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Library of Congress Catalogtng»in-Publication Data

Scheim an, M itchell.

Low vision rehabilitation : a practical guide for occupational therapists / M itchell Scheim an, M axin e Scheim an. Steven
W hittaker,
p . ; cm .
Includes bibliographical references and index.
ISBN -13: 978-1-55642-734-3 talk, paper)
ISB N -10: 1-55642-734-4 talk, paper)
1. Lo w vision--Patients--Rehabilitation. 2 . Low vision—ftitients -S e rv ic e s tor. I. Scheim an, M axine. II. W hittaker, Steven.
III. Title.
[D N IM : I . V ision, lo w -re h a b ilita tio n . 2 . Vision, Low. 3 . O ccupatio nal Iherapy-m ethods.
W W 140 S 3 19L 2 0 0 6 1
R E9 1 .L6 9 2006
6 1 7 .7 Ч 2 —dc22
2006025883

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 C ontents

Acknowledgments..................................................................................................................................................................................ix
About the ____
About the ________ _____________ .-.___ ..____________________
Preface.................................................................................................................................................................................................... .u'

Section I: Introduction and Background In fo rm a tio n .................................1

Chapter 1: Epidemiology, History, and Clinical Model for Low Vision Rehabilitation.............................. 3
Chapter 2: Review of Basic Anatomy, Physiology, and Development of the Visual System .................. 23
Chapter 3: Visual Acuity, Contrast Sensitivity, Refractive Disorders, and Visual Fields.......................... 31
Chapter 4: Eve Diseases Associated With Low V ision .........................................................................................55
Chapter r Optics of Lenses, Refraction, and M agnification..............................................................................75
Chapter 6: Psychosocial Issues Related to Visual Im pairm ent.......................................................................... 83

S ectio n II:.EyaliiatiQ P__________________________________________________ Э1

Chapter 7:________Overview and Review of the Low Vision Evaluation .................................................................... 93
Paul B. Freeman. OP, FAAO, FCOVD
Chapter 8:_______ Occupational Therapy Low Vision Rehabilitation Evaluation.................................................... 103

S ectio n -Ill: T re a tm e n t.....................................................^ ............................... 133

Chapter 9:________Overview of Treatment S tra te g y ..........................................................................................................135
Chapter 10:_______Foundation Skills and Therapeutic Activities .................................................................................145
Chapter 11:_______ Patient Education and Modification of the E n v iron m en t........................................................... 177
Chapter 12:_______Nonoptical Assistive D ev ices.................................................................................................................191
Chapter 13:_______Optical Devices and Magnification Strateg ies................................................................................207
Chapter 14: Computer Technology in Low Vision Rehabilitation ...................................................................239
Chapter 15: Adaptive Diabetes Self-Management Tools and T ech n iq u es.....................................................265
Debra A. Sokol-McKay, MS, CVRT, C D E, CLVT, OTK/L

Section IV : Practice M an ag em en t.................................................................... 287

Chapter 16:________Establishing a Low Vision Rehabilitation Specialty Practice..................................................289
Chapter 17:_______ Goal W ritin g .............................................................................................................................................311

A ppendices........................................................................................................................................................................................321

Index ....................................................... ................ .......... ........................................ ......................................................................337

Printable forms discussed in this book are available online at http://www.slackbooks.com/otvisionforms

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 A bout the C o n t r ib u t o r s

Paul B. Freem an, O D , FAAO, FC O V D

Dr. Paul B. Freeman, o p to m etrist is an internationally known lecturer, author, and private practitioner. He
is the coauthor of The Art and Practice o f Low Vision, published by Butter worth/Elsevier. Dr Freeman is chief
of low vision services at Allegheny General Hospital in Pittsburgh, Pennsylvania and consults to a num ber of
rehabilitation settings, where he works closely w ith occupational and physical therapists as well as others on the
rehabilitative team. He has lim ited his practice to the care and rehabilitation of visually im paired, brain injured,
and multi-handicapped individuals of all ages.

Debra A. Sokol-M cK ay, M S, C V R T , C D E, CLVT, OTR/L

Debbie Sokol-M cKay graduated from Temple University's occupational therapy program in 1982, and
received her m asters degree in Rehabilitation Teaching (Vision Rehabilitation Therapy) from the Pennsylvania
College of O ptom etry (PCO) in 1999. Debbie is adjunct faculty in the Graduate Low Vision Rehabilitation pro­
gram at PCO. She has practiced as an occupational therapist for more than 20 years, and in the fields of vision
rehabilitation and diabetes education for more 10 years. She holds certifications as a vision rehabilitation thera­
pist, low vision therapist, and diabetes educator. Debbie is the im m ediate past chairperson o f the Disabilities/
Visual Im pairm ent Specialty Practice Group of the A m erican Association o f Diabetes Educators (AADE) and
w as a m em ber of AOTA's expert low vision certification panel. She serves as AADE's liaison to the National
Eye Institute. Debbie has published professional articles in all three fields and presented at the national con­
ferences of ЛОТА, AADE, and the Association for the Education and Rehabilitation o f the Blind and Visually
Impaired.
 P reface
The emergence of three separate factors over the
past two decades has vaulted the profession of occu­
pational therapy into the m ainstream of low vision
rehabilitation. These three factors are the high preva­
lence of vision impairment in the elderly, which is the
fastest growing segment of our population; chronic
underfunding and the lack of availability of treatment
for the elderly through the current structure called the
"blindness system "; and the inclusion of low vision as
a disability under Medicare Guidelines in the early
1990s. Because of these three factors, occupational
therapists now have a prim ary role to play in this
field.
In addition, there are four other very strong argu­
ments for occupational therapy to play a more promi­
nent role in vision rehabilitation.
1. W hile the elderly comprise the majority of
the low vision population, they are the most
underserved by existing state, charitable, and
private programs. Because of the lack of avail­
ability of services and treatment through the
current system, rehabilitation may be delayed
and these individuals are likelv * to become
socially isolated, depressed, and dependent.
Involvement of occupational therapists through
the healthcare system provides significantly
greater access to low vision rehabilitation for
the elderlv.
2. Two-thirds of older persons have at least one
other chronic condition, in addition to low
vision, that lim its their independent func­
tioning. Occupational therapists are already
prim ary providers for older clients with other
chronic conditions.
3. O ccupational therapists are trained in the
physical, cognitive, sensory, and psychological
aspects of disability and aging, and therefore,
may be the natural choice to work with older
persons whose limitations in daily living are a
result of a combination of deficits.
4. Occupational therapists are more evenly d is­
tributed throughout the United States than
other vision rehabilitation professionals, who
tend to be located in larger metropolitan areas.
Low vision services can be more widely dis­
seminated through the healthcare delivery
svstem.
+ with vision impairment.
The challenge at this time is for occupational
therapists to achieve competency in this field. This
will require a combination of independent study
and reading, clinical experience, and in some cases.
postgraduate education. This textbook is designed to
provide a practical and clinically oriented guide to
enable occupational therapists to begin this process of
independent study and reading in order to seize this
opportunity and the responsibility of joining the team
of professionals that cares for this population.
We have established three objectives for this book.
The first is to present our viewpoint of the role of
occupational therapy in the field of low vision rehabil­
itation. Low vision rehabilitation is a relatively young,
developing discipline and occupational therapy is the
newest professional addition to this field. A number
of other professions have been involved in this area of
care for decades, and the challenge is for occupational
therapy to define a role within the established system
that will augment current service delivery rather than
factionalize service delivery into competing services.
In Chapter 1, we present our ideas about various cur­
rent roles of the occupational therapist regarding low
vision as well as a suggested "ideal" role. We consider
how these practice settings fit into current service
delivery systems as well as the cost-effectiveness of
these roles.
Our second objective for this book is to create a
resource for occupational therapists to independently
learn about low vision rehabilitation for the older adult
in preparation for providing these services in clinical
practice. W hile there arc several excellent books on
vision rehabilitation written for other professionals
involved in this field, to our knowledge there is cur­
rently no stand-alone textbook w ritten specifically for
occupational therapists on this topic.
O ur third objective is to create a resource that can
be used by occupational therapists to prepare for
certification exam inations such as that offered by the
Academy for Certification of Vision Rehabilitation
and Education Professionals (ACVREP) and the AOTA
Specialty Certification in Low Vision.
1'his book was not designed to cover vision reha­
bilitation in the pediatric population. We decided that
trying to cover both populations in one book would
not do justice to either population. W hile the needs of
children with vision impairment are significant, occu­
pational therapists are much more likelv to be called
upon to help the elderly population because of the
current insurance reimbursement system. Thus, we
chose to devote this book entirelv j to the adult client
The book is divided into four sections with 17chap­
ters, Appendices, and a companion website.
Section I contains six chapters that are designed to
provide background information about epidemiology.
 Mi Preface
history, roles of various professionals, anatom y of the
eye and visual system , eye d iseases that cause vision
im pairm ent, optics of lenses and m agnification, and
psychosocial issues related to vision im pairm ent.
Section II is devoted to the evaluation of clients with
vision im pairm ent. In Chapter 7, Dr. Paul Freem an, a
nationally recognized optom ctric expert in low vision
rehabilitation, review s the optom etric low vision reha­
bilitative exam ination. The objective of this chapter is
to provide enough inform ation so that occupational
therapists w ill be able to understand the exam ination
process and com m on term inology used in reports
they are likely to see from eyecare providers. In
Chapter 8, we describe our recom m endations for the
occupational therapy low vision evaluation.
T h e third and largest section of this book is
devoted to low vision rehabilitation. In Chapter 9,
we begin w ith an overview of the entire process and
suggest an organized, seven-step treatm ent process.
Individual chapters are devoted to the use of thera­
peutic activities, m odification of environm ent, the use
of nonoptical assistive devices, teaching clients how to
use optical devices, incorporating computer technol­
ogy in low vision rehabilitation, and an entire chapter
on adaptive diabetes self-m anagem ent tools and tech­
niques w ritten by Debra Sokol-McKay, a well-known
occupational therapist and certified diabetes educator
w ho w rites and often lectures about this topic.
The book concludes w ith a section devoted to prac­
tical issues and practice m anagem ent. All three of us
have had extensive experience presenting workshops
for occupational therapists about low vision rehabili­
tation. D uring these workshops, num erous practical
questions have been asked about howr to get started in
the field of low vision rehabilitation. Som e of the ques­
tions that have often been asked include:
1. W hat are the educational requirem ents for an
occupational therapist to provide low vision
rehabilitation services?
2. Is certification necessary to provide low vision
rehabilitation services?
3. How does the occupational therapist interact
with other vision rehabilitation professionals?
4. W hat practice opportunities arc available?
5. How do I m arket my services as a provider of
low vision rehabilitation services?
6. Are low' vision rehabilitation services pro­
vided by occupational therapists covered by
M edicare and other insurance?
7. How do I properly bill insurance for low vision
rehabilitation services?
8. Are optical aids and other devices covered by
insurance?
9. W hat equipment do I need to get started in the
field of low vision rehabilitation?
Chapter 16 is designed to provide answ ers to these
im portant questions. We also included a short chapter
designed to provide som e guidance about wrriting
goals for low' vision rehabilitation.
The book is accom panied by a website that con­
tains evaluation form s and other docum ents referred
to in the book, plus a list o f m any o f the key
resources about low vision and rehabilitation ser­
vices currently available, including general infor­
mation, large-print and audio resources, computer
technology, com m unity resources, and low vision
equipm ent vendors.
This book is a collaboration of occupational thera­
pists and optom etrists. Just as collaboration was
important for the com pletion o f this book, collabora­
tion betw een these two professions, as well as oph­
thalm ologists, vision rehabilitation therapists, orien­
tation and m obility specialists, and social workers, is
vital for insuring quality care for clients w ith vision
im pairm ent. It is our hope that this book w ill become
an im portant resource for occupational therapists
entering this exciting field, w hich the A m erican
O ccupational Therapy Association has identified as
one of the top ten em erging fields in occupational
therapy in the next m illennium .
We have built a model of practice on a foundation
of evidence, or theory derived from em pirical science.
This text will provide the professional w ith a start­
ing point, an evaluation methodology, and tools and
procedures that have been shown to be effective. With
accum ulating experience, the professional will chal­
lenge our suggestions and assum ptions. Professionals
will continue to search for published peer-reviewed
research on low vision rehabilitation and perform
careful clinical observation to build som ething better,
and, finally, tell us about their discoveries.
Section I

Introduction and Background

Information
 и
Epidemiology, History, and Clinical
Model for Low Vision Rehabilitation
T h e objectives of this chapter are to establish the
im portance of low vision rehabilitation for the prac­
tice of occupational therapy and to review the d efini­
tions, epidem iology and history of low vision and low
vision rehabilitation in the United States. We w ill also
present a model of clinical care with suggested roles
for the various professions involved with low vision
rehabilitation.
W h y S h o u ld O c c u p a tio n a l
T h e ra p is ts Be In te re s te d in
th e F ie ld o f Low V is io n
R e h a b ilita tio n ?
Effect o f Visual Im pairm ent on
Activities of Daily Living
Mrs. Sm ith is a 75-year-old wom an w ho recently
developed age-related m acular degeneration (AMD).
O ther than her vision problem, she has no other sig­
nificant medical conditions. She has always
*
been an
active woman, working until age 67 as a real estate
agent and raising her fam ily of three children. After
retirem ent, she becam e active as a volunteer in both
her church and local civic organizations. She has been
an avid recreational tennis player and continued to
play tennis tw ice a week w ith friends until recently.
Thus, she was actively involved in m any activities,
looking after herself and her family, enjoying life, and
contributing to the social and econom ic fabric o f her
community. ¥
Two years ago, however, she developed AM D
in both eyes. Her vision deteriorated rapidly and
affected alm ost every aspect o f her life. She can no
longer safely drive and this creates difficulty in many
everyday activities such as shopping, doctors' visits,
visiting her grandchildren, m aintaining her role as
a volunteer at church, and playing tennis. Because of
her vision im pairm ent, she has trouble taking care of
her personal needs as well. Her color perception has
deteriorated, so she cannot select clothes on her own
and putting on her makeup is no longer possible.
Household tasks such as cooking, w ashing dishes,
and finding ingredients for recipes have becom e
very frustrating and difficult to perform . Mrs. Smith
had m anaged the m onthly task of paying bills and
balancing the checkbook, but can no longer perform
these activities. O f course, she also has great difficulty
reading for pleasure, as well as for everyday, essential
reading tasks.
Mrs. Sm ith's vision im pairm ent has also impacted
on her social life. She now hesitates to go to meetings,
parties, and other social events because she is unable
to identify people's faces. Even if she can identify the
person by his or her voice, she is unable to see facial
expressions, and this m akes it challenging to interact
in a m eaningful manner. This devastating com bina­
tion of loss of independence in many essential activi­
ties of daily living (ADL), along with the negative
im pact on her social life, has led to secondary depres­
sion and lack of desire and motivation to deal with her
new disability.
T h is history is typical of the effects of AM D on the
life of a client with this verv * com m on ocular disease.
As a result, she is no longer able to perform daily life
activities and participate in desired roles and life situ­
ations at home and in the community. O f course, since
its inception, the focus and mission of the profession
of occupational therapy has been to care for people
with precisely these needs. In 2002, the American
O ccupational Therapy A ssociation (AOTA) published
the Occupational Therapy Practice Framework to reaffirm
and articulate occupational therapy's "unique focus on
occupation and daily life activities and the application
of an intervention process that facilitates engagement
in occupation to support participation in life."1
Tlw Occupational Therapy Practice Frameuwrk outlines
the language and constructs that define the profes­
sion's focus.1 T h is Framework states that "Engagem ent
in occupation to support participation in context is
the focus and targeted end objective of occupational
therapy intervention".1 T h e authors go on to state:
"O ccupational therapists assist individuals to link
their ability to perform daily life activities with m ean­
ingful patterns of engagem ent in occupations that
allow participation in desired roles and life situations
in home, school, workplace, and com m unity."1
Given this Framework, it is clear that the client
described above, and others w ith low vision, require
occupational therapy services. In this case, the specific
type o f intervention an occupational therapist would
provide is called low vision rehabilitation. The fol­
lowing discussion of the definition, prevalence, and
incidence of low vision and the shortage of available
resources em phasizes the need for occupational ther­
apy involvement in low vision rehabilitation.
D e fin itio n s and Ep id e m io l o g y
Definition of Blindness and Low
Vision
A com m only quoted prevalence figure for vision
impairm ent in the United States is that one in six
adults (17%) age 45 and older, representing 13.5 m il­
lion Am ericans, report som e form of visual im pair­
ment.2 M assoP argues that this figure is inaccurate
and a significant overestim ation of the prevalence
of low vision in the United States. There are a num ­
ber of problems w ith determ ining the prevalence of
blindness and visual im pairm ent.3'4 These problems
include differences in criteria to define visual im pair­
ment, differences in study m ethodology, variation in
method of assessing visual acuity, and differences in
the age range of the oldest category.
D ifferences in Criteria to D efine
Visual Im pairm ent
The criteria used to define blindness and low vision
vary from study to study. In the United States, the
standard definition of legal blindness is 20/200 or
worse in the better eye. There is much more variabil­
ity, however, in the definition of low vision. T h e World
Health O rganization (W HO) proposed a classification
system that is now accepted as the international stan­
dard. The definition o f blindness is a visual acuity of
w orse than 20/400 in the b etter eye with best correc­
tion or a visual field diam eter of less than 10 degrees
in the widest meridian in the better eve. The W HO
*
definition for low vision is worse than 20/60 in the
better eye w ith best correction.5 A nother com m only
used criterion by epidem iologists is to define low
vision as correctcd visual acuity worse than 20/40
in the better eye w ith correction/' T h is criterion is
based on the ability to obtain an unrestricted driv­
er's license. Finally, M edicare carriers have adopted
the International C lassification o f Diseases, Clinical
M odification (ICD-9-CM ) coding system definition
of low vision, w hich is w orse than 20/60 visual acu­
ity in the better-seeing eye, as the eligibility criterion
for coverage of low vision services. Because different
authors have used varying definitions o f blindness
and low vision, it is easv to understand the difficulty
r *
in establishing the prevalence of these conditions. The
practitioner needs to be vigilant to changing defini­
tions of low vision and blindness because this debate
will lead to changes in the criteria M edicare, Medicaid,
government payers, and insurance companies use for
reim bursable rehabilitation services.
Table 1-1 is an attempt to help the reader appreciate
the relationship among visual acuity loss, functional
visual problems, and definitions of blindness and
visual impairment.
The definition of low vision that w ill be used in
this book is summarized in Sidebar t-1. We define
low vision as a condition caused bv / eye
t/ disease in
which the vision is 20/70 or poorer in the best eye
and the vision cannot be improved with eyeglasses.
It is important to remember that this is not necessar­
ily the definition that has been used in prevalence
studies. However, it is a definition that makes sense
in the everyday practice of low vision rehabilitation
by occupational therapists. This is the definition that
is currently used by Medicare to establish medical
necessity for low vision rehabilitation.
The use of this definition also does not preclude
treating clients with visual acuity better than 20/70.
20/40 acuity, for example, can create significant dis­
ability for a client who values reading or occupations
that require detail vision, such as fine needlepoint.
We believe that early У intervention is critical for sue-
cess. Once a patient's visual acuity deteriorates to
20/70, he or she may have already started to disengage
from many ADL, leading to potential depression. The
prim ary impediment to routinely initiating therapy
when visual acuity is better than 20/70 is lack of reim ­
bursement. Services are not covered by Medicare until
visual acuity declines to 20/70.
Sidebar 1-1: Definition of
Low Vision
Low vision is a condition caused by eye disease
in which vision is 20/70 or poorer in the better-seeing
eye and the vision cannot be improved with eye­
glasses.
Differences in Study
M ethodology
The two m ain study methods to evaluate preva­
lence of low vision have been self-assessment surveys
and population-based vision screening studies. The
Lighthouse study quoted above was a telephone sur­
vey of 1,219 people over the age of 45 years.2 Data were
not available about refractive error (nearsightedness,
farsightedness, or astigm atism) or eye disease for the
people surveyed. M assoP argues that some of the cri­
teria used in the survey to determine if a person had
low vision could simply reflect inadequate eyeglass
correction at the time of the survey. For example, the
Baltimore Eye Study found that if they used present­
ing visual acuity only as a criterion for defining low
vision, they found a prevalence of about 10.25 million
people. However, 7.5 million people in this group
would not actually have low vision because with new
eyeglasses their visual acuity reached normal levels.
Thus, the m ain problem with estim ating low vision
prevalence from self-assessment surveys is that the
cause of the reduced visual acuity is unknown.
In contrast to the self-assessment methodology, a
number of population-based prevalence studies have
been performed in the United States.6"10 All of these
studies measured visual acuity with refractive errors
corrected and determ ined if eye disease was present.
The results of these studies indicate that the preva­
lence of low vision is much lower than the estim ate
based on self-assessm ent surveys. However, even
among these studies, there are differences in esti­
mates because the studies differ in their definitions
of low vision (visual acuity cutoff that determ ines if
client has low vision) and methodology of perform ing
the visual acuitvУ assessment.
Variation in M ethod o f Assessing
Visual Acuity
Generally, measures of distance visual acuity have
been used to define significant vision loss and there
are two important sources of variation in the current
literature when trying to categorizing persons into
affected and nonaffected groups. These include the
type of acuity chart used and the visual acuity criteria
used to define the condition.4 There is no standard­
ized method of assessing visual acuity in clinical
practice. Various charts such as Landolt C, Snellen
charts, and Sloan letters are commonly used. In recent
years, a standardized visual acuity chart was devel­
oped for research studies called the Early Treatment
of Diabetic Retinopathy Study acuity chart (F.TDRS)
and is now the standard for research involving visual
acuity measurements.11 However, this chart has not
been widely used in the low vision prevalence litera­
ture. O nly three of the five population-based studies
of low vision in the United States referred to above
used the ETDRS chart as the method for assessing
distance visual .ncuity. Even in those studies using the
FTDRS chart, the distance at which testing occurred
and the method for determ ining the final visual acu­
ity differed among the studies.
Differences in the Age Range o f
the Oldest Category
All studies, regardless of methodology, agree that
the prevalence rate of low vision and blindness
increases sharply with age. Various studies, however.
 Table 1-1.

