Visual rehabilitation of patients with advanced stages of glaucoma,optic atrophy,myopia or retinitis pigmentosa

Ninety-six patients with advanced stages of glaucoma, optic atrophy, myopia or retinitis pigmentosa (RP) who could not manage with ordinary spectacles or simple magnifying aids were taken care of at the Low Vision Clinic for rehabilitation and followed for an average of 3.6 years (the glaucoma group) up to an average of 6.0 years (the optic atrophy group). They were given high power optical aids and subjected to educational training in the proper use of these aids for best utilization of residual vision. Many of them (for optic atrophy as high a percentage as 40.7) were taught to use extra macular retina by means of eccentric viewing technique. The mean age of the oldest group, the glaucoma patients, was 69.3 years. The three other groups were about 20 to 25 years younger, on an average. (Another 35 patients) were seen for the first series of visits but could not be followed up, the main reasons being death (13 patients) and moving out of the area (9 patients).The mean power of the aids (mainly telescopes) used for distance vision was 2.1 × (RP)-5.3 x (optic atrophy). Increased near addition and hyperocular lenses were the main aids for reading and near vision, the mean power being 17.0 dioptres (glaucorna)–23.5 dioptres (RP)(4.3 × –5.9 x). Aids were also provided for intermediate distance and for spot use. The mean number of series of visits was 3.1 (myopia)–3.5 (glaucoma) and the average number of l h training sessions 2.2 (glaucoma)–2.5 (optic atrophy, RP) per series of visits.With aids and educational training, the mean visual acuity improved on the first series of visits from 0.31 to 0.60 for the glaucoma group, from 0.19 to 0.70 for the optic atrophy group, from 0.12 to 0.68 for the myopes and from 0.35 to 0.52 for the RP group. After the last series of visits acuity was still as good as 0.51, 0.61, 0.73 and 0.45, respectively.The number of individuals able to read newspaper text increased from 16.1% to 100.0% for the glaucoma patients, from 14.8% to 100.0% for the optic atrophy patients, from 75.0% to 100.0% for the myopes, and from 50.0% to 95.5% for the RP patients.The results show clearly that the methods used for rehabilitation of patients with glaucoma, optic atrophy, myopia or RP through optical aids and sessions of educational training are very successful, with substantial improvement of life quality.     

Visual rehabilitation of patients with advanced diabetic retinopathy

Seventy-nine patients with advanced diabetic retinopathy were subjected to a full range of low vision rehabilitation measures and followed for an average of 3.6 years at the Low Vision Clinic. They were provided with high power optical aids, followed by educational training in the use of such aids and of residual vision, including the utilization of peripheral retina by means of eccentric viewing technique in many cases (23%). Mean age was 52.7 years. Type I diabetes was diagnosed in 69 subjects and type II in 10 subjects. Proliferative retinopathy was present in 73 cases and background retinopathy in 6 cases. All subjects showed macular changes in varying degrees. (Another 36 patients participated in the first series of visits but could not be followed up, the main reason being that 31 of them died before follow-up. There were no major differences between the two groups regarding rehabilitation results.)The average power of the telescopes used for distance vision was 4.8 X, and the mean power of the aids used for reading and near vision, mainly increased near addition and hyperocular lenses, was 22.2 dioptres (5.6 X). The patients were also provided with aids for intermediate distance and for spot use. The average number of series of visits was 2.7 and the number of 1 h training sessions 2.5 per series of visits.With aids and training, mean visual acuity improved from 0.17 to 0.73 on the first series of visits. After the last series of visits acuity was still as good as 0.64. Ability to read TV titles increased from 15.2% to 79.7% in the group and reached 64.6% after the last series of visits. The number of individuals able to read newspaper text increased from 1.3% to 97.5%. After the last series of visits the number was still as large as 86.1%. Of the individuals who had to stop working because of poor vision, 89% would have been able to return to work after rehabilitation. However, because of unemployment problems in the area, only 72% managed to return.It is quite obvious from the results that the presented methods, including high power aids and training sessions, are extremely successful in rehabilitation of patients with advanced diabetic retinopathy, provided that they have at least some residual vision. Dramatic improvements in visual performance were seen, allowing a life of much better quality than before. This is of great importance in a group of patients often suffering from other severe complications of diabetes. Furthermore, social aid may often be reduced or eliminated.     

