MAY 2021 1
MAY 2021 Dear Colleague,
I have been privileged to visit several “boutique” establishments in our country during this time when
international tourists are absent, and these lodges/hotels are forced to rebuild their South African
market.
A few issues stuck me, and somehow, I could relate them to our own profession.
First and foremost are the people who work at this “top end” of the market. My overall impression was
that they are resilient, innovative, benefitted from good training and above all, presented with people
skills that are often lacking elsewhere. In other words, they refused to let customer service standards
drop, even when their income has halved.
It is heartening to see this trend, but it also makes me question why we as a nation cannot perform like
this when it comes to the delivery of basic services. What happened to Ubuntu or is it just a slogan for
authorities to hide behind? Or does it have to have a monetary value?
It is also notable that Zimbabweans are often part of these resilient teams. They are a remarkable
people, and it remains a mystery why some political leaders take the very people who elected them, for
granted. In Africa we seem to want to share failures instead of successes.
Another issue that I noticed was the fact that most of these places, especially the older ones, needed
some TLC that would have happened in better times. Yet, “things” worked and there was someone
who could make it work if there was a problem. Compare this to our state of municipalities who, by the
way, benefit from selling essentials like water and electricity and receive State subsidies yet cannot
maintain the very lifeline they are responsible for.
It all comes down to basics not so. Take the example of a spectacle prescription that does not work in
the chosen frame, no matter how many times you adjust/change nose pads, pantoscopic angle or temple
fit, it just does not work, and nobody is satisfied with the outcome until someone takes the bull by the
horns and starts from scratch, with a smile.
So that is the obvious lesson, a well-run establishment sees to the basics first so they can avoid the
negative outcomes and/or reputational damage with the subsequent socio-economic hardship.
Enough of my COVID paranoia. On the positive side, Discovery Health will soon embark on a drive to
better “manage” those who live with Diabetes and Optometry is included in this at two levels, those
who just want to capture data and those who wish to play a broader role in the interdisciplinary team.
The GIO will therefor offer a repeat of the Diabetes course soon. This time mostly virtual and at two
levels in synergy with the Discovery program and reimbursement proposal.
The new ruling from the HPCSA that requires all Health Professionals to upload proof of CPD
activities, has caused a bit of a panic and we have decided to speed up the publications of this
newsletter to assist those who are short of points. Feel free to talk to Ingrid or Fiona if experiencing
difficulty.
I trust you will enjoy the spread of topics the May issue has to offer.
Stef
MAY 2021 2
MAY NEWSLETTER 2021
CONTENTS:
INTRODUCTION………………………………………………………………………1
LIGHT, REFRACTION & LENS DESIGN, DISPENSING………….…Next issue
CORNEA & CONTACT LENS……………………………………………………..3
ANTERIOR SEGMENT……………………………………………………………...3
POSTERIOR SEGMENT…………………………………………………………… 5
NUTRITION & SYSTEMIC DISEASE………………………………………..5
PATHWAYS………………………………………………………………………………Next issue
TECHNOLOGY/ LOW VISION……………………………………………………..9
ETHICS……………………………………………..………………………………………20
MAY 2021 3
MAY NEWSLETTER 2021
Since acne vulgaris is a disease of the sebaceous glands, it may have potential
effects on the ocular surface and tear homoeostasis, which are essential for good
vision. Optometrists should be aware of ocular surface pathologies when prescribing
glasses or contact lenses for the visual rehabilitation of these young patients. To
evaluate the ocular surface features, meibomian glands and tear parameters of
patients with acne vulgaris, the right eyes of 70 individuals (34 patients with acne vulgaris, 36 healthy volunteers) were
evaluated.
The tear break-up time of participants was
measured, and the Schirmer’s test was performed. To determine ocular surface
characteristics, samples were taken from the conjunctiva for impression cytology.
Finally, the loss rates of the upper and lower eyelid meibomian glands were
determined by taking meibography.
Tear break-up time was significantly lower in the study group compared to the control
group. No statistically significant difference was determined between the groups with
respect to Nelson grade in the conjunctival impression cytology. Grade 3 cytological
changes were not observed in either group. The median value of the loss rate in the
meibomian glands in the upper eyelid of patients with acne vulgaris was 19.10%
(IQR: 18%), while it was 8.75% (IQR: 9.53%) in the control group. The median
value of the loss rate in the meibomian glands in the lower eyelid was 15.70%
(IQR: 15.13%) and 7.70% (IQR: 6.53%) in the acne vulgaris and control groups,
respectively.
This study showed that patients with acne vulgaris may have a predisposition to meibomian gland damage and tear
instability. Researchers suggested that a more detailed ophthalmologic examination
should be performed in patients with acne vulgaris.
Still, further investigation into the
safety and efficacy of the method on human eyes is warranted.
Corneal collagen crosslinking (CXL) with riboflavin and UVA has been successful in
preventing keratoconus progression and corneal warpage, and new research
suggests this technique also shows promise in myopia. Through animal studies, an
investigative team from China found that the modified CXL procedure may potentially help control the pathologic process of
myopia, even though further investigation into its safety is necessary.
CXL with riboflavin-UVA is a minimally invasive procedure without allograft
material implantation, which makes it possible to reduce complications such as
infection and rejection, the researchers explained. “Its effectiveness, stability and
safety make it hopeful to arrest progressive myopia or to inhibit the over-expansion of
the sclera,” they wrote in their paper.
One study in the review used white rabbits
as a model. The right eyes underwent CXL using riboflavin and UVA radiation, and
every quadrant had either two or six scleral irradiation zones. The eyelids of the right
https://www.reviewofoptometry.com/news
letter/op/optometric-physician-march-29-2021
CXL May Also Help Halt Myopia Progression
Ocular Surface Characteristics in Acne
Vulgaris
In this Newsletter
1. Ocular Surface Characteristics in Acne
Vulgaris
2. CXL May Also Help Halt Myopia
Progression
3. Update and Guidance on Management
of Myopia
4. Prescribing Supplements for AMD
5. The evolving standard of care in AMD
6. A Common Approach to Low Vision:
Examination and Rehabilitation of the
Patient with Low Vision
7.
MAY 2021 4
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eyes were sutured after therapy to establish myopia. Outcomes showed that
CXL with riboflavin and UVA effectively prevented occlusion-induced axial
elongation and that the size of the treatment area was effective.
Another investigation established a lens-induced myopia model in guinea pigs to
develop methods of CXL for the treatment of progressive myopia. The results
indicated that CXL using riboflavin and UVA irradiation effectively prevented the progression of myopia by increasing scleral
biomechanical strength. Additionally, scleral collagen fiber arrangements of the
crosslinked eyes were denser and more regularly distributed than the myopic eyes.
More recent studies have investigated the effect of oral administration of riboflavin
combined with whole-body UVA irradiation on the biochemical and biomechanical
properties of the sclera in a lens-induced myopic guinea pig model. This technique
appeared to increase the strength and stiffness of the sclera by altering the
biochemical and biomechanical properties and resulted in greater decreases in axial
elongation and myopic diopter in the treatment group.
As for the technique being used to prevent myopia, the appropriate timeline for
interventional treatment should be further investigated, the investigators said. Scleral CXL has not yet been done on human
eyes in vivo, so potential problems should be investigated further, including long-term
safety and stability of CXL, proper parameters such as exact position and
suitable area of the eye to be treated, amount of energy needed and exposure
time, they concluded.
