Low Vision Over the Life-Span: Discovery, Diagnosis, and Rehabilitation

By Jule Ann Lieberman MS CLVT/CATIS

 

What is low vision? In my graduate coursework at Salus University in low vision therapy we were all asked to define the term low vision. Many went immediately to search references on the Internet, others in textbooks, and the definitions provided were a varied collection of descriptions of vision loss. Those who have lived with “low vision” for many years or have worked in the eye care field have seen terms such as “vision impaired,” “visually impaired,” “partially sighted,” and “legally blind.”

 

Let me first tell you what low vision is not. Low vision is not seeing objects lower in a view, low vision is not necessarily a partial view, and low vision may not be a low level of recognition. Yet all these experiences can be described by persons as their vision loss.

 

The term legal blindness was first used in the creation of the social security act to identify individuals whose vision loss created difficulty in one or more activities of daily living. A clinical visual acuity standard was set at 20/200 (top line of an eye chart which contains the largest size letter or number) or a restricted field of 20 degrees (the view you may be able to see if you looked through a bathroom tissue roll). If a person had either or both these visual measurements, they were then deemed eligible for social security benefits as well as supportive educational and rehabilitation services. This definition is still used to determine eligibility of many services.

 

What we have learned over many years, however, is that clinical vision is not the only factor in vision function. Professionals working with persons with vision loss are taught to discover how to make the most of the remaining vision in functional terms.

Variations between individuals with the same clinical measurements have given rise to the concept of functional vision. This determines the best potential outcomes for the person with low vision when considerations of alternative non-visual techniques and tools are recommended.

 

Now that we have a basic framework in low vision, how does a person discover a vision loss has taken place? Let us start at the earliest this can be observed. Infants are tested by pediatricians, beginning in the nursery and throughout infancy. Visual tracking of objects, eye contact and other responses to visual stimulation can be observed. These observations are then compared to a range of expected responses for that age. If the exam indicates inconsistencies, the infant is referred to an ophthalmologist for a dilated eye exam and other studies. Parents are then advised on potential treatments or therapies that can maximize visual development for this infant.

 

Sometimes, vision loss is not discovered until the child enters school. Here, the school may provide routine vision screening as part of the school experience. Teachers may also observe such behaviors as holding objects closer to the eye than typical, physical coordination difficulties or clumsiness, or failure to meet and keep eye contact with the teacher or friends. The child would then be referred to eye-care professionals for corrective lenses or to rule out conditions that warrant further evaluation.

 

In cases where the vision loss cannot be corrected by glasses, the child may be referred for additional services that could include a comprehensive low vision exam and services included in an individual education plan. IDEA (Individual Disability Education Act) provides for students with vision loss services such as instruction by a teacher of the vision impaired, an orientation and mobility specialist, and an assistive technology instructional specialist. A learning media assessment is performed to determine accommodations such as alternative materials such as large print, braille, and audio. Students are also assessed to determine the best technology that can provide the best access to the educational material and experiences. Each school district or system makes the determination of the individual education plan and this can vary from student to student and from one school system to another.

 

Who are these professionals in vision?

There are several types of eye-care professionals and therapist that may work with you or your child. Ophthalmologists are medical doctors with additional training in the medical diagnosis and treatment of disorders of the eye. This may also include treatments such as surgery and medications. Optometrists have not completed medical school; however, they have completed training as doctors in the study of the eye, visual perception, optics, and medications. Both can perform dilation to exam the structures of the eye and diagnose disorders and prescribe corrective lenses or medications. Opticians are trained in measurement and fitting of corrective lenses. This may include a vision screening without a dilated eye exam. Low vision diplomats are typically Optometrists who have extensive training or experience in the application of optical solutions for those whose vision cannot be corrected with traditional glasses or contact lenses. Low Vision Diplomats are frequently associated with low vision rehabilitation centers within a university or a private vision care center.

