internationalArticles editionfrom C ommunity Eye Health CEHJ 77&78

JournaVOLUMEl 2 | ISSUE 4 | december 2012 indian edition Low vision: we can all do more Hasan Minto Regional Director for the Eastern Mediterranean, International Centre for

Eyecare Education. Dole Kuldeep 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. Low vision assessment. Support may be difficult to find, as low INDIA vision services are often inadequate or inaccessible in many low- and middle- vision interventions once all other treat- Low vision has a significant impact on income countries. Professionals, such as ments the person needs (surgical, medical people’s lives. People with low vision may rehabilitation workers, ophthalmologists, and/or optical) have been given. The struggle to look after themselves without mid-level eye care workers, optometrists/ definition also emphasises the importance help. Having low vision affects their refractionists, and special education of vision for day-to-day functioning. status in the eyes of others and can make teachers, may not know what to do about People who may be able to benefit from social situations difficult. It reduces the people with low vision, leaving them with low vision care will want to do a range of ability of people to pursue an education, to no-one else to turn to. different things. In many low- and middle- look after their children, and to earn Individuals who can only see light or income countries, for example, many an income. People with low vision are also movement of large objects will need people with low vision are aged over at greater risk of falls and death. rehabilitation that focuses on non-visual 50 years and cannot read or write. They With our support, people with low strategies for learning and daily tasks. will have different needs, and require vision can make better use of their sight to However, there are many people who have different services, compared to children do the things they want and need to do. slightly better vision, but are still classified or adults in employment. We hope this issue will show you how. as blind, who have the potential to use their sight. These people could benefit In this issue from low vision care, which may include 1 Low vision: we can do more 14 Making life easier for people with low refraction, provision of magnifiers, and/or Hasan Minto and Clare Gilbert vision environmental modifications. 2 Understanding low vision Clare Gilbert The World Health Organization defines Clare Gilbert 16 Low vision care: who can help? a person who needs to be assessed for 3 Comprehensive low vision services in Karin van Dijk low vision care as someone “who has West Bengal 17 Improving access to low vision services impairment of visual functioning even Subhra Sil Asim Kumar Sil Peggy Pei-Chia Chiang, Jill E Keeffe after treatment and/or standard refractive 6 Low vision: the patient’s perspective 18 CEHJ– promoting improvement in eye correction, and has a visual acuity of less Karin van Dijk health for over 20 years than 6/18 down to and including light 7 When someone has low vision Elmien Wolvaardt Ellison perception, or a visual field of less than Clare Gilbert, Karin van Dijk 19 Improving patient flow through an eye 10 degrees from the point of fixation, but 12 How to predict the near magnification clinic who uses, or is potentially able to use, vision needed Jonathan Pons for the planning and/or execution of task.” 14 Improving our patients’ experience: 20 Media’s role in eliminating The important part of this definition is ideas for change avoidable blindness Sally Crook, Boateng Wiafe that people should only be assessed for low M Deshpande, G V Rao, Sridevi S

Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 1

Community Eye Health LOW VISION service delivery Understanding Comprehensive low vision services Journalindian edition Supporting VISION 2020: The Right to Sight low vision in West Bengal

Clare Gilbert Subhra Sil DNB, Asim Kumar Sil Co-director, International Centre for Eye Health, Senior Consultant, Netra Niramay Volume 2 | Issue 4|December 2012 London School of Hygiene and Tropical Niketan Vivekananda Mission Ashram, Medicine, Keppel Street, London WC1E 7HT, Chaitanyapur, Purba Medinipur, West Editor International edition UK; Clinical Advisor, Sightsavers. Elmien Wolvaardt Ellison [email protected] Bengal, India

Editor Indian edition Who is likely to have low vision? Asim Kumar Sil DNB, MSc, Kuldeep Suhas Dole [email protected] As a rule of thumb, the following people are Medical Director, Netra Niramay Niketan Vivekananda Mission Editorial committee likely to need low vision services and must be Ashram, Chaitanyapur, Purba Nick Astbury referred wherever possible: Figure 1. Blurred vision. People with Medinipur, West Bengal, India Allen Foster blurred vision (right) have difficulty Clare Gilbert • All children who have undergone bilateral Ian Murdoch seeing details, both at distance and GVS Murthy cataract operations, both those with nearby; they often have problems with India has an estimated 280,000 blind Daksha Patel pseudophakia and those with aphakia glare. Printed materials and colours children, which is one of the highest in the Richard Wormald might seem faded. world. According to different studies (1) David Yorston • People with diabetic macular oedema whose Serge Resnikoff vision remains poor despite laser treatment the prevalence of childhood blindness in • People with age-related macular degeneration India varies from 0.62 to 1.06 per 1000 Editorial committee: Indian edition children in 0 – 15 age group as also the GVS Murthy • Children with oculocutaneous albinism Col M Deshpande • People with optic atrophy, whatever the cause causes of blindness. Earlier studies in BR Shamanna • Any person who still has difficulty performing India attributed corneal scars as the Sara Varughese Praveen Vashist their daily activities because of their vision, leading cause of blindness in the country Rohit Khanna even after treatment and refraction. (8). However, subsequent studies found Rajesh Kapse reduction in corneal blindness and globe GV Rao What does low vision look like? abnormalities emerging as the major Consulting editor for Issue 77 Figure 2. Loss of central vision. “Is the Karin van Dijk and Hasan Minto People with low vision are affected in different man sitting down my husband, and is cause. In a study done in the north Consulting editor for Issue 78 ways. They may suffer from some or all of the there a seat for me?” eastern states of India, congenital globe Sally Crook following: abnormalities was found to be the Advisors commonest cause (36%) of blindness Catherine Cross (Infrastructure and Technology) • Severely reduced visual acuity among children (2). And according to Pak Sang Lee (Ophthalmic Equipment) • Blurred vision Low vision assessment in SSA camp Dianne Pickering (Ophthalmic Nursing) Andhra Pradesh Eye Diseases Study • Visual field loss: central or peripheral (APEDS), treatable refractive error caused Editorial assistant Anita Shah education has evolved as the most scale project of identifying children with Copy Editor • Loss of contrast sensitivity 33.3% of the blindness, followed by (Indian Edition) Sridevi Sunderaranjan practical way of educating visually visual impairment and to help them Design Lance Bellers / Omkar Mulgund / Kedar D • Increased light sensitivity. congenital eye anomalies (16.7%) (3). Printing Louts Concepts impaired children. In fact, the concept of through provision of low vision devices It is unfortunate that such a large Many people with low vision suffer from blurred inclusive education developed because and corrective surgeries. Two organisa- Online edition Sally Parsley number of children are suffering from Email [email protected] vision (Figure 1), for example if they have institutional education had some serious tions having the capacity of providing low Figure 3. Loss of peripheral vision. visual impairment and blindness but the Exchange articles scarring on their corneas. drawbacks: vision services were allotted ten educa- “How many other people are there in mechanism of finding them and organ- Kuldeep Suhas Dole [email protected] People with optic atrophy or age-related the room?” Number of institutions was inadequate tional districts each for this extensive ising service for them is a challenge. Website macular degeneration will have loss of central for the total number of persons who work. Our organisation was one of them Different approaches have been tried to Back issues are available at: visual acuity (Figure 2), which means that tasks needed them. and worked among half of the State’s www.cehjournal.org find such children: examining children in requiring good central vision will be difficult. For • Establishment and maintenance of population. special schools, ICDS (Integrated Child Subscriptions and back issues example, reading, writing, threading a needle institutions was expensive. During these two years – 2009 – 11, Development Services), school Community Eye Health Journal, International Centre and sewing, putting on make-up, recognising • Individuals studying were detached 10900 children (6174 (57%) boys and for Eye Health, London School of Hygiene and Tropical screenings are the usual ones in India. people, seeing where their food is on the plate from their families and society. 4726 (43%) girls) were examined in ten Medicine, Keppel Street, London WC1E 7HT, UK. This article depicts the experience of Tel +44 207 612 7964/72 and whether they have finished eating, seeing if • Social and vocational adjustment districts by our team. Out of them, 3814 working with the special educator Fax +44 207 958 8317 their clothes are clean, finding their own pair of became difficult when the individual children were prescribed low vision Email [email protected] workforce and scaling up the same in a shoes. If they have a full field of peripheral vision returned to the community after devices and 3669 received the required Indian editorial office Figure 4. Loss of contrast sensitivity. large population. then mobility will be less of a problem. training. aids. Nine hundred and ninety three PBMA©S H. V. DESAI EYE HOSPITAL With normal contrast sensitivity (left), Sarva Shiksha Abhiyan ( SSA) 93 Tarvade Vasti, Mohammadwadi, Someone with glaucoma or retinitis • Institutional education in many students were selected for cataract and it is easy to recognise faces. With (Education for All Movement) is a Hadpasar, Pune - 411 060. pigmentosa will have constricted visual fields, occasions failed to involve the commu- other surgeries and from among them, Tel +91 020 2697 0043 / 2697 0087 reduced contrast sensitivity (right) programme by the Government of India i.e. loss of peripheral vision (Figure 3). This nities where people with disabilities surgeries were performed for 605 Email [email protected] this becomes more difficult. aimed at universalisation of elementary Website www.hvdeh.org makes it difficult to move around without come from. children. education as mandated in the 86th © International Centre for Eye Health, London bumping into objects on the floor. People may According to 2011 census, the state of For a better understanding of the Articles may be photocopied, reproduced or translated provided these amendment of the Constitution of India are not used for commercial or personal profit. Acknowledgements have difficulty finding things they have dropped. West Bengal has a population of epidemiological issues related to making free education for children aged should be made to the author(s) and to Community Eye Health Journal. Reading may still be possible, but difficult. 91,347,736 contributing to 7.55% of childhood blindness, we are showcasing Woodcut-style graphics by Victoria Francis. 6–14 a Fundamental Right. SSA is being ISSN 0953-6833 Loss of contrast sensitivity (Figure 4) can India’s population. The State has 19 our experience in one remote district of implemented in partnership with state The journal is produced in collaboration with the World Health Organization. have a very big impact on someone’s visual districts with a population density of 1029 West Bengal that borders Bangladesh Signed articles are the responsibility of the named authors alone and do function, making it difficult to recognise faces or governments throughout the country. This not necessarily reflect the policies of the World Health Organization. The per sq. km. Population in 0 to 6 age group and Assam. This study depicts our is an inclusive method of education for all World Health Organization does not warrant that the information contained find food on a plate of similar colour. is 11.07%, decadal growth rate is 13.93% experience in Cooch Behar, an economi- in this publication is complete and correct and shall not be liable for any differently able children and visually damages incurred as a result of its use. The mention of specific companies Increased light sensitivity makes it very and literacy rate is 77% (82% male, 71% cally underdeveloped district with a or of certain manufacturers’ products does not imply that they are difficult for people to see detail or make sense Figure 5. Increased light sensitivity. challenged children constitute a major endorsed or recommended by the World Health Organization in preference female). (7) population of about 2.5 million with a bulk. Earlier, specialised education used to others of a similar nature that are not mentioned. of what they see if they are in bright light, or This is how a street scene in bright During the year 2009-11, Sarva Siksha decadal growth rate of 13.86 and literacy to be imparted to these children through glare (Figure 5). sunlight would look to someone who Mission, West Bengal took up a large rate of 75% (7). has increased light sensitivity. schools for the blind. But now inclusive

