The concept of living with, or managing, ‘low vision’ can be scary for patients and practitioners alike. But what if we were to shift the paradigm? What if we were to start talking to everyone in their 50s about adapting their environment and using tools for ‘easy vision’?
Would this enable people to enjoy a greater quality of life throughout the years… and would it make transitioning to low vision tools and technologies, should the need arise, an easier adjustment?
Approximately 0.7% of males and 0.6% of females self-reported total or partial blindness in one or both eyes in Australia in 20171 – a tiny, yet undoubtedly important, group within the community whose vision needs are often managed by the likes of low vision clinics, Vision Australia and Guide Dogs.
These tools are easy to prescribe, and quick for patients to learn to use
Much bigger is the group that lives with a long-term vision disorder that may not impact their independence, but does limit their ability to work or enjoy the activities most dear to them. The Australian Institute of Health and Welfare reported that in 2017, long-term vision disorders affected 93% of people aged 65 and over.1
The vast number of these people use spectacles or contact lenses for vision correction, but may also benefit from magnification and/or illumination to assist them with occasional tasks.
The number of people who could be assisted is even greater when you consider that our vision typically begins to deteriorate in our fifth decade as the pupils reduce in size letting less and less light in.
Brett Sheil from Magnifiers Australia says many optometrists shy away from offering advice and selling illumination and magnifiers, which means patients are missing out on simple, relatively low cost products that would make their lives more rewarding. Additionally, he says, optometry practices are missing out on revenue.
“Many practitioners only consider low vision; they see it as a small market of patients who have complex needs. However there are many patients that only need a small amount of help, like a 3x magnifier, or a task light – to help them with their work, or with a craft. These tools are easy to prescribe, and quick for patients to learn to use,” he explained.
As well as enabling people to continue to enjoy activities, Mr Sheil believes that encouraging patients to use entry-level magnification and illumination when they first begin to experience subtle age-related changes will prepare them in the event of more serious vision loss.
“It becomes a transitional process, people move from a 3x magnifier to higher magnification as their vision deteriorates. They physically and psychologically adapt to the changes over time.”
This, he says, is in contrast to someone who gets by wearing ever stronger spectacles as their vision deteriorates. A low vision diagnosis comes as a mental shock accompanied by the need to learn to use new devices and high magnification powers that significantly reduce their field of view.
They may go into denial or have difficulty adapting, ultimately diminishing their quality of life and independence.
Being able to help people maintain their independence is really powerful, and incredibly rewarding
DEVICES TO ASSIST
There are myriad devices that can be offered to patients with deteriorating or low vision, beginning with stronger glasses and moving through to hand-held magnifiers with and without illumination, stand and desk magnifiers, and electronic devices that include apps for iPads and digital magnification.
Additionally, telescopes for looking into the distance (to read bus numbers etc.); task-specific lighting; talking clocks; large print phones – for landlines and mobiles; large print notebooks and phone books; pouring aids with liquid level senses and more are all available to help patients maximise independence.
Mr Sheil says the take-up of digital magnification has been rapid over the past 18 months, as older patients, who are increasingly tech-savvy, become aware of their ease of use and functionality.
“The great thing about digital magnification is that the magnification can be adapted as the patient’s vision changes. So while there may be a bigger up front cost, this is a tool that will last overtime.
“The patient views everything on a seven, ten or twelve inch screen with line scrolling, so they don’t have to move the device around. And they’re able to adjust the magnification, the contrast and the colour of the type and the background very simply to suit their needs and cope with different type styles or materials.”
Optometrists are well equipped to offer easy vision solutions and, with an ageing population, this is a smart way to build practice revenue and grow patient loyalty.
“Practices don’t lose business by selling magnifiers – their patients are still going to be wearing spectacles and contact lenses, they’re still going to come in for an eye examination. Importantly, they’ll appreciate their optometrist for making an effort to ensure they can continue to work efficiently, or enjoy sewing, reading, woodwork – whatever it is they love doing.”
Additionally, he pointed out that in the competitive world of optometry, offering easy vision services provides a point of difference.
To help optometrists understand the ‘easy vision’ market, Magnifiers Australia has developed training kits and a magnification chart that can be displayed in practice reception and consult areas. He said the magnification chart speaks for itself, showing patients how something as simple as 3x magnification can make a difference.
