• Glaucoma

    Most patients and many ophthalmologists are unaware of the services and devices available through vision rehabilitation services that assist with the secondary ef fects of glaucoma such as functional limitations, depression, lower quality of life, and disability (Arch Ophthalmol. 2004;122:1208-1209 ). Indeed, one survey given to those with self reported vision impairment found that only 1% were referred to vision rehabilitation services, and only 10% to 21% were aware of services available (Leonard, 2002). Several studies have shown the benefit of incorporating vision rehabilitation services with ophthalmic care to improve quality of life and performance of specific tasks such as reading and self care,3-6 yet most patients wait 5 to 7 years before receiving rehabilitation services, while those in rural and inner city areas may never receive services (Am J Occup Ther. 1995; 49:927-930). Glaucoma patients with vision loss have various needs outside of traditional medical care that can be addressed by vision rehabilitation services, but, until now, access to these services has been significantly lacking. This article discusses the models, services, and assistive technology available to glaucoma patients and the issues surrounding their care, so that ophthalmologists may better serve those suffering from low vision.

    Vision Rehabilitation Services

    Patients in need of vision rehabilitation services can be referred to either the medical and/or the educational/vocational rehabilitation models. The professionals in each model have a specific role to play in the rehabilitation of a patient with low vision.


    Table 1. Medical model. The medical model employs the skills of 4 professionals.
    Professionals
    Role
    Ophthalmologist
    dot Refers patients to low vision services and oversees their care.
    Optometrist
    dot Assesses patients’ vision loss
    dot Prescribes optics and devices (e.g., eyeglasses, contact lenses, and magnifiers) to correct refractive errors in the eye
    dot Some low vision optometrists provide limited Activities of Daily Living (ADL) training to patients with vision loss.
    Low vision therapist
    dot Teaches patients how to use their vision more efficiently with and without optical devices
    dot Helps low vision patients with their daily activities

    Occupational therapist*

    dot Evaluates patients’ functional visual abilities (i.e., what patients can and cannot see in their natural environment), ADL performance, assistive technology needs, and home and work environments
    dot Provides training, as needed, in areas including visual efficiency skills, ADL training, assistive technology training, and bioptic driving
    dot Helps patients adjust to vision loss, improve psychosocial skills, and refers them to other services and programs that can provide assistance
    dot Adapts patients’ home and work environments to help them perform their daily activities in an efficient and effective manner.
    *Only qualified to provide services to patients with a limited range of vision impairment – between 20/60 and 20/400

    The educational or vocational rehabilitation model overlaps with the medical model by utilizing the services of ophthalmologists, optometrists, and low vision therapists to provide for the eye care needs of their clients including vision training with and without optics. There are 3 additional professionals that differ from those in the medical model. Their role in vision rehabilitation services is illustrated in Table 2.


    Table 2. Educational/vocational rehabilitation model.
    Professionals
    Role
    Rehabilitation counselor
    dot Gatekeeper for service provision in educational/vocational rehabilitation model
    dot Serves as case manager for provision of services to clients
    dot Arranges vocational evaluations and training, orientation and mobility assessments and services, assistive technology evaluation and training, and daily living skills training
    Orientation and mobility specialist
    dot Assesses patients’ ability to orient and travel in and around their homes and communities as well as their ability to access and use public transportation
    dot Teaches concept development, motor development, sensory development, residual vision stimulation and training, human guide techniques, upper and lower body protective techniques, locating dropped objects, cane techniques, how to follow directions and compass directions, route planning, analysis and identification of intersection and traffic patterns, use of traffic control devices, transportation and navigation techniques, and low vision device instruction
    Low vision therapist
    dot Teaches patients how to use their vision more efficiently with and without optical devices
    dot Helps low vision patients with their daily activities

    Vision rehabilitation therapist

    dot Evaluates patients’ performance of activities of daily living, ability to read print or Braille, assistive technology needs, and home and work environments
    dot Trains patients, as needed, in the following skills: use of communication systems (e.g. Braille), personal care, home management, activities of daily living, leisure and recreation, medical management, and basic orientation and mobility skills
    dot Performs environmental modifications
    Ophthalmologists dot Same as in medical model
    Optometrists dot Same as in medical model
    Low vision therapists dot Same as in medical model