Due to the urgency of the increasing prevalence
of myopia worldwide, the European Society of
Ophthalmology, in cooperation with the
International Myopia Institute, published a review article to
increase awareness among eye care professionals and provide
recommendations to prevent the development and progression of myopia in children and adolescents.
Based on the IMI White Papers, this review paper makes several specific conclusions
regarding interventions for controlling myopia:
• Environmental influences: Indoor near work and outdoor activity play
important roles in developing myopia and preventing myopia, respectively.
There is strong evidence that less near work and more outdoor activity protect
against myopia development in the human eye. Time outdoors itself, rather
than physical activity, has been suggested to be the protective factor.
The link between time outdoors in the prevention of myopia is stronger than
the link between time outdoors and slowing the progression of existing
myopia. • Contact lenses: Ineffective—rigid gas
permeable contact lenses showed
inconsistent results in myopia progression (very low-certainty
evidence). Comparing spherical aberration SCLs with single vision SCLs
reported no difference in myopia (refractive) progression nor axial length
elongation (low-certainty evidence).
• Contact lenses: Effective—axial elongation was slightly less for bifocal
SCL wearers than for single vision SCL wearers (low-certainty evidence).
Orthokeratology contact lenses were more effective than SVLs in slowing
axial elongation (moderate-certainty evidence). There is evidence of myopia
control with soft multifocal contact
https://www.reviewofoptometry.com/news/a
rticle/cxl-may-also-help-halt-myopia-progression
Update and Guidance on Management of
Myopia
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lenses (low-certainty evidence), specific
myopia control soft lens designs (moderate-
certainty evidence), and orthokeratology
(moderate-certainty evidence).
• Pharmaceutical agents: Antimuscarinic
eye drugs such as atropine eye drop or pirenzepine eye gel may
slow the progression of myopia (moderate-
certainty evidence). Axial elongation was
lower for children treated with atropine
than those treated with placebo (moderate-
certainty evidence) in studies using higher
doses. However, there is a weaker association
between refractive error and axial length
changes than optical studies. According to
Cochrane summary, systematic seven-methylxanthine had a small effect on
myopic progression and axial elongation compared with placebo in one study (moderate-certainty evidence). One
study did not find slowed myopia progression when comparing timolol eye
drops with no drops (low-certainty evidence).
• Combination therapies: Myopia progression was slower in children
treated with combinations of atropine eye drops and multifocal spectacles
than in children treated with placebo eye drops and single vision lenses
(moderate-certainty evidence). Orthokeratology with low-dose atropine
improved myopia control by the synergistic effect compared with
orthokeratology treatment alone. Further studies are needed to fully
assess the efficacy and safety of
atropine and orthokeratology or
bi- or multifocal soft contact lens
combination therapy.
The authors
conclude by reminding eye
care professionals that myopia information is
continually evolving, so it is
essential to stay abreast of studies
published in the peer-reviewed
literature
A look at the research and
patient considerations Conversion from dry
AMD to wet AMD is not necessarily
inevitable, in that several modifiable risk factors can impact
the risk of disease progression. These include smoking status, cardiovascular
disease, diet and systemic antioxidant levels. Studies also have suggested that
healthy macular pigment optical density (MPOD) can play a role. As a brief
refresher, the macular pigment is comprised of three carotenoids: (1) lutein,
(2) zeaxanthin and (3) meso-zeaxanthin. Together, they protect the macula from
Prescribing Supplements for
AMD
Abstract
Update and guidance on management of myopia. European Society of Ophthalmology
in cooperation with International Myopia
Institute
The prevalence of myopia is increasing extensively worldwide. The number of people with
myopia in 2020 is predicted to be 2.6 billion
globally, which is expected to rise up to 4.9 billion
by 2050 unless preventive actions and interventions are taken. The number of
individuals with high myopia is also increasing
substantially, and pathological myopia is predicted
to become the most common cause of irreversible vision impairment and blindness worldwide, and
also in Europe. These prevalence estimates
indicate the importance of reducing the burden of
myopia by means of myopia control interventions to prevent myopia onset and to slow myopia
progression. Due to the urgency of the situation,
the European Society of Ophthalmology decided
to publish this update of the current information and guidance on management of myopia. The
pathogenesis and genetics of myopia are also
summarized and epidemiology, risk factors,
preventive and treatment options are discussed in detail. Update and guidance on management of myopia.
European Society of Ophthalmology in cooperation with
International Myopia Institute. European Journal of
Ophthalmology, 1120672121998960.
Click here for the article:
DOI: https://doi.org/10.1177/1120672121
998960
https://reviewofmm.c
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guidance-on-
management-of-
myopia/?utm_campaig
n=Research&utm_me
dium=email&utm_sou
rce=Research&utm_co
ntent=Update and
Guidance on
Management of
Myopia&utm_term=3.
20&utm_source=What
CountsEmail&utm_me
dium=Review of
Myopia Management
2019&utm_campaign
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h2021_v2
MAY 2021 6
MAY NEWSLETTER 2021
oxidative stress and blue light. (On the heels of this finding, office-based devices
have been created to measure MPOD to aid optometrists in their management
decisions).
This article discusses the research and
patient considerations associated with the treatment used to increase MPOD and the
vitamins shown to reduce the risk of AMD progression: ocular nutritional
supplementation. Optometrists can use this information to make prescribing decisions.
THE RESEARCH
The foundational evidence for the role
of ocular nutrition in age-related eye
disease was provided by AREDS (Age-
Related Eye Disease Study) and AREDS2.
AREDS shows that a supplement
formulation comprised of vitamin C, vitamin
E, beta-carotene, zinc and copper led to a 25% risk reduction of progressing to late
AMD over five years in patients who had intermediate or advanced AMD.
Additionally, for those who had advanced AMD in one eye, this risk reduction applied
to the fellow eye. Finally, no significant benefit was seen in patients without AMD or early AMD.
AREDS2 studied the addition of lutein, zeaxanthin and omega-3 and the
elimination of beta-carotene and a reduced level of zinc to the AREDS ocular nutritional
supplement. Results show that the combination of lutein and zeaxanthin had a
small beneficial effect in patients who had intermediate or advanced disease,
especially in those patients who had the lowest levels of dietary intake of the
carotenoids, and that omega-3 had no beneficial effect. Additionally, as beta-
carotene increases the risk of lung cancer
in current and former smokers, AREDS2 researchers concluded that substituting
lutein and zeaxanthin for beta-carotene in an ocular nutritional supplement was
advised.
Both foundational studies received criticism
for the following:
• Study subjects. The patients enrolled
in the AREDS studies differ from the average American socioeconomically, in
that these patients tended to have higher levels of education and better baseline nutrition.
• Other supplementation use. Some of the patients were
taking antioxidant vitamin supplementation prior to the
initiation of the trial.
• A missing carotenoid. The
AREDS2 ocular nutritional supplement did not contain meso-
zeaxanthin. Some research shows that an ocular nutritional
supplement that contains all three carotenoids benefits AMD
patients.
• Not enough omega-3. It has been
questioned whether the formulation of omega-3 used in AREDS2 was optimal,
as other research shows dietary oily fish and seafood consumption was
substantially lower in AMD patients, and serum red blood cell EPA and EPA and DHA were linked with a substantially
reduced risk of wet AMD. (See “Supplementation and Dark
Adaptation,” below.)
