tiffany l. chan, o.d., f.a.a.o. assistant professor of ophthalmology lions vision rehabilitation...

Tiffany L. Chan, O.D., F.A.A.O.Assistant Professor of OphthalmologyLions Vision Rehabilitation CenterThe Wilmer Eye Institute, Johns Hopkins University

Understand the utility of Low Vision Rehabilitation

Identify Low Vision patients

Gain knowledge about educating and counseling patients with vision loss

(Patient case example)

* Low Vision Research Network (LOVRNET) Study Group

Median age - 77 yo Female - 66% Macular disease –

55%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

18 22 26 30 34 38 42 46 50 54 58 62 66 70 74 78 82 86 90 94 98

Perc

ent o

f pati

ents

Age (years)

Trouble reading Difficulty writing Inability to recognize faces Blur watching television Difficulty w/ steps and curbs Glare Problems driving

Visual acuity Peripheral visual field Corneal Edema Intraocular pressure Retinal/Macular edema Neovascularization Optic nerve damage

Physician Patient

Any chronic uncorrectable visual impairment that limits daily functioning

▪ When ordinary eyeglasses, contact lenses or surgery cannot provide sharp vision

Leading cause of disability in daily living among Americans

The WHO estimates that over 135 million people are visually disabled, and nearly 45 million people are blind

Incidence of LV cases from age-related eye disease is expected to double over the next 25 years

• Can cause major safety concerns▪ Increased risk of falls▪ Difficulty with medication management

▪ Kitchen accidentsStove/oven turned offCutting foodSeeing when food is properly cooked

Nurses Physicians

▪ Ophthalmology, PM&R, Geriatric Medicine, etc. Low Vision specialists Occupational, Physical, Rehabilitation

Therapists; Speech and Language Pathologists

Orientation and Mobility specialist Social workers Teachers for the Visually Impaired

To maximize the patient’s remaining sight to enhance function and independence

▪ Visually assistive equipment (VAE)▪ Sensory substitution (i.e. Hearing or touch)

No surgical or medical interventionsNot “fixing” vision

Problems with activities of daily living Difficulty reading and writing Driving concerns / questionable renewals Safety in mobility Evaluating rehab options in high risk eye

procedures Post –procedure with remaining vision

impairment

ObservationsCase HistoryVisual Acuity measure(s)Contrast sensitivityRefractionVisual Field Medical evaluationAssessment/Plan

The ability to distinguish an object from its background

Patients with poor contrast report difficulties with: navigation (curbs, steps, getting into the tub, etc.)

Solutions include: House-hold

manipulations Increased lighting Step markings

Normal Vision

Reduced Contrast Sensitivity Vision

Magnification

Contrast Enhancement

Lighting

Control Glare

Non-optical aids

Recommend Appropriate Resources

Spot reading Sorting Mail Reading a Menu Medication Label

Continuous Text Reading (Leisure reading) Books Magazines Newspaper

Accessibility features on Mac or PC Large Cursor, Magnifier, Control +/-

Zoomtext Software Program Keyboard Camera

Zoom Caps

20/20 Pens Bold lined paper Line guides Large print checks

Sighted Guide Visual Scanning Strategies

Within the clinic Navigate throughout hospital

Orientation and Mobility Specialist

Vocational Rehabilitation (≤ 55 yo) Goal: maintain or re-gain employment Provision of visually assistive equipment (VAE) Work-site assessment Career training / Job placement assistance

Independent Living Older Blind (>55 yo)

Goal: Independence Provision of visually assistive equipment (VAE) Home Visit (ADLs / safety)

Non-visual skills training• Computer (JAWS)• Braille• Orientation &Mobility / travel• Cooking

Educational seminars/ Field Trips

• Diabetes management• Baltimore Museum of Art

Veterans Affairs Medical Center (VAMC) Division of Rehabilitation Services (DORS) Blind Industries and Services of Maryland (BISM) Maryland Library for the Blind and Physically

Handicapped Orientation and Mobility (O&M) Guide dogs (e.g. “The Seeing Eye”) Driving evaluation/training Support groups Social Workers State and Federal Organizations

• Jim Deremeik• Rehabilitation Therapist• Kristen Lindeman• Occupational Therapist• Kim Soistman• Staff• Chantal

Haberman• Office Manager

• Dr. Judith Goldstein• E. Baltimore• Green Spring Station

• Dr. Tiffany Chan• E. Baltimore• Bel Air• Bayview

• Dr. Alexis Malkin• E. Baltimore

• Dr. Nicole Ross (Fellow)• E. Baltimore• Green Spring Station

•The goals of LVR are to maximize function and independence

LVR “Treatment” ▪ Visually assistive equipment▪ Visual skills training▪ Referral to appropriate resources

There is always something that can be done!!

84 yo Caucasian femaleCC: Trouble reading

• Books, newspapers• Menus at restaurants• Medication bottles

Referred by Wilmer Retina Service• Non-neovascular age-related macular degeneration

(AMD) both eyes• Dense cataract both eyes (patient does not want

surgery)

Reading / Computer• Difficulty reading books and newspaper

(has given up reading for pleasure)• Able to read headlines and large print• Difficulty reading menus at restaurants• Cannot read medication bottles• Tried an OTC magnifier, but didn’t

seem to help muchVisual Information / SeeingDrivingMobilityVisual Motor Skills / ADLs

Reading / ComputerVisual Information / Seeing

• Watches a large, 52” television, sitting 14 feet away

• Sometimes moves closer, like when an Oriole’s game is on

DrivingMobilityVisual Motor Skills / ADLs

Reading / ComputerVisual Information / SeeingDriving

• Very limited to local and familiar areas (i.e. grocery store, church, etc.)

• Family lives near-by and can drive her

MobilityVisual Motor Skills / ADLs

Reading / ComputerVisual Information / SeeingDrivingMobility

• No falls• Travels independently• More careful walking on poorly lit curbs or

stairs• Glare: wears transition lenses and feels

they darken sufficiently in the bright sunlight

Visual Motor Skills / ADLs

Reading / ComputerVisual Information / SeeingDrivingMobilityVisual Motor Skills / ADLs

• Lives alone in a two story house (family lives near-by)

• Manages ADLs independently (cooking, laundry, shopping, etc.)• Difficulty seeing appliances, especially in poor

lighting• Sometimes hard to read labels and price tags

at the grocery store

• Diabetes mellitus (oral meds)• Hypertension• High Cholesterol

• Manages own meds• Tries to keep pill bottles organized

• Sometimes forgets if she has taken a pill• Rarely measures blood sugar

• Hard to see the glucometer

Best corrected visual acuity• RE 20/70• LE 20/200

• Central scotomas in BEContrast Sensitivity: • 0.60 log units (severe loss)NVAcc

• 16 point font (20/100 Snellen equivalent)

(newsprint is 8 point font)Confrontation Visual field• Full RE/LE

Pleasure reading: (a.k.a. continuous reading)• E-reader (i.e. Kindle)

• Increased font• Reverse contrast

• Large print books• Directed light source

Spot reading: • Illuminated hand magnifier

▪ For medication bottles, menus andpackaged directions

Medication Management•Pill Box•Large print/Talking glucometer

(additional resources if IDDM: Insulin pen (hear clicks))

Home Visit•Mark appliances•Assess lighting•Safety evaluation