vision who are successfully uses a magnifying device to his/her professional abilities willing to explain the difference that low • Tell the teacher why a child needs to use and limitations) people with low vision services have made to them. They a certain device and for what tasks vision to other established low can speak with parents, ophthalmologists • Help the teacher to create a positive vision practitioners or low vision and others who need convincing atmosphere in the classroom. It is helpful centers.” • People working in low vision can talk to if classmates can try out the device and their colleagues in clinical eye care about see for themselves why it is useful. the importance of low vision care. Use REFRACTIVE ERROR What devices are best suited to real examples of children who benefited. AND LOW VISION children? How can we persuade people with low Here are some tips. Each child is different! Two readers reported that many vision to accept their condition? • Where possible, first make tasks bigger, children were referred to low vision • People who have lost much of their sight brighter, and bolder before introducing services before they had received will go through a process of grieving, magnifiers adequate refractive error services. consisting of several stages, including • Younger children might find it easier to Vicky Hopley, in Madagascar, denial, anger, bargaining, and learn to use a dome or stand magnifier looked at the records kept by depression; acceptance is the final stage. first as they do not have to hold the Madagascar’s first low vision clinic This process takes time and cannot be magnifier off the page. Try high-plus during its first year of operation. hurried. Be there, listen, and provide spectacles and/or hand magnifiers later She found that, of the 65 children what support you can • Older children do not want to be different seen in 2008, 15 (around 23%) • Put the person in contact with someone from their peers, so pocket magnifiers had uncorrected refractive error. of similar age who has accepted the might be liked as one can quickly put situation and has benefited from low them in one’s pocket when not in use. K Sapkota, in Nepal, examined vision services. the patient records of the low vision How can we keep a child’s attention clinic in Nepal Eye Hospital over a How can we convince children to use during an examination? 16-month period, ending October a low vision device? • For practical tips, see ‘When your eye 2011. Of the 69 children • Start with tasks that are fun to do. Play a patient is a child’ (Community Eye Health examined, general spectacles game with the child, using the device J 2010;23(72): 4-11). Available on CD improved the visual acuity of 52 • Avoid using just an acuity chart! Use real or www.cehjournal.org/journal.html children (75%). LOW-COST PEN-MOUNTED CCTV CAMERA Our consulting editors respond: Using locally available CCTV cameras, Even if someone has low vision, used for surveillance in banks or offices, their refractive error must still be V Srinivasan and his team at Aravind Eye corrected. The right pair of Hospital have built a magnification system spectacles will improve the vision of that can be connected to a normal Aravind Eye Hospital people with low vision, even if it television. The system costs approximately doesn’t bring their vision back to US $60 to make and can be adapted to ‘normal’. Many people with low connect to a laptop computer. It is also vision will not have received good possible to use a very small CCTV camera refractive correction before they are mounted on a pen, allowing the user to seen in the low vision clinic. These see the writing magnified on screen. For findings emphasise the importance copies of plans and more information on how to produce such a system, write to Prof V Srinivasan, LAICO, 72, Kuruvikaran Salai, of refraction during any low vision Gandhi Nagar, Madurai 625 020, Tamil Nadu, India. Email: [email protected] assessment.

© 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 use, CEHJ | VOLUME 25 ISSUE 77 17 distribution, and reproduction in any medium provided the original work is properly cited.

TRACHOMA UPDATE SERIES The Trachoma Update series is kindly sponsored by the International Trachoma Initiative, www.trachoma.org

Trachoma: the beginning of the end?