• No benefit for early
AMD. Observational studies demonstrate an association between
increased macular pigment levels and de-creased prevalence of macular
disease. Additional studies demonstrate the ability of nutritional
supplementation to increase the macular pigment level of an individual
patient. Therefore, one may draw the
A few notes from Dr.Ed Jervis about guidelines for AMD supplementation.
1. Patients must have intermediate dry AMD
(large drusen (bigger than the width of the retinal vein as it enters the optic nerve)
and/or retinal pigment changes (hyper-reflective foci on the OCT) 2. The patient needs to quit smoking
3. A balanced diet(including no processed food) and being close to your “goal weight” is
more important than simply taking a vitamin supplements.
5. Every patient should leave with an Amsler Grid (to be performed weekly, one eye at a
time- eg. every Friday) 6. Any distortions or drop in vision should be
scanned to determine the need for Avastin etc.
For more information, click here.
MAY 2021 7
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conclusion that supplementation has the potential to decrease risk for AMD in
individuals who have low levels of macular pigment, especially in those
who have a positive family history of AMD.
PATIENT CONSIDERATIONS
Optometrists should assess the following
information prior to prescribing an ocular nutritional supplement:
• Smoking. In patients who smoke, research shows that supplementation with high-dose beta-carotene can
increase the risk of lung cancer. As a result, Optometrists should
turn to formulations that do not contain beta-carotene.
• Genetics. A subgroup analysis of the AREDS data
suggests that different genotypes respond
differently to supplementation.
Specifically, patients who have one or two CFH
(complement factor H) risk alleles but no ARMS2 (age-related maculopathy
sensitivity 2) risk alleles were at an increased risk for progression to
advanced AMD with zinc supplementation. As a result, some
clinicians and researchers advocate for the routine use of genetic testing before beginning supplementation.
An independent study published in the British Journal of
Ophthalmology corroborated these results, but NEI researchers did not
reach the same conclusion. In the absence of a prospective clinical trial to
assess the value of genotyping, controversy remains regarding the role
of routine genotyping in supplement choice.
• Anticoagulants. Patients using anticoagulants, such as warfarin sodium
(Coumadin, Bristol-Meyers Squibb),
may experience complications from supplementation. Specifically, high
doses of vitamin E may inhibit platelet aggregation, interacting with this
medication. In addition, omega-3s may increase the risk of bleeding in those
using anticoagulant therapy. Due to these findings, O.D.s should
communicate with patients’ other medical providers before prescribing
supplements that contain vitamin E or omega-3. For those patients who cannot use
supplementation, Optometrists should tell them to avoid smoking and second-
hand smoke and eat a diet rich in omega-3 long-chain polyunsaturated
fatty acids (such as fish), and low in saturated fats and
cholesterol, among other risk-decreasing information.
AT THE READY. Our patients intuitively understand that diet is
one of the most important modifiable risk factors for
various diseases, including AMD. Some of them are even
reminded of their mothers telling them, “You are what you eat.” This tees
us up nicely to discuss the role of ocular nutritional supplements in AMD. But, to
be able to provide a prescription for a specific supplement and answer related patient questions, we must be
knowledgeable of the available research and patient considerations. Patients
depend on us. The pharmacy's supplement section has a dizzying array
of options.
Apply lessons learned in glaucoma to treating macular degeneration
Impaired dark adaptation occurs several years before clinically evident damage to
https://www.optometricmanagement.com/issues/2020/may-2020/prescribing-
supplements-for-amd
SUPPLEMENTATION AND
DARK ADAPTATION. Recently, impaired dark
adaptation has been proposed
as an early biomarker of AMD.
There is evidence that these
patients may benefit from the
early use of supplementation.
Currently, the NEI is recruiting
subjects for a clinical trial to
investigate; the role of vitamin A supplementation in AMD
patients and delayed dark
adaptation.
The evolving standard of care in AMD
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the eye has occurred in AMD. Technological advances have revolutionized dark
adaptation testing, allowing it to be carried out easily in virtually any setting.
When new technology can impact an entire
generation of patients, optometrists have an opportunity to change. Such was the
case a generation ago in glaucoma with functional testing
(automated perimetry), and we are witnessing this same change now with age-related
macular degeneration (AMD).
Prior to automated perimetry,
glaucoma diagnoses were based on structural changes of the optic nerve along
with intraocular pressure (IOP) and documented with fundus photography. In
many cases, subtle optic-disc changes were questioned or ignored. All of this changed
with the advent of automated perimetry, which provided eyecare professionals a
means to support glaucoma diagnoses by assessing early functional changes. Indeed,
automated perimetry had a dramatic influence on the diagnosis, monitoring, and
care of glaucoma patients, and it became the standard of care.
When glaucoma’s sea change occurred, I remember the impact it had on our
profession. Optometry appears to be witnessing another paradigm shift—this time in how we approach AMD.
Missing the diagnosis
AMD is more prevalent than glaucoma and
diabetic retinopathy combined, yet very few optometrists can say they have three
times as many AMD patients as they do glaucoma patients. Why might this be the
case? Put simply, optometrists are not diagnosing it as often or as early as they
could be.
Historically, the failure to diagnose was
largely due to a lack of diagnostics. After all, Optometrists are great clinicians, but
research demonstrates that even stereoscopic macular observation and
evaluating fundus photos for subtle drusen and pigmentary changes can be tedious. A
study published in JAMA Ophthalmology showed just how often
diagnoses are missed by optometrists and ophthalmologists alike—even when the
doctors were aware that their findings would be double-checked
by trained graders.
This cross-sectional study, which included 1,288 eyes (644 adults)
from patients enrolled in the Alabama Study on Early Age-
Related Macular Degeneration (ALSTAR), revealed that eyecare practitioners are
missing AMD about 25 percent of the time. Also quite concerning is that 30 percent of
the undiagnosed eyes in the study had large drusen, a well-known risk factor for
progression to advanced disease.
Shifting our understanding of
diagnostic standards
Much like glaucoma, subtle functional
changes are present in AMD prior to the earliest clinical indicators of the condition.
Also, like glaucoma care before automated perimetry became the standard of care and
subsequently software advances aided in earlier diagnosis, AMD screening and
disease classification was—until recently—based exclusively on structural changes.
However, functional changes presenting as
impaired dark adaptation take place several years before clinically evident damage to
the eye has occurred. As a result of not diagnosing AMD early and not actively
monitoring disease progression, up to 78 percent of wet AMD patients are seeking
their first treatment after experiencing substantial, irreversible vision loss—
including 37 percent who are legally blind in at least one eye. Identifying early AMD
before significant visual impairment is the goal, yet the condition is difficult to observe
MAY 2021 9
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with clinical examination or even advanced imaging technologies.
Eyecare practitioners are able to use dark adaptation to identify patients with
subclinical disease. Delayed dark adaptation is the first clinical biomarker for
AMD and precedes visible presentation of drusen. Based on the preferred practice
patterns of the American Academy of Ophthalmology, dark adaptation functional
testing may overcome the practical challenges associated with diagnosing AMD using only traditional objective clinical
assessment.
Dark adaptation screening for AMD
generally is being applied to patients over age 50 years because this was the earliest
inclusion age in the Age-Related Eye Disease Study (AREDS). Careful probing for
subtle low-light vision impairment will likely lower this threshold and also reveal this
change in patients who may consider visual changes as “age appropriate.”
As more eyecare practitioners incorporate dark adaptation testing into their practices,
they are likely to see a trend similar to that of glaucoma with older patients having
higher rates of AMD than currently document in their charts.