Improvement of reading speed after providing of low vision aids in patients with age‐related macular degeneration

Purpose: Age‐related macular degeneration (AMD) is the most common cause of severe visual impairment, including loss of reading ability, among elderly persons in developed countries. The aim of the present study was to evaluate reading ability before and after providing of appropriate low vision aids. Methods: Five hundred and thirty patients with different stages of AMD (age 82 ± 8 years) were included in this retrospective study. All patients underwent a standardized ophthalmological examination including evaluation of magnification requirement and careful providing of low vision aids. Before and after the provision of low vision aids, reading speed [words per minute (wpm)] was evaluated using standardized reading texts. Results: For the whole group, the average best‐corrected distance visual acuity of the better eye was 0.18 ± 0.15, with 69% of patients having visual acuity of 0.1 (20/200) or better. The mean magnification requirement was 7.4 ± 6.3‐fold (range 2–25). Visual rehabilitation was achieved with optical visual aids in 58% of patients, whereas 42% of patients needed electronically closed‐circuit TV systems. Mean reading speed was 20 ± 33 wpm before and increased significantly to 72 ± 35 (p < 0.0001) after the provision of low vision aids for the whole group. Between patients with visual acuity < 0.1 and patients with visual acuity of 0.1 or better, there are highly significant differences in reading speed before (0.4 ± 3.8 versus 20 ± 28 wpm, p ≤ 0.0001) and after providing of visual aids (40 ± 13 versus 84 ± 30 wpm, p ≤ 0.0001). Patients with severe visual impairment (visual acuity ≤ 0.1) showed significantly lower improvement of reading speed compared to patients with visual acuity of 0.1 or better following rehabilitation (p ≤ 0.0001). Before providing of low vision aids, only 16% of patients were able to read; in contrast, reading ability was achieved in 94% of patients after the provision of low vision aids for the whole group. Conclusion: Our results indicate the great value of low vision rehabilitation through adequate providing of vision aids for the improvement of reading ability, with a highly significant increase of reading speed without training of eccentric viewing in patients with retained central fixation. The prompt implementation of low vision aids in patients with macular degeneration will help them to maintain and regain their reading ability, which can lead to an increase in independence, communication, mental agility and quality of life.     

Senile Macular Degeneration – The Effects and Management

The previous papers in this series on the effects and management of senile macular degeneration (SMD) have identified the population of patients, discussed the pathology and ophthalmological management and detailed the assessment of the visual impairment caused by SMD. This paper discusses in detail the various forms of optometric treatment available for the patient with SMD. Particular emphasis is given to low vision treatment, such as distance and near magnification and non-optical aids and techniques, aimed at alleviating the visual disabilities caused by SMD.     

Vision Rehabilitation of Persons with Age Related Macular Degeneration

As the population of the United States ages, there is an increase in the number of persons with age related macular degeneration (ARMD). Even as new prevention and treatment techniques are developed, the vision loss associated with ARMD may lead to loss of independence and quality of life. Low vision is a rehabilitative process designed to improve visual function and restore independence. This paper is a review of the current research related to low vision in the areas of magnification, contrast and illumination, reading, training, driving and outcomes assessment.     

Low vision service delivery: an audit of newly developed outreach clinics in Northern Ireland.

Recent publications recommend that low vision services are multi-professional; easily accessible; freely available to all those with visual impairment; monitored by professional and patient groups, and responsive to user feedback. These standards were applied when developing low vision outreach services in Northern Ireland in 1999/2000. Results are reported of the complete clinical audit cycle, coupled with a patient satisfaction telephone questionnaire, which was used to evaluate the service. Of the 48 patients randomly selected from the list of clinic attendees, 28 (58%) were female, 27 (56%) over 80 years of age and 38 (78%) had a primary ocular diagnosis of age related macular degeneration (AMD). Of the 46 low vision aids issued at patients' first appointments, 30 (67%) were illuminated stand magnifiers and 29 (63%) had magnification levels of x5 or less. A total of 46 (96%) patients reported that they had benefited from low vision services.     

