MANAGING LOW VISION When someone has low vision Clare Gilbert Co-director, International Centre for Eye Health, London School of Hygiene and Tropical Medicine, Keppel Street, Karin van Dijk London WC1E 7HT, UK; Clinical Advisor, Sightsavers. Karin van Dijk CBM global advisor on low vision; low vision consultant to Light for the World Netherlands and to Kilimanjaro Centre for Community Ophthalmology. Grutto 21, 7423CZ Deventer, The Netherlands. [email protected] As clinicians, being faced with a patient whose vision we cannot improve any further can make us feel like a failure. However, there are many ways to help such a person with low vision. Figure 1 shows the difficulties someone is likely to have, based on their distance visual acuity, and what support Teaching the use of an illuminated hand magnifier. PHILLIPINES they may be able to benefit from. These include optical devices, non-optical 2 Has all the medical, surgical, and optical Once you have established that the devices, advice on environmental modifi- treatment possible already been given? person does need low vision services, cations, and referral to rehabilitation and 3 Has the prognosis for vision been you can begin the low vision assessment. (special) educational services. confirmed by a medical professional? The following are the steps that In this article, we will show you how normally form part of a low vision If the answer to any of these questions is to assess a person with low vision and assessment: ‘no’, refer the person to the appropriate find out what it is they really want to be services, where possible. • Taking a history able to do. We will then outline the If we know the diagnosis, this will give • Explaining the eye condition interventions that are possible, and give us some idea of the likely impact on the • Determining the patient’s needs some guidelines. person’s visual function and thus on their • Performing an accurate refraction Before you start main visual needs (see page 2). • Assessing visual functions Ideally, people with low vision should • Magnification needed When you are faced with a person with poor have undergone refraction, and be • Designing a management plan vision, it is important to check that every- wearing their spectacles, before they are • Referral for further training and support thing possible has been done to improve given low vision support. In practice, and contacting educational or their vision, and that they really do need many eye care practitioners find it too rehabilitation services if needed. low vision services. Here is a checklist: challenging and/or time-consuming to • Selecting low vision devices and training 1 Has the person’s diagnosis been refract someone with low vision. This is the person in their use confirmed by an ophthalmologist or why refraction should always form part of • Suggesting non-optical interventions other eye care worker? a standard low vision assessment. and environmental modifications. Figure 1. How the type of assistance provided is influenced by distance visual acuity Spectrum of distance visual acuity (ideally, with the person wearing the correct prescription) Can see 6/18 < 6/18; can see 6/60 <6/60; can see 3/60 <3/60; can see 0.1/60 < 0.1/60 Difficulties with activities of daily living: dressing, eating, walking around, recognising faces +/- + ++ +++ ++++++ Potential to benefit from optical devices such as magnifiers +/- + ++ ++ Highly unlikely Potential to benefit from making changes to the environment (see page 12) +/- + ++ ++ ++ Need for rehabilitation and special educational services +/- + ++ +++ ++++++ 4 CEHJ | VOLUME 25 ISSUE 77 Taking a history CASE STUDY 1 This is an important part of the low vision This case study, and those that follow, are of actual people and demonstrate assessment and provides an opportunity practical low vision assessments and interventions. They show how the diagnosis for you and the patient to get to know and history can guide us in setting priorities for assessment and knowing which each other. interventions, especially non-optical, might benefit the person. Encourage the patient to talk about their problems. Asking open-ended 60-year old retired near vision was 1M (N8) at 15 cm. His questions will help; these are questions professor with age-related near acuity improved to 0.63M at 25 cm starting with words such as ‘when’, ‘what’, A macular degeneration complained with an add of +3.00D, a reading lamp, ‘how’, and ‘where’ – questions which that he could no longer read small text, and a reading slit. With these, he was don’t have ‘yes’ or ‘no’ as an answer. which had been an important part of his also able to read the newspaper and his Ask questions about: life. He also taught college students and writing was legible. • Their own eye health – how their vision worked extensively on the computer at The professor was advised to wear his is affected, what makes it worse or home. On further questioning, it became bifocal glasses constantly, to read with a better