Introduction
According to World Health Organization (WHO) data from 2010, there were an
estimated 285 million people living with visual impairment worldwide. Of these, 39
million were reported as blind and 246 million as having low vision. The most
common causes (80%) of these visual impairments are treatable conditions such
as uncorrected refractive errors and
cataract. These are followed by age-related macular degeneration (AMD), glaucoma,
and diabetic retinopathy. It has been reported that 65% of visually impaired and
82% of blind people are 50 years of age or older. Considering that the population is
aging, this suggests that more people will be at risk in the future. Definitions of low
vision and blindness may vary between countries. According to the definition
accepted in the USA, best corrected visual acuity less than or equal to 6/60 in the better eye or a visual field less than or
equal to 20° in the better eye is considered
legal blindness. In the 2016 version of the
International Classification of Disease (ICF)-10, visual impairment is classified in
5 categories based on presenting visual acuity. While older definitions were based
on best corrected visual acuity of the better eye, the current definition is based on
presenting visual acuity (with glasses if any, without glasses if not) in order to
emphasize the burden of uncorrected refractive errors (Table 1). According to
this, presenting visual acuity in the better eye equal to or better than 6/18 is defined
as mild or no visual impairment; equal to
https://www.optometrytimes.com/view/the-evolving-standard-of-care-in-amd
Table 1. Classification of visual
impairments according to the International
Classification of Disease-10 2016 revision
A Common Approach to Low Vision:
Examination and Rehabilitation of the
Patient with Low Vision
MAY 2021 10
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or better than 6/60 and worse than 6/18 as moderate visual impairment (category 1);
equal to or better than 3/60 and worse than 6/60 as severe visual impairment
(category 2); and worse than 3/60 as blindness. Blindness is also separated into
3 categories: visual acuity worse than 3/60 (category 3), worse than 1/60 (or counting
fingers at 1 meter) (category 4), and no light perception (category 5). According to
this classification, those with moderate and severe visual impairment (visual acuity worse than 6/18 and equal to or
better than 3/60) and those with a visual field less than or equal to 20° are
defined as having “low vision” and require rehabilitation. Functionally, low
vision can be regarded as a level of vision that prevents someone from
performing their everyday activities. Having a presenting visual acuity worse
than 3/60 and a corresponding visual field smaller than 10° is defined as
blindness. Because this new definition also includes uncorrected refractive
errors which were previously unaccounted for, the prevalence of
blindness in various countries increases to 15% in all age groups and 25-30%
among older adults. Studies have shown that the prevalence of low vision is up to
60% among older adults.
The prevalence and causes of blindness and low vision in different societies vary based on their level of development.
According to WHO data, the prevalence of blindness is 7.3/1000 in Africa, 3.5/1000 in
the USA, 8.5/1000 in the Eastern Mediterranean Region, 3.0/1000 in Europe,
6.9/1000 in Southeast Asia except India, and 5.3/1000 in the Western Pacific Region except China. Global data indicate there
are 3 people with low vision for each blind person; in the USA and Europe, which have
the lowest rates of blindness, the prevalence of low vision is 25.6 and 28.7
per 1000, respectively. This rate is 25.4/1000 in Africa and 32/1000 in
Southeast Asia.
According to data from 2000, it was estimated that there were 937,000
(0.78%) blind and 2.4 million (1.98%) people with low vision over 40 years of age
in the USA. Age-related macular degeneration (AMD) is the most common
cause of blindness among Caucasians, accounting for 54.4% of cases. By 2020,
the prevalence of blindness in the USA is predicted to increase by 70% to reach 1.6
million, and a similar increase is expected
in the low vision population.
Globally, 42% of visual impairment is due
to uncorrected refractive errors, while 33% is caused by cataract. Other major causes
include glaucoma, diabetic retinopathy (DR), trachoma, AMD, and corneal
opacities. The primary cause of blindness is cataract (51%) (Figures 1 and and22). In
North America and other developed countries, the main causes of vision loss are AMD, DR, and glaucoma. Other causes
include herpes simplex keratitis, retinal detachment, retinal vascular diseases, and
hereditary retinal degenerative diseases. In developing countries, the primary causes of
vision loss are uncorrected refractive errors and cataract, followed by glaucoma,
infectious diseases, injuries, and xerophthalmia. In short, visual impairment
Figure 1 ;Distribution of global causes of visual impairment (taken from WHO report entitled Global
Data on Visual Impairments 2010)RE: Refractive errors,
AMD: Age-related macular degeneration, CO: Corneal opacity, DR: Diabetic retinopathy
MAY 2021 11
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in developed countries is a result of unpreventable and/or currently untreatable
causes, whereas preventable (infectious, e.g. trachoma, or nutritional, e.g. vitamin A
deficiency) and/or treatable (e.g. cataracts) causes still play a major role in developing
countries. The fact that most of the diseases that cause blindness and low
vision are preventable or treatable has
prompted many organizations to take action, especially WHO. According to the VISION 2020 report from WHO, low vision
prevention and rehabilitation are among
the primary global goals.
A person’s ability to perform important
sight-based tasks is defined as “visual functioning”. Reduced visual functioning
due to disorders of the eye or visual system results in low vision. In addition to visual acuity, visual functioning should be
assessed using parameters such as visual field, contrast sensitivity,
electrophysiological tests, adequacy of preferred retinal locus, color vision,
binocularity, and stereopsis.
Low vision rehabilitation aims to increase quality of life by enabling patients to live independently, have a vocation or skill with
which they can financially support themselves, and enjoy life. The stages of
modern low vision rehabilitation include the intake, assessment of residual visual
function, assessment of residual functional vision, interventions and recommendations,
and vision rehabilitation therapy.
1. The Intake
The purpose of low vision assistance and rehabilitation is to enable
individuals to perform the sight-based activities they want to do but
currently cannot, using special
methods and/or equipment.
The initial interview is of key
importance, as it will influence the entire rehabilitation process. The patient’s family members should also
be involved in some parts of this process, and it is imperative that
sufficient time be allocated. History-taking from a patient with low vision
differs from that in the classical ophthalmologic examination. The
patient’s sociocultural characteristics, medical and ocular history, priorities,
and goals must be questioned in detail and recorded. A patient is
asked which tasks are difficult or impossible for them to perform in order to
gain insight into their visual functioning. In particular, they should be asked about
which activities they are limited in and wish to continue doing. It should be determined
whether they use any methods to help them perform the activities that they have difficulty with. The environmental
conditions in locations such as their home, school, and workplace should be
questioned, as well as what provisions are needed to increase their visual functioning
in these places.
It must be kept in mind that patients may have different needs, and each patient should be offered personalized solutions.
Visual needs important to the patient may include reading, doing crafts, watching
television, seeing the board in school, or reading road signs or bus numbers. Some
Figure 2 : Distribution of global causes of blindness (taken
from WHO report entitled Global Data on Visual Impairments
2010)
RE: Refractive errors, AMD: Age-related macular degeneration, CO:
Corneal opacity, DR: Diabetic retinopathy
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patients can have unrealistic expectations of low vision rehabilitation, such as being
able to drive. Although rehabilitation has a high success rate in regaining abilities such
as reading, patients with low vision are not eligible to receive a driver’s license in
Turkey. It may be necessary to inform patients what expectations are realistic
without being discouraging. In cases where the patient and their family cannot adapt to
their current situation and are pessimistic, the negatives of the patient’s visual impairment and disease should not be
emphasized during the interview; instead, they should be guided and encouraged
about what they can do.