老年低视力和盲的病因及光学助视器在康复中的应用

目的:分析老年低视力和盲的病因及光学助视器在康复中的应用.方法:收集我院老年视力残疾患者87例,其中低视力74例,盲13例.其中男53例,女34例.先进行常规内外眼检查,必要时采用特殊检查,再进行病因分析.均屈光矫正,然后试配远用和近用光学助视器,检查配戴助视器后远、近视力,远视力≥0.05为脱盲,远视力≥0.3为脱残,近视力≥0.5为有效,<0.5为无效.结果:老年低视力患者致盲原因占首位的是高度近视,其次为黄斑变性、各类白内障、青光眼、糖尿病视网膜病变.经屈光矫正后视力提高≥2行者62例(71%),视力不矫正或矫正≤1行者25例(29%).联合远用助视器后视力≥0.3脱残者70例(80%),远视力≥0.05脱盲者10例(11%),<0.05者7例(8%),脱残率92%.配阅读眼镜及近用助视器后近视力>0.5者 60例(69%),<0.5者27例(31%).助视器经常使用者58例,不经常使用18例,基本不用或放弃者11例.结论:老年低视力及盲的病因占首位的是高度近视,其次是黄斑病变.光学助视器在其康复中的应用仍是目前可靠、经济、有效的矫治方法,应鼓励患者使用助视器,提高助视器的利用率,从而提高患者的生活质量.     

土耳其低视力患者的病因及特征

目的：探讨土耳其配戴助视器的低视力患者的病因和特点,及其与父母近亲结婚是否有关系。 方法：回顾性研究了2009/2013年间伊斯坦布尔诊所接受236例低视力患者。分析年龄、性别分布、低视力原因、近亲结婚、低视力辅助类型规定及视力变化。在回顾性研究中,根据世界卫生组织定义基于最佳矫正视力将视力分为（失明,视力〈20/400;视力严重受损,视力〈20/200～20/400;视力轻度到中度受损,视力〈20/60～20/200）。基于双眼主要病因,根据国际疾病分类第十版可以确定失明和低视力的病因。根据视力和患者需求规定了视力辅助,并使用平均值依标准差和频率对数据进行了描述。 结果：研究包括236例患者,65%为男性,平均年龄为38.5依24.2岁（年龄范围6～95岁）,男性多于女性。年龄在15～30岁（35.6%）之间是最大的年龄群体。轻度至中度视力受损患者为122例,严重视力受损患者为84例,失明患者为30例,他们分别占总人数的51.6%、35.6%和12.7%。脉络膜疾病和视网膜疾病（62.7%）是导致视力低下的主要原因。老年低视力患者黄斑变性逐渐成为视力低下的首要原因（61.3%）。造成视力低下的原因有视网膜和脉络膜疾病（62.7%）,眼球震颤（23.7%）,视神经和视神经束疾病（11%）,先天性白内障（0.8%）及青光眼（1.7%）。88例患者（37.3%）为伽利略类型,116例患者（49.2%）为开普勒类型。18例患者（7.6%）在接受LVA后视力无明显改善。14例患者被准许使用放大镜矫正视力。在大多数患者中,使用LVA的近视和远视患者视力均得到改善。62例近亲结婚患者占总人数的26.3%。 结论：14岁以上患者视力受损主要原因是视网膜和脉络膜疾病,15岁以下的患者常见原因为眼球震颤。在近亲结婚群体中黄斑营养不良和色素性视网膜炎患者显著增高。研究疾病病因学的遗传非常有效,因此,近亲结婚在土耳其仍是一大问题。     

