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Low Vision 2015-A Beginner’s Guide to Vision Rehabilitation Care in Private

Practice

Harvey Richman, O.D., FAAO, FCOVD

Classification of VA Loss: WHO

Normal 20/25 or better

Mild vision impairment 20/32 - 20/63

Moderate vision impairment 20/80 - 20/160

Severe vision impairment 20/200-20/400

Profound vision impairment 20/500-20/1000

Near total vision impairment < 20/1000

Total vision impairment NLP

Low Vision Statistics

There are approximately 5.5 million elderly individuals who are blind or visually impaired.

Approximately 1.3 million Americans are legally blind.

Approximately 93,600 visually impaired or blind students.

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Diseases Causing Vision Loss

Leading Causes of Legal Blindness from Birth to 19

Congenital Cataract

Optic Atrophy

Albinism

Retinopathy of Prematurity

Cone-Rod Dystrophy

Leading Cause of Legal Blindness from 20 to 44

Albinism

Cone-Rod Dystrophy

Optic Atrophy

Myopia

Retinitis Pigmentosa

Diabetic Retinopathy

Macular Degeneration

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Eye Diseases and Conditions for the Over 45 year old

Age-related macular degeneration (AMD)

Cataract

Diabetic eye disease

Glaucoma

Dry eye

Low vision

ARVO 2002: AMD Study predictions (neovascularization & geographic atrophy)

ARVO 2002: AMD Study predictions (neovascularization & geographic atrophy)

The Low Vision Examination

An optical and functional evaluation to determine whether a patient’s vision can be enhanced to participate in desired activities

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Members of the Rehabilitation Team

Social Workers Education Experts/VI

Teachers Occupational Therapists Early Intervention

Specialists Orientation and Mobility

Specialists Rehabilitation Teachers

Patient motivation is most important factor in determining which patients will

be successful

Factors Affecting Patient Motivation

Type of Loss

Family Reaction

Life Stage

Significant Life Events

Self-concept

Personality

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Exam Modifications

Refraction– Trial frame

refraction

– Increase add power

– Evaluation for prism

Modifications in a LV exam

History– Patient Medical History

– Patient Ocular History

– Patient GoalsDifficulty performing activities of daily

living– Education

– Vocation

– Avocation

Exam Modifications

Visual Acuity

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When a patient has poor acuity . . .

Where to start?

Device Evaluation Optical vs. Non-optical

A logical place to start

Manufacturer Dependant

#1 Point

Magnification

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As magnification increases . . .

Working distance decreases

Field of view decreases

Near Magnification

Bifocal Add/Prismatic Reading Glasses– Advantages

Hands free magnification

– Disadvantages Decreased working distance

Near Magnification

Hand-held magnifiers Advantages

Lighted vs. non-lighted

Portability

Disadvantages Requires dexterity

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Near Magnification

Stand magnifiers Advantages

Lighted vs. non-lighted

Requires less dexterity

Disadvantages Not as portable as HH

Near Magnification

Dome magnifiers Advantages

Requires less dexterity

Portable

Durable

Disadvantage Inability to write underneath

Near Magnification

Coil near reading glasses

Max Detail

Loupes Advantages

Hands free

Disadvantages Cosmesis

Weight of devices

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Near Magnification

Electronic magnifiers Advantages

Portable

Increase mag without decrease working distance

Disadvantage Cost

Distance Magnification

Hand-held telescopes Advantages

Portable

Good for spotting

Disadvantages Decreases field of view

Distance Magnification

Hands - free telescopes Advantages

Use for extended periods of time

Disadvantages Cosmesis

Weight of device

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Driving

Driving is a privilege, not a right

Access to independent mobility at any level is a primary goal in vision rehabilitation

States allowing bioptic driving

Bioptic Driving

Patient is looking through lenses as he/she is driving

Bioptic is used like a rearview mirror

Head is tilted downward to look through the bioptic

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Visual Field

Central visual field loss

Eccentric viewing techniques Use of scanning laser ophthalmoscope to

locate PRL

Prisms to assist with eccentric viewing

Light Sensitivity/Glare

Wavelength Specific For reading

For mobility/distance

To Ensure Optimal Acuity is Achieved

Illumination-Adequate lighting– Avoidance of glare

– Adequate lighting

– Allow student to wear hat indoors

• Posture– Patient should be allowed a close working

distance

– Patient should be permitted to tilt head and/or paper for optimal acuity

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Non-optical Devices

Behavior Modification

Physical activity

Fish consumption

Greens

Smaller portions

Alcohol in moderation

Nutritional supplements

Blocking blue light from reaching retina

Behavior ModificationBehavior Modification

Sedentary lifestyle

Smoking

Excess Alcohol

High BMI

HTN, Cholesterol

Diet low in fish, green veggies

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Distance Magnification

Electronic Magnification Advantages

Disadvantages Mobility

Cost

Electronic Magnification

SL IDES  COURTESY  DAV ID   L EWERENZ ,  OD,   FAAO

NORTHEASTERN  STATE  UN IVERS I T Y

OKLAHOMA  COL L EGE  OF  OPTOMETRY

The iPad As A Low Vision Tool

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Features for the Visually Impaired Right Out of the Box

