Considering all of these aspects, it should be clear that comprehensive vision rehabilitation extends beyond the provision of low-vision aids, although that is still vitally important (see Chapter 24). Since any rehabilitation requires teamwork involving different professionals to deal with the various components and since vision loss is the common denominator, the ophthalmologist should coordinate the team.
Before considering a rehabilitation plan, the patient’s goals and needs must be clarified. For the general ophthalmologist, this may involve only a general question, such as, “How does your vision loss bother you most?” or “Can you still read the newspaper?” If the answer reveals a problem, clinicians should do the same as they do for retinal, glaucoma, or other problems and tell the patient, “I understand your problem and I will refer you to someone who can help you.”
When future deterioration is a possibility, it is not necessary to wait until there is severe vision loss before recommending action. Early adaptations to minor loss can facilitate later adaptations to major loss. The possibility of deterioration of vision is best made known from the beginning but must be accompanied with advice about the availability of skilled professionals and resources. Unfortunately, many practitioners are poorly trained in conveying bad news, a skill that should be taught and practiced in medical school. All ophthalmologists should master this skill, which includes informing the patient about options and knowing the appropriate referral sources.
The American Academy of Ophthalmology (AAO) recognizes several levels of competence in vision rehabilitation. Some ophthalmology practices may employ professionals who can provide basic services in-house. For more complex cases, referral to specialized vision rehabilitation services is appropriate.
To determine the range of services that are appropriate, the AAO recommends the following checklist:
Reading—For many patients, this is their foremost concern.
Activities of daily living (ADLs)—Even though reading may be the most prominent complaint, most people spend the larger part of their day performing a variety of other activities.
Safety—Are people at risk for falls? How do they cross the street?
Community participation—Can they still participate in community events or at church?
Physical, cognitive, and psychosocial well-being—Since many patients with vision loss are elderly, this is an important aspect that should not be overlooked. If problems exist, they may affect the recommendations to be made.
Not all areas may have problems, but the simple 5-point checklist is important so that priorities can be set and specific rehabilitation goals formulated that reflect the patient’s needs and desires, not just the practitioner’s expectations.
The standard ophthalmic examination, including identification of any conditions amenable to specific treatment, needs to be adapted as discussed in Chapter 24.
Observation of visual performance is important in young children, where regular testing may not be possible. Reports from parents and teachers are often as informative as direct observation in the office. Even for adults, observation of the performance of daily living tasks can be helpful. It provides a baseline against which future progress can be measured. It can also give insight in the patient’s problem-solving skills and motivation.
Questionnaires can assess the subjective difficulty of tasks, including those that cannot be assessed in the office. A disadvantage is that the responses are subjective, with some patients exaggerating their difficulties and others understating them.
Assessment of mobility, including identification of peripheral visual field loss, is very important since impaired mobility should trigger referral for assessment by an orientation and mobility (O+M) instructor. Mobility training may be crucial to reestablishing independence. Patients also need to be made aware of the importance of appropriate signaling of their visual impairment. Many feel that carrying a long cane or similar aid publicizes their vulnerability to individuals who might take advantage of it, but well-meaning individuals need to be made aware of the patient’s visual impairment, so that they can provide assistance where needed.
Comprehensive Rehabilitation Plans
A comprehensive vision rehabilitation plan requires attention to more than just how the eyes function. Figure 25–2 provides a summary of the possible interventions. It is useful to use this as a checklist, although not all parts will be needed in every case.
Vision substitution refers to the use of senses other than vision. Common examples include talking books and voice-output devices (see Chapter 24), Braille, and long canes. Vision enhancement and vision substitution are not mutually exclusive but complementary. A patient may use a magnifier to read price tags and talking books for recreational reading. A patient with retinitis pigmentosa, who has normal mobility in the daytime, may need a cane at night. Audio cassettes may have Braille labels.
Assistance is a form of vision substitution using the eyes of others. Family members, caregivers, and office personnel should be familiar with sighted-guide techniques to effectively assist visually impaired patients with minimal embarrassment. Guide dogs are another possibility. They require training of the dog as well as of the patient, who needs to be physically active and able to manage the dog.
Coping skills: Vision loss often causes reactive depression, which renders the patient less receptive to rehabilitative suggestions. Conversely successful rehabilitation can be therapeutic and motivate the patient to pursue further improvements. Dealing with severe depression may involve other professionals, but the authority of the ophthalmologist can play a major role in convincing patients that they can do far more than they may believe after the initial shock of vision loss.
Human environment: As patients go through the stages of adaptation to vision loss, a supportive home environment is essential, and it is important to include spouses, children, and significant others in the counseling process. The clinician should make sure that the significant others understand the underlying condition, what can be expected, and how to support the patient. Answering their questions directly, by having them attend the examination, is often better than leaving this to the patient, who initially may not have absorbed everything that was said. An overprotective environment that deprives patients of opportunities to do things themselves can be as detrimental as an overdemanding one that puts too much emphasis on the patient’s shortcomings. The same applies to work, school, and social groups. Initially, patients often feel isolated and believe that they are the only ones experiencing these problems. This is where peer support groups can be helpful; in these groups, they can experience how others are dealing with similar problems.
Physical environment: An uncluttered environment, where things have a defined, fixed place is helpful because it eliminates the need for searching. Good general illumination and task lighting often help, because at higher illumination levels retinal cells that are damaged but not dead can still contribute. Good contrast is important; for instance, milk should not be served in a white Styrofoam cup and edges of steps and stairs should be marked.