Relating Visual Acuity Loss, Functional Problems, and

_______ Definitions of Blindness/Low Vision

Best Corrected Visual Acuity Functional Problems Standards Met for Legal Blindness or
Visual Impairment

6/150 (metric) 20/500 (Imperial) Can barely read newspaper W H O criteria for blindness
headlines at 40 cm

6/60 (metric) 20/200 (Im perial) Can barely read newspaper USA criteria for blindness, eligible for
bylines or chapter headings at all services by State, Federal agencies
40 cm and Veterans A dm inistration

6/18 (m etric) 20/60-20/70
(Im perial)
Can barely read newsprint
Eligible for M edicare reim bursed
services, and receive lim ited services
from State, Federal and Veterans
adm inistration. M any states prohibit
driving.

6/12 (m etric), 20/40 (Imperial) Reading norm al print and Im paired Visual A cuity becom es
street signs is slower and disabling. Legal criteria for unrestricted
more difficult driving in m ost states

have categorized the age brackets differently. T h is cre­
ates difficulty in com paring one study to another.
Prevalence o f Low Vision and
Blindness in the United States
In this section, we review the prevalence and
incidence of low vision and blindness in the United
States. This research is im portant to someone plan­
ning to develop a new low vision service. The planner
com bines these statistics with published census data
to estim ate the potential need for services in a given
area. Prevalence refers to the current num ber of people
suffering from an illness in a given year. This num ber
includes all those who may have been diagnosed in
prior years, as well as in the current year. For example,
if the prevalence of a disease is 80,000, it m eans that
there are 80,000 people living in the United States with
this illness.
Incidence refers to the frequency of development
of a new illness in a population in a certain period of
time, norm ally 1 year. W hen we say that the incidence
of a disease has increased in past years, we mean that
more people have developed this condition year after
year, eg, the incidence of thyroid cancer has been ris­
ing, w ith 13,000 new cases diagnosed this year.
W hile m any studies have used less than 20/40
visual acuity in the better-seeing eye as the criterion
for low vision, from a practical standpoint it is rea­
sonable for occupational therapists to be interested
in the 20/70 or worse criterion that has been adopted
by M edicare carriers. M edicare is the m ain source of
reimbursem ent for low vision rehabilitation for occu­
pational therapists and the ICD-9-CM coding system
definition of low vision is worse than 20/60 visual
acuity in the better seeing eye.
M assof3 analyzed the data from all five popula­
tion-based studies of vision im pairm ent in the United
States. He used the 20/70 or worse criterion as the
definition of low vision along with the 2000 census
data. Based on these param eters, he estim ated that
1.275.000 whites and 230,000 blacks over age 45 have
low vision. Looking only at the M edicare eligible
population (65 years and older), he estim ates that
1.120.000 whites and 135,000 blacks have low vision.
It is im portant to note that even these num bers are
an overestim ation because they include many poten­
tially correctable cases of cataract (about 15% to 20%).
Although these prevalence rates are certainly sign ifi­
cant, they are only about one-tenth the num ber cited
by other authors.2'12
 The most up-to-date estim ates of the prevalence
of visual im pairm ent in the United States were pub­
lished by the Eye D iseases Prevalence Research Group
in 2004.13 Because of the difficulty and expense of
im plem enting an appropriate sam pling schem e, few
population-based studies of a national scope have
been carried out in the United States to estim ate the
prevalence of visual im pairm ent.13 To m eet this need
for prevalence data, principal investigators from eight
population-based vision studies agreed to standard­
ize definitions and m ethodology so that their data
could be analyzed together. Age- and race/ethnicity-
specific prevalence of blindness and low vision were
calculated based on eight different studies. These
estim ates were then applied to the population of the
United States as reported in the 2000 census to esti­
mate the num ber of visually impaired persons nation­
ally. Projections of prevalence in 2020 were also made
based on census projections for the US population in
that year. The definition of blindness used was 20/200
or worse in the better-seeing eye and for low vision
20/40 or worse in the better-seeing eye.
Using this approach, the authors found that in
2000 there were an estim ated 937,000 blind A m ericans
older than age 40, a prevalence of 0.78%. The num ­
ber of persons with low vision was estim ated to be
2.4 m illion (1.98% prevalence). This num ber is sig­
nificantly higher than the estim ate from M assof of
about 1.5 m illion. The m ain reason for the difference
is likely the definition of low vision used in each
study. M assof3 used 20/70 or worse in the better-see­
ing eye as the criterion, versus 20/40 or worse in the
better-seeing eye used in this recent study. Because
occupational therapists in the United States function
w ithin the healthcare system and depend prim arily
on M edicare funding for reim bursem ent of low vision
rehabilitation, the lower estim ate is more representa­
tive o f the need for occupational therapy services for
low vision rehabilitation in the United States.
Incidence o f Low Vision an d
Blindness
The only published incidence data (new cases of
low vision each year) for the United States are from
the Beaver Dam Eye Study.14 The num ber of new cases
of low vision and blindness is greatest for people over
the age of 65 years, and based on the Beaver Dam Eye
Study data, M assof3 estim ated the incidence to be
about 250,000 cases per year in 2000 and 500,000 new
cases per year in 2025.
The prevalence and incidence of low vision in the
United States are high, and experts predict a large
increase over the next tw o decades because the preva­
lence of low vision increases sharply in persons older
than 65. In the study by Congdon et al, persons older
than 80 years made up only 7.7% o f the population but
accounted for 69% o f the severe visual im pairm ent.13
It is this group that is the fastest-grow ing segm ent of
the US population. Prevalence and incidence clearly
depend on ethnicity, age, and socioeconom ic vari­
ables. Som eone planning to develop services should
look to the most recent published research and census
data to develop m ore precise estim ates o f need by
considering age and ethnic and socioeconom ic com ­
position of the region being studied.
L e a d in g C auses o f V isual
I m p a ir m e n t in the U nited
States
The leading cause of severe visual im pairm ent
am ong w hite A m ericans in 2000 was AMD, which
accounted for 54% o f visual im pairm ent w ith cata­
ract (9%). Diabetic retinopathy (6%) and glaucom a
(5%) were the next most com m on causes13 (Table 1-2).
These conditions are described in detail in C hapter 4.
The leading causes o f severe visu al im pair­
ment in black persons were cataract (37%), diabetic
retinopathy (26%), glaucom a (7%), and A M D (4%).
Among H ispanics, glaucoma w as the most comm on
cause (29%), followed by AM D (14%), cataract (14%),
and diabetic retinopathy (14%).
It is surprising that there is such a high prevalence
of low vision due to cataract, since it is generally a treat­
able condition. Surgical treatm ent of cataract has been
show n to be a very effective procedure. A national
study of cataract surgery investigators found that 96%
of the clients were improved based on Snellen visual
acuity and 89% reported improvement and satisfaction
based on a 14-item instrum ent designed to m easure
functional im pairm ent. Since cataract surgery is so
successful, it is questionable w hether it should even be
included as a cause of low vision, because low vision
is defined as a loss of vision that cannot be treated
w ith lenses or any other m edical/surgical treatment.
There arc, of course, som e situations in which cata­
racts cannot be treated surgically because o f other
coexisting m edical or ocular conditions. In such cases,
cataracts could indeed be a cause of low vision. Evans
and Rowlands15 reviewed the literature to determ ine
the prevalence of correctable visual im pairm ent in the
United Kingdom. Many of their findings apply to the
Lnited States. They reported that betw een 20% to 50%
of older people have undetected reduced vision and
the m ajority of these had correctable vision problem s
such as refractive error and cataracts. The Baltim ore
Eye Study found that alm ost 70% of people report­
ing low vision based on reduced visual acuity alone
Co

Causes of Blindness (Visual Acuity <20/2001 bv Race/Ethnicity
Age-Related
Macular
Degeneration
W hite Persons 54.4%
Black Persons 4.4%
H ispanic Persons 14.3%
Adapted from Congdon N, 0'Colm«iin B, Klaver CC, et al. Causes and prevalence of visual impairment among adults in the United States
Arc h Ophthalnwl. 2004;122(4>:477-485-
would not actually have low vision because with new
eyeglasses their visual acuity reaches norm al levels.6
C orrectable vision im pairm ent is associated with
poorer general health, living alone, and lower socio­
econom ic status.15 O ften the therapist becom es the
first person to identify correctable im pairm ent and
initiate appropriate referral to an ophthalm ologist or
optom etrist. In the m eantim e, when correctable vision
loss is encountered, the therapist needs to have avail­
able relatively inexpensive, short-term interventions
that enable clients to m aintain their occupations and
routines until the underlying problem is corrected.
M ost studies have indicated that AM D is the lead­
ing cause of low vision in developed countries.16'17
The prevalence of A M D in low vision clinics has been
reported to be betw een 23% and 44% .18 W arren19
reported on her experience as an occupational thera­
pist w orking in a low vision program in an oph­
thalm ology departm ent. Th irty-seven percent of
the clients referred for occupational therapy (low
vision rehabilitation services) had AMD, 9% diabetic
retinopathy, 7% glaucom a, 3% neurological problems,
and 44% had other m iscellaneous conditions. Thus,
low vision caused by AM D is the condition that
occupational therapists will be most likely to treat.
Note that because people w ith stroke and resulting
hem ianopia or oculom otor problem s do not meet the
criteria for low vision, the current estim ates of low
vision associated with neurological problem s likely
are underestim ated. In these cases, the underlying
condition can be still be treated by an occupational
therapist using the neurological diagnostic codes.
Table 1-2
Diabetic
Cataract Glaucoma Retinopathy Other
8 .7 % 5.4% 6.4% 9.7%
36.8% 7.3% 26% 25.6%
14.3% 28.6% 14.3% 28.6%
P ro fe s s io n s In v o lv e d W it h
Low V is io n C a re
Low vision rehabilitation is a relatively young,
developing discipline and occupational therapy is the
newest professional addition to this field. The various
professions and their roles are listed in Table 1-3. At
the end of this chapter, we present our ideas about the
roles and relationships for these various professions
in the field of low vision rehabilitation.
O phthalm ologists
O phthalm ologists are physicians who, after gradu­
ating from medical school, specialize in the diagnosis
and treatm ent of eye disease by com pleting a resi­
dency in ophthalmology. M any ophthalm ologists also
com plete a fellowship program to further specialize
in an area of ophthalmology. A num ber of specialty
areas exist, including cataract, glaucom a, retina, cor­
nea, pediatric ophthalm ology, and neuro-ophthal­
mology. Considering that the most com m on causes
of low vision are retinal and neurological pathology,
the main sources of potential referrals for low vision
rehabilitation are ophthalm ologists specializing in
retinal disease and neuro-ophthalm ologists. There is
no specific subspecialty o f low vision in the profes­
sion of ophthalmology. Occasionally, ophthalm olo­
gists specialize in low vision rehabilitation. There are
currently about 16,000 practicing ophthalm ologists in
the United States.
Typically, the prim ary areas of interest and respon­
sibility of ophthalm ologists are the diagnosis and
 Table 1-3.

Low Vision Professionals and Their Roles

Profession Role
O phthalm ologists Exam ination and diagnosis o f eye disease
Treatment of eye disease
Medication
Surgery

O ptom etrists Low vision exam ination

Treatm ent of refractive error
Eyeglasses
Contact lenses
Treatm ent of low vision
O ptical m agnification
M odification of lighting and contrast

O ccupational Therapists Low vision rehabilitation exam ination

Low vision rehabilitation

Vision Rehabilitation Therapists Low vision rehabilitation exam ination

(Formerly Rehabilitation Teachers) Low vision rehabilitation, Braille reading instruction

O rientation and M obility Specialists Orientation and m obility exam ination

Orientation and mobility

Teachers of the Visually Impaired Special education of children with low vision and blindness