 

Students receiving services in their individual education plan (IEP) may likely work with a teacher of the vision impaired who is a certified special education teacher with specialized training in the education of students with vision loss and blindness. They work as part of an inter-disciplinary team, which may include the classroom teacher and school counselor. When it is determined that safe mobility is of concern, an orientation and mobility specialist joins this team. The orientation and mobility instructor can train the student in safe travel with remaining vision, the recognition of environmental clues, and, when needed, safe use of a white mobility cane. The IEP team may also include an assistive technology instructional specialist, who will evaluate the need and train in the use of technology designed or accessible for use by a student with low vision. This could include both mainstream technology such as computers or mobile devices with accessibility features enabled or with assistive software added. Large monitors, video magnification systems and braille devices may be included in the student’s plan.

 

Once the student reaches high school, plans are initiated with the state’s office for vocational rehabilitation and in Pennsylvania this is then referred along to the Bureau of Blindness and Visual Services (BBVS). Transition plans are begun, and further assessments can determine additional support for employment or post-secondary life.

 

What happens if your vision loss occurs later in life? The largest number of persons defined as having low vision are those who acquire vision loss as adults. Frequently, this comes as the result of medical conditions such as diabetes, conditions that develop because of a vascular condition such as heart attacks or strokes, or age-related or genetic conditions that cause retinal degenerative changes, as well as injuries that result from accidents.

 

Many adults may experience a slow loss of vision; whether they need larger print or bifocal lenses or magnification to read or fail to recognize faces of friends and loved ones at a distance. Adults may not recognize that their field of vision has narrowed or become distorted until they find themselves having difficulty moving through spaces without encountering an obstacle or recognizing changes in elevation such as steps or curbs.

 

At first, the adult may contact their primary care doctor to rule out medical conditions that may have contributed to this vision loss such as undiagnosed diabetes, MS, and heart or vascular medical conditions. The physician may then refer them to either an Ophthalmologist or Optometrist for a dilated eye exam. In some cases, the dilated eye exam can detect other medical conditions. A comprehensive low vision exam may be advised where several acuity and field measurements are taken. A refracted correction of near sighted or far-sighted vision is explored and there is a determination as to whether there is value in glasses for a functional outcome. Technology for magnification may also be explored or they might be referred to a technology provider for evaluation. Where field measurements and mobility difficulties are observed, a referral will be made for training with an orientation and mobility specialist. Coverage for these services can vary with multiple factors; private or public medical plans may or may not pay for the exam and currently optical devices or technology are not covered by insurers. BBVS has limited provision to cover the cost of low vision exams and devices unless they are considered as part of the written individual rehabilitation plan for post-secondary training or employment. BBVS will also consult with the employer as to what can be provided under the ADA regulations, BBVS provides devices as the resource of last resort in employment after it is determined that employers are exempt for provision under reasonable accommodations.

 

Adults not seeking post-secondary education or employment can seek support for devices purchased through alternative financing from sources such as PATF (Pennsylvania Assistive Technology Foundation) or vendor payment plans. Used equipment in working condition can be found through contacting private agencies that support persons with low vision or blindness, TechOWL network throughout the state in regional assistive technology centers, and from listings in various publications and on-line sites such as Craig’s List and others. Applications for financial grants to reduce the cost or cover the entire cost of assistive technology and devices can be found online at such resources as Association of Blind Citizens and Virginia DelSordo fund from TechOWL. Reduced pricing of computers with assistive technology can be found at Computers for the Blind.

Contact TechOWL at 800-204-7428 for additional information on these options.

 

How do I learn how to use these devices? For students in K-12 education, training is provided as part of their IEP. As adults in vocational rehabilitation, BBVS contracts with technology training providers and low vision centers for support. If neither of these options apply to you, consider contacting your peers at PCB, the nearest low vision support group, or contact sources such as the Hadley Institute for the Blind and Vision Impaired by visiting www.hadley.edu or by calling (847) 446-8111 for training options.

 

 

Contact the PCB Office to locate the eye-care professional and rehabilitation agency nearest you. If you believe or have been told “there is nothing more I can do,” consider being your own health care advocate and ask how and where you can get the help you need to make the most of your remaining vision or learn new techniques without using vision. I hope this article has given you a sense of the journey from discovery to diagnosis to rehabilitation. The PCB Vision Loss Resource Team and PCB peers are here to help!

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