When planning the rehabilitation program, questionnaires and scales about activities
of daily living can be used to determine in detail what difficulties the patient faces in daily life. These scales are also used to
evaluate the effectiveness of low vision rehabilitation. One of these scales is the
Low Vision Quality of Life Questionnaire (LVQOL), developed by Wolffsohn and
adapted to Turkish by Idil et al. and another is the National Eye Institute Visual
Functioning Questionnaire (NEI-VFQ 25), which was adapted to Turkish by Toprak et
al. The purpose of these scales is to characterize and determine the impact of
visual impairment in daily life. The Turkish version of the LVQOL consists of a total of
24 items in 5 dimensions, including 12 items about distance vision, mobility, and
lighting, 3 items about adjustment, 5 items about reading and fine skills, and 4 items
on activities of daily living. The NEI-VFQ 25 comprises 25 items in 11 subgroups and 12
optional items. This scale includes items assessing general vision, difficulty in activities requiring near and distance
vision, limitations of peripheral and color vision, ocular pain, vision-related limitation
of social functions, role limitations, dependency, mental health symptoms, and
driving difficulties, and general health. Higher scores in these scales correspond to
better quality of life. When evaluating the patient with low vision, quality of life scales
are useful for assessing the patient’s perceptions of their disease and whether
rehabilitation has resolved their vision-
related problems.
2. Assessment of Residual Visual
Functions
Determining visual function is essential
when examining the patient with low vision. Low vision examination differs from routine ophthalmologic examination in
some respects. Distance and near visual acuity are assessed in detail. Best visual
acuity should be determined with the most appropriate correction, because the
patient’s residual vision will inform the
selection of rehabilitation methods.
Measurement of Distance Visual Acuity
Visual acuity measurement is the easiest and most useful method of assessing visual
functioning, although it does not fully reflect a low vision patient’s performance in daily life. At this stage, it is essential to use
charts that a person with low vision can see and place them at an appropriate test
distance. A person with low vision gaining the ability to read some letters on a
suitable and correctly applied chart when they could not read any letters in previous
examinations is an important positive initial experience in the rehabilitation process.
Accurate determination of visual acuity in a patient with low vision is also important to
monitor disease, determine the amount of magnification needed for glasses or other
optical device, evaluate response to therapy if provided, and to create disability
reports if required. Examination should be performed under standard conditions (e.g.,
fixed chart distance and lighting) and with suitable charts. The Snellen chart is not
appropriate for examination of the low vision patient because it has low sensitivity in the 6/10-6/24 range due to its irregular
geometric arrangement and because the top lines are easier to read due to the
crowding phenomenon. Instead, the logMAR-based Bailey-Lowie or Early
treatment diabetic retinopathy study charts
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are preferred. Advantages of these charts are that they use logarithmic scales and
the lines include equal numbers of letters of similar legibility. The spacing between
the letters and lines is determined based on the size of the letters in each line. More
lines are included at the low vision levels. Visual acuity is scored as 0.1 logMAR for
each line and 0.02 logMAR for each correctly read letter. Better visual acuity
corresponds to a lower logMAR score. Depending on visual acuity, measurement can be performed by adjusting the distance
between the patient and chart to 2 meters or even 1 meter. It is suitable for use in
low vision examination because it provides more sensitive measurement at low vision
levels, facilitates refraction examination,
and is preferred for academic purposes.
Measurement of Near Visual Acuity
For patients with low vision, charts that include text samples are better for
assessing near vision than charts that use optotypes. This enables the evaluation of
reading performance, detection of any scotomas, and assessment of the effectiveness of therapy or rehabilitation.
During examination, it must be ensured that the distance between the individual
and the near vision chart is appropriate and fixed. The patient’s near vision is measured
monocularly and binocularly using an addition suitable for the working distance of
the reading chart. The metric M-unit is used for letter size. Near vision acuity is
recorded as reading distance in meters divided by letter size in M-units. The
Minnesota Low Vision Reading Chart (MNREAD), which can be applied using a
computer screen or printed cards, is one of the charts frequently used in patients with
normal or low vision, especially for
international comparisons.
Refraction Test-Retinoscopy
Refraction testing must be performed more carefully in a patient with low vision. When examining low vision patients with
abnormal head position, eccentric gaze, or nystagmus, the use of trial frames and
lenses should be preferred over phoropter.
For patients with eccentric fixation or
nystagmus and for uncooperative patients, cycloplegia and dynamic retinoscopy should
be performed when measuring refractive error. Although refractive error can be
measured using an autorefractometer in patients with low vision, determining
refractive error by retinoscopy is ideal. When a clear reflection cannot be obtained,
the patient should be approached until a reflection is seen, and necessary
adjustments should be made based on this distance. After retinoscopy, the patient’s
refractive error is confirmed using subjective methods such as fogging and
cross-cylinder.
Remarkably, for approximately 15% of
patients referred for low vision rehabilitation, functional vision can be
restored by simply prescribing appropriate
distance and/or near vision spectacles.
Visual Field
Visual field is one of the most important parameters of visual function in the low vision patient. Diseases involving the
macula, such as AMD, hereditary macular dystrophies, and macular edema, lead to
scotomas that significantly impact visual functioning and reading performance. The
Amsler Grid test is especially useful for identifying the location and size of central
scotomas. However, this test is inadequate for small scotomas and conditions such as
macular diseases in which fixation is commonly extrafoveal and unstable. These
types of visual field defects are best evaluated by scanning laser
ophthalmoscope (SLO). Because SLO provides instant retinal images, visual field defects and the related area of the retina
can be evaluated simultaneously. Microperimetry using SLO technology
enables the detection of important parameters such as preferred retinal locus
and fixation stability in low vision patients
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with central scotoma, and trained retinal
locus training can be provided.
Peripheral visual field loss adversely affects an individual’s orientation in unfamiliar
environments, mobility, and hazard perception. These defects are often seen in
patients with advanced glaucoma and retinitis pigmentosa. Kinetic (Goldman) and
static (Humprey, Octopus) perimetries can
be used to evaluate such defects.
High-power prism designs are used for hemianopias and quadrantanopias of
neurological origin and cases of tunnel vision due to diseases such as retinitis
pigmentosa.
Assessment of Contrast Sensitivity
Contrast sensitivity is the power to distinguish differences in shade between two regions. Although contrast sensitivity
tests are not used in clinical practice for every patient with low vision, they can be performed for patients whose visual
functioning is poorer than expected based on their measured visual acuity. Clinically,
deficits in contrast sensitivity are especially common in corneal edema, cataract, optic
nerve diseases, and some retinal diseases. Patients with low contrast sensitivity might
require more magnification than expected for their visual acuity and may benefit from
increased ambient light. Closed-circuit television systems that increase contrast
and broaden the visual field can be recommended to these patients. Many
contrast sensitivity charts are used in clinical practice to measure perceived
contrast, such as the Vistech VCTS test, Pelli-Robson Letter chart, Arden chart,
CSV-1000 chart, and Regan chart. For patients with low vision, contrast sensitivity
tests designed specifically for low vision should be used, such as the CSV-1000LV,
ELCT, and CSV-1000 1.5 cycles/degree.
Color Vision
Hereditary and acquired color vision disorders have several distinguishing
features. Hereditary color blindness (protanopia and deuteranopia) is a stable,
binocular, usually red-green color vision deficiency that preferentially affects males.