Low Vision Therapist Low vision rehabilitation exam ination

Low vision rehabilitation

Social Worker Individual and group counseling, facilitate access to

resources and support services

treatm ent of eye disease. Treatment m odalities gener­
ally involve the use of m edication and surgery. Thus,
clients often see the ophthalm ologist first because of
a perceived significant change in vision. T h e ophthal­
m ologist attem pts to restore norm al visual function
by treating the eye disease. In som e cases this fails,
or in other cases the vision can never be restored to
norm al and the client is now faced with perm anent
low vision. It is at this point that the ophthalm ologist
should refer the client with low vision to other profes­
sionals for further evaluation and rehabilitation.
O ptom etrists
A fter graduating from a 4-year college program ,
optom etrists com plete 4 years of additional educa­
tion at one of the 17 colleges of optom etry in the
United States. D uring this 4-year program , optom etry
students learn to diagnose and treat vision and eye
health problems. Treatment m odalities include the
use of eyeglasses, contact lenses, eye drops and other
m edication, vision therapy, and low vision rehabilita­
tion. After graduating from optom etry school, som e
optom etrists com plete residency program s in special­
ty areas such as low vision, vision therapy, pediatrics,
contact lenses, and prim ary care optometry.
Trying to locate a qualified low vision optom etrist
for a client can be challenging because the profes­
sion of optom etry does not recognize specialties.
Therefore, any optom etrist can provide low vision
services, regardless of his or her experience in this
area. However, the Am erican Academy of O ptom etry
Low Vision Section has a Diplomate program for
interested optom etrists. To becom e a Diplomate in
Low Vision, an optom etrist m ust pass a w ritten
test, an oral exam ination, and a practical low vision
exam ination. A s of 2006, there were only about 45
practicing Low Vision Diplomats worldwide. A cur­
rent list of optom etrists that have successfully com ­
pleted this process can be found at the website for the
A m erican Academy of O ptom etry (www.aaopt.org).20
The Am erican O ptom etric A ssociation also has a Low
Vision Section. Although there is no testing program
required to becom e a m em ber of this section, optom ­
etrists who have joined are likely to have a strong
interest in the area of low vision. Som e low vision
optom etrists have completed a residency program
and/or a m asters degree in low vision rehabilitation
while others have chosen to specialize in this area
and have acquired additional knowledge and clinical
skills through continuing education and independent
learning. Currently there are about 36,000 optom ­
etrists in the United States and there are about 1000
m em bers in the Low Vision Section of the American
O ptom etric Association.
O ptom etrists who specialize in low vision help
those with vision problems sec better, even if surgery,
m edications, and conventional glasses can no longer
im prove sight. They design and prescribe low vision
devices (eg, optical, nonoptical, electronic) and make
recom m endations about lighting, contrast, and other
environm ental factors that influ ence vision. Low
vision optom etrists often work along with low vision
therapists such as occupational therapists, vision
rehabilitation therapists, and orientation and m obility
specialists who teach clients how to use these assis­
tive devices in A D L and assist with orientation and
m obility issues.
O ccupational Therapists
According to the AOTA's Practice Framework, occu­
pational therapists focus on assisting people to engage
in daily life activities or occupations that they find
m eaningful and purposeful. O ccupational therapists'
expertise lies in their knowledge of occupation and
how engaging in occupations can be used to affect
hum an perform ance and the effects of disease and
disability.1 O ccupational therapists work with individ­
uals w ho have conditions that are mentally, physically,
developmentally, or em otionally disabling, including
low vision.
O ccupational therapists may work exclusively with
individuals in a particular age group or with particu­
lar disabilities. In schools, for exam ple, they evaluate
children's abilities, recom mend and provide therapy,
m odify classroom equipment, and help children par­
ticipate as fully as possible in school program s and
activities. O ccupational therapy also is beneficial to
the elderly population. Therapists help the elderly
lead more productive, active, and independent lives
through a variety o f m ethods, including the use of
adaptive equipment.
O ccupational therapists in m ental-health settings
treat individuals who are m entally ill, developmen­
tally disabled, or em otionally disturbed. To treat these
problems, therapists choose activities that help people
learn to engage in and cope w ith daily life. Activities
include tim e m anagem ent skills, budgeting, shop­
ping, hom cm aking, and the use of public transpor­
tation. O ccupational therapists also may work with
individuals who are dealing with alcoholism , drug
abuse, depression, eating disorders, or stress-related
disorders.
Currently, a bachelor's degree in occupational ther­
apy is the m inim um requirem ent for entry into this
field. Beginning in 2007, however, a m aster's degree
or higher will be the m inim um educational require­
ment. All states and the D istrict of Colum bia regu­
late the practice of occupational therapy. To obtain a
license, applicants must graduate from an accredited
educational program and pass a national certification
exam ination. The National Board for Certification in
O ccupational Therapy, Inc. (NBCOT®) is a not-for-
profit credentialing agency that provides certification
for the occupational therapy profession. Those who
pass the exam are awarded the title, Occupational
Therapist Registered (OTR).
As of 2006, entrv-level education was offered in
about 40 bachelor's degree program s, three postbac­
calaureate certificate program s for students w ith a
degree other than occupational therapy, and about 85
entry-level m aster's degree programs.
O ccupational therapists have been peripherally
involved in the rehabilitation of clients w ith low
vision since the early days o f the profession in 1917.19
Their involvement, however, was never as the main
caregiver for low vision clients. Rather, if a client w ith
other disabilities also happened to have low vision,
the occupational therapist would attempt to take care
of these needs as well. Until recently, low vision reha­
bilitation was rarely the prim ary focus of occupational
therapists. This all changed in 1990, when the Health
Care Finance A dm inistration (HCFA) expanded the
definition of physical im pairm ent to include low
vision as a condition that can benefit from rehabilita­
tion. With this change, physicians could specifically
refer clients w ith only low vision to occupational
therapists for low vision rehabilitation services.19
O ccupational therapists are currently the only
therapists among the group described in this chapter
that are licensed and can function independently in
the M edicare reim bursem ent program . Thus, occupa­
tional therapists have a unique opportunity to make
an impact as providers for the older client with low
vision in the United States. T hree other professions
have been providing rehabilitation services for people certification process adm inistered by the Academy for
with low vision for decades. Certification of Vision Rehabilitation and Education
In 2006, the AOTA introduced a program in which Professionals (ACVREP). W hen a vision rehabilitation
an occupational therapist or occupational therapy therapist becom es certified, he or she can use the ini­
assistant who has substantial clinical experience may tials CVRT (Certified Vision Rehabilitation Therapist)
achieve certification in low vision rehabilitation. The with his or her signature.
certification does not require a test. Rather, certifica­ Certified vision rehabilitation therapists are cur­
tion is based on a review of a reflective professional rently not eligible Medicare providers. A recent pol­
development portfolio and a series of narrative reflec­ icy change by the Centers for Medicare & Medicaid
tions. Services (CM S) also prevents ophthalm ologists and
optometrists from billing for services provided by
Vision Rehabilitation Therapists vision rehabilitation therapists who are salaried to
work with their clients. However, a CM S sponsored,
Recently, the name for rehabilitation teachers has
5-year demonstration program started in April 2006.
been changed to vision rehabilitation therapists.
This project (Pub 100-19, Transmittal 25 CR 3816, June
According to Crews and Luxton:21
7,2005) is designed to extend coverage under M edicare
В for the same services to treat vision impairment that
Rehabilitation Teachers constitute a cadre of uni­
would be payable when provided by an occupational
versity-trained professionals who address the
or physical therapist if they are now provided by a
broad array J of skills needed bv
* individuals who vision rehabilitation professional under the general
are blind and visually impaired to live indepen­
supervision of a qualified physician. O nly vision reha­
dently at home, to obtain employment, and to
bilitation professionals certified by the ACVREP are
participate in comm unity life. As a discipline,
eligible to participate in this demonstration project.2-4
Rehabilitation Teaching combines and applies the
best principles of adaptive rehabilitation, adult
education, and social work to the following broad
O rientation and Mobility
areas: home management, personal management, Specialists
comm unication and education, activities of daily
Orientation and mobility specialists (O&M s) are
living, leisure activities, and indoor orientation
professionals who specialize in teaching travel skills
skills.
to persons who are visually impaired, including the
use of sighted guides, canes, and electronic devices.
Vision rehabilitation therapists provide instruction
They may also teach skills that will prepare their cli­
and guidance in adaptive independent living skills,
ents to travel with a dog guide. The goal of orientation
enabling individuals who are blind and visually
and mobility instruction is to enable individuals with
impaired to confidently carry out their daily activi­
visual impairments to travel safely, efficiently, confi­
ties. Historically, vision rehabilitation therapists have
dently, and independently throughout their environ­
em phasized use of nonsighted strategies, although
ment. O&M s are prepared to work with individuals
they have certainly employed low vision techniques
of all ages, including young children.
as well. Vision rehabilitation therapists are also quali­
To become an O&M , one must attend an under­
fied to teach Braille. They are active members of mul­
graduate or graduate program accredited by the
tidisciplinary and interdisciplinary service team s and
Association for Education and Rehabilitation o f the
provide consultation and referrals through the utili­
Blind and Visually Impaired (AER). At present, there
zation of comm unity resources. Vision rehabilitation
are approximately 19 program s that prepare O&M s.22
therapists provide services in a variety of settings:
The majority of O&M program s are at the graduate
agencies serving people who are blind and visually
level and attract students with diverse backgrounds,
impaired, community-based rehabilitation teaching
including the social and physical sciences, art and
services, centers for people with developmental dis­
music therapy, and general education.
abilities, state vocational rehabilitation services, hospi­
O&M s are also currently not eligible M edicare
tal and clinic rehabilitation teams, residential schools,
providers, but are part o f the CM S Low Vision
and local school districts.22
Rehabilitation Demonstration Project that began in
There are currently about 10 colleges and univer­
April 2006.
sities in the United States, Canada, central Europe,
and New Zealand that provide either a bachelor's or
master's degree or a certificate in vision rehabilitation
Teachers of the Visually Impaired
therapy. Six of these universities are located in the The profession that takes care of the needs of ch il­
United States.22 dren with low vision is the Teacher of Children with
There is currently no state licensing for vision Visual Impairments (TVI). These individuals gener­
rehabilitation therapists; however, there is a national ally acquire the common core of knowledge and skills
essential for all beginning special education teachers
in addition to the specialized body of knowledge
required for teachers of students w ith visual im pair­
m ents.22 TV Is work with blind and visually impaired
infants, children and youth of all ages, including those
with multiple disabilities. They apply low vision and
blindness adaptive equipment and strategies, and, like
vision rehabilitation therapists, are qualified to teach
Braille. TV Is often operate as itinerant teachers, trav­
eling from school to school to serve children where
they are located. They serve as the child's prim ary
case m anager in school, and m ay solicit the expertise
o f additional therapists to develop specific goals and
objectives that com prise the child's Individualized
Education Plan (IEP).
TV Is are prepared in accredited higher education
program s recognized by the AER in the United States
and Canada. At present, there are approximately 40
institutions of higher learning offering special educa­
tion program s for teacher preparation in the area of
blindness and low vision.22 TV1 program s often rec­
ommend or require prior degrees or certification in
elementary, secondary, or special education. TV Is are
certified through their appropriate state’s Departm ent
of Education.
Low Vision Therapists
In recent years, a more generic term has developed
to describe therapists who engage in low vision reha­
bilitation and have been certified by the ACVREP as
Certified Low Vision Therapists: CLVT. T h is term
is actually trademarked and can only be used by
som eone who has been certified by the ACVREP. An
individual w ho has been certified as a low vision
therapist by the ACVREP w ill have the initials CLVT
after his or her nam e and degree. There are currently
two university program s that offer a degree in low
vision therapy (Pennsylvania College of O ptom etry
and University of Alabam a, Birm ingham ). However,
the term is also being used in the low vision field to
describe any therapist engaged in low vision reha­
bilitation. To becom e a low vision therapist, one must
pass a national certification exam ination adm inistered
by the ACVREP. To be eligible for this exam ination,
one m ust possess a bachelor's degree. Thus, a vision
rehabilitation therapist, an O & M , a teacher of the
visually im paired, an occupational therapist, a physi­
cal therapist, and a nurse would all be qualified to
take this exam ination. There is no licensure for a low
vision therapists and such a person would not be eli­
gible for M edicare reim bursem ent as an independent
practitioner, with the exception of the occupational or
physical therapist. These two professionals would be
eligible because they are already part of the healthcare
and M edicare system s. Many occupational therapists
also have becom e certified low vision therapists with
additional continuing education, by passing a certifi­
cation exam , and also com pleting supervised clinical
training.
Social W orkers
Social workers help people function optim ally in
their environm ent, deal w ith their relationships, and
solve personal and fam ily problems. Social workers
often see clients who face a life-threatening disease or
a social problem, such as inadequate housing, unem ­
ployment, a serious illness, a disability, or substance
abuse. Social workers also assist fam ilies that have
serious domestic conflicts, som etim es involving child
or spousal abuse. Social workers often provide social
services in health-related settings that now a rc gov­
erned by managed care organizations.
In regard to low vision rehabilitation, social work­
ers provide individual and group counseling and
facilitate consum er access to appropriate com m unity-
based services, including public assistance program s,
rehabilitation program s, senior centers, hospitals,
and clinics.24 They use self-help techniques to assist
blind and visually impaired adults who m ay be eco ­
nomically, physically, mentally, or socially in need of
vision-related rehabilitation services.24 Because o f the
significant psychosocial problem s related to vision
im pairm ent, social workers play a key role in the field
o f vision rehabilitation.
Although a bachelor's degree is sufficient for entry
into the field, an advanced degree has becom e the
standard for many positions. A m aster's degree in
social work (MSVV) is typically required for positions
in health settings and is required for clinical work as
well. As of 2004, the Council on Social Work Education
(CSW E) accredited 442 BSYV program s and 168 MSVV
program s. All states and the D istrict o f Colum bia have
licensing, certification, or registration requirem ents
regarding social work practice and the use of profes­
sional titles. Most states require 2 years (3,000 hours) of
supervised clinical experience for licensure o f clinical
social workers. In addition, the National Association
of Social W orkers (NASW ) offers voluntary creden­
tials. Social workers w ith an MSVV m ay be eligible
for the Academy o f Certified Social W orkers (ACSIV),
the Q ualified Clinical Social Worker (QCSW ), or the
Diplom ate in Clinical Social Work (DCSW ) credential,
based on their professional experience.
H istory of L o w V is io n
General H istory
Eyecare professionals have been treating correct­
able vision problem s such as myopia (nearsighted­
ness), hyperopia (farsightedness), and astigm atism for
M a te ria l c o m direitos autor
centuries using eyeglasses and, more recently, contact
1950s to 1970s
lenses and refractive surgery. However, attem pts to
From the 1950s to 1970s, low vision rehabilitation
help people with perm anent vision loss secondary to
for adults finally becam e a priority for the various
eye disease is a relatively new phenom enon.25 Earlier
professions involved in low vision care. With the
in this chapter, we demonstrated that the incidence
return of veterans from World W ar II and with the
and prevalence of low vision is currently quite high,
increasing life expectancy o f the population, the num ­
and as the population ages, these num bers are expect­
ber of people with low vision increased, leading to a
ed to grow significantly. However, until the mid-20th
greater demand for low vision services. T h is lead to
century, the prevalence of low vision w as not sign ifi­
the development o f a low vision service delivery sys­
cant and most of the care provided was for children
tem that has been called the "blind ness system ," the
w ith blindness and visual im pairm ent. We know
educational rehabilitation model, or the nonm edical
that the most com m on causes of low vision— m acular
vision rehabilitation system .29 This system is a com ­
degeneration, diabetic retinopathy, glaucom a, and
prehensive nationw ide network o f services consisting
cataract— are all diseases related to the aging process.
of state, federal, and private agencies serving children
Given the fact that age is the single best predictor
and adults w ith blindness and low vision.32 Table 1-5
of low vision,25 and that longer life expectancy has
characterized the 20th century, it is not surprising that lists the four com ponents o f the blindness or non m ed­
ical rehabilitation system in the United States.
more attention has been given to low vision rehabilita­
O ne of the key com ponents in this system o f care has
tion in the past 50 years.
been the Veteran's A dm inistration (VA). In the 1950s,
G oodrich has w ritten extensively about the history
the VA was am ong the first organizations to establish
of low vision2*'29 and divided low vision history into
com prehensive low vision care and has served as a
a num ber of stages that are sum m arized in Table 1-4.26
model for others.33 Two well-known private agencies
In the follow ing sum m ary, w e have modified his five
also started com prehensive low vision program s in
stages into four.
the 1950s. T h e Industrial I lome for the Blind began
Pre-1950 in 1953 and the Lighthouse {New York Association
for the Blind) in 1955. The professionals working in
This was a tim e period during w hich low vision
the blindness system included optom etrists, ophthal­
rehabilitation for adults essentially did not exist. Most
mologists, rehabilitation teachers, O&Vl specialists,
services were provided for blind children and little
and teachers of the visually im paired. The blindness
distinction w as made betw een those children who
system is separate from the traditional healthcare sy s­
were blind and those who had low vision. A comm on
tem in the United States and services provided arc not
belief at the tim e w as that it was im portant to prevent
reim bursed by M edicare or any other type of health
further loss of vision in these children by restricting
insurance. O ccupational therapists have generally not
the use o f their eyes. By the end of the 1940s, about 17
been part of this system o f care.
residential schools for the blind had been established
The blindness system has been chronically under­
with specially equipped classroom s for children with
funded. As a result, agencies have had to prioritize
low vision. W hile som e schools began to question
their services, generally favoring children and young
whether blind children should be separated from
adults of working age. In addition, the limited num ber
those w ith low vision, the principle of sight conser­
of rehabilitation professionals in the blindness system
vation prevailed in the m ajority of schools.26 This
prim arily work in m etropolitan areas. Thus, for many
was the era in which the rehabilitation teachers and
older clients and for those not living in large m etro­
teachers of the visually im paired becam e defined as
politan areas, low vision rehabilitation has not been
professions.
readily available through the blindness system .34
In 1934, the A m erican M edical Association (AMA)
T h is is also the tim e period in w hich educators
defined legal blindness as visual acuity 20/200 or
developed new m ethods for teaching children w ith
worse in the better-seeing eye. This definition was
low vision how to more effectively use their vision,
adopted for establishing eligibility for special services
rather than trying to conserve their vision. T h is m ove­
and benefits for the blind in the Social Security Act
ment w as lead by Barraga, who developed a visual
o f 1935. T h is stage of low vision history was also the
efficiency scale and a set o f sequential learning activi­
era in which W illiam Feinbloom , an optom etrist and
ties designed to develop visual efficiency in children
pioneer in low vision, began to develop num erous
w ith low vision.35-36
optical devices for people w ith low vision. Som e of the
Finally, this w as the era in w hich a num ber of
earliest journal articles about low vision were written
influential books on low vision care were published,
by W illiam Feinbloom .30'31 Nevertheless, the field of
w hen a variety of professional organizations devoted
low vision rehabilitation was in its infancy.
significant tim e at conferences to low vision, and new
 Table 1-4.

History of Low Vision - Five Stages

Stage Key Issues/Developments
Stage 1: Pre 1950 • No distinction betw een blindness and low vision
• Almost all services provided to children
• Com m only believed that children with poor vision needed to
restrict the use of their eyes to prevent further loss (sight-saving
programs)
• Residential schools for the blind established (by the end of the
1940s, 17 schools established)
• In 1934 the ЛМА defined legal blindness
• 1930s W illiam Feinbloom (optom etrist) began developing optical
devices for people w ith low vision

Stage 2: 1950s to 1970s • Various professional disciplines developed know ledge bases for
treating people w ith low vision
• Beginning of "B lind ness System " for low vision rehabilitation
with adults
• Emphasis on sight-saving for children replaced by concept of low
vision rehabilitation
• O ptom etrist and ophthalm ologists developed reliable tools for
assessm ent of vision and new optical devices for the treatm ent of
low vision
• O ptom etrists and ophthalm ologists develop low vision practices

Stage 3: Mid-1970s to Mid-1980s • Concept of team approach to low vision care developed
• Low vision becom es more prevalent as life expectancy increases
• Expansion of low vision rehabilitation program s
• Significant increase in low vision research

Stage 4: M id-1980s to Mid-1990s • Significant increase in low vision research continues

• Significant expansion of the interdisciplinary approach
• Professionals of each discipline becom e more fam iliar with
philosophies, skills, and techniques o f associated disciplines

Stage 5: Present • Im portant changes in M edicare leads to changes in delivery

system for low vision rehabilitation including occupational
therapists for the first tim e
• Significant increase in low vision research continues

Adapted from Goodrich GL. Sowell V. Low vision: Л history in progress. In: Corn AL, Koenig A|. Eds. foundations o f Low Vision: Clinica.
and functional Perspectives. New York: American Foundation tor the Blind; 2000.

testing equipm ent and optical devices, including the
first video m agnification units, were developed.
1970s to 1990s
From the 1970s to the 1990s, the team approach to
low vision care gained m om entum as professionals
from various disciplines becam e m ore fam iliar with
the philosophies, skills, and techniques of associated
disciplines.26 As life expectancy continued to increase,
the prevalence of low vision in the elderly popula­
tion grew and fueled the expansion of low vision
program s. This era also saw a significant increase in
the quantity and quality of research on low vision.
This started with a National Eye Institute initiative in
the mid-1980s and the grow th in low vision research
continues to grow today w ith publications in major
 Table 1-5.