2 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 3 service delivery Continued

Asim Kumar Sil Earlier study reports on childhood Services at a glance Anatomical causes of blindness blindness in India were based mainly on schools for the blind; very few of them Total surgeries done : 34 children, Cause <6/18 -6/60 <6/60 - NPL total n % n % n % were community based. This experience 44 eyes (includes 29 cataracts, 5 is unique as it looks at the pattern of Refractive errors 34 35 24 23.5 58 29 optical iridectomies, 4 squint, 4 (Myopia (17) (17.5) (17) (16.6) (34) (17) blindness amongst children identified ptosis corrections) mentioned within through SSA and more importantly, the brackets) service need for them. Number of spectacles dispensed : Whole globe abnormality 24 24.7 33 32.3 57 28.6 153 Corneal scar 14 14.4 10 9.8 24 12 Target Beneficiaries: Lens (Cataract/pseudophakia/ Number of optical devices given : aphakia and related amblypia) 13 13.4 20 19.6 33 16.5 All children below 16 years of age as 215 (multiple devices for one) Strabismic amblyopia 03 03 04 3.9 07 03.5 per UNICEF definition of childhood were Retinal diseases 01 01 04 3.9 05 02.5 included. There were a few students Number of non optical devices Optic atrophy 01 01 02 1.9 03 01.5 above 16 years. All children with dispensed : 226 Nystagmus and others 07 07 05 4.9 12 06 functional low vision were examined. Total 97 100 102 100 199 100 According to a World Health Still a good response was received from Organisation (WHO) consultant, a person all the stakeholders. Thirty eight special Conclusion and recommendation: with low vision is one who has impairment educators were successful in bringing Many children received both glass and This project is a good example of a of visual function even after treatment or 453 children for examination devices. One hundres and sixty three comprehensive approach of reaching refractive correction and has visual acuity overcoming all the hurdles of communi- children showed at least one line children in large scale and providing them of less than 6/18 to perception of light or cation. Children screened by teachers improvement in vision. The breakup of service with equity and also helping in visual field of less than 10° in the better had high false positives but needy visual improvement is as follows. designing Individual Education Plan (IEP) eye, who uses or is potentially able to use children were not missed out. for the class VI students. This is the first vision for planning or execution of a task Distance vision improvement with LDVs This project has helped many such type of project conducted in India. (5). Other state governments have shown children access to normal print. VA 6/6-6/12 22 13.5% Previously they were either reading via interest towards this project. Our recom- Process: VA <6/12-6/60 62 38.0%v Braille system or only listening to their mendation is to incorporate this project in Following a two day training programme teachers. Early introduction of low vision VA 6/60-3/60 17 10.4% the National Programme for Control of at base hospital, the special educators Children with low vision devices will make these visually Blindness in India. identified children with visual impairment. VA<3/60 62 38.0% fication. As the children were from far off Children with presenting VA <6/18 in impaired children more confident, and References: Visual Acuity (VA) was assessed in each places, PPC was done in all cases, since the better eye: 199 (male 111, female 88) they will be able to compete with their Near vision improvement with LVDs 1. Clare Gilbert, Jugnoo Rahi, magnitude and causes of eye by using a Snellen’s tumbling “E” visual impairment and blindness in children, The we felt that these underprivileged Mean - age of children: 10.7 years. peers who have sight. Sarva Siksha has visual acuity test chart. All the identified N6 59 36.2% Epidemiology of Eye Diseases, 3rd. edition, 2012, children will not be able to come for a Low Vision (<6/18 – 6/60) in the successfully included several children Imperial College press children were brought to the Block level regular follow up. Other common better eye 97 (47.74%) in the mainstream education. Still many N8 22 13.5% 2. Bhattacharjee H. et al, Causes of Childhood Blindness Circle Office by the special educators. in North Eastern States of India, Indian Journal of surgeries were surgical capsulotomy, Severe visual impairment and more are left out but there is no infor- In each of the low vision camps, a team N10 7 4.3% Ophthalmology, 2008,56:495-9 pupilloplasty, optical iridectomy, ptosis blindness (<6/60 – NPL) in the better eye mation available about their visual 3. Dandona R, et al, Childhood blindness in India: a of four optometrists did a detailed exami- correction (blepharophimosis syndrome 102 (52.26%) status. N12 5 3.0% population based Perspective, Br J Ophthalmol, nation of around 40-45 visually impaired 2003;87:263–265 constituted a major bulk) and squint Most significant aspect of this project

4 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 5 PATIENT PERSPECTIVES MANAGING LOW VISION Low vision: When someone has low vision the patient’s perspective

For this issue on low vision, Impact Clare Gilbert the Community Eye Health Adults described how low vision Co-director, International Centre for Eye Journal contacted low vision Health, London School of Hygiene and services had resulted in the Hari Bdr Thapa Hari

Tropical Medicine, Keppel Street, Dijk van Karin

practitioners in India, Kishiki Elizabeth following: Tanzania, Nepal, and Peru to London WC1E 7HT, UK; Clinical Advisor, Sightsavers. help gather the views of • Greater independence, eighteen people attending confidence, courage, hope, Karin van Dijk their low vision clinics. The and dignity CBM global advisor on low vision; low people varied in age from 14 • A better understanding of the vision consultant to Light for the World Netherlands and to Kilimanjaro Centre to 81, and suffered from a Damodar BC Mbaraka Omary reality of the visual loss. Nepal (22) Tanzania (18) for Community Ophthalmology. range of vision problems “Society used to view me in a “I have really started living. Children talked about how the Grutto 21, 7423CZ Deventer, The including nystagmus, retinitis negative way … I used to wonder With my glasses, I can recognise low vision service had helped Netherlands. [email protected] 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 As clinicians, being faced with a patient The interviewees (or their which society views me. Most of watch football and see faces of • Starting school whose vision we cannot improve any parents) described how their the time, I get to hear people say, my favourite stars. With my • Doing desired activities, such further can make us feel like a failure. low vision had affected them ‘People with low vision can also magnifier, I can read even the as reading print, even small However, there are many ways to help before treatment, how their life do good deeds and can work like smallest letters. I have become print such a person with low vision. changed after they received normal people.’” a different person now.” • Increased independence, for Figure 1 shows the difficulties low vision care, example being able to read someone is likely to have, based on their the blackboard and learning distance visual acuity, and what support and what they felt they still Teaching the use of an illuminated hand magnifier. PHILLIPINES needed. to write they may be able to benefit from. These We hope that these experi- • Improving the attitudes of include optical devices, non-optical 2 Has all the medical, surgical, and optical Once you have established that the ences of people with low Kishiki Elizabeth peers and teachers “… who devices, advice on environmental modifi- treatment possible already been given? person does need low vision services, vision will highlight what is now see I can do many things.” cations, and referral to rehabilitation and 3 Has the prognosis for vision been you can begin the low vision assessment. important in a low vision service. • Better social interaction, for (special) educational services. confirmed by a medical professional? The following are the steps that example “… recognising the In this article, we will show you how If the answer to any of these questions is normally form part of a low vision Martizala Cruz De Zuasnabar Before faces of my friends.” to assess a person with low vision and ‘no’, refer the person to the appropriate assessment: find out what it is they really want to be services, where possible. Before they received low vision • Taking a history Maribel Tomateo Falcon Abdi Kajembe able to do. We will then outline the If we know the diagnosis, this will give care, the adults said they had What more is needed? • Explaining the eye condition Peru (27) Tanzania (9) interventions that are possible, and give us some idea of the likely impact on the been unable to do their Low vision services helped her Thanks to low vision services, • Some people still lacked the • Determining the patient’s needs some guidelines. person’s visual function and thus on their desired activities, such as to set realistic goals. “The visual school is now a lot easier for confidence to use their optical • Performing an accurate refraction main visual needs (see page 2). driving or reading. They were rehabilitation helped me a lot, him. “With my spectacles, devices in public • Assessing visual functions Before you start Ideally, people with low vision should worried about their vision and mostly to be aware of my I can sit at my front desk and • Most people also wanted to • Magnification needed When you are faced with a person with poor have undergone refraction, and be had negative feelings, limitations, to accept them read well on the blackboard be informed if there were new • Designing a management plan vision, it is important to check that every- wearing their spectacles, before they are including stress, depression, and to know up to where I can and in books, and I can see technological developments, • Referral for further training and support develop and set my goals.” people well.” thing possible has been done to improve given low vision support. In practice, many anger, and frustration. They and hoped for lower prices for and contacting educational or their vision, and that they really do need eye care practitioners find it too had also felt dependent on software and electronic low rehabilitation services if needed. low vision services. Here is a checklist: challenging and/or time-consuming to their family, and that they were vision devices • Selecting low vision devices and training of vision, provision of optical devices, and refract someone with low vision. This is a burden to the family. The adults had also • Some children did not know enough 1 Has the person’s diagnosis been the person in their use suggestion of environmental modifica- why refraction should always form part of struggled to accept their condition as about their condition and wanted confirmed by an ophthalmologist or • Suggesting non-optical interventions tions. Specific interventions included: a standard low vision assessment. being irreversible. someone to explain it to them in terms other eye care worker? and environmental modifications. School-age children and young adults • Changes such as sitting near the they could understand. Figure 1. How the type of assistance provided is influenced by distance visual acuity 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 Spectrum of distance visual acuity (ideally, with the person wearing the correct prescription) 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 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 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 Difficulties with activities of daily living: dressing, eating, walking around, recognising faces 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 Potential to benefit from optical devices such as magnifiers children who are still struggling. One of the biggest problems they had • Someone taking the time to clearly +/- + ++ ++ Highly unlikely 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: Potential to benefit from making changes to the environment (see page 12) 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 Need for rehabilitation and special educational services 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.