    Occupational therapists*

    dot Same as in medical model

    *Only qualified to provide services to patients with a limited range of vision impairment – between 20/60 and 20/400

    Low Vision Assistive Technology Options

    The Technology Related Assistance for Individuals with Disabilities Act of 1988 defines assistive technology as “any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities.” Many assistive technology devices can be used to help patients accomplish multiple activities of daily living. These devices can be divided into 2 categories: low-tech and high-tech technology (Table 3). Low-tech devices are inexpensive, simple, and manually operated. The most common low-tech devices available to patients with low vision are large print materials and Braille books. On the other hand, high-tech devices are more costly and are electronically or computer operated. High-tech devices for people with low vision and glaucoma can be separated into 7 types of assistive technology: Braille translation and printing options, refreshable Braille displays, computer screen magnification software, screen reading software, cell phones, personal digital assistants (PDAs), and closed circuit televisions (CCTVs).


    Table 3. Assistive technology.

    Category
    Technology

    Low-tech devices

    dot Magnifying glasses
    dot Long canes
    dot Bold-line pens
    dot Signature guides, check writing guides, and writing guides
    dot Large print materials (e.g., address books, recipe books, magazines, bank checks, thermometers, clocks, watches) can be obtained from bookstores, libraries, banks, and some retail outlets
    High-tech devices
    dot Braille output devices
    dot Computer screen enlargement software
    dot Screen reading software
    dot Optical character recognition system
    dot Mobile devices
    dot Closed circuit televisions (CCTVs)

    Braille translation software provides an alternative way of printing Braille text on paper. Instead of using a manual Braille writer, Braille translation software allows the user to convert document text into Braille and vice versa. Once the text is converted into Braille, a hard copy of the typed document can be printed with a Braille printer. Refreshable Braille displays attach to the computer and use tiny pins that move up and down to produce Braille characters on a portion of the computer screen. Various refreshable Braille display models exist and are available in 20, 40, and 80 characters.

    Meanwhile, computer screen magnification programs enable a person with low vision to manage files, navigate the desktop, access the internet, and use various software applications. Various software programs that can be used to magnify the computer screen are available and range in price from $100 to $600. If only limited magnification is needed, all of the current Microsoft operating systems provide limited magnification of the computer screen through its accessibility options. Many software programs such as the Microsoft Office suite and WordPerfect also allow users to increase the font size or size of the page.

    On a related note, screen reading software allows the icons, menus, and words on a computer monitor to be read aloud through the computer speakers. This allows a person to navigate the computer desktop, access files and documents, and use various word processing, scheduling, and spreadsheet programs. Similarly, optical character recognition systems are used to read printed text to the user by placing the material on the computer scanner and having the optical character recognition software read the material through the computer speakers.

    Some cell phones can now be purchased or programmed with voice output software that will enable low vision or blind users to access the various menus and dialing features of their phone. Likewise, personal digital assistants (PDAs) have been developed to provide the same functionality and programs for people with visual impairments as PDAs sold to those without visual impairments. These PDAs have various input (standard or Braille keyboard) and output (refreshable Braille display or audio) methods. A global positioning system (GPS) can also be attached to many of these PDAs, making it possible for a person who is visually impaired to navigate around the community. These mobile devices have provided those with visual impairments an increased independence and freedom that was unheard of even 5 years ago.

    Finally, CCTVs can increase the size of any written material or picture. A typical system includes a monitor anywhere between 14 to 26 inches, a camera that has controls for contrast control and size enlargement, and a viewing table where the book or other materials are placed. Some viewing tables are automated and can be controlled with a foot pedal. However, the development of portable CCTVs and optical character recognition (OCR) scanners has improved access to printed materials in the home and community and reduced reliance on the larger desktop models of the same products.