and how it has changed over time clear that he also had difficulties in table lamp and reading slit, and to use a • Their general medical history, their communicating with others. From the reading stand. A signature guide helped mobility, and their medications history, interview, and diagnosis, we knew him to sign cheques. • Their family’s eye health history that the man had central field loss and He was taught how to use eccentric • Their occupation and hobbies reduced contrast sensitivity, which would viewing (see page 8), which helped him • Any previous low vision assessments. require improved lighting and contrast. to recognise people more easily. This The low vision team assessed his best helped him socially. Here are examples of questions you can corrected distance and near visual The professor was advised about the ask about their eye health and vision: acuity, contrast sensitivity, reading and importance of explaining to his friends • When did you first notice a problem writing ability, and the extent of his field and family why he was not able to make with your vision? loss. direct eye contact. • What kinds of problems have you noticed? His visual acuity, tested on a logMAR He was also directed to the local • What problems do you have in the chart, was 6/36 (0.8 logMAR) in the government office to obtain a disability day? better eye, and with a +2.00D add his certificate and other paperwork. • What problems do you have at night? • What changes, if any, have you noticed in your vision? • Can you walk around in familiar places they want to be able to do. This will guide • What makes your vision worse? without assistance? the interventions you suggest. • What makes your vision better? Activities Ask for specific examples of what • Can you choose and find the clothes would help them to regain independence Explaining the eye condition you want to wear? or self esteem. For example: Some people with low vision will not have • Can you add the correct spices and • Regaining the ability to read their had their eye condition explained to them, herbs to the food while cooking? personal correspondence or they may not have understood the • Can you still do your hobby, e.g., • Helping to cook again instead of just explanation at the time. needlework or woodcarving? sitting around It is always worthwhile taking time to • Can you read religious texts, the • Learning to identify the correct explain the eye condition again, in terms newspaper, or utility bills? medication and taking it independently the person can understand. Even if patients Participation • Making a visit to a neighbour on their with low vision have heard it all before, • Do you attend family functions? own, whenever they feel like it. they will probably find it reassuring to have • Do you attend religious or other events? you explain it again, thereby confirming When discussing these topics, think • Are you still able to vote? what they have heard from others. about the following: Be positive. Emphasise that they have Check with relatives that this is what they • Do they need help with near and some residual vision and that you and have observed or experienced; sometimes intermediate vision, with distance your colleagues are committed to helping people feel embarrassed to acknowledge vision, or with all distances? them make the most of that vision. how dependent they have become. • Is the task long (reading) or short Reassure them that they cannot harm It is also important to find out what (looking at the oven temperature dial)? their residual vision by using it – they will kind of support they have at home. • Do they need to have one or both hands not ‘wear out’ their eyes! free? • Who do they live with, and is this person • What other visual functions might be able to provide help some of the time, affected and must be assessed? Determining the patient’s or all of the time? needs • Is providing this support having a Accurate refraction Start on a positive note by first asking negative effect on the family in any way? The importance of good refraction in a what they can still do, before going on to • What is the home like? Are there steps? low vision assessment cannot be ask what they may be struggling with. Where are the washing and sanitation overstated. Ask about their mobility, activities, and facilities? How is cooking done? Refracting people with low vision participation. Here are some examples. Having established broadly what support differs from refracting people whose Mobility they have at home, and what they can vision can be improved to normal (6/6 or • Can you walk beyond the house without and cannot do in relation to mobility, 20/20), as the person with low vision is assistance? activities, and participation, find out what Continues overleaf ➤ CEHJ | VOLUME 25 ISSUE 77 5 MANAGING LOW VISION Continued Assessing residual vision Using the bracketing The support we provide depends on having a thorough understanding of the technique person’s overall visual function.