6 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 7 MANAGING LOW VISION Continued

Taking a history Case STUDY 1 Assessing residual vision Using the bracketing This is an important part of the low vision This case study, and those that follow, are of actual people and demonstrate The support we provide depends on technique assessment and provides an opportunity practical low vision assessments and interventions. They show how the diagnosis having a thorough understanding of the for you and the patient to get to know each and history can guide us in setting priorities for assessment and knowing which person’s overall visual function. For Because patients with poor visual other. interventions, especially non-optical, might benefit the person. example, people with poor contrast sensi- acuity may have difficulty in deter- Encourage the patient to talk about tivity may require more magnification than mining small changes in lens power their problems. Asking open-ended 60-year old retired professor near vision was 1M (N8) at 15 cm. His suggested by their near visual acuity and clarity, it is often necessary to questions will help; these are questions with age-related macular degen- near acuity improved to 0.63M at 25 cm alone. make large power changes. starting with words such as ‘when’, ‘what’, eration complained that he could with an add of +3.00D, a reading lamp, When assessing someone with low A bracketing technique can be ‘how’, and ‘where’ – questions which A vision we therefore need to have a better no longer read small text, which had and a reading slit. With these, he was useful. For example, use a +2.00DS don’t have ‘yes’ or ‘no’ as an answer. been an important part of his life. He also able to read the newspaper and his idea of their overall visual function, trial lens and compare this with a Ask questions about: also taught college students and worked writing was legible. including: −2.00DS trial lens. If the patient is Figure 2. A logMAR chart has an equal • Their own eye health – how their vision extensively on the computer at home. On The professor was advised to wear his • Distance visual acuity able to differentiate between the two, number of letters in every line, regular is affected, what makes it worse or further questioning, it became clear that bifocal glasses constantly, to read with a • Near visual acuity the lens giving the better vision can spacing between lines and letters, and a better and how it has changed over time he also had difficulties in communicating table lamp and reading slit, and to use a • Contrast sensitivity be added and the technique uniform progression in letter size • Their general medical history, their with others. From the history, interview, reading stand. A signature guide helped • Visual fields repeated using, say, a +1.00DS and mobility, and their medications and diagnosis, we knew that the man had him to sign cheques. • Light sensitivity a −1.00DS lens, etc. It may be power of trial lenses and may respond • Their family’s eye health history central field loss and reduced contrast He was taught how to use eccentric • Colour vision necessary to refract the patient with much more slowly. Patience is essential, • Their occupation and hobbies sensitivity, which would require improved viewing (see page 8), which helped him the chart placed at 3 m or less. If this and using the bracketing technique (see If you work in a setting with limited • Any previous low vision assessments. lighting and contrast. to recognise people more easily. This is done, the result is over-plussed The low vision team assessed his best helped him socially. panel) can help. resources, the improvement of distance (the chart at 3 m acts as a near Here are examples of questions you can Fatigue and frustration can negatively and near visual acuity can be emphasised; corrected distance and near visual The professor was advised about the object and therefore adds a vergence ask about their eye health and vision: influence the outcome of the refraction. the other visual functions can be tested acuity, contrast sensitivity, reading and importance of explaining to his friends of about −0.30D in the plane of the Ensure the person is seated comfortably functionally, as suggested here. • When did you first notice a problem writing ability, and the extent of his field and family why he was not able to make trial lens) and a correction should be and give them time to recover from any If you work at a large eye hospital, use with your vision? loss. direct eye contact. made according to the test distance. signs of stress or tiredness. the appropriate tests and equipment. • What kinds of problems have you noticed? His visual acuity, tested on a logMAR He was also directed to the local While doing refraction, the test chart Adapted from: Subjective Refraction: Principles and • What problems do you have in the day? chart, was 6/36 (0.8 logMAR) in the government office to obtain a disability Techniques for the Correction of Spherical should be at a distance where the patient Distance visual acuity • What problems do you have at night? better eye, and with a +2.00D add his certificate and other paperwork. Ametropia, Andrew Franlin http://www.banjoben. can see at least the top line of letters. Full We are used to testing distance visual com/low_vision_refraction.htm • What changes, if any, have you noticed aperture trial lenses should be used to acuity using standard Snellen charts at in your vision? allow the patient to move their head or only two distances: six metres (20 feet) • What makes your vision worse? without assistance? ventions you suggest. Near visual acuity eyes in order to fixate eccentrically (see or three metres. However, when testing • What makes your vision better? Ask for specific examples of what would It is very important to test everyone’s Activities panel on page 8). someone with low vision, we should help them to regain independence or self near vision, not just those who can read • Can you choose and find the clothes you Assess the near addition (lens) needed preferably use logMAR charts as they esteem. For example: and write, as good near vision is needed Explaining the eye condition want to wear? and measure the working distance with give better measures of acuity. If the for a very wide range of other activities. Some people with low vision will not have • Can you add the correct spices and • Regaining the ability to read their which the patient is comfortable. Record person cannot see the letters at three We must also know the near visual acuity had their eye condition explained to them, herbs to the food while cooking? personal correspondence their best corrected near and distance metres, we must also test at other test so that we can prescribe low vision or they may not have understood the • Can you still do your hobby, e.g., • Helping to cook again instead of just visual acuity. distances, such as two metres, one magnifiers for near tasks, if needed. explanation at the time. needlework or woodcarving? sitting around metre, etc. Near visual acuity can be tested using It is always worthwhile taking time to • Can you read religious texts, the • Learning to identify the correct logMAR charts (Figure 2) similar to those explain the eye condition again, in terms newspaper, or utility bills? medication and taking it independently Case STUDY 2 used for testing distance visual acuity. It the person can understand. Even if patients • Making a visit to a neighbour on their 45 year-old man with dark background. Mobility was tested in Participation is important that comparable tests for with low vision have heard it all before, own, whenever they feel like it. glaucoma, who drove himself to different lighting conditions by going for • Do you attend family functions? both are used. The choice of test depends they will probably find it reassuring to have • Do you attend religious or other events? work in a factory, was referred to a short walk with the client. His distance you explain it again, thereby confirming When discussing these topics, think about A on age, development level, and literacy the low vision clinic. He was married with visual acuity was 6/24 • Are you still able to vote? the following: of the client, e.g., tumbling Es or what they have heard from others. two school-age children, and was the (0.60 logMAR) with his myopic glasses of • Do they need help with near and Landolt rings. Be positive. Emphasise that they have Check with relatives that this is what they main breadwinner in the family. -4.00D. He could read 1M (N8) without intermediate vision, with distance It may be useful to assess near vision some residual vision and that you and have observed or experienced; sometimes The man said that he had problems his glasses at 20 cm. vision, or with all distances? at a distance of 25 cm (see article on your colleagues are committed to helping people feel embarrassed to acknowledge with driving and working in the evenings, A 6D hand-held magnifier was • Is the task long (reading) or short page 9). Note that people with presbyopia them make the most of that vision. how dependent they have become. and had difficulty navigating inside the prescribed to make reading the (looking at the oven temperature dial)? may need an appropriate addition in order Reassure them that they cannot harm It is also important to find out what kind factory. These difficulties were the result newspaper and small print on the • Do they need to have one or both hands to read at this distance. In addition to near their residual vision by using it – they will of support they have at home. of loss of peripheral field and reduced machinery more comfortable, and he free? vision, reading and writing performance not ‘wear out’ their eyes! • contrast sensitivity related to the was advised to wear a cap with a visor to Who do they live with, and is this person • What other visual functions might be should be assessed among those who are able to provide help some of the time, or glaucoma. He also had difficulty in reduce glare when in bright sunlight. Determining the patient’s affected and must be assessed? crossing roads, identifying curb edges, After consultation with his employer, literate. This is because reading requires all of the time? other functions that are not assessed in needs • walking in shaded places, and identi- levels of illumination in the factory were Is providing this support having a Accurate refraction acuity testing, for example, locating the Start on a positive note by first asking fying landmarks. These findings increased. This improved contrast, negative effect on the family in any way? The importance of good refraction in a next line of print. If near acuity only is what they can still do, before going on to • suggested a need for better illumination enabling him to navigate doorways and What is the home like? Are there steps? low vision assessment cannot be measured, difficulties with reading may be ask what they may be struggling with. in the evenings and in situations of concrete pillars more easily. This Where are the washing and sanitation overstated. missed. Ask about their mobility, activities, and poor lighting. improved his mobility, working efficiency facilities? How is cooking done? Refracting people with low vision The best way to assess reading is to participation. Here are some examples. The low vision assessment included and confidence. He was advised to travel Having established broadly what support differs from refracting people whose distance and near visual acuity with best to work using public transport or share use printed text from a newspaper or book they have at home, and what they can and Mobility vision can be improved to normal (6/6 or correction, visual field testing by confron- rides with co-workers. The need for and to ask the person to read it aloud. cannot do in relation to mobility, activities, • Can you walk beyond the house without 20/20), as the person with low vision is tation, and contrast sensitivity testing regular review and continued use of Reading aloud allows the assessor to and participation, find out what they want assistance? less sensitive to small changes in the using light-coloured objects against a glaucoma medication was explained. hear mistakes and observe the person’s • Can you walk around in familiar places to be able to do. This will guide the inter- Continues overleaf ä

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visual skills. Case STUDY 3 areas of significant visual loss within the Figure 4. Increasing magnification reduces the field of view (right) Contrast sensitivity central 20° of the visual field (the area of iabetic retinopathy made a Contrast sensitivity is the measure of the The interventions recommended the retina providing fine detail). The 75-year-old woman unsure of focused on improving her near visual