_____________ Four Major .Subsystems..of the Blindness System_______________

1. Federal and state vocational rehabilitation system administered by the Rehabilitation Services
Administration (RSA) of the US Department of Education, O ffice of Special Education and
Rehabilitative Services, which serves prim arily adults
2. The US Department of Veterans Affairs
3. The Private nonprofit sector, which serves both children and adults
4. The O ffice of Special Education Program s which prim arily serves children through its
educational services

Adapted from Ponchillia PE, Ponchillia SV. Foundations o f Rehabilitation Teaching with Persons Who are Blind or Visually Impaired. New
York, NY: American Foundation for the Blind; 1996:3*21.

vision and vision rehabilitation journals throughout
the world. Starting with maybe a dozen publications
before 1950, the number of publications has doubled
every decade to approximately 3700 between 1990 and
2000>
1990s to Present
"The last decade of the twentieth century produced
what is perhaps the greatest change in vision rehabili­
tation since the 1950s."25 Beginning in the late 1980s,
the federal government dramatically reduced funds
for programs that provided services to individuals
who were blind or visually impaired. Subsequently,
in 1991 the HCFA, which administered Medicare,
amended its definition of physical impairment to
include visual impairment. T h is change allowed
M edicare coverage for the first tim e by licensed
healthcare providers for low vision rehabilitation with
vision loss as the primary diagnosis when prescribed
by a physician. This amendment also set the stage for
the involvement of occupational therapy in the field of
low vision rehabilitation.
This delivery system of low vision rehabilitation
service is sometimes referred to as the "health care
system " in contrast to the blindness system described
above. Because M edicare does not recognize vision
rehabilitation therapists or O&M specialists as
licensed healthcare providers, these professionals are
not reimbursed for their services through Medicare.
W hile these changes were certainly welcomed by
occupational therapists, other professionals such as
rehabilitation therapists, O&M specialists, and low
vision therapists were concerned about being left out
of this alternative system for providing low vision
rehabilitation. In addition, some vision rehabilitation
therapists even expressed concern about the abil­
ity o f occupational therapists to provide low vision
rehabilitation care as indicated in the following state­
ment from a report of the American Foundation
for the Blind's National Task Force on General and
Specialized Services, Working Group on Allied Health
Professional Relationships:
Professionals in the vision field are demonstrating
a heightened awareness o f a concern about the
increasing number o f allied health professionals
(ie, occupational therapists) who are providing
vision-related services that have been traditional­
ly administered by trained and certified rehabili­
tation teachers, teachers of students with visual
impairments, O&M specialists, and low vision
therapists.37
O rr and Huebner go on to state that "the concern
of professionals in the vision field is that allied health
professionals may not have the specialized knowledge
base and skills needed to work with this population
because they have not received university training in
rehabilitation teaching and/or O&M ."37
There have been several failed attempts in which
legislation has been introduced into the US Congress
to provide Medicare coverage for vision rehabilita­
tion professionals other than occupational therapists.
These efforts are ongoing and at this tim e it is dif­
ficult to predict the results o f these efforts. The topic
of Medicare coverage for low vision rehabilitation will
be covered in detail in Chapter 16.
H istory of O ccupational Therapy
Involvement in Low Vision
Rehabilitation
The impetus for occupational therapy's involve­
ment in the area of low vision rehabilitation was the
1991 amendment by the HCFA that allowed M edicare
coverage for the first time for licensed healthcare pro­
viders for low vision rehabilitation. Since that time,
efforts have been made at the national, state, and local
levels to enable occupational therapy to play a pri­
mary role in low vision rehabilitation.
M ary Warren has been a strong advocate of occu­
pational therapy involvement in low vision rehabilita­
tion. She has lead the way w ith significant publica-
tions,12'19'34'38*40 national leadership,40 presentation
o f m any continuing education courses, clinical work
as an occupational therapist treating clients w ith low
vision,19 and helping to establish a university-based
training program in low vision rehabilitation for
occupational therapists at the U niversity of Alabama,
Birm ingham . In 1995, she stated "Although occupa­
tional therapists have been involved in the rehabilita­
tion of persons with vision loss since the inception
of the profession in 1917, we never played an exten­
sive role in low vision rehabilitation."38 Occupational
therapists have indeed always played a role in low
vision rehabilitation because nearly tw o-thirds of
older adults w ith low vision have at least one other
chronic medical condition that mav у interfere with
ADL and require occupational therapy.41 Thus, in
the context of providing care for other chronic condi­
tions, occupational therapists routinely m anage issues
related to low vision in their elderly clients.
However, with the inclusion of low vision as a d is­
ability under M edicare guidelines in the early 1990s,
occupational therapists now have a prim ary role to
play in this field. This sudden involvement by occupa­
tional therapists in low vision rehabilitation has lead
to som e controversy. The prim ary basis for this con­
troversy was a perception that the im petus for occupa­
tional therapy's entrance into the low vision arena was
not a change in education and preparation of its practi­
tioners. Rather, it w as purely based on reim bursem ent
issues. Thus, other vision rehabilitation therapists
have raised questions about occupational therapists'
qualifications, education, and clinical experience in
the area of low vision. For example, Lam bert42 raised
the following concerns about occupational therapists:
• They m ay be u nfam iliar w ith the various disci­
plines in the field, and thereby fail to appropri­
ately refer clients for other needed services.
• They have inadequate knowledge or specialized
training in low vision.
• C linics may favor occupational therapy in the
delivery of low vision services even though more
disability-specific professionals may be the most
appropriate provider.
As discussed earlier, sim ilar concerns were raised
by O rr and 1 luebner in 200137 when they expressed
their unease about occupational therapists' lack of
specialized knowledge base and skills needed to work
w ith the low vision population.
O thers have argued that there are a num ber of
im portant reasons why the occupational therapist
should play a prim ary role in low vision rehabilita­
tion.38-43 These reasons arc listed below:
1. Although the elderly com prise the m ajority of
the low vision population, they are the most
underserved by existing state, charitable, and
private program s. Because of the lack o f avail­
ability of services through the blindness sys­
tem, rehabilitation m ay be delayed and these
individuals are likelv
•f to becom e socially
у
isolat-
ed, depressed, and dependent. Involvement of
occupational therapists through the healthcare
system provides significantly greater access to
low vision rehabilitation for the elderly.43
2. Two-thirds of older persons have at least one
other chronic condition, in addition to low
vision, that lim its their independent func­
tioning. O ccupational therapists are already
prim ary providers for older clients w ith other
chronic conditions.38'43 O ccupational thera­
pists are trained in the physical, cognitive, sen ­
sory, and psychological aspects o f disability
and aging, and therefore, m ay be the natural
choice of professionals to work with older per­
sons w hose lim itations in ADL are a result of a
com bination of deficits.31*
3. O ccupational therapists are more evenly d is­
tributed throughout the United States than
O & M s and vision rehabilitation therapists,
who tend to be located in larger metropolitan
areas. Low vision services can be m ore widely
dissem inated through the healthcare delivery
system .38
O ccupational therapy as a profession, as well as
individual therapists, have reacted in a positive way
to this debate. In the past 15 years, many occupational
therapists have gained the knowledge base and clin i­
cal skills necessary to provide excellent care to clients
requiring low vision rehabilitation. This h as been
accomplished through a variety of learning formats,
including independent study, continuing education
courses, clin ical internships, and university-based
training. In addition, m any occupational therapists
have completed the sam e national certification pro­
gram that other low vision rehabilitation therapists
must complete. T h is certification process is run by
the ACVREP, which was established in January 2000.
It is an independent and autonom ous legal certifica­
tion body governed by a volunteer Board of Directors.
ACVRHP's mission is to offer professional certification
for vision rehabilitation and education professionals
in order to improve service delivery to persons with
vision im pairm ents. As o f January 2006, there were
approximately 2,100 certified O &M specialists, 600
certified vision rehabilitation therapists, and 300 cer­
tified low vision therapists. Although ACVREP does
not release data on how many occupational therapists
arc certified, it is likelv
/
that many
J of the 300 who are
certified low vision therapists arc occupational thera­
pists.
In 1995, the AOTA devoted its entire October issue
to the topic of low vision and in 1998 developed the
Occupational Therapy Practice Guidelines fo r Adults with
Low Vision. In recent years, the ЛОТА has listed low
vision rehabilitation as one of the "10 em erging areas"
of clinical practice for occupational therapists. The
AOTA has also created a low vision panel to develop
a set of competencies bv which occupational thera­
pists and occupational therapy assistants can achieve
specialty certification from the AOTA, indicating that
they have acquired the knowledge and skills to be
specialists in low vision intervention.44
Fifteen years in the history of a profession is a
relatively short time. Yet within this timeframe, occu­
pational therapy has made dramatic strides toward
becom ing a prim ary care provider in the area of vision
rehabilitation. With the need for these services grow­
ing significantly as the US population grows older,
there is a need for many more occupational therapists
to become involved in this exciting area of practice. As
occupational therapists become involved, it is critical
to be aware of the history of low vision rehabilitation
in the United States, the various professions involved,
and some of the sensitivities and important political
issues described above.
C lin ic a l M o d el
Although the blindness system or educational
model ot low vision rehabilitation has been the domi­
nant system since the 1950s, the four factors listed
below challenge the continued viability of this model
o f care.
1. Growing demand for low vision services: The
demand for low vision services is expcctcd to
grow rapidly in the next decade. The popu­
lation of the United States is aging and the
prevalence of eye disease that causes low
vision is greatest in people 65 years of age and
older. More therapists are needed to meet this
demand.
2. Poor distribution of vision rehabilitation pro­
viders: Vision rehabilitation therapists and
O&M specialists are not well distributed
throughout the country. They tend to be locat­
ed in larger metropolitan areas. As a result,
large num bers of people requiring low vision
rehabilitation could not be served within this
model.
3. Decrease in funding for the blindness system:
There have been significant budget cuts, creat­
ing funding problems and limited availability
of services for the older population.
4. Changes in M edicare: Changes over the past
decade in M edicare policy now allow occupa­
tional therapists to provide low vision reha­
bilitation in medical settings such as hospi­
tals, outpatient clinics, nursing homes, and in
client's homes.
M assof45 proposed a practice model for standard­
izing low vision rehabilitation as a healthcare service
(Table 1-6). He and others have emphasized the sim i­
larities between physical medicine and rehabilitation
(PM&R) and low vision rehabilitation.45'47
According to Fishburn,47 the aim s o f PM&R are
to prevent injury or frailty, m inim ize pathology, pre­
vent secondary complications, enhance function of
involved systems, and develop compensatory strate­
gies. She argues that these are essentially the same
aim s of low vision rehabilitation. In addition, many
clients now being served w ithin the PM&R system
have low vision as a secondary disability. The primary
reason for their rehabilitation might be physical, neu­
rologic, or cognitive impairments caused by stroke,
diabetes, brain injury, or demyelinating disease.47
Thus, low vision rehabilitation should be part of
the larger rehabilitation system. We agree with this
approach and believe that this model addresses each
of the four issues listed above.
W hen designing a model for vision rehabilitation,
it is also important to review the WHO vocabulary
defining impairment and disability. In 1980, the WHO
proposed four term s that should be used when defin­
ing impairment and disability.5 This terminology is
illustrated in Figure 1-1.
• A disorder is an anatomical deviation from nor­
mal and can be congenital or acquired. Examples
of visual disorders causing low vision are AMD,
diabetic retinopathy, glaucoma, and cataract.
• Impairment is a loss or abnorm ality in function.
The impnirment can be cither physiological
or psychological. Visual im pairm ents include
decreased visual acuitv, m reduced contrast sensi*
tivity, central scotom as (blind spots in the center
of the visual field), and constricted visual fields.
• Disability refers to a restriction or an inability to
perform a task in the normal way. Examples are
difficulty reading newspaper print, recognizing
faces, and driving a car.
 Table 1-6.

Low Vision Rehabilitation in the United States Healthcare System

Service Delivery Model

Physical Medicine and Low Vision Rehabilitation

Rehabilitation Professional Role Professional

Physiatrist Responsible for evaluating the O phthalm ologist
client, diagnosing functional O ptom etrist
disabilities, planning therapy,
coordinating health care and
perform ing procedures that are
w ithin the purview only of a
licensed physician

O ccupational Therapist Specializes in the rehabilitation of O ccupational Therapist

daily living and other functional Vision Rehabilitation Therapist
activities

Physical Therapist Specializes in m obility training, Orientation and M obility

joint m obilization and muscle Specialist
strengthening exercises

Social Worker Helps the client and fam ily cope Social Worker
w ith psychosocial issues related to
disabilities and to identify and use
resources

Based on model proposed by Massof RW, et al. Low vision rehabilitation in the U.S. health care system. 1 Vis Rehab. 1995;9<3):3-31.

Definition Term Examples

Anatom ical deviation from norm al, D isorder Cataract, Age-related m acular
w hether congenital or acquired degeneration, Glaucoma

Loss or abnorm ality of function, Visual acuity loss

w hether phsyiological or psychologi­ Im pairm ent Reduced contrast sensitivity
cal Constricted visual field

Restriction or inability to perform a Inability to read

task in a m anner considered normal D isab ility Inability to recognize faces
Inability to drive a car

Disadvantage that prevents or limits Inability to work

H andicap
fulfillm ent of a role that the individ- Restricted social interaction
ual would consider normal G iving up hobbies

Figure 1-1. W orld Health O rganization terminology for im pairm ent and disability. W H O . International classification o f im pair­
m ents, disabilities, a n d h andicaps: A m anual o f classification relating to the con seq uences o f disease. G en eva: W H O ; 1980.
 Table 1-7.

Optometric Low Vision Evaluation

Case History
Distance Visual Acuities
Near Visual Acuities
Central Visual Field Testing
Color Vision Testing
Visual/Mobility Field Testing
Contrast Sensitivity Testing
Refraction
Eye Health Evaluation
Magnification Evaluation

• Handicap is a disadvantage that prevents or
lim its the fulfillm ent of a role that is normal for
the client. Examples are the inability to work or
engage in hobbies, and restricted social interac­
tions.
In the model presented below, the ophthalmologist
and optom etrist are prim arily interested in the disor­
der and impairment, while the occupational therapist
m anages the disability and handicap, although there
may be overlap in some areas.
Role of the Ophthalmologist
The role of the ophthalmologist is to diagnose and
treat the eye disease. This might involve the use of
medication or surgery. W hen it is clear that vision has
been permanently impaired due to the eye disease,
the ophthalmologist refers the patient to a low vision
optom etrist for evaluation and treatment.
Role of the Low Vision Optometrist
The optometric low vision exam ination is described
in detail in Chapter 7. The evaluation includes the
components listed in Table 1-7.
The role of the optometrist is to evaluate the patient
and determ ine whether a change in the traditional
eyeglass proscription might be of benefit. The o p t o m ­
etrist also perform s a detailed evaluation of distance
and near visual acuity, contrast sensitivity, assessment
of central scotomas, and peripheral visual field. Based
on the results of this evaluation and the case historv,
the optometrist begins the process of determ ining the
m agnification needs of the client for various ADL and
selects and prescribes appropriate low vision opti­
cal aids. The optometrist then refers the client to the
occupational therapist for training in the use of the
prescribed devices for various ADL.
Although the scenario described above represents
current thinking about the interaction between the
optometrist and occupational therapist, we suggest
that to provide optimal care for clients, the ideal work­
ing relationship could be modified as detailed in the
section below.
Role of the Occupational Therapist
The role of the occupational therapist is to deter­
mine the cognitive, psychosocial, and physical needs
of the client to resum e m eaningful roles, routines, and
occupation. The occupational therapist perform s a
comprehensive evaluation o f the client's performance
areas such as ADL and instrum ental activities of
daily living (IADL), education, work, play, leisure, and
social participation.1 According to the AOTA Practice
Framework, ADL refers to activities that are oriented
toward taking care of one's own body, such as: bath­
ing, bowel and bladder management, dressing, eating,
feeding, functional mobility, personal device care,
and personal hygiene.1 IADL refers to activities that
are oriented toward interacting with the environment
and are generally optional in nature, such as: care
of others, child rearing, comm unication device use,
com m unity mobility, financial management, health
management, and meal preparation.1 The occupation­
al therapy low vision evaluation includes review of
the reports from the ophthalm ologist and low vision
optometrist, and further evaluation of the im pairm ent
as needed to identify what client and environmental
factors might limit performance. This evaluation is
described in detail in Chapter 8.
Based on the results of the optometric low vision
evaluation and the occupational therapy evaluation,
the therapist designs a vision rehabilitation treatment
program to enable the client to achieve the established
performance goals. The rehabilitation program should
include education about the functional implications
o f visual im pairm ent, m anagem ent of psychosocial
issues, referral to com m unity resources, teaching
the client visual scan n in g skills that optim ize the
use o f rem aining vision, the use of both optical and
nonoptical assistive devices in ADI., and environm en­
tal m odifications including m anagem ent of lighting,
contrast, and glare. In most states, a physician must
approve and periodically review the occupational
therapy treatm ent plan. The physician approving the
plan should be a low vision optom etrist even in states
in which approval is not required. Effective low vision
rehabilitation requires the specialized expertise of a
low vision optom etrist because rehabilitation requires
integrated m anagem ent of the visual effects of the
disease, refractive error, and the optical dem ands of a
task. The occupational therapist will need to refer the
clicnt back to the low vision optom etrist if it becom es
apparent that the prescribed optical devices are not as
effective as desired. O ther potential referrals include
orientation and m obility and social work.
An im portant issue is how the occupational thera­
pist interacts w ith eyecare providers. In the sections
above, we described a typical model where the oph­
thalm ologist will generally refer the client to a low
vision optom etrist for further evaluation and treat­
ment. Then the optom etrist refers to the occupational
therapist. There are exceptions to this standard of
practice. W hen an ophthalm ologist has advanced
training in low vision, a direct referral might be made
to the occupational therapist, along w ith collabora­
tion with the occupational therapist in evaluation and
treatm ent of the visual im pairm ent. Many occupa­
tional therapists practice in educational, home care,
or other settings in w hich a low vision optom etrist
is not physically present. In these settings, eyecare
providers not specializing in low vision rehabilitation
or other physicians may refer clients directly to the
occupational therapist. In such cases, we propose that
follow ing the initial occupational therapy evaluation,
the occupational therapist refers the patient to a low
vision optom etrist before implementation of the treat­
ment plan.
However, it is our belief that an alternative model
should be considered. We believe that the ideal prac­
tice situation would be for an occupational therapist
to play a role in the final determ ination of the appro­
priate optical devices. In this model, after the optom ­
etrist perform s the optom etric low' vision exam ination
and determ ines the approxim ate ideal m agnification
based on visual acuity, the client would be exam ined
by the occupational therapist. The role of the occupa­
tional therapist would be to assess the client's goals
and to determ ine the physical lim itations that might
im pact on the optom etrist's final decision about opti­
cal aids and m agnification selection. The therapist
would convey this inform ation to the optom etrist,
who would then determ ine and w rite the final pre­
scription. O f course, to be effective this would have
to be an ongoing and interactive process in w hich the
optom etrist and occupational therapist work together
to determ ine the appropriate optical devices for a cli­
ent. Under either model, ultimately, the optom etrist
would prescribe all recom m ended optical devices.
The prim ary support for this model is that occu­
pational therapists routinely observe their clients
engaged in various occupations and ADL. T h is creates
an ideal situation to help determ ine the type o f device
and m agnification that will work best for the client in
the ADL most im portant to the client. In every other
area of practice, occupational therapists routinely
include m easurem ent of physical function as part of
the evaluation. W hen an occupational therapist with
advanced training in low vision rehabilitation works
with a low vision optom etrist, an occasion may present
in which the occupational therapist m ay be asked to
m easure acuity, visual fields, and contrast sensitivity.
O ptom etrists, w ith their specialized understanding
of optics, refractive error, and the functional effects
of disease and progression of disease, must insure
that all optical device options are considered and that
the optical devices and prescribed eyeglasses work
together. This model highlights the strengths o f each
profession and allow s both the occupational therapist
and low vision optom etrist to provide com plem en­
tary and essential com ponents of the rehabilitation
process. T h is model would also be a cost-effective col­
laboration, with the occupational therapist perform ­
ing many of the tim e-consum ing procedures typically
required in a low vision evaluation, thereby decreas­
ing the tim e required by the eyecare provider.
Su m m a r y
This chapter w as designed to establish the im por­
tance of low vision rehabilitation for the practice of
occupational therapy and to review the definitions,
epidemiology and history o f low vision and low
vision rehabilitation in the United States. W e also pre­
sented a model of clinical care w ith suggested roles
for the various professions involved w ith low vision
rehabilitation.
R eferences
1. American Occupational Therapy Association. Occupational
Therapy Practice Framework: Domain and Process. Arr> / Occup
Ther. 2002;56<6):609-639.
2. The Lighthouse National Survey on Vision Loss. Гhe txperiencc.
Altitudes, and Knowledge or Middle-Aged and Older Americans.
New York: The Lighthouse; 1995:11.
 3. Massof RW. A model of the prevalence and incidence of low
vision and blindness among adults in the US. Opiom Vis Sci.
2002;79i1j;3l-38.
4. Tielsch JM. The epidemiology of vision impairment. In: Silverstone
B. Lang MA, Rosenthal B, Faye EE, eds. The Lighthouse
Handbook on Vision Impairment and Vision Rehabilitation. New
York: Oxford University Press; 2000: 5-17.
5. World Health Organization. International classification o f impair­
ment, disabilities, and handicaps: a manual o f classification relat-
infj to consequences o f disease. Geneva, Switzerland: W HO:
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60.
 ш
Review of Basic Anatomy,
Physiology, and Development of the
Visual System
B asic A n a t o m y and
P h y s io l o g y
T h is chapter is designed to provide a review of the
basic anatomy and physiology of the visual system.
Space lim itations prevent a com prehensive d iscu s­
sion of this topic. Readers requiring more in-depth
inform ation about these topics should review the texts
listed in the Bibliography of this chapter.
O rbit, Eyelids, and Eyeball
A traditional method of describing the anatomy of
the eye is to begin with the outerm ost structures and
move inward. The orbit of the eye, which is a bony
recess in the skull, contains a num ber of major struc­
tures, including the eyeball, the optic nerve, the m us­
cles o f the eye, and their nerves and blood vessels. The
eyeball, w hich is about 2.5 cm long, is suspended in
the orbital cavity in such a way that the six extraocular
m uscles can move it in all directions.
The eyelids protect the eyes from injury and exces­
sive light and keep the cornea moist. As illustrated in
Figure 2-1, the upper eyelid partially covers the iris,
whereas the entire inferior half of the eve is normally
uncovered. The eyelids are covered internally by the
highly vascular palpebral conjunctiva. The palpebral
conjunctiva continues onto the eyeball and is called
the bulbar conjunctiva. Inflam m ation of either the
bulbar or palpebral conjunctiva is referred to as con­
junctivitis, com m only called pink eye. Conjunctivitis
can be secondary to bacterial, viral, or allergic etiol­
ogy. Infection of the conjunctiva is generally self-lim it-
ing, but occasionally conjunctivitis can lead to inflam ­
mation of the cornea as well.
The bulbar conjunctiva covers the w hite portion of
the eye called the sclera. The sclera is the external coat
of the eye and is a w hite tissue covering the posterior
five-sixths of the eye. The anterior one-sixth of the
outer coat of the eye is the transparent structure called
the cornea (Figure 2-2). The cornea is an extrem ely
im portant structure of the eye because it is the key
optical component responsible for refraction of light
that enters the eye. It is an unusual tissue because
it is clear and has no blood vessels. T h e cornea is
susceptible to infection from bacterial, viral, fungal,
or allergic causes, and inflam m ation of the cornea is
referred to as keratitis. Severe inflam m ation, a corneal
burn due to exposure to toxic substances, or traum a to
the cornea can all lead to scarring and loss o f trans­
parency of the cornea. T h is can then lead to a loss of
vision if the scarring is located in the central portion
of the cornea. Reduced visual acuitv secondary
у * to
central corneal scarring is a condition that may be
encountered by occupational therapists in clients who
have experienced head trauma. O ther com m on age-
related problem s of the anterior part of the eye that
affect vision and cause discom fort include blepharitis
(chronic inflam m ation of the lids) and dry eye. These
can be m anaged m edically but with varying success.
Figure 2-1. Th e upper eyelid par­
tially covers the iris, w hereas the
entire interior half of the eye is
norm ally uncovered (Steinman).
Figure 2-2. Cross-section of the
eye. The anterior one-sixth of the
Ciliary
outer coat of the eye is the trans­
parent structure called the cornea
(Steinman).
D irectly behind the cornea is a clear, watery fluid
called the aqueous humor, w hich is produced in the
posterior cham ber and fills the anterior cham ber of
the eye (Figure 2-3). The aqueous is continuously pro­
duced by the ciliary body and provides nutrients for
the avascular cornea and lens. A fter passing through
the pupil from the posterior cham ber into the anterior
cham ber, the aqueous is drained off through canal of
Schlem m (Figure 2-3).
Lens
T h e lens is a transparent, flexible structure that is
held in position by zonular fibers (see Figure 2-3). It is
located posterior to the iris and anterior to the vitreous
humor. Like the cornea, the lens is both transparent
and avascular and is another key part of the refractive
system o f the eye. To accom m odate or focus on objects,
the lens m ust change shape. The ciliary m uscle con­
tracts, and this allow s the lens to thicken, enabling
the individual to focus. As an object moves away, the
ciliary m uscle relaxes, the lens becom es thinner, and
the focusing system relaxes. The lens of the eye is the
structure that gradually loses its transparency as a
person ages. T h is loss of transparency and develop­
ment of opacities is referred to as cataracts.
Retina
Macula
O ptic Nerve
V itreous
The vitreous body is located behind the lens (see
Figure 2-3). It consists of a jelly-like substance called
vitreous humor, in w hich there is a m eshwork o f col­
lagen fibrils. Vitreous humor is a colorless, transpar­
ent gel. It consists of 99% w ater and form s four-fifths
of the eyeball. In addition to transm itting light, it
holds the retina in place and provides support for the
lens. Unlike the aqueous humor, it is not continuously
replaced.
Choroid
T h e eyeball has three concentric coats. The first or
outerm ost coat, the sclera, was described above. The
middle coat is a heavily pigmented, vascular layer
consisting of the iris, ciliary body, and the choroid.
The iris, w hich is the colored portion of the eye (Figure
2-4), is located between the cornea and the lens. The
eye color depends on the am ount and distribution of
pigment in the iris. The iris is a contractile diaphragm
that has a central, circular aperture for transm itting
light called the pupil. The size o f the iris continually
varies to regulate the am ount of light entering the eye
through the pupil. The ciliary body lies betw een the
 Ciliary Muscle

