Low Vision Assessment and Rehabilitation
L. David Ormerod, MD
Overview
This case reviews diabetic retinopathy and its management. The main purpose is to describe low vision assessment and rehabilitation in a patient with markedly impaired vision. The case is intended for low vision specialists, rehabilitation professionals, ophthalmologists and optometrists, and for patients with low vision and their families who desire a better understanding of how patients with visual impairment can be helped to use the remaining vision to its maximum potential.
The remainder of the eye is comprised largely of transparent structures, such as the corneal window on its front surface, the lens situated behind the pupil, and the anterior and posterior chambers of the eye which are filled with clear fluids.
People with more severe or with total visual loss require non-visual solutions for their disability.
VISUAL LOSS FROM THE PATIENT'S PERSPECTIVE
Dr. Cole had not had annual diabetic eye examinations. He had no suspicion of an impending problem until the vision in both eyes suddenly worsened over one to two days. "I couldn't read. I couldn't drive." He was referred to the eye clinic.
"I figured I would become totally blind for the rest of my life. Many diabetic patients I have had over the years have gone blind. I felt very depressed the first two weeks or so. After that, I had pretty much accepted the fact that my work was going to take more effort."
"There was more stress at home. The family couldn't accept the fact that I couldn't see well, and I just couldn't help out, couldn't do the carpentry, and couldn't help my kids with building their houses. My wife has been understanding, but it's been difficult that she has to do so much more."
"I continued with my practice. My established patients were very supportive, but I may have lost some. Work was difficult at first, particularly writing receipts, and doing the daily log and booking schedule. I particularly had problems with reading journals. With all my assessments and treatments, I was having to be away from work a lot."
VISUAL REHABILITATION BY MISSOURI REHABILITATION SERVICES FOR THE BLIND
Vocational Rehabilitation
The urgency of Dr. Cole's employment difficulties was recognized. It was determined that he met the state's visual acuity criteria for services. The state agency facilitated an emergency enrollment, and a low vision assessment was authorized.
He was appraised by a senior vocational counselor from the state agency in late October 1998 in an expedited review. Although he was still able to perform direct chiropractic patient care, the paperwork, documentation of medicare and medicaid billing, insurance forms, receipts, etc. were problematic. His wife had come out of retirement to help him with these tasks, but this was putting added stress on the home.
Environmental Modifications
A few modifications were necessary in both of his practice offices. The state agency purchased a talking clinical thermometer, a business envelope writing guide, and a desk top light box for use with his CCTV for reading x-rays. Ambient illumination levels were satisfactory.
Many items were purchased for Dr. Cole to function independently in the home, a prerequisite for functioning independently in the workplace. For personal care use, he was provided with a talking scale, liquid level indicator, braille watch, tel-timer, long oven mitts, easy grip cutting board, adjustable slicing knife, bold line paper, hand magnifiers, NOIR glasses for glare control, white cane, talking clock, match-makers clothing identifiers, and a double-sided spatula.
What is Low Vision?
Low vision, or vision impairment, is a term used to describe varying degrees of vision loss, up to but not including total blindness, caused by disease, trauma, or a congenital disorder. Vision loss may be due to:
- decreased visual acuities (can identify only larger-sized objects at a specific distance),
- visual field defects (contraction of the visual area seen, or defects within the normal span of vision),
- decreased contrast sensitivity (reduced ability to discriminate an object against a similarly-colored background),
- loss of color perception,
A patient who is legally blind but has some vision would be considered "Low Vision," but many patients with "Low Vision" are not legally blind. Legal blindness of 20/200 is certainly not a complete loss of sight, which is considered as total loss of all vision (no light perception). In fact, if placed on a continuum between normal vision and no light perception, legal blindness would be closer to normal sight. Thus a person can be "legally blind," but still function relatively well visually, although constrained by the inability to read unless they have low vision rehabilitation, and by the inability to meet visual requirements for driving.
People with more severe or with total visual loss require non-visual solutions for their disability. This Low Vision website is primarily designed to aid individuals with partial sight.
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