eye’s ability to detect differences in person is tested while wearing their Silver Janet Silver Janet greyness and background, or small Dher bearings at home, even acuity and included an 8 dioptre illumi- reading glasses or bifocals, if appropriate. changes in brightness. Most of our world though she had undergone cataract nated stand magnifier, which enabled her For perimetry, e.g. Humphrey is in moderate to poor contrast. Visual surgery with intra-ocular lens implan- to read 1M print, using a reading stand to perimetry, a new hand-held perimeter is acuity charts are one of the few things in tation. She was unable to identify help her read more comfortably. She available from the Low Vision Resource high contrast! different utensils and other items, such could also use the magnifier to identify Centre (see page 13). It is quick to use Reduced contrast sensitivity can be as spices, in the kitchen. She also could money. and provides reliable and repeatable assessed functionally by asking questions not see the knobs on the gas cooker. She She was trained in the use of results. such as: was keen to do her own cooking, eccentric viewing to assist in daily activ- gardening, reading, and shopping. ities and was shown how to fold paper Visual fields: tips for daily activities • Do you find it more difficult to walk Pseudophakia is accompanied by loss money in different ways so she could tell For people with central visual field loss: Low magnification Moderate magnification around in very bright sunlight, or at of accommodation, while diabetic retin- which amount they were for. 1 Provide high magnification primary colours, e.g. red, green, and blue. apply. However, these devices are a lot dawn and dusk? opathy can result in sensitivity to light, To help in the kitchen she was 2 Show them how to use eccentric This can be tested using pencils or pieces more expensive than lenses. • Can you see the white light switch on the patchy field loss, with reduced contrast advised to use different coloured labels viewing (see panel below). of coloured fabric, for example, and Remember: to maximise the benefit light-coloured wall in your house? sensitivity and color discrimination. for different pots and to use containers asking the person what colour they see. of magnifiers, it is important that • Can you read your bills (which are often These visual functions were all of varying shapes or sizes for her spices. For peripheral visual field loss, the best However, clinical colour vision testing people wear an up-to-date pair of on grayish paper, with poor contrast)? assessed. Her best corrected distance She was also advised to remove all advice is to keep pathways clear and to can be valuable to make the correct distance correction spectacles when avoid moving furniture in the house. A There are several ways of testing contrast visual acuity was 6/60 (1.0 logMAR) with unnecessary furniture in the living areas. diagnosis concerning the cause of a testing magnifiers and that they wear cane for walking around outside may be sensitivity clinically, such as the Pelli astigmatic correction. Other non-optical interventions she liked person’s decreased vision. their reading spectacles with stand very useful. Robson chart, but these charts are With a near add of +4.00D, she could were a signature guide for banking, and Colour: tips for daily activities magnifiers.For suggestions on predicting expensive and require that the person read 1.6M at 20 cm. extra illumination for near work. the level of near magnification someone Colour vision People with a colour vision deficiency or with low vision is literate. A less expensive will require, see the article opposite. It is rare for a person to be completely with blurred vision may find it difficult to alternative is the Lea low-contrast flip glare, contrast is reduced and recognising window or try different lamps. colour-blind, but reduced colour vision distinguish between two colours that are chart (see page 13 for ordering details), objects or people can become very You can determine the best lighting Designing a occurs more often in people with low similar. Suggest the following: which is suitable for those who are not difficult. conditions for particular tasks, such as management plan vision. This can be assessed by asking • literate, including children. Low contrast People with reduced light sensitivity reading or sewing, by letting the person try Arrange the food cupboard so tins or Develop a management plan based on all questions such as: do you have difficulty may explain why a person with a visual also struggle to see, and will often also out different types of lamps in the clinic. foods of contrasting colours are next to the information you have gathered about when trying to find clothes of matching or acuity of 6/36 can manage many tasks have reduced contrast sensitivity. People with increased light sensitivity each other the person with low vision. similar colours? Have you noticed any • well, but struggles in poor light. could wear tinted glasses, sunglasses, or Ask someone to help label clothes or to Ask yourself: what does the person Light: tips for daily activities problems when discriminating shades of a cap outdoors to help with glare. put matching outfits together ahead of need? This depends on their history, their Contrast: tips for daily activities Getting the amount of light right is the key colours? Filters (Figure 3) can help people with time (on the same hanger/shelf) physical capabilities, the nature of their It is not easy to translate these findings to intervention in this situation. Ask what the There are formal methods for colour • both contrast and/or light sensitivity by Use other senses (touch and smell) to residual vision, and what they want to do. impact on daily activities. In general, person is struggling with, such as seeing vision testing, such as Ishihara plates and minimising glare and increasing contrast. find out which fruit are ripe. You may suggest some or all of the moderate contrast sensitivity might have at night (reduced light sensitivity) or the Farnsworth dichotomous test (D-15), Filters look like safety glasses and are following: an impact on reading, whereas very poor seeing outside in bright sunlight or when which involves colour arrangement. In Magnification needed available at low cost (see page 13 for • Optical low vision devices: for near or contrast sensitivity might indicate the the light reflects off the blackboard practice, it is usually sufficient to see Many people with low vision can benefit ordering details). Many different colours distance vision need for visual rehabilitation and mobility (increased light sensitivity). whether the person can see or match the from magnification: using lenses to make and shades are available, such as yellow, • Non-optical interventions, such as caps training. For people with reduced light sensi- objects appear bigger. However, magnifi- brown, grey, red, etc. for glare, a reading stand to reduce You can help people with low contrast tivity, recommend that they sit near a Eccentric viewing cation has its limitations. It is important People may need two different shades fatigue, a reading guide, various lamps, sensitivity by advising them how to to understand these limitations and of a particular filter: one for indoor use It is likely that people with loss of filters, sunglasses, etc. See the ‘tips’ increase contrast in their environment. explain them to the people you are (light) and one for outdoor use (dark). central vision (often associated with given on pages 7 and 8; the case There are two main ways: helping so they have realistic expecta- macular degeneration) will need to studies also contain useful ideas. tions about what is possible. 1 Use better lighting. For example, sit by Chan Ving Fai Visual fields develop an eccentric viewing technique, • Environmental modifications, such as the window to read or sew, or use a Ideally, the clinician making the diagnosis in which they use their peripheral vision • Stronger magnifiers have smaller painting lines on stairs or using lamp. Be aware: very bright light, will have assessed the patient’s visual instead of their central vision. They lenses. You cannot have a strong contrasting colours around the home including direct sunlight, can reduce fields as part of their clinical assessment. might find it easier to see things if they magnifier that has a big lens! (see page 12 and the case studies in contrast. If not, questions can help. do not look directly at them, but rather • Stronger magnifiers have more this article). 2 Make adaptations in the environment. Patients may realise that they cannot to one side or the other. distortion around the edge of the lens, Think about when the person should For example, use paint or coloured tape see detail clearly but can see well enough Eccentric viewing can be difficult to which means you can see clearly come back to see you again. Make an to create contrasting strips on steps or to walk around. This suggests central teach, and to learn. However, you through the centre of the lens only. around light switches. visual field loss; this is often due to could start by encouraging the appointment if possible. macular degeneration. person to try finding the best area for So, although the object or word looks This is also the point during the low Light sensitivity Someone with peripheral field loss viewing for themselves, starting with bigger, only a few letters or a small part of vision assessment where you consider Both too little light, and too much light from glaucoma or retinitis pigmentosa real objects, then faces, and later on the object can be seen at any one time what other support the person will (glare), can affect what someone with low can see detail but will bump into furniture with larger letters or words. The (see Figure 4). This reduces reading or need, for example, educational support vision is able to see. or fall over things on the floor. person will eventually learn to control working speed. and/or visual rehabilitation and mobility People with increased light sensitivity There are a range of tests available, their eye movements. Therefore, we recommend you training. lowest possible struggle to see in the presence of bright including confrontation (face-to-face) If you have internet access, you can prescribe the power of Write the necessary letters or notes light (for example, light reflected by a testing, static tests (e.g. Friedmann visual visit http://www.mdsupport.org/ magnifier that can be used comfortably and ensure the person knows where to go. shiny blackboard or table top). This is a Figure 3. A red filter has helped this man field analyser), and dynamic tests (e.g. evtraining.html for a guided for a long time (if needed). If possible, follow up with the referral common problem for people with low with achromatopsia (a rare form of colour tangent screen or Goldmann tests). introduction in how to use eccentric With electronic devices such as closed- service to check whether your patient has vision. blindness causing extreme light sensitivity) The Amsler grid test is used to plot viewing. circuit television cameras and electronic taken up the referral. If not, why not? In the presence of such bright light, or to see in daylight Continues overleaf ä readers, the same limitations do not Continues on page 12

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Figure 5. Examples of optical low vision devices (left to right): stand magnifiers, hand-held magnifiers, and spectacle magnifiers 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 Hong Kong Society for the Blind the for Society Kong Hong Blind the for Society Kong Hong Blind the for Society Kong Hong 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 PRACTICAL ADVICE 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 patient. amount of magnification needed. • The physical condition of the person. If It takes time to learn how to use a new How to predict the near magnification needed low vision device; learning one device • Use a reading chart with sentences. Ask 8 dioptres (D) is needed: 2 x 4 = 8D successfully builds the person’s confi- It is possible to use a simple formula to FROM THE FIELD them to hold the chart at 25 cm • If you do not know the dioptres, check if dence and they will be more likely to come predict the amount of near magnification • If needed, particularly in older people, the box of the device gives the ‘x’ (e.g., back for further support. a person might need. add positive lenses (from +1DS to 2x) magnification. This is often given for How to train people to use Depending on the task the person The actual amount of magnification +4DS) to both eyes, to enable them to a reference distance of 25 cm, which is wants to do, demonstrate one or more Iow needed will vary according to the person’s accommodate at 25 cm the same distance used in this section. low vision devices vision devices that will provide the magni- visual needs, environment, and the low • Ask the person to read aloud fication they need. Allow them time to try the vision device chosen. However, this is a Table 1. Text sizes in M notation (at both 25 Ving Fai Chan is 2 Try to explain that there are things • The smallest size the person can read devices for themselves to see which work useful starting point when selecting low and 40 cm) and in N notation an optometrist they can and cannot do as a result of with comfort and good speed gives their best. vision devices to try out. who works for the their decreased vision, even with the near acuity at 25 cm (Note: this is not M M N Usual type International Centre Where possible, let them do something In this article, we use the testing help of the low vision devices. If that the smallest size they can see!) (40 cm) (25 cm) text size for Eye Care similar to what they would like to do at distance of 25 cm, rather than the usual is not made clear, patients will have • Write down the near acuity achieved at Education (ICEE). home, work, or school. Check the ease 40 cm, for two reasons: 2.0 3.2 16 Large print unrealistic expectations and will be 25 cm, whether in M or N notation. He is a lecturer at the with which they are able to use the 1 Bringing objects closer makes them Asmara College of Health Sciences in Eritrea 1.6 2.5 12 Children’s books disappointed with the results – different devices and suggest modifica- easier to see and improves contrast, Note: M sizes differ depending on the and is the only person providing low vision 1.25 2.0 10 Magazine print which means they may give up tions as needed. For example: add a important for people with low vision. testing distance used. Table 1 shows the services in that country. 1.0 1.6 8 Newspaper print learning how to use the device. reading guide, provide a reading stand, or 2 If we know the magnification needed at M sizes of different types of text at both The first time I tried to drive a car, my 3 Give clear and step-by-step instruc- Paperback print increase available light. 25 cm, it is easy to calculate the 25 cm and 40 cm. The latter is more 0.8 1.25 6 dad was sitting beside me, expecting tions. People with low vision usually dioptres needed to provide this. familiar to most people. For our purposes, 0.6 1.0 4 Footnotes me to do it right the first time. When I respond well to verbal instructions. Adapting the magnification it doesn’t matter which you use, provided struggled, I was extremely disappointed You can also give written instruc- to fit the person Finding the magnification you use the same notation throughout. Magnification for tasks and felt I would never drive again. tions if the person or a family The magnification you predict a person needed for reading It is the same when people with Step 2. Find the required near acuity at other than reading member is literate. Use good will need (see page 9) is merely a starting The formula we use is given below. It lets low vision try to use a device for the first 25 cm Magnification is useful for many other contrast and bigger letters where point. Consider increasing the magnifi- us predict the amount of magnification tasks, not just reading. For example, time. We, as low vision practitioners, possible. • Ask what they want to be able to read cation by the smallest step possible for the person will need (2x, 6x, etc.). sewing, sorting seeds, and drawing. may expect them to know 4 Provide regular, routine • Determine the text size and record the the following factors: For people who cannot read, test their how to use the low vision ‘Follow up Near acuity achieved required near acuity at 25 cm, in the training. Teach your patients • Poor light: if there is no electricity or the near vision using an E chart and record devices perfectly, without Magnification at 25cm same notation. your patients. new skills only after they light is dim and cannot be improved = the size they can very easily see at 25 cm giving them any encourage- needed Required near acuity have mastered the previous • Tasks done for a longer time, such as Note: Don’t aim to record the smallest (Step 1). It is much easier to see the direc- ment or training. We think at 25cm Everyone loves ones. Giving too much infor- reading or studying size a person can see. Recording the size tions of just five ‘E’ letters than it is to read that, as long as the person mation at once will make • Poor contrast, such as bills or other Step 1. Find the near acuity achieved the person can read with comfort and speed sentences, so the tester must resist the has achieved his or her to be cared for’ your patients feel stressed. printed matter with poor contrast at 25 cm in Step 2 ensures that you will be able to temptation to ask the client to read desired vision in the clinic, 5 Follow up your patients. • A longer working distance needed, for • Make sure the person is wearing their choose the right amount of magnification. smaller and smaller sizes. Stop early! our job is done. Far from it! Everyone loves to be cared for. example, if the person is physically distance prescription, if any Estimate a size of text equivalent to the Using low vision devices involves the Step 3. Use the formula to calculate Encourage them and praise them unable to hold reading materials closer. the magnification needed level of detail they would require for their development of completely new skills, when they have done well. Try to activity (Step 2). You can now predict the Demonstrate one or more devices that will • Divide the near acuity achieved at 25 cm often involving complex hand-eye build their confidence and listen to near magnification required (Step 3). by the required near acuity at 25 cm. This coordination. And this requires practice. their challenges. Sometimes it is provide the magnification the person Use the actual activity they want to gives the amount of magnification required. What seems natural and easy to us, better to listen than to talk. needs to do their chosen tasks, and let perform to try out the different magnifying For example: near acuity achieved is such as focusing a telescope, feels 6 Help them to solve their challenges them choose which one works best. devices, so keep sewing thread and 2M, required near acuity is 1M: 2x quite unnatural to a patient the first one at a time. Sometimes meeting It is important to listen to the person: needles, or seeds for sorting, etc., in the magnification is needed to achieve this time. The only way to solve this problem someone else with low vision can what is comfortable for them? What can clinic; or ask the person to bring their • Now that we know the magnification is to support and encourage our show patients that it is possible to they physically manage? There is no point materials. Advise them on different ways needed, we can calculate which dioptre patients continuously. overcome their problems. in giving someone a magnifier which they of holding their work and the magnifier, lenses can provide this level of Here are some basic steps: don’t enjoy using. and give advice on lighting. If they need Whenever my patients come back with magnification at 25 cm. two hands free for their activity, spectacle 1 Always explain to patients that it is a problem, providing support and With thanks to Tanuja Britto (ophthalmol- David de Wit de David Dioptres at 25 cm = Magnification x 4 magnifiers are the best device to use. fine if they are unable to perform the encouragement is always the best way I ogist) and Anitha Jayan (rehabilitation Use a reading chart with sentences (or an task the first time. Emphasise that can help them. professional), Joseph Eye Hospital, E chart for people who cannot read). Hold • So to provide 2x magnification at With thanks to Karin van Dijk, Caroline this is normal. Tiruchirapally, India it 25cm from the face. VIETNAM 25 cm (see example above), a device of Clarke, Mark Esbester, and Renee du Toit.