Z o n u le s

Lens

V itre o u s

Ciliary Body

Canal of Schlemm

Figure 2-4. The iris is (he colored portion of the eye located
between the cornea and the lens (Steinman).
Figure 2-3. D irectly behind the cornea is a clear, watery fluid
called the aqueous humor. Aqueous is drained off through
the Canal of Schlem m (Steinm an).

iris and the choroid (see Figure 2-3). This structure
secretes aqueous humor. The ciliary body also con­
tains the ciliary muscle, which can contract or relax
to perm it accom m odation or focusing of the eye. The
choroid is a dark brown m em brane and is also part
of this m iddle coat of the eye. It continues from the
ciliary body and covers the entire posterior portion of
the eye. The choroid attaches firm ly to the retina and
contains the venous plexus and layers of capillaries
that are responsible for nutrition of the retina.
Retina
The most internal coat of the eye is the retina,
which is a thin, delicate membrane. T h e retina is the
posterior portion of the eye and there is a circular
depressed area called the optic disc (Figure 2-5). This
is where the optic nerve enters the eye and its fibers
spread out in the neural layer of the retina. Because it
contains nerve fibers and no photoreceptor cells, the
optic disc is insensitive to light. For this reason, it is
som etim es referred to as the blind spot. A nother very
im portant structure ju st lateral to the optic disc is the
fovea (see Figure 2-5). T h e fovea is the part of the eye
that contains the area of most acute vision. W henever
we look at an object, we m ust aim the eye so that the
im age of the object is focused on the fovea. Smooth
eye movements, called pursuits, and jum p eye m ove­
ments, called saccades, arc both designed to allow the
individual to use the fovea.
T h e retina is com posed of 10 layers, including the
pigmented epithelium , which is closest to the choroid
and the photoreceptors (cones and rods).
Beneath the pigmented epithelium of the retina
are these four layers (Figure 2-6) from the outside
(furthest from the retina) to the inside (closest to the
retina):
1. Sclera (white part of the eye)
2. Large choroidal blood vessels
3. Choriocapillaris
4. Bruch's mem brane (separates the pigmented
epithelium of the retina from the choroid).
Note that light must pass through all layers of the
retina to reach the photoreceptors, where the visual
process begins. D iseases such as m acular degenera­
tion or diabetic retinopathy that affect the clarity of
retina, or sw elling that affects the shape of the retina,
w ill have a profound effect on vision.
Photoreceptors (Cones and Rods)
Light causes a chem ical reaction in cones and in
rods, beginning the visual process. Activated photore­
ceptors stim ulate bipolar cells, w hich in turn stim ulate
 Blood Vessels
Fovea
M acula
Figure 2-5. The retina as view ed through the dilated pupil:
the optic disc is a circular depression in the posterior portion
o f the retina. This is w h ere the optic nerve enters the eye
and its fibers spread out in the neural layer of the retina. The
fovea is lateral to the optic disc iSteinm anl.
ganglion cells. The im pulses continue into the axons
o f the ganglion cells, through the optic nerve, and to
the visual cortex at the occipital lobe of the brain.
There are about 6.5 to 7 m illion cones in each eye,
and they are sensitive to bright light and to color. The
highest concentration of cones is in the macular. The
center of the m acular contains onlv* cones and no rods.
The highest concentration of rods is in the peripheral
retina, decreasing in density up to the macular. Kods
are used for night vision and do not detect color,
which is the m ain reason it is difficult to tell the color
o f an object at night or in the dark. Defective or d am ­
aged cones results in color deficiency. Defective or
dam aged rods result in problem s seeing in the dark
and at night.
Muscles of the O rbit and Their
Innervation
Six extraocular m uscles attach to each eve and
allow m ovem ent in all directions of gaze. There are
four rectus m uscles— the superior, inferior, lateral,
and medial recti m uscles— and two oblique muscles
called the inferior and superior oblique muscles.
Each of the six m uscles has one position of gaze
in which it exerts the main influence on eye position.
Figure 2-7 illustrates the various positions of gaze that
are evaluated clinically. The diagram also displays
the m uscle that is prim arily responsible for movement
into each position of gaze. T h is diagram is the basis
for the clinical evaluation of eye m uscle problems.
For exam ple, if a client has difficulty moving his
eyes down and to the right, the two possible muscles
Nerve Fiber Layer
Ganglion Cen Layer
Innef Plexiform Layer
Inner Nuclear Layer
[ Outer Ploxilorm Layer
Outer Nuclear Layer
Photoreceptor Outer Segments
Retinal Pigment Epitnetium
Choroid
Figure 2-6. Ten layers of the retina (Steinm an).
involved would be the right inferior rectus and the left
superior oblique. The left superior oblique moves the
left eye down and to the right and the right inferior
rectus moves the right eye down and to the right. To
determ ine which of the two rem aining m uscles is at
fault requires additional clinical testing.
Three cranial nerves supply innervation to the six
extraocular muscles. The third cranial nerve inner­
vates the superior, inferior, m edial recti, and the infe­
rior oblique muscle. The fourth cranial nerve supplies
innervation to the superior oblique, and the sixth
cranial nerve innervates the lateral rectus.
Diplopia, or double vision, is a very com m on
symptom of clients treated by occupational therapists,
particularly after cerebrovascular accident or head
trauma. Diplopia occurs when the object at which
the individual is looking stim ulates the fovea of one
eye and a nonfoveal part of the retina of the other
eye. Thus, diplopia suggests m isalignm ent of the
eyes. There are a num ber of disorders that can lead
to diplopia. Brain injury from stroke or traum a that
affect the midbrain or cerebellum area often affect
both balance and eye movements. Among the more
com m on problem s are cranial nerve palsies. The most
com m on nerve palsies seen by occupational therapists
are sixth and fourth nerve palsies.
The m ost com m on causes of fourth nerve palsy
are head traum a and vascular problems. Fourth cra­
nial nerve palsy can be unilateral or bilateral and can
affect the superior oblique muscle. Bilateral fourth
nerve palsy is often seen follow ing vertex blow s to the
head, such as those that occu r in m otorcycle accidents.
The presence of a fourth nerve palsy causes the eye

RSR
RSR RIO LIO
RIO
KSO
with the affected muscle to drift upward. The client
has difficulty looking down and to the right if it is a
left superior oblique problem, and down and to the
left if it is a right superior oblique problem.
Sixth cranial nerve palsies are the most frequently
reported ocular motor nerve palsies. The nerve has
the longest intracranial course of any nerve and is
often subject to damage with raised intracranial pres­
sure. The causes include vascular disease, trauma,
elevated intracranial pressure, and neoplasm. The
sixth nerve innervates the lateral rectus. A sixth nerve
palsy will interfere with the client's ability to abduct
the eye (move the eye away from the nose).
Visual Pathways
One of the most common vision problems occu­
pational therapists encounter after acquired brain
injury is visual field deficits. A right or left field loss
is referred to as an homonymous hemianopsia. To
understand why a client would lose vision on just
one side, it is necessary to understand how visual
information travels from the retina to the visual cor­
tex. Vision begins with the capture of images focused
by the optical media on photoreceptors of the retina.
The fibers from the upper half of each retina enter the
optic nerve above the horizontal meridian, and those
from the lower half enter below the horizontal merid­
ian. Fibers from the periphery of the retina lie periph­
erally in the optic nerve, and fibers from the fovea lie
centrally. This arrangement persists throughout the
entire course of the visual pathways from the optic
nerve through the chiasm, the optic tracts, and optic
radiations.
Visual information from the right field strikes
the nasal half of the retina of the right eye and the
Figure 2-7. Positions
o f gaze that are evalu­
ated by clinicians when
testing the extraocular
LSR
LIO LSR muscles.
temporal half of the retina of the left eye. Similarly,
visual information from the left field strikes the nasal
half of the retina of the left eve and the temporal half
of the retina of the right eye (Figure 2-8). When the
fibers from each optic nerve reach the optic chiasm , a
semi-decussation or partial crossing takes place. The
fibers from the temporal part of the retina rem ain on
the temporal or outside aspect of the chiasm and are
called uncrossed fibers. The nasal fibers of the retina
cross over in the chiasm and arc called crossed fibers.
After leaving the chiasm , the fibers form the optic
tract. Thus, all visual information originating from
the right field travels in the left optic tract, and all
visual inform ation originating from the left field trav­
els in the right optic tract. The fibers in the upper half
of the tract originate from the upper half of the two
retinas, and the fibers from the lower half of the tract
com e from the lower half of the two retinas. The fibers
from the optic tract synapse in the lateral geniculate
body. The cells of the lateral geniculate body give rise
to new fibers, which form the optic radiation. These
fibers then proceed to the cells of the visual cortex
(Figure 2-9). Any lesion that affects the visual pathway
on only the right or left side after this decussation
takes place will affect either the left visual field or
right visual field.
Vision Areas of the Brain
The brain is divided into several different lobes.
Starting anteriorly are the frontal lobes, which are
responsible for decision m aking, planning ahead,
emotional tone, abstract thinking and carrying out
intentions. Immediately behind them and in front
of the motor area is the prefrontal cortex, which
is involved in organizing and sequencing complex
Figure 2-8. The right visual cortex
receives information from the left
visual field and the left visual cor­
tex receives information from the
right visual field.
Figure 2-9. V isual pathw ay from
the optic nerve to the visual cor­
tex.
O ptic Radiations
motor behavior. The temporal lobes are associated
with hearing and also provide som e contribution to
vision. The parietal lobes are responsible for tactile
recognition. Parietal lobe injury com m only results
in perceptual deficits that disrupt am bulation and
self-care activities. H em i-sensory neglect is a com ­
mon problem in clients with a lesion in the posterior
parietal cortex.
The occipital lobe contains the visual cortex, with
nerve pathw ays leading to higher centers in the
parietal and temporal lobes, w here visual sensations
acquire m eaning. Lesions in the visual cortex and in
associated areas can produce visual and perceptual
problem s.
A ll of the visual fibers end in the striate area of the
cortex, w hich is called area 17. Area 17 is considered
Optic Radiations
LGN
Steinman
Visual
O ptic Chiasm
O ptic Nerve
to be the prim ary visuosensory area in man. Outside
of area 17 and closely follow ing its contours are two
other areas that are concerned with visual reactions
as well. These are called areas 18 and 19. M ost physi­
ologists agree that vision is a function of higher parts
of the brain than just the visual cortex. The message
relayed to area 17 enables a person to see. It docs not
enable a person to recognize what he or she sees or to
recall things that have been seen. These functions are
dependent on other parts o f the brain. In order for a
person to be able to interpret the sensory inform ation
reaching area 17, the m essage must be sent on to the
two secondary'«/ visual areas and areas 18 and 19. Area
18 is concerned exclusively w ith the recognition of
objects, anim ate or inanim ate, but is not concerned
with the recognition of w ritten or printed sym bols
of language. Area 19 is conccrned with the rccall of
visual memory relating to objects but not to language
Su m m a r y
symbols. In general, occipital areas are involved with
Since low vision is a condition in which visual acu­
spatial relations while temporal occipital areas are
ity is reduced because of eye disease, it is important
involved with object and letter recognition.
to have a basic understanding of the anatomy and
Two parallel routes carry visual information from
physiology of the eye and visual system. We urge
the occipital lobe to the prefrontal lobe and the fron­
readers who feel a need for more detail to refer to the
tal eve
V
fields. Fibers from these two routes distribute
Bibliography provided at the end of this chapter.
fibers to many other areas along each route before
term inating in the prefrontal cortex and in the frontal
eye fields. The first route is the superior route via the
parietal and frontal lobes. The other route is the infe­ B ib lio g r a p h y
rior route via the temporal and frontal lobes.
Moore KL. Clinicdlty Oriented Anatomy. Baltimore. МП: Williams and
The cerebellum integrates the smooth coordination
Wilkins; 1980.
of m uscular activity. If it is damaged, general motor Moses R/V Adler's Physiology o f fhe Eye. 7th ed. St. Louis. Mo: CV
clum siness occurs. This mav у interfere with manual MosI>v Co; 1981.
dexterity and other forms of fine m uscular perfor­ Solomon H. Binocular Vision. A Programmed Text. London: William
mance, as well as eve Heinermnn Medical Books Ltd: 1978.
¥ movement control. Dvsfunction
¥
within the cerebellum yields problems with equilib­
rium, motor control, body image, laterality, and some­
times w ith reading and speech.
 Visual Acuity, Contrast Sensitivity,
Refractive Disorders, and Visual Fields
V is u al A c u it y
Definition
Visual acuity is a m easure of the sm allest high-con-
trast detail that one can resolve. Visual acuitv / usually
¥ literature, and in some clinics in the United States,
is m easured with letters or words: the detail is l/5th
the size of the letter or about the stroke width or the
gap in a C. Most people are fam iliar with the concept
of 20/20 visual acuity. An individual with "20/20"
acuitv is considered to have norm al ability to see small
detail at the distance tested. The num erator refers to
the testing distance at w hich the subject recognizes
the stim ulus. The denom inator refers to the letter size.
Letter size is described as the distance at w hich the
letter being viewed could be identified by a client with
norm al visual acuity. Since larger letters can be seen
further away, a larger num ber in the denom inator
indicates a larger size letter on the eye chart. For an
exam ple, we will use a client w ith 20/100 acuity. This
indicates that he or she was tested at 20 feet and the
sm allest letter the client could see was large enough so
that som eone w ith norm al visual acuity could identify
the letter presented at a distance of 100 feet. A letter
that could be seen at 100 feet is 5X larger than a letter
seen at 20 feet. The client in our exam ple could only
see this letter at 20 feet, indicating that the visual acu­
ity is reduced 5X relative to the norm al finding. This
method of recording visual acuity is routinely used in
the United States and the units in feet are referred to
as "im perial units". In other countries, in the research
m eters rather than feet are used to express distance
visual acuity using the M system described below. For
example, 6/6 is equivalent to 20/20 acuity (6 m eters is
about 19 feet), 6/60 is equivalent to 20/200 acuity, and
6/30 is equivalent to 20/100 acuity.
In traditional vision screen ings, visual acuity
below the level of 20/30 to 20/40 is considered cause
for referral. However, clinically, any deviation from
20/20 is considered a problem, and in the course of
the vision evaluation the clinician must determ ine the
basis for the loss of visual acuity.
The m eaning of 20/20 visual acuity can also be
expressed based on a m athem atical concept. Som eone
with 20/20 visual acuity is able to recognize a letter
that subtends a visual angle of 5 m inutes of arc at the
eye (Figure 3-1); the critical detail is 1 m inute o f arc.
As illustrated in Figure 3-1, this m eans that if you
draw a line from the top of a 20/20 letter to the eye
and another line from the bottom of the letter to the
Figure 3-1. Definition ot 20/20
visual acuity (Steinm an).