    The following table contains examples of the services and technology devices an eye care professional may refer to glaucoma patients with varying degrees of vision loss. These scenarios represent only the general pattern of progressive visual loss in glaucoma.


    Table 4. Examples of service and technology for glaucoma patients with varying degrees of visual impairment.

    Services
    Patient A
    Patient B Patient C Patient D

    Ophthalmologist

    x
    x
    x
    x
    Optometrist
    x
    x
    x
    x
    Low Vision therapist
    x
    x
    Occupational therapist
    x
    x
    x
    x
    Vocational counselor
    x
    x
    x
    x

    Orientation & mobility specialist

    x
    x
    x
    x
    Rehabilitation teacher
    x
    x
    x
    Technology
    Patient A
    Patient B
    Patient C
    Patient D
    Low tech devices
    x
    x
    x
    x

    Computer screen magnification software

    x
    Closed circuit TV
    x
    Braille output devices
    x
    x
    Screen reading software
    x
    x

    Optical character recognition systems

    x
    x
    Mobile devices
    x
    x
    x
    x
    Others*
    x
    x
    x
    x

    *Devices include talking watches, liquid level indicators, auditory or large print blood pressure cuffs, glucometers, etc.

    Patient A exhibits some peripheral and central vision loss, decreased visual acuity, contrast sensitivity, and stereopsis. This patient has increased difficulty performing near point tasks, driving, and other activities of daily living and work.

    Patient B exhibits no central vision and some peripheral vision. The patient has several vision deficits including decreased visual acuity, contrast sensitivity, stereopsis, scanning, and tracking as well as increased glare sensitivity. This patient reports having problems with near point tasks, self care, several activities, and orientating and navigating.

    Patient C has only central vision with normal visual acuity. Functionally, the patient has difficulty with tracking, scanning, reading, writing, driving, self-care, work-related tasks, and household tasks.

    Patient D has no central or peripheral vision and is totally blind. This patient is impaired in all activities of daily living.

    Barriers to Accessing Vision Rehabilitation

    Pollard, Simpson, Lamoureux, and Keeffe (Ophthalmic Physiol Opt. 2003;23:321-327) identified 4 main barriers people with vision loss encounter in accessing vision rehabilitation services: (1) understanding awareness and attitude; (2) inadequate transportation; (3) ignorant eye care professionals; and (4) lack of services. Many patients and their family members do not correctly understand the term low vision and, as a result, do not consider themselves as having low vision. Additionally, many lack an understanding or awareness of the benefits of low vision rehabilitation. Difficulty accepting vision loss also impedes patients’ willingness to seek services. There is a fear and vulnerability of not knowing what is in the future for them as well as concern about being around other people with vision impairments. Lack of transportation to a rehabilitation facility was another concern voiced by patients, and fear of utilizing public transportation or taxis was mentioned in this study. Poor referral practices to and lack of knowledge regarding available vision rehabilitation services also limit access.1,8,9

    The Goal of Vision Rehabilitation

    Glaucoma is the second leading cause of blindness in the world and 1 of 4 leading causes of visual impairment in the United States.10,11 Twenty-five percent (2.5 million) of those with a visual impairment in the U.S. have glaucoma, and 120,000 individuals are blind due to the condition. Unfortunately, approximately 10% of people with glaucoma who receive appropriate, regular treatment still experience loss of vision (Glaucoma Research Foundation). One population based study found that 40% of people experiencing vision loss due to glaucoma were not diagnosed at the time of the study (Arch Ophthalmol. 2000;118:264-269). Those with low vision due to glaucoma must learn not only to live with their disease, but also to cope with its functional consequences.

    Specialized services are an important step in helping patients with glaucoma to maintain or regain independence and achieve a higher quality of life. Vision rehabilitation requires teamwork and education on the part of various agencies, eye care professionals, patients, and their family members in order to overcome various barriers. The goal is to help low vision patients lead a normal life and accomplish routine daily tasks like reading and writing, raising a family, having a social life, traveling, maintaining a career or launching a new one, and enjoying recreational sports and games.