Other visual functions are normal. Acquired color vision deficiencies can be monocular
and asymmetrical, are often progressive, and usually involve blue-yellow color
blindness. Most color vision disorders in patients with low vision are blue-yellow
dischromatopsia. Pseudoisochromatic plates are the most commonly used color vision tests. They are simple and can be
performed quickly. They comprise colored numbers or paths on a background of equal
saturation. The Ishihara test, the most well-known pseudoisochromatic table, only
tests red-green vision. For blue-yellow dischromatopsia, which is more common
among patients with low vision, color arrangement tests such as the Farnsworth
100 Hue and D 15 tests or the Wang & Wang color vision plates are more
appropriate than the Ishihara test. In addition, the reliability of
pseudoisochromatic tests decreases at visual acuity levels lower than 6/20. In
general, blue-yellow color blindness is considered to be associated with large
lesions involving the outer retina, while red-green color blindness occurs in lesions
involving the inner retina and optic nerve. Furthermore, blue-yellow color blindness is seen in cataract and glaucoma, while red-
green color blindness occurs in cone dystrophy. As part of rehabilitation,
patients can be advised to seek high color
and tone contrast.
Glare Test
Glare refers to excessive brightness in the visual field and can be accompanied by
asthenopia, headache, and squinting. Glare can be associated with media opacities
such as cataracts and corneal scar, or albinism, achromatopsia, or aniridia. It can be assessed simply during visual acuity
measurement by holding a light source near the fixation line and observing the
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reduction in the number of lines or letters
the patient can read.
3. Assessment of Residual Functional
Vision
Low vision patients with similar residual
visual functions may have very different performance when it comes to utilizing
their vision. Assessment of residual functional vision determines how and to what extent the low vision patient can use
their residual vision and the individual and environmental factors that affect this
ability. This also includes educational vision assessment to facilitate appropriate
education planning.
As explained in detail in ICF system, in addition to their visual functions, an individual’s activity and participation and
environmental factors must be evaluated in a rehabilitation program. In other words,
visual functions determine a person’s capacity, whereas functional vision refers
to their performance.
Therefore, functional vision assessment identifies how the patient uses their vision and
what visual skills and environmental adjustments
they need to better use their vision. It is based on the
patient’s actual performance in the target activity and
measurement of the adequacy of this performance. For
example, in a patient whose primary goal is to read,
residual visual function is determined using methods
such as visual acuity, refractive error, and visual
field, while residual functional vision is measured using a performance index such
as reading speed. Reading performance should be assessed using continuous text cards instead of solitary optotypes.
Continuous text cards must be representative of commonly read materials
and commonly used words in the population, be standardized in terms of
length and width, and be printed in the
native language of the population.
An objective measure of reading performance is maximum reading speed.
Other parameters that can be used in assessment include reading acuity, critical
print size, and Reading Accessibility Index. Maximum reading speed is the reading rate
that is not limited by print size. Reading acuity is the smallest print size that can be
read without making any errors; critical print size is the smallest print size that can
be read at maximum speed. The recently developed Reading Accessibility Index
indicates the visual accessibility of familiar printed material and is calculated as the
mean reading speed across the ten largest print sizes on an MNREAD chart. It
represents reading performance in daily life. MNREAD cards, developed at the University of Minnesota, can be used to
assess reading performance. They provide corresponding values for reading acuity in
Snellen, logMAR, and M-units from 40 cm. Although originally
in English, they have been validated
in various languages. A
Turkish version has also been
developed and validated and is of
equal difficulty to versions in other
languages to allow its use in
international
studies (Figure 3).
Quality of life scales can be used in the
subjective evaluation of functional vision. It is also possible to evaluate the
effectiveness of rehabilitation with these
scales.
Daily visual goals usually include reading, writing, watching television, dressing,
performing personal care, moving around, cooking, doing home maintenance,
Figure 3: Assessment of reading performance
using MNREAD cards
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cleaning, and working. A rehabilitation program is designed taking into account
the patient’s visual priorities and their distance, near, or intermediate distance
vision needs. This planning requires a multidisciplinary low vision team. In order
to increase the patient’s participation and motivation, their family should be involved
in planning and implementing the low
vision rehabilitation.
4. Interventions
The data obtained in the first three stages
are evaluated and an individualized intervention program is planned for each
low vision patient. This program encompasses the necessary techniques
and/or assistive technology.
Devices Used in Low Vision
Rehabilitation
Optical systems
I. Telescopes
Advantages of telescopes include being able
to magnify an image at long
working distances with hands-free
use; however, they also have
disadvantages such as being difficult and dangerous to use when moving
due to narrowing of the visual field, causing difficulty in achieving binocularity, and
being costly, and they can also cause esthetic concerns. They can be integrated
into the patient’s own prescription glasses, and some models are also focusable
(Figure 4). Their length increases with their magnifying power, and visual field narrows
as their length increases and diameter decreases. Bioptic telescopes can be used
at magnifications of up to 6x. When a
telescope is prescribed for a patient with
low vision, they must be trained in its use.
Telescopes are either Galilean or Keplerian depending on their optical principles. The
Galilean telescope consists of two lenses, a low-power plus objective lens and a high-
power minus eyepiece lens, and it gives an upright image. The Keplerian telescope also
consists of two lenses, a low-power plus objective lens and high-power plus
eyepiece lens. The inverted image obtained with Keplerian telescopes is corrected with
prisms. Although Galilean telescopes have certain advantages such as being shorter
and lighter and having a larger visual field, Keplerian telescopes have better image
quality because they use light more efficiently. Keplerian telescopes are more
complex with a wider range of focus. The telescopes used in low vision rehabilitation
are usually Keplerian.
Telescopes can be focusable or fixed-focus
depending on their focusing characteristics. In focusable telescopes, the patient’s
spherical error can be corrected and a base lens may be required for high astigmatism.
With fixed-focus telescopes, the patient’s refractive error (spherical + cylindrical)
must be given as the base lens.
Depending on the patient’s vision level,
telescopes can be prescribed monocularly or binocularly. For near vision, a +3.00 to
+12.00 D cap (reading cap) can be attached. Telescopes can be hand-held,
clip-on, or spectacle-mounted (large-scale, bioptic, mini-telescope). Spectacle-mounted telescopes are mostly used for
watching television or by school-aged children for looking at the board, whereas a
monocular hand telescope is hung around the neck and used only when needed,
allowing the user to continue their
everyday activities.
Although telescopes are not suitable for use when moving due to narrowing of the
visual field, various special designs have been developed in an effort to overcome
this limitation.
Figure 4: Some types of
telescopes used in our clinic
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These designs, which are used when in motion, are bioptic telescopes and
autofocus telescopes. In bioptic telescopes, a
compact, low-power magnifying telescope is
placed in an area in the patient’s visual field,
usually the superotemporal region.
When the patient looks through their glasses, the magnified image from the
telescope can be viewed when needed by
adjusting their head or eye position. With
autofocus telescopes, this process is modified with a
motorized focusing system so that the user
can easily follow objects at different distances
(Figure 5). Although bioptic telescopes are
useful for distance viewing, their use is
limited by their appearance and the ring
scotoma surrounding the magnified image. This led to the recent
development of ‘in-the-spectacle-lens’ telescopes, a design in which a wide-field
Keplerian telescope is built completely within the
spectacle lens. By simultaneously using the
magnified and nonmagnified view of the viewing area, the
vision multiplexing feature provided by these devices
facilitates the patient’s
orientation and navigation.