eye, the size of the angle at the intersection of these m ake the calculation. It is very im portant to note that
two lines at the eye is 5 m inutes of arc. equivalent acuity is only valid at the recommended
W hen m easuring near visual acuity, the convention test distance for the chart. A nother num ber listed next
is based on the "m eter system " or "M " notation. In to each line on som e acuity charts is "logM A R". This
this system , a 1 M letter w ill subtend 5 minutes of arc is a m easure of the angular subtense o f the critical
at 1 meter. To com pare acuity at distance and near, it is detail of the letter at the recom m ended test distance,
im portant to be able to convert from one m easurem ent and is used for research (not clinical) purposes.
system to the other. The formula for converting metric
acuity to im perial notation is as follows: Clinical Assessment
Visual acuity testing is a critical aspect o f a vision
D/S = 20/X
evaluation and is perform ed by every type o f eye care
where D = the test distance in meters, and S = the
professional and is repeated at every eye exam ination.
letter size in M units. O ne would solve for X by cross-
The standard Snellen Acuity C hart (Figure 3-2) is the
m ultiplying DX = 20S, then solve for X. X = 20S/D
most comm on method o f testing visual acuity.
The Snellen visual acuity chart has a num ber of
Be careful that the numerator and denom inator arc
flaws that m ake it an inappropriate chart for clients
the sam e units.
w ith low vision. As Figure 3-2 illustrates, there is only
one letter at 20/200, two letters at 20/100, and three at
Example: What is the Snellen equivalent to 1A1 acuity
2 0 /7 0 . On the other hand, as visual acuity approaches
at 40 cm?
20/20, the num ber o f letters per line increases and the
If the m etric acuity was 1.0 M at 0.4 m eters (40 cm),
gradations become sm aller (ie, 20/40, 20/30, 20/25,
the form ula would be 0.4/1 M = 20/X
20/20). The construction of this chart is ideal for cli­
cross multiply,
ents w ith 20/20 visual acuity and allow s the eye doctor
X = 20S/D, S = 1, D = 0.4
to precisely exam ine clients with norm al visual acuity
X = 20/0.4
requiring standard eyeglasses. In most offices today,
X = 50
these charts are not hung on the w all; rather, the chart
Atiswcr: 0.4/1 M = 20/5 0 acuity
is projected on the wall using a special visual acuity
projector. Projected acuity charts com m only used also
A nother way to approach the problem is to multi­
suffer from low lum inance and poor contrast and are
ply the num erator by a num ber that results in 20. Then
not typical of everyday objects som eone m ight try to
m ultiply the denom inator by the sam e number.
resolve. The contrast also varies w ith the age o f the
A short cut method is to divide the num erator and
projector bulb. Thus, although the standard Snellen
denom inator in half so it equals 0.2/0.5, then multiply
visual acuity chart is w idely used, it is not an accept­
by 100 to 20/30. Since the test distance w as not actu-
able chart for the low vision client.
ally 20 feet, 20/50 would be called equivalent visual
Low vision clients, however, have visual acuity
acuity.
poorer than 20/70. To exam ine such an individual, the
chart should have sm all gradations in the poorer visu­
Tabic 3-1 can also be used to convert comm on
al acuity range. Instead of 20/200, 20/100, and 20/70
visual acuity findings from one notation system to
that are large gradation changes, the chart should
another.
have sm aller increm ents, such as 20/400, 20/350,
O ften, m etric visual acuity charts provide equiva­
20/300, 20/275, and 20/250. Visual acuity charts for
lent Snellen acuity on the chart so one does not need to
low vision clients should have letters that start at
 -------------------------------------------ТаЫсЗ-Т.-------------------------------------------

Near Visual Acuity Equivalents at 40 cm Near Test Distance

5ле//ея Equivalent Meter System Point Usual Type Size

"M " Notation

20/250 5.00 40 Newspaper Headlines

20/200 4.00 32 Newspaper subhead 1i nes
20/100 2.00 16 Large-print material
20/80 1.60 12 Children's books
20/60 1.20 10 M agazine print
20/50 1.00 8 Newspaper print
20/40 0.80 6 Paperback print
20/25 0.50 4 Footnotes
20/20 0.40 3

Figure 3-2. The standard Snellen

Acuity Chart (Steinman).

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11
Figure 3-3. Feinbloom Chart
(Steinman).
much higher acuity levels, such as 20/700, 20/800, and
20/1000. In addition, the chart should have an equal
num ber of letters at each acuity level. W hen only one
or tw o letters are available on a line, the client could
m em orize the line, guess the letter(s) correctly, and
the clinician could not be sure that the visual acuity
obtained was accurate and reliable. Current standards
for near and distance acuity charts standardize the
letters and space all lines at the sam e 25% difference
in size, corresponding to a m athem atical progres­
sion of l/10th (0.1) of a logarithm ic unit. Log spacing
enables more precise and repeatable m easurem ents
and also enables the experienced practitioner to more
easily perform calculations at nonstandard test d is­
tances and estim ate m agnification. C harts adhering to
this standard are referred to as Log charts.
A ny therapist who has been involved with low
vision rehabilitation w ill relate to the follow ing sce­
nario. A client is referred for low vision rehabilitation
with a m edical diagnosis of m acular degeneration. The
referral also indicates the best-corrected visual acuity
as: right eye 20/200, left eye: counting fingers. W hat
does counting fin gers m ean and how does the therapist
use this inform ation to properly code for Medicare
docum entation and reim bursem ent? Generally, the
term counting fingers m eans that the eye doctor used
the standard projected Snellen chart for the visual
acuitv exam ination. The client was unable to see even
the large letter " E " at the top of the chart. The eye doc­
tor, therefore, held up his hand and waved it, show ing
anyw here from 1 to 5 fingers, and asked the client
"H ow m any fingers do you se e ?" This is obviously
not an appropriate assessm ent of visual acuity and
indicates that the eye doctor sim ply did not have the
proper equipm ent to com plete the exam ination and
did not use an acceptable method for the visual acu­
ity assessm ent. In such cases, the therapist will need
to repeat visual acuity testing using an appropriate
target and technique described below.
Because of these issues special visual acuity eye
charts have been developed. T here are a num ber of
excellent visual acuitv ¥ ch arts that are available for
6 1 5 4 8 2
the low vision client. In this chapter we w ill review
three visual acuity charts that are effective and widely
used.
Low V is io n D is ta n c e V is u a l
A c u it y C h a r ts
O riginal D istance Test C h art for
the Partially Sighted
T h is chart (Figure 3-3) is often called the Feinbloom
Distance Test C hart and is widely used and consid­
ered the gold standard by som e authorities.1 The
advantage is that the chart has num eric optotypes
at the follow ing visual acuity levels: 20/700, 20/600,
20/400, 20/350, 20/300, 20/225, 20/200, 20/180, 20/160,
20,140, 20/120, 20/100, 20/80, 20/60, 20/40, 20/30,
20/25, 20/20, 20/10.
The chart w as calibrated for 20 feet, but is typically
used at a 10-foot distance, which m eans the acuity val­
ues listed above would be doubled. T h is m eans that
at a 10-foot distance, the acuity range extends from
20/1400 to 20/20.
Freem an and Jo se1 discuss the advantages o f per­
form ing this test at 10 feet and include the following:
• Doubles the num ber of lines the client can
attempt com pared to a standard visual acuity
chart.
• D ecreases the background confusion because
the num bers are not spaced as close together as
w ith a standard visual acuity chart.
• Allows for better lighting and less glare.
• Elicits a m ore positive response than a standard
visual acuitv chart.
If a client cannot even see the large " 7 " at 10 feet,
the chart can be moved to 5 feet. At this distance, the
acuity range is extended from 20/1400 to 2800 because
ial co rr
each tim e you decrease the distance by half, you
double the denominator.
A nother m ajor advantage of this visual acuity chart
is that because of the large visual acuity range that can
be assessed, alm ost all clients with low vision will be
able to read at least som e letters on the visual acuity
chart. This is im portant from a psychological stand­
point. M any clients w ith low vision have had negative
experiences during visual acuity testing (being unable
to even see the large "E "). This can be depressing.
The client feels that there is no hope if he or she could
not sec the eye chart at all. With the Feinbloom chart,
however, most clients are able to read quite a few lines
on the chart, leading to a much more positive experi­
ence.1'2
A m ajor advantage of the Feinbloom chart is porta­
bility. For this reason, the Feinbloom chart is recom­
mended for home-based evaluation. The Feinbloom
chart is also valuable because it can be used to assess
eccentric viewing. T h is technique is often required
when an occupational therapist is assessing eccentric
view ing, and is reviewed in detail in Chapter 8.
O ne major problem with the Feinbloom chart is
that it does not have an equal num ber of optotypes
per acuity level. There is only one num ber at the
20/700, 20/600, 20/400, 20/350, 20/300, and 20/225
levels, and only three per line from 20/200 to 20/60.
Another problem is the letters arc not standard, so
acuity measured w ith the Feinbloom ch art m ay not
match acuitv measured with another chart. Because
o f these shortcom ings, the Feinbloom C hart should be
supplemented w ith one of the two described below, if
possible.
Early Treatm ent Diabetic
R etinopathy Study C h art
Using a design developed by Lovie-Kitchen and
Bailey,3 this Log chart provides five letters per line
and also standardizes the separation betw een let­
ters. A unique aspect of the Early Treatm ent Diabetic
Retinopathy Study C hart (ETDRS) is its geom etric
progression of size differences betw een lines, referred
to as logM A R progression (Figure 3-4). O ptotypes
on each line are 0.1 log unit or 25% larger than the
previous line. T h is format results in every three lines
representing a halving or doubling of visual acuity
at any given view ing distance, eg, if one starts at 100
and goes down three steps (step 1 = 80, step 2 = 80
to 63, and step 3 = 63 to 50), w hich is one-half of 100.
These characteristics allow for consistent and accurate
evaluation of visual acuity. This chart is considered
the gold standard for accurate, repeatable m easure­
ment. However, the FTD RS chart is large and cannot
be easily carried for home healthcare. Thus, it may not
be practical for home health practice.
The standard test distance is 4 m eters, but for low
vision evaluations the test distance is usually halved
to 2 m eters to insure that a client can read the largest
letters. This also m akes conversion to Snellen equiva­
lent easy. O ne ju st adds a zero to the num erator and
denom inator. For exam ple, a 2/10 acuity m easurem ent
in M units becom es 20/100 in im perial notation.
C hronister Pocket A cuity C h art
The C hronister Pocket A cuity C hart (CPAC) is
very sim ilar to the Feinbloom chart (Figure 3-5). It
has m any acuity gradations, from 20/220 to 20/10
when used at 20 feet, from 20/449 to 20/20 at 10 feet,
and from 20/880 to 20/40 at 5 feet. The m ajor advan­
tage is that it can be held in one hand and carried in
one's pocket. Therefore, it is easy for an occupational
therapist to carry this chart when providing care in a
client s home, hospital room, or nursing hom e room.
It does share the sam e shortcom ing as the Feinbloom
chart, having only two letters per visual acuity level
from 20/220 to 20/40, and then four letters per visual
acuity level from 20/30 to 20/10.
Low V is io n N e a r V is u a l
A c u it y C h a r ts
A com m on goal of clients with low vision is to be
able to read again. Therefore, the evaluation of near
visual acuity is essential because this visual acuity
testing is perform ed at the reading distance. Generally,
near visual acuity should be m easured w ith words or
continuous text because word acuity better predicts
the visual requirem ents for reading than letter acu­
ity.4-5 Near visual acuity testing differs from distance
visual acuity testing in tw o ways.
1. In addition to testing the client's ability to read
single letters or num bers, charts w ith phrases
and sentences are also used to evaluate read­
ing ability.
2. The meter system of notation is often used for
near visual acuity testing as mentioned earlier
in this chapter (see Table 3-1).
Three com m only used near visual acuity charts are
described below.
Lighthouse N ear A cuityTest (M eter
System)
The Lighthouse N ear A cuity Test (LHNV-1) letter
chart is illustrated in Figure 3-6 and shows that the
card has both Snellen equivalent and m eter system
notation. N ear visual acuity testing is typically per­
formed at 40 cm with clients with norm al vision. If
 06
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04
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02 Н Z С К О 32

01 N С К Н D 25
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Figure 3-4a. ET D R S Visual A cuity Chart (Steinm an).

Figure 3-4b . ETD R S Visual A cuity Chart (Steinm an).

Figure 3-5. Chronister

Pocket A cuity Chart (Gulden
O phthalm ics) (Steinm an).

a client with low vision is unable to see the largest Lighthouse Reduced ETDRS
letters at 40 cm, the testing can be performed at any
distance. W hen recording the result, it is im portant C h art
to record the distance at which the testing occurred
The sam e advantages that w ere described above for
as well as the visual acuity achieved. For example,
the ETDRS visual acuity chart apply to the reduced
if a client can see the 4 M print at 25 cm , it would be
ETDRS near visual acuity chart illustrated in Figure
recorded as 0.25/4 M.
3-8. The chart also has both Snellen and m etric system
A typoscope is often useful when testing near
notation and can be adm inistered at any distance.
visual acuitv.¥ It enables the exam iner to isolate one Recording should include the distance at w hich the
line at a tim e and tends to sim plify the task for the
test was adm inistered. The m ajor disadvantage of
client (Figure 3-7).
this chart is that it only presents individual sym bols.
A shortcom ing of this chart is the limited num ber
In the low vision evaluation, we are more interested
o f optotypes w ith the larger size letters.
 THE LIGHTHOUSE NEAR ACUITY TEST *..д ж л ;
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Figure 3-6. Lighthouse Near Visual Acuity Chart (Steinm an).

in the client's ability to read words, not letters. If an
ETDRS test was used at distance, the Lighthouse
Reduced ETDRS C hart will allow the therapist to
com pare distance and near acuity. D ifferences of more
than one line betw een letter and word acuity may
indicate severe restriction in central visual fields or
distortions in vision (discussed below).
M innesota Low-Vision
Test (M N Read Test)
O ne of the major differences betw een distance
visual acuity and near visual acuity testing is the use
o f charts with phrases or sentences for near visual
acuity. This is recomm ended because of the im por­
tance o f reading in our society. If a client is going
to regain independence in activities of daily living
(ADL), he or she will need to be able to read again.
We know that near visual acuity for single letters is
often considerably better than near visual acuity for
reading phrases and sentences. Therefore, to better
understand the im pact o f low vision on reading, it is
im portant to assess both single letter and continuous
text near visual acuity.
A popular test for assessing continuous reading
acuity is the M innesota Low-Vision Reading Test (MN
Read Test) illustrated in Figure 3-9. An advantage of
Reading using this test is that it not only provides an assess­
m ent of near visual acuity with continuous text, it also
allow s us to evaluate the client's reading speed. Unlike
visual acuity, which is not expected to improve with
vision rehabilitation, reading speed is one function
that can be improved. Thus, reading speed is one of
the areas for w hich the occupational therapist m ay be
able to docum ent im provem ents w ith treatm ent and
justify additional vision rehabilitation in M edicare
docum entation.
Figure 3-8. Lighthouse Reduced ETD RS
Chart (Steinman).

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(Steinman). U N R E A D ,MACUITY CHART 1