     

    References

    1. Gieser JP. When treatment fails: caring for patients with visual disability. Arch Ophthalmol. 2004;122:1208-1209.
    2. Leonard R. Statistics on vision impairment: a resource manual. New York, NY: Lighthouse International; 2002.
    3. Stelmack JA, Stelmack TR, Massof RW. Measuring low vision rehabilitation outcomes with the NEI VFQ-25. Invest Ophthalmol Vis Sci. 2002;43:2859-2868.
    4. Hinds A, Sinclair A, Park J, Suttie A, Paterson H, Macdonald M. Impact of an interdisciplinary low vision service on the quality of life of low vision patients. Br J Ophthalmol. 2003;87:1391-1396.
    5. Ellexson MT. Access to participation: occupational therapy and low vision. Topics Geriatric Rehab. 2004;20:154-172.
    6. Lovie-Kitchin, JE, Devereaux, J, Wells S, Sculpher KA. Multi-disciplinary low vision care. Clin Exp Optom. 2001;84:165-170.
    7. Bachelder JM, Harkins D Jr. Do occupational therapists have a primary role in low vision rehabilitation? Am J Occup Ther. 1995;49:927-930.
    8. Pollard TL, Simpson JA, Lamoureux, EL, Keeffe JE. Barriers to accessing low vision services. Ophthalmic Physiol Opt. 2003;23:321-327.
    9. Gieser DK, Williams RT, O’Connell W, et al. Costs and utilization of end-stage glaucoma patients receiving visual rehabilitation care: a US multisite retrospective study. J Glaucoma. 2006;15:419-425.
    10. Resnikoff S, Pascolini D, Etya'ale D, et al. Global data on visual impairment in the year 2002. Bull World Health Organ. 2004;82:844-851.
    11. Congdon N, O’Colmain B, Klaver CC, et al. (2004). Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol. 2004;122:477-485.
    12. Weih LM, VanNewkirk MR, McCarty CA, Taylor HR. Age-specific causes of bilateral visual impairment. Arch Ophthalmol. 2000;118:264-269.
    13. Horowitz A. The prevalence and consequences of vision impairment in later life. Topics Geriatric Rehab. 2004;20:185-195.
    14. Nelson P, Aspinall P, O’Brien C. Patients’ perception of visual impairment in glaucoma: a pilot study. Br J Ophthalmol. 1999;83:546-552.
    15. Noe G, Ferraro J, Lamoureux E, Rait J, Keeffe JE. Associations between glaucomatous visual field loss and participation in activities of daily living. Clin Experiment Ophthalmol. 2003;31:482-486.
    16. Centers for Medicare and Medicaid. Low vision rehabilitation demonstration. Washington, DC: Department of Health and Human Services. 2005:100-119.

    Additional Educational Resources and Support Services

    American Foundation for the Blind
    Eleven Penn Plaza, suite 300
    New York, NY 10001
    (800) 232-5463
    Email: mailto:afbinfo%40afb.org

    Provides public education, social, and technological research for the blind or visually impaired. Also provides information on legislation affecting blind and visually impaired persons.

    American Academy of Ophthalmology
    P.O. Box 7424
    San Francisco, CA 94120
    (415) 561-8500

    Sponsor of EyeCare America, a project that provides a free initial eye exam to qualified patients. Also sponsors a program that provides eye exams to people older than 65 who cannot afford care. Offers listing of national and local eye care organizations.

    American Optometric Association
    243 N. Lindberg Boulevard, suite 300
    St. Louis, MO 63141
    (314) 991-4100

    Coordinates Vision USA, a program of free eye care to uninsured, low-income workers and their families. Also supports the Council on Research, which coordinates and develops research proposals to improve eye care.

    Canadian Glaucoma Society
    1525 Carling Avenue, suite 610
    Ottawa, Ontario K12 8R9
    (800) 267-5763
    (613) 729-7209

    Canadian National Institute for the Blind
    1929 Bayview Avenue
    Toronto, Ontario M4G 3E8
    (416) 480-7580

    Provides counseling, rehabilitation, and educational materials to Canadians with low vision. Also offers large print books and books on tape.