Results obtained with low vision aids

In this retrospective study of 261 patients (181 female and 80 male) the results obtained in a special low vision clinic are described. The mean age of the patients was 73.5 years (range 16–95 years). Visual acuity of the best eye was 0.08 in 26 patients (10.0%); better than 0.08 but 0.25 in 130 (50%); 0.30 in 62 (23.8%) and better than 0.30 in 42 patients (16.1%). Persons with a visual acuity better than 0.30 either could not read normal print or had restricted visual fields. Main causes of visual impairment were macular degeneration (38.9%), diabetic retinopathy (16.1%), glaucoma (8.4%) and cataract (7.4%). Low vision aids could be prescribed for 208 persons (79.7%). Follow-up of an average of 12 months (range, 3–22 months) was carried out in 250 cases (96%). In this period 24 patients (9%) died. At least 161 persons (62%) used their aids regularly, i.e. 77% of the patients who were given a low vision aid.     

Age-related macular degeneration and its management

Age-related macular degeneration is a major cause of vision loss in older individuals. The clinical picture and pathogenesis of age-related macular degeneration is reviewed. Present treatment modalities for subretinal vascularization in exudative-type macular degeneration and their limitations are discussed. The role of low-vision aids in providing magnification for reading vision is described. The role of intraocular lens implantation is discussed, as well as the newly developed intraocular lens which, with the addition of a plus-lens, functions as a Galilean telescope to provide magnification for near vision.     

Ophthalmological rehabilitation – experience at the University Eye Hospital Heidelberg

BACKGROUND: The rehabilitation of low vision patients is of increasing importance since the number of these patients has grown rapidly. We wanted to evaluate the actual spectrum of patients concerning age and diagnoses and the appropriate low vision aids (LVA) in 1 year. METHODS: The records of the patients seen in our low-vision unit in 1996 were retrospectively evaluated. We correlated visual function, ophthalmological diagnoses and age to the magnification needed for rehabilitation and the use or prescribed LVAs. RESULTS: There was a nearly homogeneous distribution concerning age with a range from 0 to 99 years. Most patients presented with age-related macular degeneration (25.6 %) while 10 % each had retinitis pigmentosa and optic atrophy. Simple low vision aids such as high plus reading additions (29 %) and magnifiers (18.5 %) were prescribed in the majority of patients. However, closed-circuit TV (CCTV) systems were necessary in 25 %. CONCLUSIONS: Rehabilitation of low vision patients is often possible with simple LVAs. This is especially true for patients suffering from age-related macular degeneration. Since there is a tremendous-amount of different diseases, adequate diagnostic and individual counseling is of major importance.     

Ophthalmologische und soziale Rehabilitation sehbehinderter Patienten

BACKGROUND: In addition to medical care, the visual and social rehabilitation of low-vision patients is of increasing importance. The aim of our study was to evaluate the actual spectrum of patients concerning diagnoses and appropriate low-vision aids at a low-vision clinic. METHODS: In a retrospective study, the medical records of 4,711 patients treated at our low-vision clinic from January 1999 to December 2005 were reviewed and analyzed. The main outcome measurements were age, ophthalmologic diagnoses, magnification requirement, and prescribed low-vision aids, as well as social and professional rehabilitation measures. To evaluate the efficiency of visual rehabilitation, reading speed was measured in a subgroup of 930 patients before and after administration of low-vision aids. RESULTS: Age-related macular degeneration was, at 40%, the most frequent diagnosis. Other main diagnoses were tapetoretinal dystrophies, optic atrophy, and diabetic retinopathy. The median magnification need was 4x. A highly significant correlation existed between the measured magnification power and the magnification factor of the prescribed low-vision aids. Visual rehabilitation was frequently sufficient with simple optical low-vision aids such as high-plus reading additions and magnifiers. Closed-circuit television systems were necessary in 26%; however, 85% of these patients had a high magnification need of more than 6 x. For distance vision, a monocular telescope was the low-vision aid prescribed most often. A high proportion of patients needed more than two low-vision aids for different application areas. Forty percent of patients needed special social and professional rehabilitation measures. In a subgroup of 930 patients, the mean reading speed was 35+/-50 words/min before the use of low-vision aids, which increased significantly to 81+/-46 words/min with the use of such aids. Therefore, the reading speed essentially doubled following the use of low-vision aids. CONCLUSION: Our results provide actual, quantitative data about the need for and success of rehabilitation for visually impaired patients. A large number of patients suffer from age-related macular degeneration. Independent from the causal ophthalmologic diagnoses, most patients benefited greatly from the rehabilitation measures provided by the low-vision service and were thus able to improve their quality of life. In the face of the increasing number of visually impaired elderly patients, rehabilitation should start as early as possible.     