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 The MN Read acuity chart has been validated
and can be used to provide a sensitive and reliable
m easure of reading acuity.6 Each sentence has 60
characters, which corresponds to 10 standard length
words, assum ing a standard word length of 6 char­
acters (including a space). The reading levels of the
passages are approximately the same, about a 3rd to
4th grade difficulty. An estim ate of reading acuity is
given by the smallest print size at which the client can
read the entire sentence without making significant
errors. (Usually reading perform ance deteriorates
rapidly as the acuity limit is approached, and it is easy
to determ ine the level where reading becomes impos­
sible.) The exam iner uses a stopwatch to record the
tim e required to read each paragraph and this allows
a determination of reading speed.
S ig n ific a n c e o f V is u a l A c u ity
in Low V is io n R e h a b ilita tio n
As we reviewed in Chapter 1, the definition of low
vision is based on either distance visual acuitv or
visual field. Thus, visual acuity is a critical assessment
in low vision care. The definition used to determine
M edicare eligibility is 20/70 or worse in the better-
seeing eye with best correction. In the United States,
visual acuity is used to categorize a person as legally
blind (20/200 or worse in better-seeing eye with best
correction). This entitles the individual to a number
of entitlements and benefits, such as property tax
exemptions, an extra income tax exemption, reduced
fares on public transportation, access to social security
disability, and books on tape. Visual acuity is also
used by the low vision optometrist to estim ate the
m agnification needs of a client. The optometrist deter­
mines the actual visual acuity and divides that value
bv the desired acuitv level. Let's say a client's visual
acuity is 20/200 and the client needs to see 20/50
print for the desired ADL. O ne would divide 200 by
50, yielding an estimate of 4X enlargement needed to
achieve this task.
T h e difference betw een target size and acuity
threshold is acuity reserve, estimated by dividing
the target size being viewed by target size al acuity
threshold. If a person with normal vision wishes to
read 1M print (typical of newspaper) at 40 cm, he or
she requires better than 0.5 M acuity threshold at the
same distance. Print size must be twice acuity thresh­
old for fluent, comfortable reading (see Chapters 7
and 9).
C o n tr a s t Sensitivity
D e fin itio n
An important topic that is related to visual acuity
is contrast sensitivity. W hile visual acuity tests enable
the therapist to estim ate how well som eone can see
small high-contrast objects, contrast sensitivity testing
enables the therapist to estim ate how well someone
can see larger low-contrast objects. Contrast sensitiv­
ity is related to visual acuity, but provides information
that is not as well captured by visual acuity m easure­
ment.7 Contrast sensitivity is strongly associated with
reading performance,8 mobility,9'10 driving,11'12 face
recognition,12'15 and ADL.13'14 Contrast sensitivity
testing tells us about the quality of the available vision
when view ing larger objects. For instance, it is pos­
sible for a client to have reasonably good visual acu­
ity, but still complain of problems such as dim, foggy,
or unclear vision or sensitivity to bright light. Visual
acuity only allows us to evaluate one limited aspect
of the person's ability to see. Contrast sensitivity is a
measure of how faded or washed out an image can be
before it becom es indistinguishable from a uniform
field. A person with impaired contrast sensitivity
might describe the problem by saying "it is like look­
ing through a dirty windshield when 1 drive". People
with reduced contrast sensitivity often are very par­
ticular about lighting. They usually are glare sensitive
or can see best over only a very narrow range of light
intensity.
Contrast sensitivity determ ines the lowest contrast
level that can be detected by a client for a given size
target. Contrast can vary from no contrast (0%) to
highest contrast (100%). For example, high-quality
print has 85% to 95% contrast, while paper currency
lias only 55% to 60% contrast. Another term that
is used is contrast threshold. Contrast threshold is
defined as an object with the lowest contrast that a
client can recognize. A client with normal vision can
usually see objects with as little as 2% to 3% contrast.
If the contrast of an object is less than the contrast
threshold of the client, the object cannot be seen. Table
3-2 shows the contrast of some common everyday
objects. This table indicates that the contrast of most
objects is considerably higher than the normal contrast
threshold of 2% to 3%. The difference between the
contrast of objects and a client's contrast threshold is
contrast reserve, expressed as a ratio of object contrast
divided by contrast threshold. For fluent reading and
presumably quick identification of objects, contrast
reserve must be greater than 10:1 (10 tim es threshold),
and ideally greater than 20:1 (sec Chapter 9).
 Table 3-2.
Contrast of Common Everyday Objects
Contrast (%)
5 M aroon chair on m aroon carpet
74
80
82
32
55-60
71-75
76-80
88-93
Adapted from Brilliant RL. Essentials o f Low Vision Practice. Boston, MA: Butterworth•Heinemann; 1999:48-49.
Contrast sensitivity is the reciprocal of the contrast
at threshold, ie, one divided by the lowest contrast at
which forms or lines can be recognized. If a person
can see details at very low contrast, his or her contrast
sensitivity is high, and vice versa. A client with a con­
trast threshold of 2% has higher contrast sensitivity
(1/2 = 30) than a client with a contrast threshold of
10% ( 1/10 = 10).
Exam ples of Low C on trast in
Activities of Daily Living
• C o m m u n ic a t io n : T h e fa in t s h a d o w s o n p e o p le 's
faces carrv¥ the visual inform ation related to
facial expressions.
• Orientation and m obility: We need to see low-
*
contrast form s such as the curb, faint shadows,
and the last step of carpeted stairs when walk­
ing. W hen driving, seeing in dusk, rain, fog,
snow fall, and at night are challenging tasks
requiring good contrast sensitivity.
• Reading and w riting: Poor quality copies, news­
print, an old Bible.
• Kitchen tasks: Cutting chicken, onion or other
light colored objects on a white or light colored
cutting board, pouring a glass of water.
W h y Is C on trast Sensitivity
Im p ortan t to Measure?
In all conditions w here visual acuity is reduced,
contrast sensitivity is reduced as well. However, in
som e conditions that reduce acuity, contrast sensitiv­
ity is reduced more than expected based upon the
visual acuity alone. This m eans that if visual acuity
only is tested, the visual disability of the person with
relatively reduced contrast sensitivity will be under­
Object
Maroon chair on gray carpet
Illum inated Red Exit sign
Black automobile on sunny street
Gray automobile on shady street
US currency
Daily newspaper
Paperback books
Glossy periodicals
estim ated. People with im paired contrast sensitivity
often are sensitive to lighting. They are more sensitive
to glare, and often see best over a narrow range of
light— som etim es bright, som etim es dim light. There
is m ounting evidence in the literature that suggests
that contrast sensitivity may be a sensitive indicator of
disease and disease progressions.15’18 Contrast sensi­
tivity should be assessed when a client's perform ance
does not match the expected results,19 eg, if a client
reports difficulty seeing on a cloudy day or a very
bright day and visual acuity testing shows no change
from previous visits. A nother exam ple: if a client can
rend enlarged print well but cannot re a d with e q u iv a ­
lent m agnification w ith an optical device (assum ing
all other factors such as visual acuity and working
distance arc the sam e), the therapist should consider
contrast sensitivity testing. O ptical devices degrade
print contrast and create lighting problems. In our
clinical experience, people with impaired contrast
sensitivity (higher than 5%) often are very sensitive to
glare from reflections from optics, degraded contrast
from optics, and problems with lighting.
Clinical Assessment o f C ontrast
Sensitivity
Contrast sensitivity has traditionally been m ea­
sured with gradings (Figure 3-10) that m easure the
ability to see low contrast over a full range of object
sizes. In recent years, however, letter contrast sensitiv­
ity testing has becom e the preferred m ethod in clin i­
cal settings because it is easy to adm inister and clients
are fam iliar w ith the use of letters to test vision.20 The
Pelli-R obson Contrast Sensitivity ✓ C hart has been a
popular method o f testing letter contrast sensitivity.21
The Pelli-Kobson Contrast Sensitivity C hart (Figure
3-11) is a large wall-m ounted chart, 59 cm wide and
84 cm high, that consists of 16 triplets of letters, each
 Figure 3-10. VisTech Contrast Sensitivity Testing.
VISION CONTRAST TEST SYSTEM
The client is instructed to begin w ith the top row
and identity the orientation of as many of the cir­

Ф Ф Ф Ф -V cular patches as possible (Steinman).

• e t!i
s
f ■
ЧЙ-:

|\V/* b m m .u

1СГТ ВЮНТ UP IU *N K

«x imoesc*» сомглм» iv c»«m Figure 3-11. Pelli-Robson Contrast Sensitivity

Test {Steinman).

V R s К D R
N H с s О К
S С N
Figure 3-12. M ars Letter Contrast Sensitivity
Test (reprinted with perm ission from the
Mars Perceptrix Corporation).
subtending 2.8 degrees at the intended 1 M test d is­
tance, arranged in eight rows of two triplets each.
The three letters w ithin each triplet have constant
contrast, w hereas the contrast across triplets, read­
ing from left to right, and continuing on successive
lines, decreases in contrast. The client reads the letters
across and down the chart, as in standard letter acuitv
m easurem ent. Instead of the letters decreasing in size,
however, they decrease in contrast. T h e final triplet
in which the client reads two of three letters correctlv
determ ines the Log contrast sensitivity.
Although widely used by researchers, it has not
been widely used by clin ician s for a variety of rea­
sons.20 First, it is inconvenient for testing in small
clin ical spaces, as it requires a large amount of wall
space. Second, it is difficult to arrange lighting that
will uniform ly illum inate such a large area. Third, a
wall-m ounted chart is difficult to keep clean and free
o f defects.20
Recently, A rditi20 reported on a new letter con­
trast sensitivityу test called the Mars Letter Contrast
Sensitivity Test (Figure 3-12). It is sim ilar to the
Pelli-Robson, but has greater accuracy due to its finer
contrast decrem ents and scoring procedure. It is
handheld, w ith a recom m ended view ing distance of
50 cm, and is portable. These advantages m ay make
this chart more desirable in a clinical setting.
Either test involves instructions to test at a set d is­
tance based on near normal vision. For low vision,
one must be careful that testing was performed at a
d istance w here the letters w ere larger than letter size
at acuity threshold. This can be easily done by first
finding the distance where the high contrast letters on
the chart are barely visible, and then decreasing the
test distance by one-half and then one-half again.
Significance o f Disorders
of C on trast Sensitivity for
O ccupational Therapy
As indicated above, contrast sensitivity testing
provides us with inform ation about the clients' visual
function that is not available from standard visual
acuity testing. Because contrast sensitivity is closely
associated w ith reading, m obility, driving, and other
ADL, it is particularly im portant for occupational
therapists.
In vision rehabilitation, occupational therapists
can help clients with contrast sensitivity problems
by increasing the contrast o f objects being viewed.
M ethods of m odifying contrast include the environ­
mental m odifications that enhance contrast or add
color contrast, lighting m odifications that elim inate
glare, m obility instruction, and the use of closed cir­
cuit televisions.19 These interventions are described in
detail in Chapters 10 and 14.
R efractive D isorders
Definition
Refraction is the term used to describe the evalua­
tion of the optical system o f the eye. We use the term
refractive error to describe any disorder of refraction.
W hen the optom etrist perform s the refraction, he or
she determ ines w hether the individual is em m etropic
(absence of refractive error), myopic (nearsighted),
hyperopic (farsighted), or astigm atic. The refraction

is the exam ination procedure used to determ ine if a
client w ill benefit from glasses and the exact prescrip­
tion that is appropriate.
Classification o f Refractive
Conditions
Em metropia
This term is used to describe the condition in which
there is an absence of refractive error. In emmetropia,
the light rays entering the eyes focus right on the
retina. Figure 3-13 illustrates how the light rays enter­
ing the eve are perfectly focused on the retina in
emmetropia. In such a case, the client is neither near­
sighted nor farsighted and does not have astigmatism.
Emmetropia is not necessarily considered normal,
expected, or desirable. In fact, the average person is
slightly hyperopic.
Myopia (Nearsightedness)
M yopia is a condition in which the light rays enter­
ing the eye focus in front of the retina. In myopia, the
vision is blurred at distance but clear at near. Figure 3-
14 shows why a client with myopia experiences blurred
vision. The light rays entering the eye are focused in
front of the retina because the optics of the eye are too
strong relative to the length of the eye. The myopic
eye has a longer axial length than the emmetropic or
hyperopic eye. The hum an eye can make no internal
adjustment to overcome the optical problem associ­
ated with myopia. An individual with myopia can
squint, which actually does allow improved vision,
but this is generally considered an unacceptable way
to regain clarity because it can cause discom fort and
is cosm etically unacceptable. Squinting helps com­
pensate for the blur associated with myopia because it
creates a pinhole effect. A pinhole effect occurs when
Figure 3-13. Light rays entering
the eye are perfectly focused
on the retina in emmetropia
(Steinman).
an individual views an object through a sm all open­
ing in front of the eye. This setup will bring an object
into focus on the retina regardless of refractive error.
Any attempted focusing adjustment by the lens of the
eye (accommodation) will simply m ake the blurred
vision worse. Thus, a client with myopia will have to
move closer to the object he/she is trying to view. A
person who has myopia ("nearsightedness") will have
better visual acuity at near than at distance if he or she
is not wearing correction.
Hyperopia (Farsightedness)
Hyperopia is a condition in which light rays enter­
ing the eve focus behind the retina and the indi­
vidual must accommodate to see clearly. * This need to
accommodate requires the use of m uscular effort. The
amount of effort necessary is greater when the indi­
vidual looks at near. Figure 3-15 illustrates that to see
clearly, a person with hyperopia must contract the cili­
ary muscle to change the shape of the lens in the eye
and regain clarity. Contraction of the ciliary muscle
leads to a change in focus and is referred to as accom ­
modation. The effort that is necessary to accommodate
is directly related to the degree of hyperopia. A very
high degree of hyperopia requires so much m uscu­
lar effort that it cannot be overcome and results in
blurred vision. Moderate degrees of hyperopia can be
overcome using accommodation. The constant need
for accommodation, however, requires the use of m us­
cular effort and leads to signs and symptoms, such as
blurred vision, eyestrain, tearing, burning, inability to
concentrate and attend, avoidance of visual tasks, and
the need to move the object of interest closer or farther
away. In younger people, sm all degrees of hyperopia
are generally successfully overcome without sym p­
toms. Remember that a low degree of hyperopia is
considered normal, expected, and desirable. An older
person w ith hyperopia (older than 45 to 50 years of
Figure 3-14. The light rays entering
the eye are focused in front of the
retina in m yopia causing blurred vision
(Steinman).

Figure 3-15a. To sec clearly, a

person w ith hyperopia must co n ­
tract the ciliary m uscle to change
the shape of the lens in the eye
and regain clarity (Steinm an).

Figure 3-13b. After contracture

o f the cilia ry m uscle, the shape
of the lens changes and light rays
are now focused on the retina
(Steinman).

age) cannot accom m odate w ell enough to com pensate Astigmatism

for the hyperopia and w ill, therefore, have better acu­
Astigmatism is a condition in which vision is blurred
ity at distance than at near. A younger person with
and distorted at both distance and near. An astigm atic
hyperopia who can com pensate w ith accom m odation
eye is not spherical. Rather, it has an oval shape, and
m ight have norm al acuity at near but com plain of eye­
this causes the light rays entering the eve to focus
strain or blurry vision at near when tired.
at two different points. Figure 3-16 illustrates the

Normal Vision Astigmatic Vision
Spherical Cornea Astigmatic Cornea
effect that astigm atism has on the light rays focusing
on the retina. In order to see clearly, a person with
astigm atism will attem pt to accom m odatc. W hile
accom m odation may improve clarity in one direction
(eg, vertical lines), accom m odation never completely
clears an im age w ith astigm atism , and the effort that
is necessary to accom m odate may lead to discom ­
fort. As discussed above for hyperopia, the degree of
accom m odation necessary is related to the degree and
type of astigm atism . In som e cases of astigm atism ,
accom m odation has no beneficial effect on clarity.
A very high degree of astigm atism generally cannot
be overcom e and results in blurred vision. If not cor­
rected carlv, such problems can lead to amblyopia
(loss o f vision) and difficulty interacting w ith the
Figure 3-16a. The affect of astigm a­
tism on the light rays focusing on the
retina (Steinm an).
Figure 3-16b. Distortion caused by
uncorrectod astigmatism (Steinman).
environm ent. Moderate degrees o f astigm atism can
som etim es be overcome using accom m odation. The
constant need for accom m odation, however, requires
the use of m uscular effort and leads to signs and
sym ptom s, such as blurred vision, eyestrain, tearing,
burning, inability to concentrate and attend, avoid­
ance of visual tasks, and the need to m ove the object
of interest closer or farther away. Sm all degrees of
astigm atism are com m on and are generally success­
fully overcom e w ithout sym ptom s. A person with
astigm atism w ill have reduced acuity at both distance
and near, and may see stripes in one direction more
clearly than stripes in another, so som e letters may be
easier to see than others.
Figure 3-17. The phoropter, an instrument used to find the
com bination of lenses that w ill provide the best possible
vision for any client being exam ined (Steinman).

to accurately and objectively assess refractive status in

Clinical Assessment of Refractive virtually any client. The optom etrist directs the light
E rro r from the retinoscope into the clien t’s eye and views
the light that is reflected out o f the eye. As the optom e­
Refraction is a test that is perform ed by all eyecare
trist moves the retinoscope from side to side, he or she
professionals. There are two general m ethods of eval­
interprets the m ovem ent of the reflected light. Lenses
uating the refractive status of the eye: objective and
are used to alter the m ovement of light and help the
subjective. Subjective tests can only be successfully
clinician determ ine the refraction and necessary eye­
perform ed with cooperative, attentive clients with
glass prescription. The procedure generally requires
reasonable cognitive ability. O bjective testing, how­
less than 1 m inute per eye. It can be perform ed with
ever, can be successfully perform ed at any age and for
or without eye drops. Using objective refraction, the
virtually any client.
optom etrist or ophthalm ologist is able to identify and
correct refractive error in infants and patients who are
Subjective Refraction Techniques
unable to comm unicate.
M ost adults have had an eye exam ination at least
once in their lives, and if so thev are likelv to remem- Screening fo r Refractive Error
ber the subjective refraction portion of the exam ina­
O ne can quickly screen for potential problem s with
tion. T he instrum entation used is illustrated in Figure
refractive error w hen glasses are not available by hav­
3-17. T h is instrum ent, called the phoropter, contains
ing the patient look through a pinhole. T h e therapist
num erous lenses and allow s the optom etrist to find
can create this pinhole by simply punching a small
the com bination of lenses that w ill provide the best
hole in an index card. The pinhole bypasses the optics
possible vision for any client being exam ined. The
of the eye and focuses an im age on the retina regard­
procedure is very subjective and the optom etrist will
less of refractive error. The pinhole w ill greatly reduce
ask questions such as "W h ich is better, choice one or
the am ount of light but will improve acuity regard­
choice tw o?" or "D oes this lens m ake the letters look
less of the refractive error if the chart is illum inated
clearer or just blacker and sm aller?" This subjective
enough. If reduced visual acuity im proves with a pin­
approach works well for m ost of the population, but is
hole, vision can usually be improved with eyeglasses.
generally not used w ith children under the age of 6 or
7 or w ith clients w ho have attention problem s, percep­
tual and cognitive disorders, or other special needs.
Significance o f Refractive
Disorders for O ccupational
O bjective Refraction Techniques
Therapy
The instrum ent illustrated in Figure 3-18 is called
a retinoscope. T his instrum ent perm its the optom etrist It is im portant that significant refractive errors be
treated by an eyecare practitioner before low vision
 Figure 3-18 a ,b . The retinoscope can be used to accurately and objectively assess refractive status in
virtually any client (Steinman).
rehabilitation is initiated. Som e m ight Feel that a sm all
am ount of refractive error might not significantly
affect functional vision in som eone who has severe
vision loss. However, a good refraction should always
be the very first step in the treatm ent of any low
vision client, even w ith severe vision loss. Researchers
have been surprised at the high prevalence of uncor­
rected refractive errors in the elderly population.
The Baltimore Eye Study found that alm ost 70% of
people reporting low vision based on reduced visual
acuity alone actually only needed new eyeglasses.22
C orrectable vision im pairm ent is associated with
poorer general health, living alone, and lower socio­
econom ic status.23
V is u a l F ie l d D is o r d e r s
D e fin itio n
The term visual fie ld describes how much of the
visual world an individual can see while looking
straight ahead at a point of fixation. W hen a client has
a normal visual field, he or she can see everything
from the fixation point superiorly about 50 degrees,
interiorly about 70 degrees (Figure 3-19a), tem po­
rally (toward the ear) about 90 degrees, and nasally
(towards the nose) about 60 degrees (Figure 3-19b).
Thus, with only one eye open, a client has a horizontal
visual field of about 150 degrees and vertically about
120 degrees. T h is is true for each eye. Note that with
both eyes open, the horizontal field only increases by
about 30 degrees. W hile only the object being viewed
directly is seen clearly, the client is able to see this
entire area peripherally and can perceive movement
and the presence of objects in the entire visual field.
As indicated in Chapter 1, the definition o f low vision
includes not only visual acuity, but visual field as well.
A person is said to be legally blind if the visual field is
20 degrees or less in the better-seeing eye. Therefore,
an individual could have perfect 20/20 visual acuity
and still have low vision. For M edicare, a diagnosis
of a significant visual field deficit would qu alify the
client for low vision rehabilitation even if visual acu­
ity is normal. Although visual requirem ents for driv­
ing vary from state to state, in m ost states the field
requirem ent for driving is 120 degrees horizontally.
Causes of Visual Field Loss
Visual field loss is usually classified as central ver­
sus peripheral visual field loss. As described above
and in Figure 3-19, the visual field is 150 degrees hori­
zontally and about 120 degrees vertically. The central
Figure 3-19a,b. Normal visual field (Steinm anl.
10 to 20 degrees are referred to as central visual field.
Outside this central 20 degrees is referred to as periph­
eral visual field . We use these term s to classify visual
field loss as central or peripheral visual field loss. The
"rule of thum b" is that the thum b at arm's length is
about 2 degrees; a fist is about 10 degrees wide.
Peripheral Visual Field Loss
Peripheral visual field problem s are associated with
many eye d iseases and diseases that affect the brain,
such as acquired brain injury, glaucoma, and retinitis
pigm entosa (described in detail in Chapter 4). O ne of
the most com m on peripheral visual field disorders is
a right or left field loss, referred to as an homonymous
hem ianopsia. To understand why a client would lose
vision to just one side, it is necessary to understand
how visual inform ation travels from the retina to
the visual cortex (Figure 3-20a). Vision begins with
the capture of im ages focused by the optical media
on photoreceptors of the retina. The fibers from the
upper h alf of each retina enter the optic nerve above
the horizontal m eridian, and those from the lower
h alf enter below the horizontal m eridian. Fibers from
the periphery of the retina lie peripherally in the optic
nerve, and fibers from the fovea lie centrally. This
arrangem ent persists throughout the entire course of
the visual pathways from the optic nerve through the
chiasm , the optic tracts, and optic radiations.
Visual inform ation from the right field strikes the
nasal half of the retina of the right eye and the tem ­
poral h alf of the retina o f the left eye. Sim ilarly, visual
inform ation from the left field strikes the nasal half of
the retina of the left eye and the temporal h alf o f the
retina of the right eye (see Figure 3-20a). W hen the
fibers from each optic nerve reach the optic chiasm , a
decussation takes place. T h e fibers from the temporal
part of the retina rem ain on the tem poral or outside
aspect of the chiasm and are called uncrossed fib ers (see
Figure 3-20a). The nasal fibers of the retina cross over
in the chiasm and are called crossed fibers. A fter leav­
ing the chiasm , the fibers form the optic tract. Thus,
all visual inform ation originating from the right field
travels in the left optic tract, and all visual inform ation
originating from the left field travels in the right optic
tract. The fibers in the upper half of the tract originate
from the upper half of the tw o retinas, and the fibers
from the lower h alf of the tract com e from the lower
h alf of the two retinas. The fibers from the optic tract
synapse in the lateral geniculate body. The cells o f the
lateral geniculate body give rise to new fibers, which
form the optic radiation. These fibers then proceed to
the cells of the visual cortex (see Figure 3-20a). Any
lesion that affects the visual pathway on only the right
or left side after this decussation takes place in the
optic chiasm will affect either the left visual field or
right visual field in both eyes. For exam ple, Figure 3-

