At the completion of this article, optometrists and other readers should be able to improve their management of people with low vision, including:
- Identify three key questions to ask all patients with vision loss to assist with appropriate intervention or referral
- Review the relevant low vision services available for patients
- Understand how support and resources for patients can enable them to maintain independence
Carol Chu
B.Optom (Hons), GradCertOcTher
Senior Staff Optometrist
Centre for Eye Health (CFEH)
University of New South Wales
Michael Yapp
B.Optom (Hons), M.Optom, GradCertOcTher, FAAO
Head of Clinical Operations
Centre for Eye Health (CFEH)
University of New South Wales
Too often, low vision predicts a decline in confidence for independent daily living. CAROL CHU and MICHAEL YAPP detail the crucial role optometrists can play in identifying and assisting patients with low vision, and they include a useful case study.
A patient presents to an optometrist’s practice with symptoms of reduced vision in their ‘better’ left eye – reportedly, the right has been worse for years. Examination shows visual acuities of 6/24 in the right and 6/15 in the left with geographic atrophy in the right eye and exudative age related macular degeneration in the left eye. The optometrist arranges a prompt referral to a medical retinal specialist and ensures the patient is seen. The optometrist’s role in this patient’s care is now complete, or is it?
What is low vision?
Terms such as ‘vision impairment’, ‘vision loss’, ‘low vision’ and ‘blindness’ are often used interchangeably. Vision impairment can be categorised as mild (visual acuity <6/12 and ≥6/18), moderate (visual acuity <6/18 and ≥6/60), severe (<6/60 and ≥ 3/60) and blind (<3/60), as adopted by the World Health Organisation.1 Major causes of low vision in developed countries include diabetic retinopathy, age related macular degeneration, glaucoma and inherited retinal dystrophies.
A more patient-centred and practical definition however is: “any symptomatic impairment in vision that cannot be corrected with conventional methods including glasses, medical or surgical intervention.”
It is important to remember that visual acuity is only one measure of vision disability/impairment. Individuals with vision impairment typically also experience diminished contrast sensitivity, difficulty with glare and light sensitivity as well as limitations in their field of vision.
Accompanying the visual loss are negative functional, social, economic and psychological consequences. For example: in comparison to the general population, people who are blind or have low vision experience more than four times the rate of unemployment, suffer twice as many falls, have three times the risk of depression, are admitted to residential care three years earlier than people in their age bracket and often lose confidence to independently manage everyday life.2
The need and number of people receiving low vision services
It is estimated that over 284,000 people in Australia currently live with low vision or blindness.3 Population growth and ageing of the population combined with the increase in risk of eye disease with age means that the number of people suffering from low vision is expected to rise significantly, in particular at the early end of the scale. This risk is significantly higher for Aboriginal and Torres Strait Islander people, who experience six times the rate of blindness and three times the rate of vision impairment compared to the rest of the population.4
Vision 2020 Australia created The Adult Referral Pathway for Blindness and Low Vision Services5 with the aim of ensuring that patients with newly-diagnosed vision impairment are connected to the supports and services they need to maintain their independence.
Despite this, work and the many benefits of low vision services, it is estimated that fewer than one in five people with low vision in Australia receive appropriate assessment and access to low vision aids.6
There are a number of factors occurring at various levels which contribute to this problem:
Location
While low vision providers in Australia often provide transport facilities or home visits to assist, physically accessing low vision services has been shown to be a barrier to access of services for patients. This is exacerbated in remote and regional locations, highlighting the need for local optometrists to advise and support these patients.7-9
Costs
Although low vision assessment and training in the use of aids in many cases is provided at no-cost to patients, low vision aids themselves can be a considerable out-of-pocket expense to a person with low vision. Government welfare support (such as the National Disability Insurance Scheme and My Aged Care) can assist with these costs, however, navigating these systems is complex.
Other priorities
A study by the Royal Society for the Blind10 found that one of the most common reasons for patients not accessing low vision services after being referred were concurrent major health problems.
Lack of referral/identification
The same study also showed that patients’ perceptions were that either the service was not necessary or would not help them. Similarly, patients may have the misconception that low vison services are only for people who have severe visual impairment or are legally blind, and they may not be aware there are various visual aids and assistance available suited for earlier stages of vision loss. This also works the other way in that referrals are often not triggered until the patient has moderate or severe loss.
There is, however, well-established evidence for the benefit of early intervention.11 It is also easier to build skills such as learning to effectively use low vision aids in earlier stages before patients experience more severe vision loss.
Other key factors include patients not wishing for others to know that they have a visual impairment, language barriers and cultural sensitivities.12,13
Identifying and Assisting Patients in Your Practice
The first step in visual rehabilitation is identifying that a problem exists. Taking an effective history is pivotal to an ocular health assessment, but if vision loss is identified, asking about how the patient is dealing with this is critical.
While low vision-specific questionnaires exist (such as the ‘Impact of Vision Impairment’ and ‘Low Vision Quality of Life’ questionnaires), incorporating these and a full low vision history can be lengthy and goes beyond a standard optometric examination into areas such as understanding the patient’s specific visual challenges, remaining visual capabilities and identifying their functional needs.
