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5/12/2015
1
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