Enlarging print with finger gestures

Changing font sizes and types

Siri – the intelligent personal assistant

Enlarging Print with Finger Gestures

"Pinching" and "Spreading" works in iWork suite – Pages, Numbers, Keynote Mail Web pages Photos Many appsDoes not work in Home screen Settings iBooks Notes Contacts Calendar

Enlarging Print with Finger Gestures

Entire page available for magnification, even the portion not visible on the screen

Amount of magnification is ~3X ‐ 5X, examples

Pages default 12 point font 1.0M → 3.0M

Mail on default font 1.2M → 5.5M

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Changing Font Size and Type

The font size and type can be adjusted in iBooks, iWorks suite within the application

Examples Pages

o Minimum 10 pt = 0.7M

o Default 11 pt = 0.8M

o Maximum 288 pt = 24M

iBooks (average of three I tested)o Minimum 1.0 M

o Maximum 7.2M

Notes, Mail, Messages Font size controlled in Accessibility Settings, covered later

Siri

Voice activated "intelligent personal assistant"

Available beginning with 3rd Generation iPad and Mini

To launch press "Home" button for 1‐2 sec.

What can it do?  Examples Ask for information in your Contacts list

Take a note

Set an alarm

Search the web for an answer to a question

Available in 10 languages plus country‐specific for some; can select male or female voice

Accessibility Features

Zoom – Enlarges display with finger taps

Text Options– Change text to larger font; change contrast options

Invert colors – To improve contrast, reduce glare

VoiceOver – Voice description of screen content

Speak Selection

Speak Auto‐text

Triple Click Home and Other

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Apps for the Vis. Impaired Patient

Magnification for readingLarge type browserScrolling textCalculators – large type and talkingVoice readersMoney identificationMobilityColor identificationGamesImage recognitionVisual stimulation / development

Video Magnifier Stands

Justand $89

Justand V2 $99

Examples of iPad stands from ProComputing Products that can be used for video magnification. 

Talking Calculators

Talking calculator HD+ (free)

TalkCalc ($0.99)

Talking Calculator ($1.99)

Talking Scientific Calculator ($4.99)

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Voice Readers

Voice Dream More full function text‐to‐speech program than 

VoiceOver More control and options Many voices available $9.99 Voice Dream Lite is free, full function version, but 

requires you to hit the "Play" button every few sentences (300 characters)

Others include NaturalReader ($9.99), Text Aloud ($4.99), Voice Reader Text ($2.99), Voice Magnet ($1.99), Speak it! ($1.99)

Money Identification

EyeNote (free) US Bureau of Engraving and Printing

New version  identifies currency immediately in video mode –no need to take a photo

US currency only

Privacy mode available

Only works on iPhone, iPod Touch and iPad 2?

LookTelMoney Reader ($9.99) iPhone (5, 4S, 4, 3GS), iPod Touch (4th), iPad (2 and 3)

Identifies currency immediately in video mode – no need to take a photo

All types of bills from many countries http://www.looktel.com/moneyreader

Apps for the Visually Impaired

GPS for mobility (cell internet required) The Seeing Eye by Sendero Group is the 1st fully 

accessible app $70/yr or $130/3 yrs BlindSquare ($24) Navigon ‐ USA ($50), North America ($60) Aridne GPS ($5.99)

Color Identification Color ID Free (free) and Color Identifier ($4.99) from 

GreenGar speak the names of colors captured by the iPad's camera

Games Accessible Mine Sweeper ($0.99) is one of many

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Image Recognition

Take a photo of an object ‐ book cover, historical landmark, consumer product, etc.

A search will locate the object and provide information about it

Tap Tap See ‐ requires activation of VoiceOver, $4.00 for 50 pictures, $7.00 for 100 pictures, $9.99 for 1 month unlimited use

Google Goggles for Android, iPhone 

3Gs and 4

QR and bar code readers

I. Implantable Telescope Technology

II. Clinical Outcomes

III. Treatment Program – CentraSight™

Today

Anterior Segment Device for Macular Disease

IMT™ by Dr. Isaac Lipshitz

Implantable Telescope Technology

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End-Stage AMD

Disciform Scar or GA

No Active CNV

Bilateral Scotomas

20/160 – 20/800 BCVA

Age 75 or older

Phakic in prospective telescope implant eye

Patient Population

Field of View –External Telescope vs. Implanted

Mounted Telescope ~ 6 -12°

Mounted Telescope ~ 6 -12°

Implantable Telescope ~ 20-24°

Telescope Eye = Central Vision

Distance: Recognizing faces, watching TV, seeing store signage

Near: Reading, playing cards, dining

Retains scanning capability

Other Eye = Peripheral Vision

Allows orientation and safe mobility

How Does It Work?Bi-ocular Viewing

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20/160 to 20/800

Patient must improve with (respond to) magnification pre-surgery

Visual Acuity

Key Indications/Contraindications

Operative Eye:

No hx of intraocular or corneal surgery; evidence of cataract

Min. anterior chamber depth, endothelial cell density

Anterior Segment

Key Indications/Contraindications

Additional Services

Vocational RehabilitationDivision of Blind ServicesTransportation servicesBooks on tape/large printDirectory AssistanceLighthouseBraille ClassesGuide Dogs

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Thank You

For additional information American Optometric Association Vision Rehab Section