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Tiffany L. Chan, O.D., F.A.A.O.Assistant Professor of OphthalmologyLions Vision Rehabilitation CenterThe Wilmer Eye Institute, Johns Hopkins University
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Understand the utility of Low Vision Rehabilitation
Identify Low Vision patients
Gain knowledge about educating and counseling patients with vision loss
(Patient case example)
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* Low Vision Research Network (LOVRNET) Study Group
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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)
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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
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Any chronic uncorrectable visual impairment that limits daily functioning
▪ When ordinary eyeglasses, contact lenses or surgery cannot provide sharp vision
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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
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• Can cause major safety concerns▪ Increased risk of falls▪ Difficulty with medication management
▪ Kitchen accidentsStove/oven turned offCutting foodSeeing when food is properly cooked
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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
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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
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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
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ObservationsCase HistoryVisual Acuity measure(s)Contrast sensitivityRefractionVisual Field Medical evaluationAssessment/Plan
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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
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Magnification
Contrast Enhancement
Lighting
Control Glare
Non-optical aids
Recommend Appropriate Resources
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Spot reading Sorting Mail Reading a Menu Medication Label
Continuous Text Reading (Leisure reading) Books Magazines Newspaper
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Accessibility features on Mac or PC Large Cursor, Magnifier, Control +/-
Zoomtext Software Program Keyboard Camera
Zoom Caps
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20/20 Pens Bold lined paper Line guides Large print checks
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Sighted Guide Visual Scanning Strategies
Within the clinic Navigate throughout hospital
Orientation and Mobility Specialist
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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)
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Non-visual skills training• Computer (JAWS)• Braille• Orientation &Mobility / travel• Cooking
Educational seminars/ Field Trips
• Diabetes management• Baltimore Museum of Art
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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
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• 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
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•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!!
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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)
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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
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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
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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
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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
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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
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• 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
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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
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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
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Medication Management•Pill Box•Large print/Talking glucometer
(additional resources if IDDM: Insulin pen (hear clicks))
Home Visit•Mark appliances•Assess lighting•Safety evaluation
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