12 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 13 ENVIRONMENTAL MODIFICATIONS Making life easier How to make an eye clinic more accessible for people with low vision

for people with low vision Jaya Srivastava high contrast, e.g., white or Low Vision Consultant, Spectrum Eye yellow lettering on a black or Clare Gilbert Figure 2. Using contrasting colours to improve visibility Care, Prasad Chambers, 169, Peters Co-director, International Centre for dark background Before you Road, Gopalapuram, Chennai, Tamil make any changes, make sure Eye Health, London School of Hygiene Nadu, India 600086. and Tropical Medicine, Keppel Street, people with low vision can London WC1E 7HT, UK; Clinical Advisor, Good patient flow read the signs! Sightsavers. • In the waiting area, use

Clare Gilbert/ICEHClare • The unit should be laid out in such a There are many things you can suggest that way that it is easy for patients to go brightly coloured chairs, or will help people with low vision make the paint them in a contrasting from one part of the unit to another Figure 1 Figure 2 most of their vision, whether they are able • Some hospitals paint coloured lines on colour compared to the walls to benefit from magnification devices or not. the floor which patients can follow. For and floor. This will help people paint the door a different colour If you are working at the community or example, a brightly coloured line may with low vision to find them and see the (Figure 2). at primary level, remember that these lead straight from registration to the ones that are empty environmental modifications should never • Use tape or paint to apply a thick line to With normal vision, the rice is visible against all backgrounds. With low vision (right), the first waiting area Staff assisting someone with be a substitute for referral: always refer the edges of steps to make them more rice is much easier to see on the green banana leaf and red plate • Remove obstacles that people with low vision someone with low vison for an eye exami- visible. Use ramps with a handrail low vision may fall over or collide with. • Be patient: people with low vision may nation, refraction and low vision services Figure 3. The effect of contrast on the legibility of text instead of stairs, if possible have visited many eye units or wherever possible. If you are working at Use of colour, contrast, and lighting • White hand basins and toilets against professionals already, and have told district/secondary or tertiary level, refer Once upon a time there Once upon a time there Once upon a time there • Use large, clear letters for all the signs white tiles can make bathrooms very their stories many times before your patient for vision rehabilitation. was a man who lived at was a man who lived at was a man who lived at in the department. Ensure there is difficult to use. Change the colour of • Be kind: people may initially be angry The suggestions given here are a good the top of a long, steep the top of a long, steep the top of a long, steep good overall illumination and avoid the walls and/or floor to improve starting point, but some people may track track track creating glare, which could be caused contrast when they are told they have require further support and training in by using shiny white tiles on the floor • If there are lifts, put a brightly coloured untreatable visual loss. Listen and be order to make the most of their vision. Poor contrast Good contrast Best contrast and walls. For signs, use colours with arrow or ring around the call button, or supportive, but do not give false hope. A way of remembering environmental At meal times, people with low vision other family members’ shoes modifications is to think about: can sit near the window or doorway so • Mark the bottle of medication that is to they can see what they are eating and • Making things bigger and bolder be taken in the morning with a big yellow when they have finished. Useful resources for low vision • Using colour and contrast circle (to represent sunrise) and the • Improving lighting, using lines, and evening bottle with a big black circle Lines. Many people with low vision find it Low vision devices Community Eye Health Journal articles, mainly aimed at ophthalmologists. trying to lift what you want to look at. (to represent night). hard to follow a row of text: they may not Hong Kong Society for the Blind back issues be able to scan the words easily, they may www.mdfoundation.com.au – practical Contrast makes things easier to see. For For visual assessment charts, refraction These back issues are available online Bigger and bolder find it hard to know when they have got to guides (PDF format) for patients and their example, a black pen on white paper is equipment, training materials, and low (www.cehjournal.org – click on ‘Past Bringing things closer to our eyes makes the end of a row of text, or they may carers, with a focus on macular degener- easier to read than pencil. White writing vision devices. Visit www.hksb.org.hk issues’) and on the Community Eye Health them appear bigger. This mainly helps struggle to find the beginning of the next ation. Look in “Fact Sheets & on a black background gives the greatest Update CD which was sent out with Issue young people and children who have very line. Partly blanking out the lines above ICEE Global Resource Centre Publications”. contrast and hence is easier to read, but 76: Instruments and Consumables. good accommodation. and below the line being read, for example, For low-cost spectacles, frames, lenses, this can usually only be generated on a Please let us know if you have not yet www.afb.org – advice on living with vision People (including children) who have using a reading slit (see page 10), makes and low vision devices. Prices for low vision computer screen (Figure 3). received a copy. New subscribers: an loss. had cataract surgery and those with the visible line of print easier to read. A aids start from US $2.50. Contact Vivasan updated CD will be sent to you in 2013. presbyopia will need a near add (a plus Lighting, lines, and lift reading slit can be made of black card Pillay at [email protected] www.svrc.vic.edu.au – for people with low lens) to bring things into focus if they bring with a rectangle cut out of it. vision who are in education. Lighting is perhaps the best way to or +27 312023811. Vol. 20 No. 62, 2007. The visually them nearer. Lines can help with mobility and improve contrast, so if someone wants to impaired child http://www.ski.org/Colenbrander/ Use charcoal or a felt pen to write safety. For example, paint the edge of Internet browsing support read make sure the page is well lit. Vol. 17 No. 49, 2004. Low vision care: the Images/Low_Vision_Exam.pdf – bolder messages, and write with larger stairs in a contrasting colour, or put white LowBrowseTM Ideally, the light should shine directly onto need to maximise visual potential practical guidance on performing a low letters than usual (Figure 1). Keep it short paint on the top of stones which mark the is a free the page, but without producing glare. It Vol. 16 No. 45, 2003. Helping the blind vision assessment, aimed at trained low and simple! Put it somewhere visible and path to a neighbour’s home. add-on to the should not shine in their eyes. Good and visually impaired vision practitioners. 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, Mozilla Firefox to attract the person’s attention. For information on testing near vision: important, particularly where the person foldable reading stand, lifts the page web browser, Enlarging photocopiers and computer Rènée du Toit. How to prescribe Low vision courses may be nervous, e.g., going up and down closer to the eyes and makes reading less which is also screens are also ways that print and spectacles for presbyopia. Community Kilimanjaro Centre for Community stairs or going to an outside latrine. tiring, particularly if magnifiers are used. free. It lets other images can be made bigger and users read all Eye Health J 2006;19(57): 12-13. Ophthalmology, Tanzania hence easier for the person with low vision Figure 1. Bigger and bolder (right) Figure 4. Reading stand with angled lamp text in web For information, contact Genes Mng’anya, to see. pages in a special reading frame at the Online resources for low vision KCCO, Good Samaritan Foundation, PO top of the screen. The frame presents text http://bit.ly/L2Y5VS – article on Box 2254 Moshi, Tanzania. Tel: +255 27 Colour and contrast in a single line and users can change the assistive technology by someone with low 275 3547. Email: [email protected] or visit Colour can be used in many ways to help size, font, colour contrast, and letter vision. PDF (1.6MB) www.kcco.net someone in their home. For example: Gilbert/ICEHClare Gilbert/ICEHClare spacing without having to zoom in and out. It www.lowvisiononline.unimelb.edu.au – October 17–26: Training in clinical low • Use brightly coloured plates (Figure 2) a guided learning resource for eye care has a speech option which reads the text. vision care. Basic and advanced clinical • Put red tape around light switches workers who want to learn more about low vision care. Aimed at optometrists. • Use paint or red nail varnish to put spots LowBrowse: https://addons.mozilla. working with patients with low vision. October 29–30: Population-based of red to help the person line up the “off” org/en-US/firefox/addon/lowbrowse/ Available in English, Chinese, and French. approach to establishing a low vision buttons on the gas cooker (123.5 kB) www.lighthouse.org/for-professionals/ service • Stand the person’s shoes on a brightly Small writing (left) is not as easy to read as Mozilla Firefox: www.mozilla.org (32 MB) practice-management – a collection of coloured mat to distinguish them from big, bold writing. Shorter is better.