Danny Haddad costly. There is Director: International the human cost Scaling up the SAFE strategy Trachoma Initiative of vision loss or 2020 INSight suggests the following: www.trachoma.org Victoria Francis blindness that S (surgery) Blinding trachoma, leads to loss of There are an estimated 4.6 million people one of the oldest social status, who need surgery in the districts with known infectious stigmatisation, confirmed trachoma. To clear this eye diseases, and exclusion backlog would require the global may be facing its from society. community to scale up from 160,000 end. Formerly There is also the to more than 500,000 operations per economic burden the world’s year. Training trachoma surgeons is just leading cause of trachoma on the first step – there are many other of preventable the lives of challenges, including low productivity. blindness, Examining a child for trachoma individuals, trachoma has families, and A (antibiotics) brought physical suffering and economic communities. Conservative estimates More mass drug administration (MDA) devastation to tens of millions of people, suggest that the annual loss of produc- programmes must be rolled out. The mostly women and children in poorer tivity due to trachoma is between main barriers are getting the drugs to countries. As a result of development and US $3 billion and US $6 billion, and that the target population. Co-distribution targeted interventions, however, nine eliminating trachoma in Africa will boost with other drug programmes can help. countries with trachoma have already the continent’s gross domestic product F (facial cleanliness) reported achieving elimination targets, (GDP) by 20%–30%. Behavioural change initiatives are and more than 80 per cent of the burden Those of us involved in the fight against needed in all districts, including about of active trachoma is now concentrated in trachoma are hopeful. We have made 500 new districts, but this remains 14 countries. much progress over the past 12 years. If difficult. Co-ordination with broader But this is not enough. We want to the global community uses this new campaigns can be part of the solution ensure that trachoma is eliminated strategic plan to focus its efforts, (e.g., including face washing in worldwide by 2020, and that the attention, and funding, trachoma does national hand washing campaigns). 4.6 million people suffering from trichiasis not stand a chance. receive the sight saving surgery they need. Trachoma surgeons and community E (environmental improvement) The World Health Organization health workers around the world have a Access to clean water and latrines (WHO)-endorsed SAFE strategy (Surgery, role to play. We invite you to contact us to must be improved dramatically. There Antibiotics, Facial cleanliness and learn more about what you can do. Please are still difficulties, but the trachoma Environmental improvement) provides the visit www.trachoma.org or read more community can push for more framework whereby trachoma can be about 2020 INSight at http://trachoma. co-ordination and better information eliminated. But success depends on org/global-strategy-2020-INSight sharing with ministries and other partners having in place everything we need to focused on water and sanitation. carry out all four elements of the strategy. EYE HEALTH HERO To help us get there, the International Trachoma Initiative has Alemayehu Sisay been working with partners in the International Coalition of Trachoma The international an overriding sense of duty, Dr Sisay has Control to create the global strategic sight-saving organ- been known to stop people in the street plan called 2020 INSight. This plan isation ORBIS has if he thinks that they have symptoms of looks at where we are, where we want to nominated trachoma. On his way to meetings or go, how we get there, and the cost and programme program assessments, it is not unusual impact of eliminating blinding trachoma. manager and for him to examine people and direct Scaling up public health interventions ophthalmologist them to the nearest source of help. described in the SAFE strategy, including Alemayehu Sisay as an Eye Health The goal of ORBIS, Dr Sisay, and antibiotic treatment with Zithromax® Hero for the International Agency for the international partners, including the (donated by Pfizer Inc.) and improved Prevention of Blindness (IAPB) 9th International Trachoma Initiative, is to access to water and sanitation, are the General Assembly. eliminate trachoma globally by 2020 most crucial elements of the plan. Dr Sisay, who works in southern using the WHO-endorsed SAFE strategy. 2020 INSight also provides direction on Ethiopia, is a hands-on programme As an Eye Health Hero, Dr Sisay will what else is needed to reach this ambitious manager, travelling to rural areas and be able to attend the IAPB 9th General goal: country leadership, international remote health points to assess Assembly in Hyderabad, 17–20 coordination, logistical and planning projects, make recommendations, and September, where he will be able to support, and adequate funding. assist with professional development of meet the world’s leading thinkers in All the elements of the plan must be in eye care professionals working to prevention of blindness. place by 2015 if we are to eliminate the eliminate trachoma. For more information, visit disease by 2020. Delayed action will be Driven by passion for the cause and www.9ga.iapb.org © The author/s and Community Eye Health Journal 2012. This is an Open Access article distributed under 18 CEHJ | VOLUME 25 ISSUE 77 the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided the original work is properly cited. CONTINUING PROFESSIONAL DEVELOPMENT Picture quiz: non-optical measures to support children with low vision

Throughout this issue of the journal, there are practical suggestions for supporting people with low vision by improving their environment. However, each person and each situation is different. Look at these pictures, read the questions, and try your best to come up with as many ideas as possible. Answers given below. it David de W David de Wit Karin van Dijk

If there is no telescope, how can you How can you increase legibility and How can you ensure the child with 1 ensure a child with low vision can 2 comfort for this student who is 3low vision can read the textbook? access the information on the blackboard? writing notes? David de Wit Karin van Dijk

What advice can you give to improve reading? Find the child with albinism. Is this the best place for him? 4 5Please give advice.

ANSWERS • comfortable. Place the child nearest the blackboard. the nearest child the Place

• Use a stand for writing – this brings the book closer and is more more is and closer book the brings this – writing for stand a Use direct sunlight falls on them on falls sunlight direct

• easily see, at a better distance. Consider providing a bigger notebook bigger a providing Consider distance. better a at see, easily Children with albinism should not sit in a place where where place a in sit not should albinism with Children

• Question 5 Question The child can be encouraged to write in a size that the child himself can can himself child the that size a in write to encouraged be can child The

• The child can write with a very dark pencil or black pen (preferred) (preferred) pen black or pencil dark very a with write can child The

magnification. magnification.