II. Microscopes (High-
Diopter Near Spectacles)
After correcting hyperopia, near addition and reading distance are calculated according to
Kestenbaum’s rule. For example, in a patient with a corrected visual acuity of
20/100, the near add is the inverse of visual
acuity, 100/20=5 D, and near reading distance is
1/5=20 cm. The add is gradually increased to the
dioptric power that allows the patient to comfortably
read a text size of 1 M. The actual value will be higher than the predicted
value in patients with low contrast sensitivity or
macular scotoma and those who want to read
letters smaller than 1 M. Binocular vision up to +10
D is possible. As the dioptric power increases,
reading distance is reduced accordingly. If
the reading distance is too short, it can be
increased with high-power plus lenses held away
from the eye with special clip-on systems. The
effect of additional illumination must also be assessed during
examination. The advantages of microscopes include their wide visual field, hands-free
operation, and pleasing esthetic appearance.
Negative aspects are their short working distance and
inability to tolerate values greater than 10 D binocularly
(Figure 6).
In patients whose binocular
vision is better than their monocular vision (i.e., with
similar visual acuity in both eyes), a base-in prism can
be added to facilitate accommodative convergence
(Figure 7). Although there are various formulas to calculate Δ
Figure 5
Various examples of bioptic telescopes
Figure 6: Some types of
microscopes used in the clinic
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addition, a base-in Δ roughly twice the D power addition can be added to both eyes.
If the patient’s reading performance is better
when their less sighted eye is closed
(i.e., the patient is functionally
monocular), a frosted lens can be prescribed
for the less sighted eye or the patient can be instructed to close
the weaker eye when
reading.
Because high D
(greater than +4.5 D) additions in bifocal
and progressive lenses are difficult to tolerate binocularly and the
likelihood of problems at intermediate and far distances increases
in parallel with D power, dedicated reading glasses should be recommended to patients
with low vision. Moreover, as the use of near vision spectacles provides a larger
visual field, it will enable eccentric viewing.
III. Magnifiers
Magnifiers can be used in addition to near vision spectacles in order to meet the needs of low vision patients when reading
and performing tasks requiring near vision. They can be used simultaneously with near vision spectacles, and do not require
myopic correction in most patients. Remember that with magnifiers, the
greater the working distance, the smaller the visual field. Magnifiers are available as
hand-held, stand, illuminated, fiberoptic,
and dome/bar magnifiers.
Advantages of hand-held magnifiers are that they are portable, can be used at
longer working distances than spectacles, and are inexpensive. Some have built-in
illumination. The virtual image can be brought closer to the focal plane at the
back of the eye by changing the object
distance. Aspheric magnifiers provide better image quality. They are useful when
looking at mobile phone screens and price tags while shopping.
However, they must be held steady at a fixed working
distance (Figure 8).
With stand magnifiers, the
object distance can be adjusted easily. They require a fixed, flat
surface and
usually include a
built-in light
source. This
increases contrast and
reduces the amount of
magnification needed, thus increasing reading speed. Stand magnifiers should be
used in conjunction with near vision spectacles of about +3.00 to +3.50 D in
older patients.
They may be preferable
for those who cannot
use hand-held
magnifiers due to
tremor, paralysis,
arthritis, or poor hand-eye
coordination, or those who
require more magnification than spectacles
provide (Figure 9).
IV. Filtering Lenses
These lenses filter certain wavelengths of light while allowing the passage of other
Figure 7. Microscopes with prism
additions
Figure 8. Hand-held
magnifiers
Figure 9. Stand magnifiers
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wavelengths. This reduces the patient’s photophobia and provides clearer vision by
increasing contrast sensitivity. According to the patient’s needs, different filtering
lenses can be prescribed for both indoors and outdoors. The lenses are different
colors based on the wavelength they filter. Although there are filters recommended for
certain diseases, it is more appropriate to
try a set of filtering lenses to identify the
filter the patient is most comfortable with
(Figure 10).
V. Electro-optical Systems
Closed-circuit television (CCTV) systems
are systems that project visuals such as written text or images to a screen and
enable adjustments such as magnifying the image and changing brightness and
contrast. They are so called because of the direct cable connection between the
camera imaging system and the display. Features such as variable magnification,
auto-focus, magnification without focusing, reverse contrast, voice-command controls,
and automatic forwarding have also been added to these systems. Electro-optical
systems mitigate or overcome many problems associated with magnifying
systems, such as narrow visual field, short working distance, reduced contrast,
aberrations, and illumination. The main problem with electro-optical systems is that
they are large and costly. However, with technological advances, systems now come
in portable sizes and have become
relatively less expensive (Figure 11).
Mouse magnifiers are devices that look like a computer
mouse and contain a
camera that is moved
over the material to
be viewed. They are
easy to carry,
cheaper than CCTV
systems, and can be
connected to most personal
computers. They can
have variable magnification, reverse contrast,
and focusing features. Their main disadvantage is limited viewing area
(Figure 12).
Today,
electronic tablets have
become more popular than
most optical systems due
to their many functions and
applications that assist
those with low vision,
especially school-age
children. Most individuals
with low vision can benefit from electronic reading devices such as the iPad (Apple,
Cupertino, CA, USA) and Kindle (Amazon, Seattle, WA, USA). A prospective study showed that these types of electronic
Figure 12. Mouse electronic
magnifier
Figure 11. Examples of electro-
optical systems
Figure 10. Filtering lenses
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devices increased reading performance in most patients. These devices include
applications that enable the user to increase the size and darkness of
characters, adjust the contrast, brightness, and color of the display background,
magnify and zoom, zoom by taking a photograph of an image, take spoken
commands, and read text aloud. Their advantages include ease of access,
relatively low cost, and combination of different functions that can be used for
both distant and near tasks.
Non-Optical Systems
Non-optical systems increase the patient’s residual visual function or use signals that
stimulate one of the other senses. Illumination, large-print books, increased
contrast, typoscope, reading stands, and sunglasses or spectacles with filtering
lenses to reduce glare can be used alone or in conjunction with optical systems in
patients with low vision.
Illumination reduces the need for
magnification and increases reading performance, particularly in macular
degeneration patients who have reduced contrast sensitivity. Patients must be
taught how to properly direct table lamps while reading. The built-in illumination in
hand-held and stand magnifiers increases reading performance for most patients. On
the other hand, patients complaining of excessive glare will benefit from reducing the light level and using hats, sunglasses,
filtering lenses, and light-blocking glasses. Patients can be advised to increase the
contrast when printing documents, try different contrasts such as a light-colored
object on a dark background, use glasses with contrast-enhancing yellow or orange
filtering lenses, and use a typoscope or
electro-optical system.
5. Recommendations and Vision
Rehabilitation Therapy
As visual impairment progresses, patients
can be offered alternate tools and
techniques such as white cane training, use of the Braille alphabet, audio books, and
voice recording devices. It is also very important to modify the patient’s living
conditions. Taking measures such as sitting students in the middle of the front row of
the classroom, organizing the kitchen and other home environments in a contrasting
and appropriate way, and accentuating steps and handrails will make daily life
easier. Vision loss can have a major impact on some quality of life and emotional state in some individuals. These people should
receive psychological counseling to help them adjust and overcome the emotional
problems they are experiencing.
Low vision rehabilitation is not just the prescription of a low vision aid. Training
programs consisting of habituation exercises practiced in the clinic or at home constitute one of the most important
stages of rehabilitation. Various training programs and courses are implemented in
vision rehabilitation therapy to develop related functions and improve performance.