Primary success with low vision aids in age-related macular degeneration.

The benefit obtained from various low vision aids (LVAs) was studied in 65 consecutive patients with atrophic (70.3%) or disciform (29.7%) age-related macular degeneration (ARMD). 13.8% were able to read newsprint with age-related reading correction under proper lighting conditions. The primary success achieved with LVAs was good, 91.4% of patients being able to read newsprint. In most cases a simple magnifier (52.3%), high-powered reading glasses (10.8%) or Fonda's glasses (12.8%) were sufficient. The magnification preferred was 5x or less in 25.6% and greater than 5x to 9x in 48.8%. Patients with disciform degeneration required higher magnification than those with atrophic degeneration. It is concluded that most patients with ARMD found low vision aids useful for reading purposes and that a simple optical device was sufficient to achieve reading vision.     

视觉训练对低视力儿童阅读速度的影响

目的评价视觉训练对已有助视器的低视力儿童阅读速度的影响。方法共有9位有助视器使用经验的低视力儿童,先测量其阅读速度,再进行一系列的视觉训练和阅读训练,2个月后,当他们完成训练时,再次测量对相同文章的阅读速度,并比较训练前后患儿阅读速度的变化。结果在训练前后患儿阅读四号字的速度差异有显著性(P=0.003);在训练前后患儿阅读小五号字的速度差异有显著性(P=0.002)。结论视觉训练和阅读训练对提高低视力儿童的阅读速度是有效的,在临床低视力康复工作中,我们不应仅仅只把助视器提供给低视力儿童,同时还应进行适当的视觉训练和阅读训练来提高患儿的阅读速度,这对于正在学习阶段的儿童尤为重要。     

Long-term results of low vision rehabilitation in age-related macular degeneration

One to five years after successful low vision rehabilitation, 199 patients with agerelated macular degeneration were asked by means of a questionnaire whether they still used their low vision aids and whether they were satisfied with the low vision counceling. We received feedback from 66% of the patients. 20 patients had already passed away. 74% of the 112 answering patients still use a low vision aid today. Three-quarters of them still use the originally prescribed low vision aid. Interestingly enough, the daily reading time was rather short, only 16% of the patients read more than 1 hour per day, 42% read somewhat more and 13% somewhat less than 10 minutes per day. Retrospectively, 81% of all responding patients found their low vision counceling at least a little, more of them quite or very helpful. These numbers suggest, that the initial labor of patiently examining and training older, visually handicapped patients is worthwhile.     

Scotoma size reduction as an adaptive strategy in age-related macular degeneration

Objective: Retinal areas with reduced sensitivity to light stimuli represent the true scotoma size in patients with age-related macular degeneration (AMD), whereas the perceived visual field defect area that covers a specific target of regard may represent an effective size of the same scotoma. This study was designed to highlight the conceptual difference between the “true scotoma size” and its “effective scotoma size” counterpart.Design: Prospective nonrandomized observational case series.Participants: Ten adults with documented AMD, low vision, and best-corrected visual acuity of 20/50-20/200 in the better eye.Methods: Effective scotoma size and true scotoma size were calculated from measurements with the macular grid test performed with automated perimetry and from microperimetry performed with the Nidek MP-1, respectively.Results: Ten patients aged 70-92 years (mean 81 years) met the inclusion criteria. Mean effective scotoma size measured with the macular grid test was 40.19 (SD 34.88) deg². Mean true scotoma size measured with microperimetry was 75.17 (SD 56.08) deg² (p ≤ 0.003). The log unit change in scotoma size, defined as scotoma utility score, was −55.91%. The effect size observed for the scotoma utility score was 0.74.Conclusions: Effective scotoma size experienced by patients with AMD is significantly smaller than true scotoma size. This reduction may be explained by adaptive variability in eye positions during any single fixation stability attempt, which ultimately results in enhanced visual field perception.     