14 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 15 PLANNING SERVICES

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 Low vision care: who can help? 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: At this level, optometrists and mid-level Karin van Dijk low vision care eye care workers can be trained to give • Complex assessment tests Primary/community level CBM global advisor on low vision; low basic low vision services appropriate to • Refraction of people with complex Nurses, ophthalmic nurses, community- vision consultant to Light for the World their skills and experience. problems Netherlands and to Kilimanjaro Centre based workers, and other mid-level They should have good communication • Provision of a wide range of devices, for Community Ophthalmology. Emereuwa Innocent personnel can do the following: [email protected] skills and be able to do the following: including electronic devices • Be alert and identify people who might • Good links to education and • Test distance and near visual acuity We know that, in many low- and middle- have low vision (ideally also in younger children) rehabilitation services income countries, low vision services are • Refer them for diagnosis, prognosis, and • • Perform objective and subjective Training the use of low vision devices. limited to tertiary or teaching hospitals, good refraction refraction which means that most people are not • Refer older children and adults who • Perform minimum essential low vision Beyond the clinic able to access them. have useful vision to low vision services assessments (page 4 onwards) There will be many more people with low If this is the case, who can those with at secondary or district level • Prescribe essential low to medium vision in the community who need our low vision turn to for help? • Refer young children and adults with magnification devices for near and services. People with low vision do not fit complex needs to tertiary level distance, with training in their use Think about how you can reach out to comfortably within the job descriptions of • After diagnosis, refraction, and referral (pages 9–10) tell them about what you offer. Plan most health and education professionals. for low vision care, advise on non-optical • Advise patients on non-optical outreach clinics, or link with others interventions and environmental • They are not blind, so rehabilitation interventions and environmental working in the community. modifications (pages 7,8, and 12) and workers may not feel able to help them modifications (page 12) Visit schools for the blind – perhaps refer for educational support and • Clinicians (ophthalmologists, An older child’s colour vision is tested during an outreach clinic. NIGERIA • Refer people to the most appropriate there are children who will be able to use community-based rehabilitation if needed. ophthalmic nurses, and other mid-level person or organisation for further their remaining vision if they receive low One of the most important things we first point of contact for the person personnel) feel there is nothing more Secondary or district level training, financial help, and education vision support. can do, whatever our own role, is to be with low vision, or their last hope for help. they can do At secondary or district level, services are • Refer young children and those with Low vision work may be challenging, aware of what other services may help Whatever the case, it is our responsibility • Optometrists and refractionists can aimed mainly at adults and older children complex needs to the tertiary level but it is immensely rewarding! the person with low vision and refer to find out whether the people who come improve their vision, but cannot help who want to access print or perform tasks • Ensure regular follow-up of adults and them. And we must communicate to us have received clinical and refractive them to see ‘normally’ with the person, the family, and our error care. If they have not, it is essential • Special education teachers are usually colleagues in these other services about that we refer them. If they have, we must trained just to work with children who the care the person needs, in clear and find out what other support they might are blind, and may not have the Improving access to low vision services simple language. need and refer them. additional training needed to help But it is not enough to just refer – it is Peggy Pei-Chia Chiang care, a trained vision technician could do • Non-governmental organisations must children use low vision devices and Importance of referral also our responsibility to make contact Postdoctoral research fellow, Singapore these tasks. work together with the private sector advise them about where to sit and the People with low vision may need clinical with our colleagues in local community Eye Research Institute; Centre for Eye • Build on the skills of existing staff. For and government to support and fund importance of using their vision. Research Australia (CERA). low vision services. However, for this to care, refraction, and rehabilitation rehabilitation and educational support Email: [email protected] example, in areas where there are no In fact, the services of all of these people support, and children and others in services. Refer people as appropriate, ophthalmologists or optometrists, work in the long term, the government are vital to ensure that the person with low full-time education will also require and share information with these Jill E Keeffe refractionists, ophthalmic nurses, and must take the lead and take ownership vision can live a full life. educational support. We may be the colleagues about any changes in the 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 Providing a basic low vision service at district level: what is the minimum we need? to their skills and experience. We recommend two strategies: Our recent survey1,2 found that low vision Sustainability The Low Vision Working Group of VISION Ophthalmic equipment • Four hand-held magnifiers (non- 1 Use strong research evidence on services were often inaccessible to large Strengthen community-based rehabili- 2020 has endorsed a Standard List for • Streak retinoscope illuminated) from 5D to 20D. For which to formulate policy. numbers of people in low- and middle- tation and outreach services. low vision services.1 However, it may not • Direct ophthalmoscope example, one of 6D, one of 10D, one of 2 Encourage NGOs and all stakeholders income countries. with an interest in low vision to come always be possible to purchase all the • An ordinary trial lens set; a full aperture 15D, and one of 20D Based on the findings of this research, • During outreach, you could explain or items on the Standard List. trial set is preferable • Non-illuminated stand magnifiers from show how the home environment can be together under one umbrella organi- we suggest three areas for action: human sation, i.e. a national VISION 2020 or We have put together a list of the • Universal trial frames 10D to 25D. For example, one of 12D, adapted and make timely referrals to resources, sustainability of services, and prevention of blindness committee. minimum equipment and devices you • At least one pair of paediatric trial frames one of 16D, one of 24D district level care. Through outreach, advocacy. However, it is important to keep The group can then deliver the policy would need to offer a basic low vision • Pen torch and measuring tape. • Use a variety of locally available in mind that these strategies must be people can be followed up to ensure service at district level. This list is based they are still able to use their low vision message with one clear voice. Vision assessment equipment sunglasses in different shades if filters adapted to suit your situation. on our experience in the field, and we hope devices, and you can give refresher Once advocacy and lobbying have started, • Distant LogMAR test charts: at least are not available Human resources it will help you to start providing low vision lessons to those who need it. In more detailed planning must be done at have tumbling Es • support where no other service is available. Non-optical devices Integrate low vision into existing addition, children with poor vision can the implementation level. For instance, • Near vision tests: at least have Keep accurate records of who you see • Reading/writing stand: locally made ophthalmic and optometric curricula be detected and supported early. encourage local government and policy tumbling Es and include it in the practical training of and how they have been helped. Collect • Reading slit, signature guide, and • Outreach services should be carried out makers to include low vision in their • Reading acuity test. This can be education and rehabilitation workers quotes from patients saying how they writing guide: all locally produced. on a regular basis, although the district VISION 2020 or eye care plans. created on computer using N or M • Offer informal low vision workshops and have benefited, and use these and your frequency may vary, depending on sizes. Further reading courses for eye care workers who have References records to ask for further training, need. 1 Standard list of low vision services. Comm Eye Health J not received formal training. • Integrate low vision services into 1 Chiang PPC, O’Connor, P., Le Mesurier, R.T., Keeffe, J.E. increased funding, and better equipment Optical low vision devices 2004; 17(49): 8. A Global Survey of Low Vision Service Provision Ophthal • Delegate tasks to less specialised health existing education, rehabilitation, and Epidemiol 2011;18(3):109-121. for your low vision clinic. Always refer • Spectacle magnifiers: locally made 2 Hasan Minto. Establishing low vision services at secondary level. Comm Eye Health J 2004;17(49): 5. workers where possible. For instance, eye care systems. Establish appropriate 2 Chiang P, Xie J, Keeffe JE. Identifying the Critical Success people with complex needs for services high positive add spectacles, from +4D Factors in the Coverage of Low Vision Services Using the Both available on the Community Eye Health Update instead of the optometrist doing the and healthy collaborations between the at a higher level. to +12D, in steps of 2D. CD and online: www.cehjournal.org/journal.html 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

16 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 Community Eye Health Journal | VolUME 25 ISSUE 77 16 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 17 readership survey report ORGANISING EYE SERVICES Community Eye Health Journal – promoting Improving patient flow improvement in eye health for over 20 years through an eye clinic

Elmien Wolvaardt Ellison the number in 2005). Jonathan Pons •Registration Preparing groups of cataract Editor, Community Eye Health Journal, Non-eye care specialists Ophthalmologist and Programme •Retrieval of medical records International Centre for Eye Health, Director, Good Shepherd Hospital patients for surgery means that made up 29% of the •Visual acuity testing London School of Hygiene and Tropical Eye Care Project, PO Box 218, scarce resources such as Medicine, Keppel Street, WC1E 7HT, UK. respondents, including Siteki, Swaziland. Email: jono@ •Slit lamp examination

theatre time can be used more Watson/Orbis Joni nurses, doctors, •Consultation Email: [email protected] goodshepherdhosp.org efficiently. ZAMBIA administrators, •Treatment The Community Eye Health Journal was pharmacists, researchers, Improving the flow of patients •Fee collection established in 1988 and is published by and technicians. through our eye programme is about the International Centre for Eye Health, If we want to consider how a patient • More than half of making their journey easier while based at the London School of Hygiene is referred to our clinic, particularly respondents had a wider making the best use of our own time and Tropical Medicine. It has editions in if our clinic forms part of a VISION range of responsibilities than and resources in the eye clinic. It French, Chinese, and Spanish, and there involves elminating unnecessary 2020 district programme or a those described by their government district health care is a special edition for India. Paper copies profession. Around 60% steps and processes, giving us more system, we can include steps such of the journal, in all four languages, are reported that community time to focus on our patients and on as ‘outreach’, ‘primary health care sent to over 35,000 people in 183 development/outreach, Over 35,000 people in 183 countries receive copies providing a good – and friendly – countries (see map). service. Eye care administrators and referral’ and so on in the list above. health promotion, and journal had improved and/or supported We would like to thank everyone who managers benefit too: better patient patient counseling were part of their their work. Understanding completed our recent reader survey. Here flow reduces waste and makes more existing work responsibilities; 40% reported being • 80% said that something they read in is a brief summary of the results. efficient use of theatre time and patient flow responsible for programme planning and the journal had led them to change their human resources, which in turn Many patients will travel through management, 22% for hospital clinical practice or management of Where our readers are reduces costs, attracts more our eye clinics and it is our responsi- administration and management, and patients. • A total of 1,418 responses were patients, and improves cost bility see that patient flow is well 14% were also policy makers. • The vast majority of respondents (89%) received (5.3% response rate). 59% recovery. managed. Before making any worked directly with patients; they had were from Africa and 32% from Access Thinking about what our patients improvements, start by assessing contact with an average of 60–79 Southeast Asia; the remaining 9% were • A total of 57% of respondents had value can help us to optimise patient (or auditing) the existing patient patients per week. spread across the other regions. internet access whenever needed, but flow. Generally speaking, patients flow in the eye clinic. This can be • 80% agreed that the journal had • Half of respondents worked in small around half cited slow speeds, high value everything that provides them done by one person, but it is often motivated them to reach out to the towns, villages or rural areas; the other costs, and lack of know-how as reasons with a good outcome: appropriate better to invite representatives from community, 75% that it had changed half worked in larger towns or capital for preferring not to read the journal referral, a correct diagnosis, the right moment of first contact with our patients both clinical and support staff to the way they conducted health cities. online. In another part of the survey, information and advice, the right to the time they are finally discharged help. Everyone’s input is valuable. education, and 70% agreed that it had • Two thirds of respondents worked for respondents described using the paper treatment, and appropriate follow-up and after a successful follow-up examination. Regular evaluation of patient flow will changed the way they talked to patients, government, a quarter in the private copy as a teaching aid when educating aftercare. They do not value things that The good news is that, by thinking about allow us to identify problems and make stimulated them to talk to non-eye care sector, and the remainder worked for patients or training students. seem unnecessary to them, for example: our patients and how to provide them with helpful changes. The suggestions that colleagues, and motivated them to stay non-governmental organisations. • Nearly two thirds of respondents had waiting longer than seems reasonable, a good experience in our clinic, we will be follow overleaf should help you to start in eye care. • Nearly 40% of respondents worked at access to a computer, and 79% had having to provide the same information able to make changes that benefit the the thinking about patient flow and identify • Respondents passed on the journal to primary level; 34% at secondary level, found the Community Eye Health more than once, or travelling to the clinic as well. See Table 1 for some areas for improvement. an average of ten other readers each. and the remainder at tertiary level. Update CD ‘useful’ or ‘very useful’. hospital more than once when two visits examples. The focus should be on what patients We are encouraged by the positive can be safely combined. value: does the way the clinic function help us to give patients the best service we can? What our readers do Impact response to the journal and appreciate It is therefore very helpful to look at our The patient journey • The biggest professional group • 91% of respondents said they used the the many helpful suggestions for future eye service as a whole from time to time, It helps to consider the patient’s visit to •List the different ‘stations’ on a typical represented were ophthalmic nurses journal to teach or educate others, themes we received. particularly if we have received negative the eye clinic as a journey. Here are some patient’s journey through your clinic. (33%), followed by ophthalmologists including patients and the community. With thanks to Prof Allen Foster, Prof Clare Gilbertl, Anita feedback from our patients. We must examples of the different ‘stations’ along a How long do they have to wait before (26%) and optometrists (12%; double • 90% of respondents agreed that the Shah, Sally Parsley, and George TH Ellison DSc. examine everything we do: from the patient journey through an eye clinic: Continues overleaf ä