Questions, however, fall into three main areas of concern: activities of daily living, mobility, and social and emotional concerns. As a result, asking three short questions covering each of these domains may identify a need for a more in-depth assessment or referral. For example:
1. Are you having any problems seeing everyday tasks like reading, seeing your phone or cooking?
2. Do you feel confident walking around indoors and outdoors, for example on uneven paths or up and down stairs?
3. Do you get upset or insecure because of your eyesight? (Figure 1)
While management and referral of the underlying cause of the vision loss is paramount, managing the patient’s functional needs is also critical to holistic care. Questions about falls, reduced illumination conditions and driving tend to be overlooked in primary care optometry. In the case example at the start of the article, asking the patient these three questions may also identify a need for action in other aspects of their healthcare.
What to do next?
There are a wide range of options for assisting patients who have vision loss. Some aspects of patients with low-to-moderate levels of vision loss can be managed effectively within primary care optometric practices with asking the right questions, assessment and simple interventions (for example: high reading adds and practical suggestions such as advice on enhancing contrast). A wide range of digital technology now exists and can provide solutions to many related issues involving activities of daily living.
However, comprehensive low vision rehabilitation service delivery often relies on an intricate interplay of numerous professions. The Vision 2020 Australia website5 and the Deakin Low Vision Initiative14 both have a comprehensive list of providers of services and information relating to visual impairment including peer-support organisations and services specific to the various states and territories.
There is some evidence patients are more likely to actually receive services when a direct referral is made on their behalf12 and engaging a range of providers and health professionals enables a holistic model of visual rehabilitation to address each of the four dimensions of quality of life: physical, functional, psychological and social factors.
Relevant low vision services may include, but are not limited to:
• Provision and training of low vision aids and equipment to enhance visual performance
• Assistive technology, including smartphone apps designed for people with vision impairment
• Occupational therapist assessment to identify any environmental adaptations that would support safe and independent functioning in the home, school or workplace
• Orientation and mobility training, which includes training on the use of electronic canes, or guide dogs to help individuals navigate their way through their environment safely and independently
• Counselling and psychology to support mental health and emotional wellbeing
• Social workers and vocational rehabilitation specialists
• Employment and education support
Case study – Multidisciplinary Care
Victor* is a 66-year-old gentleman who was diagnosed with retinitis pigmentosa at the age of 40. He was made redundant from his job at age 55 and in his early 60s, he experienced a marked decline in his vision. Victor was seeing hand movements at 1m in each eye with approximately 3 degrees of central visual field remaining. He reported glare sensitivity and night blindness. Victor reported to be in good general health, and is under the care of a psychiatrist for depression. He approached Guide Dogs NSW/ACT initially for assistance and training with use of an electronic magnifying device that his son had purchased for him.
Following several sessions of training with a Guide Dogs orthoptist, Victor was able to use his portable CCTV confidently to view his mail. Victor reported that he was increasingly reliant on his wife for assistance around the home and had become reluctant to leave the house without her.
An orientation and mobility specialist was able to introduce Victor to the use of a long cane and he was able to gradually build his confidence to walk to a park near his home independently to access the exercise equipment there, as well as to navigate to the local shopping centre via public transport.
Several home modifications were made following assessment by an occupational therapist, including tactile markers for the microwave and stove, and improved lighting in the kitchen and dining areas in the home. Victor learned to use a liquid level indicator to measure milk for his coffee machine and obtained a talking meat thermometer. With these modifications, Victor has been able to prepare simple meals independently.
Prior to his visual decline, Victor enjoyed reading for leisure and reported to be able to use his iPhone with reasonable confidence. With help from the Guide Dogs assistive technology team, Victor has learned how to access audiobooks, complete online purchases, access and reply to text messages and emails using technology that converts text to speech and vice-versa.
Victor has been able to fully transition to using screen readers on his iPhone and Windows computer (Figure 2). Despite the many challenges faced by Victor due to his vision loss, with the help of necessary support and resources he has been able to regain his independence in many of his daily activities.
Conclusion
This case is a good example of multidisciplinary care for severe vision loss. Mild vision loss is however much more common. As a result, it is critical that optometrists remember to not just manage the ocular disease, but also the visual consequences of it. This involves remembering to ask the relevant questions and arrange holistic care and/or referral for patients with any symptomatic impairment in vision that cannot be corrected with conventional methods.
NOTE: The authors would like to thank Dr Sharon Oberstein for reviewing and her input to this article.
More reading
Assistance tools for patients with low vision
Blind and low vision sector support NDIS review recommendations
Understanding funding for low vision services
References
1.International Classification of Diseases, Eleventh Revision (ICD-11), World Health Organization (WHO) 2019/2021 https://icd.who.int/browse11
2. Access Economics. The Economic Impact of Vision Loss in Australia in 2009. Access Economics. Report for Vision 2020 Australia by Access Economics.
3. Foreman J, Keel S, Xie J, van Wijngaarden P, Crowston J, Taylor HR, Dirani M. The National Eye Health Survey 2016 report. Melbourne: Vision 2020 Australia.
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10. Bruce I, McKennell A, Walker E. The RNIB survey. Volume 1: Blind and partially sighted adults in Britain. London: Her Majesty’s Stationery Office. 1991.
11. Binns AM, Bunce C, Dickinson C, Harper R, Tudor-Edwards R, Woodhouse M, Linck P, Suttie A, Jackson J, Lindsay J, Wolffsohn J, Hughes L, Margrain TH. How effective is low vision service provision? A systematic review. Surv Ophthalmol. 2012; 57 (1): 34-65
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