Question 2 Question

the magnifier is too close to text to give enough enough give to text to close too is magnifier the

is as large as possible and still clear. At the moment, moment, the At clear. still and possible as large as is

hear and write them down. down. them write and hear

• Use the hand magnifier at a distance where the text text the where distance a at magnifier hand the Use

• A friend can say the words on the board so the child with low vision can can vision low with child the so board the on words the say can friend A

piece of board to keep the text flat text the keep to board of piece

• The child with low vision can copy from her friend’s notebook friend’s her from copy can vision low with child The

• If no reading stand is available, use a clipboard or or clipboard a use available, is stand reading no If

• The teacher can say what she writes while she is writing it it writing is she while writes she what say can teacher The

• Use a reading stand and lay the text flat on the stand the on flat text the lay and stand reading a Use

clearly

Question 4 Question

regularly, writing in a larger size, where possible, and organising the text text the organising and possible, where size, larger a in writing regularly,

• • The teacher can ensure good contrast on the blackboard by cleaning it it cleaning by blackboard the on contrast good ensure can teacher The Put the book on a reading stand. stand. reading a on book the Put

blackboard as possible as blackboard textbook textbook

• •

The teacher can place the child with low vision as close to the to close as vision low with child the place can teacher The Make sure the child with low vision has her own own her has vision low with child the sure Make

Question 3 Question Question 1 Question

© 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 use, CEHJ | VOLUME 25 ISSUE 77 19 distribution, and reproduction in any medium provided the original work is properly cited. NEWS AND NOTICES

News Have your say: disability before April 2013. For scholarships and In our upcoming issue on disability, we details of application, write to: Registry, See you at the IAPB 9th GA will focus on what happens to the people LSTHM, Keppel Street, London WC1E The Community Eye Health Journal will be who leave our care with a visual disability. 7HT, UK. Tel: +44 207 299 4646 or visit at the 9th General Assembly (GA) of the What can we do to help? How can people www.lshtm.ac.uk/prospectus/masters/ International Agency for the Prevention of with visual disabilities benefit from wider mscphec.html Blindness (IAPB) in Hyderabad, from disability services in the community? 17–20 September. Come and meet the How can we support people with disabil- Kilimanjaro Centre for Community team, share your thoughts and ideas, and ities to work together for a better future? Ophthalmology (KCCO), Tanzania pick up free copies of useful teaching Send us your stories and photographs For information on courses, contact materials such as posters and books. describing how you or your team have Genes Mng’anya, KCCO, Good Samaritan The Assembly is the premier global reached out beyond the eye clinic to Foundation, PO Box 2254 Moshi, event for public health topics related to make a difference, particularly where you Tanzania. Tel: +255 27 275 3547. blindness and visual impairment. The have helped people to help themselves. Email: [email protected] or visit programme, devised by leading experts in All articles must be 250 words or fewer. www.kcco.net eye care, will feature more than 150 distinguished speakers, over 30 courses, Get your own copy Lions SightFirst Eye Hospital, keynote lectures and symposia, rapid fire Would you like to receive your own copy of Nairobi, Kenya rounds, and much more. For more infor- the Community Eye Health Journal? Or Small incision cataract surgery for mation and to register, visit have you moved or changed jobs? Send ophthalmologists wishing to upgrade www.9ga.iapb.org or write to your details to Anita Shah, International from ECCE. Duration: 1 month. [email protected] Centre for Eye Health, London School Courses run every month. Cost: of Hygiene and Tropical Medicine, US $1,000 for tuition and US $500–700 Call for London WC1E 7HT, UK. Email: for accommodation and meals. applications [email protected] Write to: The Training Coordinator, Applications are Courses Lions Medical Training Centre, invited for British Lions SightFirst Eye Hospital, Community Eye Health Institute, Council for PO Box 66576-00800, Nairobi, Kenya, University of Cape Town, South Africa Prevention of call +254 20 418 32 39, or email For information about VISION 2020 Blindness (BCPB) [email protected] fellowships, certificate courses in 2012, a worth up to £63,333 per year for 2–3 postgraduate diploma in community eye Lions Aravind Institute of years for clinicians wanting to health (PGDip) in 2013, or a Masters in Community Ophthalmology undertake a PhD or MD, and research Public Health (Community Eye Health) Instrument maintenance courses in 2013, contact Zanele Magwa, grants, worth up to £60,000 in total with a trainee:trainer ratio of 1:1. Community Eye Health Institute, and available to clinicians and Courses start on 1 Feb, 1 Apr, 1 Jun, University of Cape Town, Private Bag 3, researchers for 1–3 years. Closing 1 Aug, 1 Oct and 1 Dec 2012. Rondebosch 7700, South Africa. date: 12 October 2012. Duration: Four weeks. Cost: US $400 Tel: +27 21 404 7735. Email: Visit www.bcpb.org/training.html (including tools). Visit www.aravind.org/ [email protected] or contact Diane Bramson, education/coursedetails.asp BCPB, 4 Bloomsbury Square, International Centre for Eye Health or write to: Prof V Srinivasan, LAICO, London WC1A 2RP. MSc in Public Health for Eye Care. 72, Kuruvikaran Salai, Gandhi Nagar, Email: [email protected] From September 2013 to September Madurai 625 020, Tamil Nadu, India. 2014 or part-time over two years. Apply Email: [email protected] Community Eye Health Next issue Supported by: JOURNAL Riccardo Gangale/Sightsavers The next issue of the Community Eye Health Journal will be on running an efficient eye service

© Community Eye Health Journal 2012. This is an Open Access article distributed under the Creative 20 CEHJ | VOLUME 25 ISSUE 77 Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided the original work is properly cited.