Spectacles
Many patients who are referred to Low Vision (LV) clinics
simply need a careful refraction and new spectacles. Some
have previously been told that they will not benefit from
new spectacles but achieve an improvement in acuity of several
Snellen lines with new spectacles and need no further vision
aids!
To measure visual acuity in a low vision patient, ideally
a Bailey-Lovie chart (available from the NVRI) should be
used. These can be set at any distance from the patient,
commonly 6m, 3m or 1m. A patient previously classified as
‘less than 6/60’ or ‘Counts Fingers’ R&L may prove to
be 1/36 in one eye and 1/12 in the other – this difference
of a few lines can be very informative when deciding which
eye to use a magnifier with. Often a patient will, out of
habit be using a dominant eye despite the vision being reduced
to worse than that in the non-dominant eye.
Take the time to attempt an objective refraction – do your
best with retinoscopy. Auto-refractors can be very useful.
Perform a subjective refraction using coarse bracketing
(+/-1.00 sph and cyl or even much larger steps to +/- 10.00D
if you have no objective estimate). It can be surprising
how well a patient with poor vision can discriminate. Make
a note of your perception of the reliability of your refraction
results and suggest a re-refraction at the LV clinic if
appropriate.
For reading, try high add’s. In single vision spectacles
with base-in prism, binocular reading additions of up to
around 12 dioptres can work. Demonstrate to the patient
that the working distance will be short and that illumination
needs to be adequate.
Good spectacles can make a big difference – magnifiers
can then be used to magnify a clear retinal image rather
than magnifying a blurred one. The patient can receive a
psychological boost from an improvement in vision with spectacles
when they realise that their vision has not deteriorated
as much as previously thought. However, it is important
that the patient has realistic expectations of any improvement
to avoid disappointment.
A good, systematic method of near vision assessment is
presented in the paper Prescribing near magnification for
low vision patients. (Lovie-Kitchin JE, Whittaker SG. Clin
Exp Optom 1999; 82: 6: 214-224) – available on the OAA website:
www.optometrists.asn.au
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Magnifiers
Demonstrate the magnifiers and vision aids you have in practice
and discuss referral elsewhere for a wider selection. Give
the patient an idea of the range of LV aids available, including
CCTV devices. Although these can be expensive, Veterans
Affairs may cover the cost.
Optical aids (spectacles, magnifiers, telescopes, etc.)
& CCTV / computer aids and appropriate training can
be supplied at low cost through low vision clinics. Local
libraries might have CCTV units. If you are interested to
find out more about the range of available LV aids, contact
your local LV clinic, Guide Dogs Queensland or a LV equipment
supplier such as European Eyewear.
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Other Vision Aids
Appropriate lighting is vitally important (see advice section).
Glare reduction may be required - tinted or photochromic
spectacles, sunshields and hats. Other helpful items include
reading stands, large-print publications, large-button phones
and large-figure watches.
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Vision Training
Try to assess the size & position of any central scotoma.
Use the Amsler charts or confrontation. The patient may
have already learned eccentric viewing, but appreciate further
advice to refine and reinforce the use of this technique.
Remember, some patients will habitually use a damaged dominant
eye even though the vision may be far better in the other.
They should practice using the better non-dominant eye for
monocular tasks.
Instruction in the proper use of low vision aids for enhancing
residual vision might be helpful. Such training might include
the use of document stands, text guides, thick lined paper,
signature guides etc. This training can be done at LV clinics.
Discuss the development and use of the other senses e.g.
hearing aids, audible or talking devices. Mobility training
may be useful in patients with peripheral field loss. Refer
to an appropriate organisation (Guide Dogs Queensland provide
orientation and mobility training).
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Advice & Reassurance
Let the patient know that something can be done!
Lighting advice is often invaluable – illumination should
be ample, close or ‘over the shoulder’ and task-specific.
Demonstrate the beneficial effect of adequate lighting in
the consulting room. Know a few suppliers of cheap, adjustable
halogen desk lamps. Illuminated magnifiers can be significantly
better than non-illuminated magnifiers of the same power.
For help with mobility and tasks around the home patients
can be advised to contact an appropriate organisation e.g.
Guide Dogs Queensland or Royal Blind Foundation.
The patient will appreciate up to date information and advice.
Recent developments that may be of interest to VIP’s include
Visudyne PDT, dietary supplements for macular degeneration
as recommended following the AREDS publication, bright LED
illuminated battery magnifiers.
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Organisations & Resources
Give the patient contact details from this booklet. Write
them down in large print using a felt-tipped pen.
Refer to LV clinics or advise to contact Guide Dogs Queensland
and other blind / partial sight organisations. These organisations
will be able to refer further specialist services such as
occupational therapy. Patients may also be interested in
groups for sufferers of specific conditions – e.g. Macular
Degeneration Society, educational organisations, suppliers
of large print books / talking book libraries and general
LV support groups.
In her Vision Rehabilitation module guide for the QUT Optometry
course, Professor Jan Lovie-Kitchin suggests that, for employment
matters, you “consult with or refer to the visually impaired
Vocational Assistance Unit, Yeronga TAFE for job training;
or Vision Queensland, the Commonwealth Rehabilitation Service,
Centrelink or the Queensland Department of Families, Youth
and Community Care, for employment advice.” VIP Net may
also be helpful for patients on the Sunshine Coast and surrounding
areas.
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Government / Social Services
An eligible VIP may benefit from blind registration. This
requires a letter from an ophthalmologist declaring the
patient legally blind and provides entitlement to apply
for a blind pension via Centrelink.
Local Guide Dogs Queensland offices and other local organisations
for VIP’s can offer advice on other concessions including
transport passes / taxi vouchers, provisions by DVA eg:
CCTV etc.
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Referral
Optometrists and ophthalmologists can refer any patient
to a local LV clinic. It is helpful to include a short ocular
health history, recent refraction and acuities and field
plots. Indicate if refraction was difficult, as the optometrist
at the Low Vision Clinic might be able to refine the result.
Optometrists should keep in mind that the VIP might benefit
from a periodic check-up with an ophthalmologist to monitor
ocular pathology and review treatment options and advice.
The patient may benefit from formal written referral to
organisations such as Guide Dogs Queensland. Comprehensive
details of residual vision are very helpful for any support
worker involved in the patient’s rehabilitation.
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Bits & Bobs
A whole range of gadgets including the following are available
from various sources including the Royal Blind Foundation
of Queensland Inc’, the Vision Australia Foundation, Guide
Dogs Queensland and LV clinics: VIP badges. Money holders.
Signature guides. Talking watches / clocks. Big button phones.
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