Clinical effect of low vision aids

The number of patients with low vision is increasing as life expectancy increases. In addition, the interest and demand for low vision aids are also increasing with improved socioeconomic status and the development of mass media. Therefore, it is imperative to recognize the importance of low vision aids. We reviewed the clinical records of 118 patients who visited our low vision clinic more than twice. According to the data analyzed, optic nerve atrophy, retinal degeneration, diabetic retinopathy and age-related macular degeneration were the most common causes of low vision in these patients. The best corrected visual acuities without low vision aids were less than 0.3, but with the help of low vision aids, vision improved to more than 0.4 in 87% of the patients for near vision, and 56% for distant vision. The patients had complained that they could not read books, see a blackboard, recognize a person at a distance, and had other problems because of low vision. However, with the use of low vision aids their satisfaction with their vision rose to 70%. Hand magnifiers, high-powered spectacle lenses, and stand magnifiers were the low vision aids commonly used by people for near vision, while the Galilean telescope and Keplerian telescope were the most popular devices used for distant vision. In conclusion, low vision aids are very helpful devices to patients with low vision.     

A HOSPITAL RENTAL SYSTEM FOR LOW VISION AIDS

Costly low vision aids are rented to patients by the Otago Hospital Board Occupational therapists see the patients in the Low Vision Clinic and then as necessary in their homes As a consequence accurate follow-up and analysis of the help provided by these aids is available Patients with senile macular degeneration use telescopic reading aids for an average of 27 months after they are prescribed     

Near Vision Aids In Geriatric Patients With Reduced Visual Acuity

ABSTRACT The usefulness of near vision aids was studied in one hundred and forty-one patients in a geriatric hospital. The patients were over 65 years of age and had reduced vision. Where lens power exceeded +10DS spectacle lenses seldom worked well. Aspheric stand magnifiers were the most useful device in cases where greater magnification was needed. Elderly patients had difficulty in adapting to optical aids over 5X. Impaired cerebral function was the main reason for failure of the low vision aids of lower magnification.     

Determining magnification for reading with low vision

Background : In the past, practitioners have used distance and/or near visual acuity (VA) to calculate required magnification for low vision aids. Magnification was usually under‐estimated when compared with the final magnification prescribed. Recent studies have emphasised the importance of acuity reserve in determining the required magnification for optimum reading rate. Two different approaches have been proposed for the appropriate acuity reserve to use in calculating magnification. These are a fixed acuity reserve of 0.3 log unit or an individual determination of optimum acuity reserve. The aim of this study was to investigate the magnification and reading rates with low vision aids selected by the two methods. Methods : Nineteen low vision subjects with age‐related macular degeneration (AMD) who were experienced magnifier‐users were recruited. Reading rates and near VA with low vision aids determined by the fixed and individual acuity reserve methods were compared with the same measures made with the subjects' own magnifiers. Results : There were no significant differences in reading rate and near VA measured with low vision aids selected by either the fixed or individual acuity reserve methods or the subjects' own magnifiers. Reading rate with low vision aids was not significantly different from reading rate for large print with conventional near additions. Thus, for experienced users, magnifiers do not cause reduced reading rate. Conclusions : The fixed acuity reserve method is simple to apply as only near VA and print size of the target reading task are required. For the individual acuity reserve method, reading rates at different print sizes need to be measured. We recommend the use of a fixed acuity reserve (0.3 log unit) for the calculation of required magnification for low vision patients. If near VA or reading rate are not satisfactory with the magnification calculated by this method, individual assessment of required acuity reserve is necessary.