Some of these programs are reading and writing skills, orientation and mobility, and
driving education in countries where it is legal. Occupational therapists conduct
assessments at the patient’s home, school, or workplace to improve orientation and
mobility and facilitate adaptation. If there are target activities in the patient’s real life
environments, they are also practiced using the auxiliary devices and the necessary
environmental adjustments are
recommended.
In South African society corruption, fraud
and accounting failure have become the norm, so much so that we barely react when the latest scandal hits the headlines.
We have become fatigued, but this doesn’t mean that we can give up the fight against
these scourges of society. To quote Edmund Burke, “The only thing necessary
https://www.ncbi.nlm.nih.gov/pmc/articl
es/PMC6517854/
Ethics
MAY 2021 21
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for the triumph of evil is for good men to do nothing.” We cannot turn a blind eye
when we see minor acts of unethical behaviours, as once someone has displayed
that he can “get away with it”, what will prevent him from further, more serious
unethical behaviours?
Looking at the likes of Steinhoff, the Guptas, Tongaat-Hulett, Bosasa and other
large corruption, fraud and accounting failure cases, we have to look to the leadership of these entities and, sadly, our
country.
Corruption and bribery cannot happen with only one-party present. It is trite to say “It
takes two to tango”.
So, why do so many people follow and support them?
There are three main reasons:
Position
By placing themselves in positions of
power, these people assume positions of leadership and respect. Most of us are
taught from a young age to respect and obey people in these positions. You defer to
the chairman of the board, you listen to your teachers, you do as the police ask, even when they are wrong. People who
question the system are considered troublemakers. This is leading through fear
and cannot continue forever. As has been seen in the Bosasa matter, once freed from
this leadership, people start speaking out and the house of cards will tumble.
Expertise
If someone knows more about a topic than
you do, you are more likely to take his advice or follow his instructions. It is
rational do so. Looking at Steinhoff, with senior Chartered Accountants telling the
accounting department how to account for transactions and values, why would they
not simply do as they were told?
Relationships and Charisma
Once you’ve known somebody for a period of time and have built a relationship with
him, you are more likely to want to assist him. If you like that person, the willingness
to assist increases exponentially. Most leaders are charismatic and likeable in their
professional personas. They are able to hide who they are from the outside world
and therefore it comes as a surprise when we discover a fraud or corruption matter. Bernie Maddoff is a case in point. He was
the former non-executive chairman of the NASDAQ stock market. He also ran the
largest Ponzi scheme in the world for over twenty years.
So, how do we lead ethically and ensure
that we are running ethical businesses?
As the saying goes, the fish rots from the head. It comes down to leadership. Do you
want a high-flying CFO, with a penchant for creative accounting or the CFO who is not
afraid to challenge accounting treatments or out of the ordinary transactions? Do you
want a CEO who leads by bullying subordinates into submission or the CEO
whom people genuinely respect because she always does the right thing for the
company given the circumstances? Do you really want to be fellow directors with the person who is having an affair? What
makes you think he would be loyal to the company and the board? You cannot simply
draw a line in the sand and state that the way people behave in their personal lives
does not impact on their professional lives. It does and it will. You may not know when
and how it will transpire, but it will.
Compliance with the King IV report on corporate governance is a statutory
requirement for entities listed on the JSE. Private entities are strongly encouraged to
adopt as much of King IV as is reasonably possible. The definition of ethics included in
King IV is as follows: “Considering what is good and right for the self and the other, it
can be expressed in terms of the golden
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rule, namely, to treat others as you would like to be treated yourself. In the context of
organisations, ethics refers to ethical values applied to decision-making, conduct,
and the relationship between the organisation, its stakeholders and the
broader society.”
According to King IV, ethical leadership requires integrity, competence,
responsibility, accountability, fairness and transparency. It complements effective leadership, which is results-driven. Do you
live these principles outside of your professional environment, in your
relationships and in your communities? Being ethical may cost you a contract here
and there. However, being unethical can cost you your reputation. And that is a
much higher cost.
So, the question is - What is Ethical leadership? It’s definitely not about trying
to avoid a scandal!
The Oxford Dictionary defines ethics as: “Moral principles that govern a person’s
behaviour or the conducting of an activity.”
Ethical leadership is about acting responsibly and modelling the right
behaviours to be able to inspire and lead your employees into achieving more; and to create the most value for society. Ethical
leaders should always display ethical and appropriate behaviour in all facets of their
lives and should lead by example. In addition, they should always strive towards
creating an ethical work environment articulated by policies and rules best for the
business and its stakeholders and not by politics or personalities. Decisions and
outputs need to be value-based and in line with the organisation’s vision and mission.
This is in line with the King IV Code and
Principles (17 principles which include one extra for institutional investors) that
replaced King III. Mervyn King, chairperson of the King Committee, said that: “An
updated code became necessary because of
the international and local developments in corporate governance. In drafting the King
IV report, the committee revised the ‘apply or explain’ approach and replaced it with an
‘apply and explain’ approach. King IV advocates that the governing body must
disclose the means through which it is being held accountable to deliver. With the
code bringing to the forefront ethical and effective leadership, the first three
principles especially intensify the importance of ethics in an organisation.
Let us examine these a bit further:
Principle 1- The Governing Body Should Lead Ethically and Effectively:
This principle encompasses the six ethical
characteristics of integrity, competence, responsibility, accountability, fairness and
transparency. In any organisation, the Board of Directors must adhere to all its
duties by acting with due care and diligence. In addition, the Board must be
composed of competent individuals who can steer and set the tone for the
organisation, set the strategic direction, review and approve policies, be risk
adverse and, very importantly, ensure accountability.
Principle 2: The Governing Body Should Govern the Ethics of the
Organisation in a Way that Supports the Establishment of an Ethical
Culture:
This principle further exacerbates the need for ethics to be endorsed by organisations.
Ethical foundations must be established. A few examples of how this can be achieved
and managed is by way of documenting and implementing a Code of Ethics and
Conduct, endorsing policies around corruption and anti-bribery, Whistle
Blowers, gifts and the establishment of a Social and Ethics Committee.
Principle 3: The Governing Body
Should Ensure that an Organisation be
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a Responsible Corporate Citizen:
In order to become a good corporate citizen, the board must at minimum assess
its activities in the following areas: the workplace (health and safety of its
employees, fair and equal pay, the relevant labour legislation requirements, BBBEE
etc.), the economy (economic transformation, tax legislation etc.), society
and the environment. Overall, the King IV Code calls for leaders
to be ethical and to break away from results and compliance-based leadership
styles. Leaders should become more strategic by applying their minds to the
manner in which they conduct their day to day business, and to be held accountable
for their actions.
In an ever-changing world, as ethical leaders within our organisations, we need
to strive towards creating a culture in which people do the right thing. Leading
from the top is not always pleasant and it requires a demonstration of courage. You
are never going to please everyone and some of your decisions may leave you
questioning whether you have done the right thing. However, the running of an
organisation ethically and responsibly is never going to be an easy task.
We are at a time where the world is experiencing great difficulty and it is
becoming increasingly difficult for businesses to decipher between what is
right and what is wrong. Ethics, Integrity, Competence, Responsibility, Accountability,
Fairness and transparency have never been more important. Make the right choice!
Regards
Ingrid
https://www.moore-southafrica.com/news-
views/october-2020/leading-with-ethics