For people with low vision, occupational therapists are well equipped to help and advise on the best options to meet their needs. Optometrists and ophthalmologists can refer patients with vision impairment to an occupational therapist at, for instance, Vision Australia or Guide Dogs Australia, for assistance.
The key is to ensure patients are introduced to all the options, allowed to try them for themselves and to make decisions based on the value they add to their life (rather than focusing on price).
“Being able to maintain independence is priceless. I recently taught a man in his 80s to use a digital magnifier. Regaining the ability to read meant so much to him that he did a jig then dropped down to the floor and started doing push-ups. He was so happy,” said Mr Sheil.
And it is reactions like this, he says, that provide the greatest reason for why optometrists should consider shifting the paradigm on low vision to ensure more patients get the benefits of the available tools and technologies earlier.
“Being able to help people maintain their independence is really powerful, and incredibly rewarding,” he concluded.
- www.aihw.gov.au/reports/eye-health/eye-health/ contents/how-common-is-visual-impairment#Low-visionand- blindness
Clinical Care of Patients with Low Vision
Mae Chong, Lead Optometrist Clinical Teaching at the Australian College of Optometry; Professor Sharon Bentley, Deputy Dean Faculty of Health at Queensland University of Technology; and Associate Professor Anthea Cochrane, Clinical Teaching Coordinator at The University of Melbourne are experts on the clinical care of patients with low vision.
A series of videos on low vision, produced with the support of VOTE funding was promoted on Optometry Virtually Connected in June 2021. The videos featured Ms Chong providing a low vision consultation with a patient experiencing vision impairment. The segments were interspersed with discussion between Prof Bentley and A/Prof Cochrane who together reiterated the key points covered.
The three low vision experts stressed the importance of taking a thorough patient history when working with people with low vision, as this will help determine aids used in the past and options going forward. Information needs to be discovered about the person’s home situation, whether they have help / support, any interests / activities being impacted by their vision and the status of their mental health (people with low vision are at increased risk of depression and it needs to be addressed). Asking about falls, assessing the patient’s risk of a fall, and if necessary, arranging a consultation with orientation and mobility training professionals is essential for optimal outcomes.
As well as seeking information, it is important to offer advice about the patient’s eye disease – sometimes there isn’t time during a regular consultation to provide patients with adequate information and their GP may not have adequate knowledge. Charles Bonnet Syndrome (CBS), for example, affects many people with age related macular degeneration and many people who experience CBS hallucinations are afraid to speak out about it. For about 30% of people the hallucinations will go away after about a year.
While it’s tempting to focus on a patient’s ‘good eye’, it is important to test their poorer eye as well, especially when testing for long distance. LogMAR charts are useful for low vision patients because you can move them in closer to the patient, and near LogMAR charts, which have a top line of N80 large print reducing to small print at the bottom of the page, will give you a good idea of the patient’s near acuity.
Retinoscopy is an invaluable tool for patients with vision impairment because it gives an objective idea of refractive error, an idea of how clear the media is, and the contribution this might make to vision impairment.
Understanding a patient’s refractive error is important – you may find refractive change – however, unless prescribing new spectacles will make a difference to the patient in the real world (e.g., will improve their vision by at least two lines), there is little point – managing expectations is key.
Contrast sensitivity, something not often assessed with normally sighted patients, is critical when working with vision impaired patients as advising them on how to improve contrast can help optimise their existing vision. The Melbourne Edge Test can make the assessment of contrast straightforward and understandable for patients. It can help demonstrate to the patient and their family, why they may be having functional vision difficulties in the real world, when their vision acuity seems relatively good.
Visual fields should also be assessed as they can affect mobility performance. An Amsler grid can help measure whether damage to visual fields may be affecting a person’s ability to read, their fluency, whether they’re missing words, or unable to find the beginning or end of a line when they’re reading.
Having worked in specialist low vision centres, the three low vision practitioners agreed that the provision of low vision care is both feasible for practices and within the skill set of optometrists. Furthermore, as with all forms of rehabilitation, early intervention is very important to ensure patients receive assistance before they lose skills or independence. This will enable them to adjust to adaptive devices before they require more complex assistance.