Table 1. How improving patient flow can benefit patients and the eye programme: a few examples further reading What patients What the eye unit wants How improving patient flow could meet the needs of patients and the Putting patients at the centre of eye care want eye hospital Less waiting time Efficient use of staff time If some staff are waiting for patients, find areas where patients are Understanding what patients think from LAICO. http://laico.org/ • Visit www.institute.nhs.uk and search waiting for staff and move the staff to that part of the process. (page 22) v2020resource/files/ for each of the following (by typing the Lower prices for Reduced waste Eliminate any unnecessary procedures or diagnostic tests, provided • Visit www.institute.nhs.uk and type KAPStudyMethodology.pdf term into the search box), in turn: eye care they do not affect the quality of clinical care ‘patient perspectives’ in the search box (PDF, 410kB) ‘patient flow’, ‘bottlenecks’, ‘process • Read more about KAP surveys in on mapping’, and ‘value stream mapping’. Good quality care Sharing of scarce resources, e.g. Prepare patients for examination or theatre in a separate area so that www.uniteforsight.org/global-health- Improving patient flow (page 31) • Read case studies on patient flow from slit lamps or theatre time the time spent at the slit lamp or in theatre is kept to a minimum. university/survey-methodologies • Community Eye Health J, Vol. 23 No. 73. the UK, including ones in eye care. www. Lower travel Reduce patients who do not attend Where possible, do pre-operative examinations on the same day as the • Family planning clinics in Latin America Equipment for eye care carebydesign.org/files/no_delays_ costs, less time for operations or who do not come operation. successfully used exit interviews to • Community Eye Health J, Vol. 23 No. 74. achiever_case_studies.pdf (PDF, away from home for pre-operative examinations improve quality of care and patient Ten years to VISION 2020: why 1.1MB) Respect and care Co-operative patients, enough time Provide information at the start of the patient’s journey about what is satisfaction. www.guttmacher.org/ information matters • How Aravind Eye Care Systems in India to provide proper care, a good likely to happen, how long it might take, and how much it is likely to cost. pubs/journals/2606300.html • improves patient flow. www.accessh. Community Eye Health J, Vol. 24 No. 76. reputation This puts patients at ease, so staff can focus on what is important. • Using KAPs to plan DR services: a report Instruments and consumables org/publication/Article/14

18 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 19 ORGANISING EYE SERVICES Continued

• moving through each station? You could • of multiple services. Or set up a system AN INTEGRATED INFORMATION AND COMMUNICATION SYSTEM assign a staff member or volunteer to that allows patients to pay when they visit waiting areas and monitor the leave for all the services they have used. SALFA Eye Clinic in using Skype, a free

waiting times. What do patients think? Pons Jonathan • Good internal communication systems Fianarantsoa, software package You could conduct exit interviews with (intercoms, or an intranet) between the Madagascar, has that requires

patients or consider assigning a staff various departments will make it easier introduced a fully Henry Nkumbe internet access in member or volunteer to do patient to share information about patients and integrated electronic order to work shadowing (see page 23). will also save time (see panel on right for medical records (www.skype.com). • Look at the patients’ physical journey an example from Madagascar). system recently. The records system through the clinic. On a detailed plan of All major stations also gives the clinic the clinic, trace the paths they have to Better use of space (reception, pharmacy, manager, Somoela walk between each of the stations. Are • Arrange the different stations in the cashier, ophthalmolo- Rajaona, all the there any unnecessary back-and-forth patient journey (registration, records gists, manager, information he movements? Do patients know where to retrieval, visual acuity testing, etc.) in a stores, etc.) have a needs to manage go? Do staff often have to stop what logical sequence so that patients can computer terminal, headset and patient flow. For example, he can see they are doing and help direct patients? easily move from one to the next. webcam. This allows for quicker and how many patients are waiting to be • Trace the paths different staff members • Put related services nearby. Sometimes, cheaper communication: staff can talk seen by the doctor, the stock situation, have to take as they carry out their something as simple as moving an to and see each other free of charge and so on. various daily tasks. Include support staff optometrist into the clinic can make a Good record keeping reduces delays and improves patient flow. SWAZILAND as well, such as administrators, porters, big difference to patients! • Problems in how staff are managed can materials are available in a local • Try to avoid any back and forth movements, stock room staff, etc. Ask staff: is there they are the areas with the longest queues! improvements can be made. lead to poor team morale. Staff who are language, particularly instructions for where patients have to cross paths with anything that could be changed to make For example, one often sees long queues It is important to create an atmosphere happy, and feel respected by their medication. Where possible, ensure others, as this can create confusion. their work easier? in front of the visual acuity testing station, of teamwork and collaboration, and to colleagues or managers, find it easier to there are sufficient interpreters When a room has just one door, patients • Look at the use of equipment. Is there whereas, in another part of the clinic, the encourage everyone to contribute their be kind and friendly to patients and to available. Ask for help from local who are leaving may have to squeeze enough equipment? Is unused screening station is waiting for patients. In ideas. Janitors or stock control clerks, for contribute to clinic improvements. churches or community organisations. past patients who are queuing to get in. equipment taking up valuable space in this instance, the visual acuity testing example, may offer valuable insights into Use two doors or, if need be, open up a the passageways or consulting rooms? station is the bottleneck – it is the part of everyday processes that can be streamlined. Other problems that affect patient An ongoing journey new doorway in an existing wall. • What are the times and days of the week, the clinic where patients are getting stuck. Giving staff an opportunity to flow A patient’s journey does not end when • Clearly signpost each station in the month, or year when the clinic is busiest? Using an additional person at the visual contribute has the added advantage of There are some problems that affect the she or he leaves our clinic. Good referral clinic so patients know whether they are • Look at the procedures for stores and acuity testing stage would speed up the making staff members feel like part of a entire patient journey. to other services, such as low vision or at the right place. Paint doors different purchasing, and at how you keep flow of patients through this area and team; agreeing on a shared goal also rehabilitation clinics, must form part of the colours or number them in a large font. • Inefficient recordkeeping can cause records and identify patients (see provide a steady stream of patients at the makes it easier for people to work together. service you offer. Drawings are particularly helpful for many delays. A records retrieval rate of ‘Further reading’ on page 35). Are screening station. Patients will therefore The spacing of follow-up visits should patients who cannot read. less than 90% should not be tolerated in patients required to provide the same have a quicker journey, and eye care Practical suggestions also reflect the patient’s situation and • Use colour-coded lines on the floor to an eye clinic! Periodic review of all forms information more than once? workers’ time will be used more efficiently. Becoming better organised allows us to balance the need for good clinical care help direct patients to different stops and stationery is useful; check that It is worth noting that this is a process make better use of available clinic space and with the ability of patients to travel to the along their journey. patients do not have to provide the Knowing what to change of ongoing improvement: once one infrastructure and to make better use of staff clinic. Clearly indicate the date of any • Locate cashiers and drug dispensaries same information more than once, There are various approaches to analysing bottleneck has been dealt with, it will very time. follow-up visits on the patient’s records, at the outlet of the clinic in order to avoid unless absolutely necessary. patient flow, with names like ‘process soon become clear if another part of the This can often avoid or delay the need for and send reminder messages by unnecessary back and forth movements • Patients and clinic staff who do not mapping’ and ‘value stream mapping’ clinic has become congested and will an expensive expansion programme! cellphone (mobile phone) if possible. of patients; this reduces congestion. understand each other’s language is (see ‘Further reading’ on page 35). require attention. Here are some practical ideas for Optimising patient flow is a journey of • Have staff available to help patients who another common problem. Take steps to Finding and eliminating bottlenecks is improving patient flow. ongoing improvement. We hope that this cannot find their way. ensure that essential patient education another approach and is relatively How to make changes article has helped you take the first steps. Better systems • Sometimes, using two rooms can reduce straightforward. The aim is to reduce Once we better understand patient flow in • Standardise procedures in the clinic. waiting times. For example, while an CASE STUDY: KILIMANJARO CHRISTIAN MEDICAL CENTRE (KCMC), TANZANIA waiting times and make better use of our eye clinic, and where the delays and This will allow more patients to be seen ophthalmologist is busy with a consultation equipment and the time of clinicians. inefficiencies are, the next step is to talk to in a day and make it easier to keep in one room, a nurse or nurse assistant Bottlenecks are usually easy to identify: clinical and support staff about how Improvements on the ward and in theatre quality consistent. could get a patient ready at a slit lamp in CASE STUDY: KILIMANJARO CHRISTIAN MEDICAL CENTRE (KCMC), TANZANIA • Use tags or stickers on charts to make the room next door. Once the new community outreach improving efficiency was partly a them easy to identify. programme started bringing in large matter of clearing unnecessary Doing a baseline assessment • Make use of helpful technology where Better use of staff numbers of patients, especially late in equipment and supplies from the OT so appropriate. For example, use • Make good use of mid-level ophthalmic the day, the need to make ward and that an extra operating table could be The team responsible for leading the duties than on nursing, and doctors computers for indexing records or use personnel, nurses, and nursing theatre procedures more efficient installed. It also required many discus- changes at KCMC used a baseline were often responsible for mundane devices that will speed up intraocular assistants. They are usually highly trained became critical. The team decided that sions with the doctors as to how the OT assessment form produced by Lions management tasks. pressure readings. and can perform many tasks that will free it would be more efficient if the should be run and the importance of Aravind Institute for Community •Inefficient procedures: there were no • Some days are busier than others (e.g., up the time of ophthalmologists so they counsellor (a trained nurse) working in starting on time. Ophthalmology to help them under- standard clinical protocols for Mondays are usually busier because of can focus on what only they can do. the outreach programme recorded vital Under the leadership of the stand the eye department’s resources common problems like cataract. weekend emergencies). Part of a • Make more staff available during busy signs, completed consent forms, and nursing co-ordinator, and motivated and problems. Problem areas included: •Monitoring: basic annual patient solution to an overcrowded clinic may times, and stagger lunch breaks so that educated the patients right there in the by positive feedback and praise from •Inconvenience for patients: the service statistics were collected, but involve moving clinic activities to work flow is continuous. This will reduce field. As a result, the ward nurses had the head of the ophthalmology system for a patient to be registered these were not discussed with staff. different days to allow a better spread of patients’ waiting times. less to do at the time of admission. New deparment, more nurses began to take for outpatients or admission was •Stores and purchasing: there was no patients throughout the week. • Encouraging a culture of teamwork will forms, designed by an external nurse pride in their accomplishments; this lengthy and complicated. system for making stores reports and • To reduce unnecessary back and forth help to improve patients’ experience at consultant working with the eye was a modest but important step •Personnel used inefficiently: many none were made; there was no system movement of patients because of the clinic. Treating staff fairly and with department nurses, also saved time. forward in achieving better attitudes nurses spent more time on clerical for efficient purchasing. multiple payments to cashiers, try to respect will reduce the likelihood of In the operating theatre (OT), and motivation. offer ‘package’ prices that cover the cost interpersonal problems.