    Council of Citizens with Low Vision Intern
    c/o American Council of the Blind
    1155 15th Street N.W., Suite 720
    Washington, DC 20005
    800-733-2258
    Fax: 317-251-6588

    Glaucoma Foundation
    33 Maiden Lane, 7th Floor
    New York, NY 10038
    (800) 452-8266
    (212) 504-1901
    (212) 504-1933 fax
    E-mail: glaucomafdn@mindspring.com

    Glaucoma Research Foundation
    251 Post Street, suite 600
    San Francisco, CA 94108
    (800) 826-6693
    (415) 986-3162

    Funds research and education to protect the sight and independence of people with glaucoma and to find a cure.

    Job Accommodations Network
    918 Chestnut Ridge Road, suite 1
    P.O. Box 6080
    Morgantown, WV 26506
    (800) 526-7234  

    Library of Congress
    National Library Services for the Blind and Physically Handicapped
    Washington, DC 20542
    (202) 707-5100
    (202) 707-0744 TDD
    Email: mailto:nls%40loc.gov

    Administers a free national library program of Braille and recorded books and magazines for the visually impaired and physically disabled. “Blindness and Visual Impairments: Information and Advocacy Organizations” (Item No. 896-01) is a free publication that lists state and nationwide advocacy, advisory and counseling programs.

    Lighthouse International
    111 East 59th Street
    New York, NY 10022
    (800) 334-5497
    (212) 821-9713 TDD
    E-mail: info@lighthouse.org

    Educates professionals and the public about the effects of vision loss. Provides rehabilitation services for all aspects of low-vision.

    Lions Clubs International
    300 22nd Street
    Oak Brook, IL 60521-8842
    (630) 571-5466

    Supports SightFirst, a program that provides services for people with critical needs. Sponsors public awareness programs regarding diabetes and glaucoma. Supports eye banks, research, and clinics.

    National Eye Institute
    Building 31, Room 6A32
    Bethesda, MD 20892
    (301) 496-5248
    E-mail: 2020@nei.nih.gov

    Conducts research on the causes and cures of eye diseases. Distributes information on glaucoma, age-related macular degeneration, cataracts, and diabetic retinopathy. Cassettes may be obtained for $2.00 by writing to: VISION Foundation, Inc., 818 Mt. Auburn Street, Watertown, MA , 02172

    National Glaucoma Research
    15825 Shady Grove Road, suite 140
    Rockville, MD , 20850
    (800) 437-2423
    (301) 948-3244

    Toll-free hotline offers current information on research and treatments. Free quarterly newsletter and National Glaucoma Research Report.

    Prevent Blindness America
    500 E. Remington Road
    Schaumburg, IL 60173-5611
    (800) 331-2020
    (847) 843-2020
    E-mail: preventblindness@compuserve.com

    Sponsors vision screenings. Offers information on diseases and injuries of the eye. Also available is a newsletter, Prevent Blindness News. Some Spanish materials are available.

    Research to Prevent Blindness
    645 Madison Avenue, 21st floor
    New York, NY , 10022-1010
    (800) 621-0026
    (212) 752-4333

    Funds research to develop effective methods of treatment, prevention, and a cure for diseases that impair vision.

    Resources for Rehabilitation
    22 Bonad Road
    Winchester, MA 01890
    (781) 368-9094

    Publishes “Living with Low Vision,” a large print guide to services and products for people with low vision.

    Vision World Wide
    5707 Brockton Drive Ste 302
    Indianapolis, IN 46220
    (800) 431-1739
    (317) 254-1332

    Provides educational publications for the vision impaired and their families. Also supports referral services through a toll free help line 800-431-1739. Publishes Vision Enhancement which focuses on current research and assistance devices.

    Author Disclosure

    The authors state that they have no financial relationship with the manufacturer or provider of any product or service discussed in this article or with the manufacturer or provider of any competing product or service.