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Media’s role in eliminating Sankara Nethralaya presented well.” Mr Arun, who has reported on health issues wanted eye avoidable blindness care NGOs and hospitals to look into why certain health news is not carried? “Heart Col (Retd) Dr M Deshpande, Dr G V Rao, Ms Sridevi Sunderarajan, gets a lot of coverage. The basic reason President, VISION 2020: The Right CEO, VISION 2020: The Right to Development Communication Officer, may be that a lot of people are afraid of to Sight – INDIA; Sight – INDIA; VISION 2020: The Right to Sight – INDIA getting a heart attack and not about going blind.” All the media persons on the panel Educational role of the newspapers were unanimous that if the aim is to reach should be better tapped. Making the infor- to the masses, especially in small towns mation interesting is the key word,” and villages, it is best done through the Mr N Ram, Editor, The Hindu. vernacular news paper: be it print or

Sankara Nethralaya Sankara electronic. “There is a need to go to the ground level Mr SK Kulkarni who has travelled far to understand the situation and then write and wide in the country and has been very out the key messages. Sitting in the proactive in promoting development Participants at the workshop. INDIA air-conditioned offices will not help us sector news agreed that “if we have to write effective messages,” reach out to the masses in the villages, we the low priority given to such news. A tioned offices will not help in writing Mr S K Kulkarni, have to go with the language newspaper. phenomenon that is global in nature. effective messages.” Advisor, Kesari newspaper. It has to be in a language that is under- Political developments, business news get Senior media persons, Mr Ram and Mr stood by them.” priority over other news in the Indian Kulkarni who both have the experience of “Be accurate, consistent and don’t Ms Aarti Dhar of The Hindu who has scenario. Faced with a space crunch in heading newspapers had some sugges- compromise ever on facts but at the same been reporting on health issues for a the newspaper, the first casualty is devel- tions to encourage media coverage. Mr time there is nothing wrong make your decade now was also of the same opinion, opment news which is put on hold and Ram took the example of MS story more presentable,” “As far as English versus vernacular eventually dies a natural death. Swaminathan Research Foundation who Mr Arun Ram, Senior Editor, papers are concerned, English papers like Ms Aarti was candid in sharing that all have held regular workshops on genetics Times of India, Chennai Left to Right: Dr NK Agarwal, Dr Neeraja Prabakar, Mr J Rengarajan, Mr Arun Ram, The Hindu or NDTV may be effective, if one the presentations made during the to sensitise the media. The result may not Mr N Ram and Dr S S Badrinath. INDIA wants to influence the policy makers, but workshop to sensitise them were full of be immediate but in the long run this “ Target the vernacular press to reach out when it comes to the masses, it is best to facts and were too technical. “We have to strategy does help. problems emerging that had to be treated. Kulkarni, Advisor, Kesari, leading to the masses”, approach through the vernacular press.” understand the facts first and then Mr Kulkarni suggested a fellowship And in tackling this huge problem, “We vernacular daily in western India; Mr Arun Ms Aarti Dhar, Senior Assistant Editor, Dr Neeraja Prabhakar, Programme present it in a manner that can be under- where journalist can be assigned to study require media’s help to reach out to the Ram, Senior Editor, The Times of India, The Hindu, Delhi. Executive, All India Radio (AIR), Chennai stood by the layperson who does not know a particular problem in a particular area. general public to create awareness so Chennai edition – again one of the leading emphasised the importance and reach of what glaucoma or retinoplasty is. I have to This will take care of creating awareness that the uptake of eye care services English dailies in the country; Ms Aarti These were some of the key messages the community radio which is generally report it in such a basic level which my in remote areas like the north east and provided increases.” Dhar, Senior Assistant Editor, The Hindu, made by journalists participating in a one - not known. She said, “The mandate of maid will understand, my mother and my most important that writing well is the An overview about blindness scenario Delhi Bureau; Dr Neeraja Prabhkar, day national workshop on ‘Media and its community radio is to broadcast grandmother will understand.” key. in India; Challenges for Managing Eye Programme Executive of government run role in eliminating avoidable blindness’ programmes on health, environment etc “It does not mean that the facts have to On damage control reporting and Care Programs; Media’s role in creating All India Radio, Chennai and Mr organised by VISION 2020: The Right to should be tapped.” She suggested that be taken off. It is only to say that the story about negative reporting, Mr Ram said awareness and Mainstream media and Rengarajan, Chief Reporter, Dinamani, Sight – India held at Sankara Nethralaya, eye care NGOs could explore the possi- has to be more presentable. If we are that in event of accident/infection, the beyond for creating awareness were the Chennai – leading language daily from Chennai, India on December 10, 2012. bility of collaborating with AIR where news talking about stories on blindness then a organisation should reach the media with four sessions of the workshop. Senior south India. The aim of the workshop was to on where eye camps are being held can visual story is any day more effective than their story first before the news is ophthalmologists and head of eye The one common message threaded sensitise the media on issues of eye care be disseminated. a 200 words story in the print media,” distorted and published. He also urged hospitals presented all aspects of eye the presentations of all the media persons and also invite inputs from them on how The media persons who had been suggested Mr Arun. that such workshops be held different care – right from the burden to the was that the communication that is given VISION 2020: The Right to Sight – India listening to presentations made on eye Mr Kulkarni came out with an action regions. barriers to the role of tertiary, the need for for publishing should be interesting, and its members can communicate effec- issues requested the eye care fraternity to plan and suggested that NGOs could have The way forward for VISION 2020: The advocacy and how media can help NGOs saleable, news worthy, simple and to tively through the media to reach out to keep the messages simple and also a panel of writers, maybe journalist, who Right to Sight – India is now to analyse the working in eye care in creating awareness target the vernacular papers. the community. “ Media can be a powerful shared challenges faced by them while could write popular language about eye inputs from the media, prepare a towards sensitising the media regarding Participating in the panel discussion tool not only to deliver eye care messages reporting. care messages. “We have to go to the guideline on how in approach and how the eye care scenario in India. for the media, which was conducted by Col to the community for better uptake of One of the challenges faced by ground level to understand and then write effectively to utilise them to reach to our Dr NK Agarwal, DDG (Ophthalmology), (retd) Dr Deshpande, eminent journalist services but also as an advocacy tool to reporters covering development news is out the messages. Sitting in the air condi- target audience. National Programme for Control of Mr N Ram emphasised the increasing influence the policy makers,” said Dr GV Blindness ( NPCB), Ministry of Health and reach of the language newspaper in India. Rao, CEO, VISION 2020: The Right to Sight Family Welfare, Government of India, in He said the educational role of the Forthcoming Event – India regarding the mandate of the the inaugural session presented ‘National newspapers should be better tapped. workshop. VISION 2020: The Right to Sight – India aspects and department of eye care service demand generation: Programme for Control of Blindness’s However what is of utmost importance is The workshop was inaugurated by Col 9th Annual Conference critical to the running of a successful eye n Optometry & Optical Dispensing: (NPCB) role in eliminating avoidable making information interesting and that is (Retd) Dr Deshpande, President, VISION VISION 2020: The Right to Sight – India hospital. n Operations Management - Quality blindness in India where he outlined what the key word: “Educative of course, but 2020: measures the government was taking making it interesting is most important.” 9th Annual Conference ‘ Achieving It is proposed to include 8 Assessment & Monitoring: The Right to Sight - India who n through IEC materials to create Mr Arun Ram from the Time of India Excellence in Comprehensive Eye Care parallel tracks over two days: Technology & Innovation for equitable welcomed the audience, senior ophthal- awareness. also held a similar opinion. He rejected Management is scheduled to be held on n Organisational Development & eye care: mologists and journalists defining the Heading the panel of speakers from the common view that those who can pay April 6 & 7, 2013 at Sewa Sadan, Bhopal, Leadership n Human Resource Management & need for such a workshop. He said that the media was Mr N Ram, Editor, The get more coverage. According to him what Madhya Pradesh. The conference is n Towards quality excellence in Statutory Requirements the country had a huge backlog of eye Hindu – one of the leading mainstream was of importance was that news should unique as it is perhaps the only ophthal- Operation Theatre: n Project Management (Conceptualising related cases and now there were new eye English newspapers in the country; Mr SK be saleable. “I feel every story has to be mological conference that covers all n Reaching the unreached through to Monitoring)

22 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4 23 NEWS AND NOTICES Vision 2020 India Newsletter Past Events Sridevi S Sridevi S the session. Eminent ophthalmologist from across the country and from Gujarat through their presentations discussed what needs to be done to manage this emerging eye problem, which is the third leading cause of blindness in India. There was good participation from the government both from the Central and the State government departments of health and The WSD walkathon being flagged off School children marching at the offered a platform to VISION 2020: The by senior government officials. INDIA walkathon. INDIA Right to Sight – India for advocacy. World Sight Day (WSD) an international Banners and flags with messages on the form part of the calendar for 2013. day of awareness, held annually on the need for a regular eye check up carried In a unique effort, Ms Elizabeth Kurian, second Thursday of October to focus by enthusiastic children marching to the Secretary, VISION 2020: The Right to attention on the global issue of tune of popular songs played by a band Sight – India requested a couple of avoidable blindness and visual marked the opening of events on school children and the dignitaries for impairment is observed by a majority of October 11, 2012; the World Sight Day. the event to blindfold themselves for a eye care organisations across the globe. The event was organised by Care Group, minute to experience how the visually In India, VISION 2020: The Right to Sight member of VISION 2020: The Right to challenged’s world would feel. After a – India and its member organisations Sight – India in Gujarat. minute when the children removed the observed the World Sight Day with a The walkathon was flagged off by Ms blindfold and were asked to share their number of events ranging from Sujaya Krishnan, Joint Secretary, Ministry experience, prompt came the reply “we walkathon, painting exhibition by school of Health and Family Welfare, Government cannot see the beauty of the nature.” children, a cultural programme by the of India and Mr Ashwini Kumar – I.A.S, Ms Sujaya Krishnan, Joint Secretary, visually challenged children, exhibition, a Municipal Commissioner, Vadodara, Ministry of Health and Family Welfare, huge visually acuity chart and many more Gujarat and saw participation from school Government of India addressed the innovative events nationwide based on children, ophthalmologists from the city children advising them to participate in this year’s theme ‘Eye Testing for All’. All who weaved their way through the busy the school screening programme. She towards draw attention towards the need road of Vadodara, Gujarat. also gave them tips on nutritive food to for a regular eye check up. Dr N K Agarwal, Dy Director General eat for healthy eyes . VISION 2020: The Right to Sight – India (Ophthal), National Programme for Dr NK Dr N K Agarwal, Deputy Director held programmes over two days – Control of Blindness, Government of General (Ophthal), National Programme October 10 & 11, 2012: a technical India and Col (retd) Dr Deshpande, for Control of Blindness, Government of session - ‘Glaucoma: an emerging eye President, VISION 2020: The Right to India spoke about the need for eye care challenge in India’ at Sankara Eye Sight – India released multicoloured testing for all and how we can do the Hospital, Anand, Gujarat on October 10, balloons to mark the occasion. basic screening at home. 2012 emphasised on various aspects of School children held an exhibition creatively Visually impaired school children gave glaucoma with a special emphasis on depicting various problems of eye care. The hearth warming performance of popular problems in Gujarat state, the venue of best six paintings from this exhibition will songs from films and dance. Community Eye Health WSD 2012 Supported by: Journal

Paintings by school children on WSD. INDIA

24 Community Eye Health Journal indian edition | VolUME 2 ISSUE 4