20b illustrates what a client with normal visual fields
would see. Figure 3-20c illustrates a lesion on the right
side o f the brain and in this case the individual would
only see the dog. Any damage to the eye or optic nerve
will affect one eye. Any damage to the optic chiasm
itself often affects both eyes, with a different effect on
each eye. For example, the left field of the right eye
and right field of the left eye may be affected. Brain
injury associated with trauma or stroke often leads to
this type of visual field loss and may require vision
rehabilitation by occupational therapists.
Figure 3-20a. Illustration of
visual pathway from eye to
visual cortex.
optic radiations
Figure 3-20b. If there is no lesion
in the visual pathway, the individ­
ual sees both the cat and the dog.
Figure 3-20c. If there is a lesion
in the right side of the cortex, the
individual w ill only see informa­
tion from the right visual field (the
dog only).
Glaucoma is a disease that causes progressive
peripheral field loss that could eventually lead to total
loss of vision. A person with peripheral visual field
loss due to glaucoma loses field in all directions, not
just the left or right side. Thus, as the field loss pro­
gresses, it is like looking through a tube (Figure 3-21).
Retinitis pigmentosa causes peripheral field loss that
is sim ilar to the loss caused by glaucoma.
Figure 3-21. Illustration ot peripheral visual field loss char­
acteristic of glaucoma (Steinm an).
Central Visual Field Loss
The most com m on visual field loss that an occupa­
tional therapist is likely to encounter is central visual
field loss associated with diseases of the m acula, such
as m acular degeneration. This type of visual field loss
is referred to as a central scotoma. A scotom a is defined
as an island of absent or reduced vision in the visual
field, surrounded by an area of normal vision.
Clinical Assessment o f Visual Field
Disorders
Peripheral visual field testing is generally per­
formed in the office of the optom etrist or ophthal­
m ologist w ho refers the client for low vision reha­
bilitation. Standard field testing requires that a client
m aintain a steady fixation eye position. With people
who have gaze instability, or severe attention deficits,
visual field testing becom es m ore o f an art. As a thera­
pist teaches a client to function with gaze instability,
he/she often com bines field testing with instruction
on controlling gaze position and m ay provide criti­
cal data on a client's visual fields. Central field test­
ing is best perform ed using a simple screen set at 1
M (Tangent Screen) (Figure 3-22a,b), or using more
expensive com puterized visual field testing (Figure
3-22c). Unless one has a bowl perimeter, testing can
be done using confrontation field testing m ethods
described in Chapter 7. This requires no special equip­
ment and can easily be perform ed by an occupational
therapist.
Central visual field testing can be performed using
a device called the A m sler G rid lest. The stan­
dard A m sler Grid consists of a square grid of white
horizontal and vertical lines on a black background
(Figure 3-23). The client view s this target with one
eye open at a distance of about 13 inches. T h e clicnt
is asked to fixate the central dot and report if all the
corners arc visible, if the grid is uniform , and if any
areas of the grid are distorted or missing.
Central field testing becom es more d ifficult to
adm inister and interpret if people have central field
loss because when they attempt to look directly the
fixation target in the center of the field test, the target
disappears from view. As a result, people may look to
the side of a target to sec it, or som e with recent vision
loss just keep generating random searching eye move­
ment trying to look at a fixation target. By adapting
the standardized procedure, the eyecare practitioner
or low vision therapist can not only describe a client's
central fields, but also his or her fixation eye move­
ments (see C hapter 10).
Significance of Visual Field
Disorders for Occupational
Therapy
The status of the visual field is an im portant m ea­
sure of visual function that m ust be considered by the
occupational therapist when developing a low vision
rehabilitation treatm ent plan. In som e cases, the visual
field disorder is a secondary issue and in others it is
the prim ary reason for the client's disability. Central
field loss is the most com m on cause of low vision, and
m anaging unstable fixation that results from central
field loss presents a critical challenge in treatment. It
 Figure 3-22a. Tangent screen (Steinman).

V*•, * I •; a

\ ". A , / ... ?....\ Л . / /

'

4 7 - ....;.... ■V

Figure 3-22b. Tangent scrcen (Steinman).


Figure 3-22c. Com puterized visual field testing (Steinman).
is im portant to rem ember that a client could have per­
fect visual acuity in both eyes and yet still have low
vision based on a deficit in visual field that does not
involve central vision.
Su m m a r y
It is im portant for occupational therapists to under­
stand visual acuity, contrast sensitivity, visual refrac­
tion, and visual field disorders. T h is chapter reviewed
definitions, test procedures, and the significance of
these problem s in low vision clients.
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Practice. Boston, MA: Butterworth-Heinemann; 1999:47-69.
20. Arditi A. Improving the design of the letter contrast sensitivity
test. Invest Ophthalmol Vis Sci. 2005:46:2225*2229.
21. Pclli ПС, Robson JG. Wilkins AJ. The design of a new letter
contrast chart for measuring contrast sensitivity. Clin Vis Sci.
1988;2:187-199.
22. Tielsch JM, Sommer A. Witt K. Katz J, Royall RM. Blindness
and visual impairment in an American urban population. The
Baltimore Eve Survey. Arch Ophthalmol. 1990;l0fi(2):286-290.
23. Evans BJ, Rowlands G. Correctable visual impairment in
older people: a major unmet nned. Ophthalmic Physiol Opt.
2004 ;24i 3): 161 -180.
 Eye Diseases Associated
With Low Vision
I n t r o d u c t io n
T h is chapter reviews only the eye d iseases that are
the leading causes of low vision in the adult popula­
tion and includes description, prevalence, risk factors,
effect on vision, and treatm ent of each condition. The
leading causes of severe visual im pairm ent among
white A m ericans in 2000 were age-related m acular
degeneration (AMD), accounting for 54% of visual
im pairm ent, w ith cataract (9%), diabetic retinopathy
(6%), and glaucoma (5%) the next most com m on
causes.1 The leading causes of severe visual im pair­
m ent in black persons w ere cataract (37%), diabetic
retinopathy (26%), glaucoma (7%), and AM D (4%).
Am ong H ispanics, glaucom a was the most comm on
cause (29%), followed by A M D (14%), cataract (14%),
and diabetic retinopathy (14%).1 Therefore, w hile the
relative prevalence m ay differ depending on race and
ethnicity, the prim ary eye diseases that the occupa­
tional therapist w ill encounter when dealing w ith
adult patients w ith low vision are AMD, diabetic
retinopathy, glaucoma, and cataract.
A ge - R elated M a c u la r
D egeneratio n
Description
A M D is a degenerative, acquired disorder of the
central retina called the m acula, which usually occurs
in patients over age 55, and results in progressive,
som etim es significant, irreversible loss o f central visu­
al function from either fibrous scarring or atrophy of
the m acula. It is the leading cause of vision loss in the
adult population.
The macula is located roughly in the center of
the retina and is a sm all and highly sensitive part
of the retina responsible for detailed central vision.
The fovea is the very center of the m acula. T h e nor­
mal macula has a characteristic appearance and is
more heavily pigmented than the surrounding retina
(Figure 4-1). The macula allow s us to appreciate detail
and perform tasks that require central vision, such as
reading, w riting, recognizing faces, and driving.
To understand this disease, it is im portant to have
an understanding of the anatom y of the retina and
Figure 4-1. The normal m acula has a characteristic
appearance and is more heavily pigmented than the
surrounding retina (Steinman).
adjacent structures of the eye, w hich w as reviewed in
Chapter 2. As a brief review, the retina is com posed of
10 layers. Two of the im portant layers that becom e an
issue in A M D are the retinal pigm ent epithelium that
is closest to the choroid, and the photoreceptors (cones
and rods) (Figure 4-2). Beneath the retinal pigment
epithelium of the retina are four additional layers (see
Figure 4-2) ranging from the outside (furthest from
the retina) to the inside (closest to the retina):
1. Sclera (w hite part of the eye)
2. Large choroidal blood vessels
3. Choriocapillaris
4. Bruch's m em brane (separates the pigmented
epithelium of the retina from the choroid)
The underlying etiology of A M D is poorly under­
stood and no cu re currently exists. The International
ARM Epidemiological Study Group defined A M D in
1995.2 A M D typically occurs in adults over the age of
50 and is characterized by any o f the follow ing prob­
lem s:
1. D rusen: Drusen are discrete, round, slightly
elevated whitish-yellow spots in the m acular
area and elsew here in the retina. Drusen are
one of the earliest signs of AM D and are typi­
cally clustered in the m acular area. They may
change in size, shape, color, and distribution
over time.
2. Hyperpigmentation: Hyperpigmentation refers
to areas of increased pigmentation and may
not be associated with drusen.
3. H ypopigm entation: H ypopigm entation refers
to depigm entation and is typically associated
with drusen.
Blood Vessels
Fovea
Macula
AVID is classified as either d ry (nonexudative) or
wet (exudative).
D ry AMD
Dry (nonexudative or atrophic) A M D accounts for
90% of all patients w ith AM D in the United States.3
The disorder results from a gradual breakdown o f the
retinal pigm ent epithelium (RPE), the accum ulation of
drusen deposits, and loss o f function of the overlying
photoreceptors (Figure 4-3). Most patients w ith dry
AM D experience gradual, progressive loss o f central
visual function. This loss o f vision is more noticeable
during near tasks, especially in the early stages of
the disease. In an estim ated 12% to 21% o f patients,
d ry AM D progresses to cause vision levels of 20/200
or worse.4'5 N eovascularization is not present in drv
AMD.
W et AM D
Although wet (exudative) A M D accounts for only
10% of patients with AMD, 90% o f the AM D patients
w ith significant vision loss have this form of the
disease.4 6 Wet AM D is characterized by the develop­
ment of neovascularization in the choroid, leading to
leakage of blood and subsequent elevation o f the RPE
(Figure 4-4). Patients with wet AM D tend to notice a
more profound and rapid decrease in central visual
function. T h e leakage of blood from the new choroidal
vessels causes distorted vision, central scotom a, and
blurred vision. As the blood in the vitreous dissi­
pates, vision might improve somewhat.
 Figure 4-2. Layers of the retina
(Steinman).
Nerve Fiber Layer

Ganglion Cell Layer

Inner Plexiform L ayer

Inner Nuclear Layer

Outer Plexiform Layer

Outer Nuclear Layer

Photoreceptor Outer Segments

Hetmal Pigment Epithelium

Choroid

Figure 4-3. Photoreceptors (Steinman).

Figure 4-4. W et A M D (Steinman).

 Risk Factors Associated with Age-Related Macular Degeneration
Age
Sm oking
Genetics
Female gender
Racc (higher prevalence in whites)
High intake of fats
Elevated levels of serum cholesterol
H ypertension
Cardiovascular disease
Ultraviolet light exposure
Obesity
Cataract surgery

year and older group.15 A relationship seem s to exist

Prevalence
Most studies have indicated that AM D is the lead­
ing cause of low vision in developed countries.8'9 The
prevalence of A M D increases with age, and about 30%
o f patients 75 years of age and older are affected.3'10
W hile A M D is the leading cause of visual impairm ent
am ong w hite A m ericans (54%), it is less prevalent in
black persons (4%) and H ispanics (14%).1 W arren11
reported on her experience as an occupational thera­
pist w orking in a low vision program in an oph­
thalm ology departm ent. Thirty-seven percent of the
patients referred for occupational therapy (low vision
rehabilitation services) had AMD. Thus, low vision
caused by A M D is the condition that occupational
therapists w ill be most likely to treat.
Risk Factors
Table 4-1 lists the risk factors associated w ith AMD.
Age is the most significant risk factor and clearly
increases the risk of both developing AM D and of pro­
gressing to the late stages of the disorder.12 Although
age is a strong risk factor, AM D and vision loss do
not inevitably o ccu r w ith advancing age. People w ith
an A M D-affected first-degree relative have a 50%
lifetim e risk of experiencing advanced AM D and
vision loss, and tend to develop it earlier than those
without a fam ily history.13 Sm oking is associated with
a fourfold increase in the risk of AM D and visual loss
and, again, tends to promote earlier occurrence.14
Studies have consistently implicated fem ale gender as
a risk factor. In the Fram ingham Eye Study, fem ales
with A M D outnum bered m ales by 50% , but this may
have reflected the increased proportion of women
in the older age groups. In the Beaver Dam Study,
results controlling for age showed a twofold higher
incidence of A M D in women than in men in the 75-
betw een increased cum ulative exposure to sunlight
and ultraviolet radiation and wet A M D .,(> However,
strong epidem iologic evidence is lacking. W eaker
associations have been found w ith obesity, hyperten­
sion, m acrovascular disease, raised cholesterol, and
cataract surgery.
D ietary associations have also been found both
w ith the signs of AM D and with progression to
vision loss.17' 19 In a w ell-conducted prospective study,
dietary fat intake was system atically analyzed after
correcting for other risk factors.1* Vegetable fat intake
had the strongest relationship w ith A M D progression,
with a relative risk of 3.82 for the highest fat-intake
quartile com pared with the lowest quartile. Higher
intakes of total fat and o f saturated, monounsaturated,
polyunsaturated, and transunsaturated fats all raised
the relative risk of AM D progression about twofold.
W eekly fish intake and eating nuts two to three tim es
a week were m ildly protective. The im plication is that
a large sh ift away from vegetable oils, m argarine, and
fat-containing processed foods might reduce this epi­
dem ic of blindness in the elderlv.
There is also evidence from a random ized con­
trolled trial that high-dose dietary supplem ents of
the antioxidants vitam in C, vitam in E, beta-carotene,
and zinc can reduce the risk of progression from large
or soft drusen to advanced AM D and visual loss bv ¥
about 20% com pared w ith controls over 6 years.20
However, high-dose zinc can cause gastric irritation or
anem ia, and beta-carotene may possibly be associated
w ith an increased risk o f lung cancer am ong smok­
ers. Uncontrolled studies suggest the antioxidants
selenium , lutein, and zeaxanthin, w hich localize in
the norm al macula, may also help. There are as yet
no studies to show w hether dietary supplem ents are
protective in patients in the early stages o f dry AMD
or in the 20% of patients who are at genetic risk.

ж :
\£>
It is not yet known w hether m ajor d ietary adjust­
ment and/or introduction of dietary supplements for
large num bers of elderly people will be justified in
term s of preventing blindness. O n present evidence,
we should identify people at increased risk of AMD,
encourage them to stop sm oking, and promote a diet
that includes vegetables, fish, and nuts and reduces
fatty foods laced w ith vegetable oils. Antioxidant
supplem ents m ay be recommended if a fresh diet
is im practical and if retinal signs of progression are
present. C lients should not attem pt to treat them selves
w ith vitam in therapy and should be encouraged to
ask the eyecare practitioner w ho is treating the retinal
disease.
Effect on Vision
Visual acuity varies with the extent of the degen­
eration and includes distortion, blurred vision (espe­
cially at near), and central scotoma. With dry AMD,
visual acuity can range from 20/20 to 20/400. Visual
acuity with wet A M D is generally worse than 20/400.
All patients with only AM D have central visual field
defects w ith normal peripheral vision. Patients with
A M D alm ost never go totally blind. However, if AMD
occurs in both eyes, the visual acuity loss along with
the central scotom a significantly im pair a person's
ability to engage in activities of daily living and
quality of life. H igh-resolution tasks such as reading,
w riting, sew ing, telling tim e, taking care of financial
issues, driving, and distinguishing colors and facial
Figure 4-5. The effect of m acular scotoma in age
related m acular degeneration (Steinman).
expressions usually becom e severely im paired. The
consequences of AM D lead to loss of independence,
lowered self-esteem , decreased mobility, increased
risk of injury due to falls,21'22 and depression.23
Figures 4-5 and 4-6 illustrate what a patient m ight see
w ith A M D and a m acular scotoma.
Som e patients w ith A M D have a phenomenon
called Charles-Bonnet Syndrom e or visual hallucina­
tions.24 This is an occasional com plaint of patients
with bilateral A M D and may occur spontaneously
with no known external cause.
Treatment
Treatment of AM D includes various medical pro­
cedures to slow the progression of the disease, low
vision rehabilitation including optical and nonoptical
devices, environm ental changes, education, support
groups, and training in eccentric view ing, scanning,
and reading.
Dry AM D
There is no medical treatm ent for drv J A M D that
can restore vision loss. Patients w ho have earlv retinal
J
changes such as sm all drusen or mild pigmentation
changes may experience no sym ptom s or may notice
slowly progressive changes in visual function. These
patients are generally seen by an eye doctor every 6
months. T h e eye doctor should educate the patient
to look for signs of decreased vision, scotom a, and
distortion by covering each eye and assessing visual
Figure 4-6a. The effect of m acular
scotoma in age-related m acular degen­
eration (Steinm an).

Figure 4-6b .

Figure 4-6 c.

function monocularly. Some eye doctors give the
patient an Amsler Grid (Figure 4-7) for self-assess­
ment at home. The patient is able to see changes in
the pattern of blur, distortion, and scotoma using the
Am sler grid. Patients are instructed to return for fur­
ther examination w ithin 24 hours of the onset of new
sym ptom s because 10% of patients with dry AMD
progress to wet AMD. Studies have shown that early
treatment of wet AM D may limit the extent of damage
and v ision loss.
Wet AMD
The principal aim of treatment of wet AMD is to
preserve visual acuity and reduce the risk of addi­
tional severe vision loss for as long as possible. This
goal can be accomplished by destroying the choroidal
neovascularization without causing serious damage to
the retina. There are several treatm ents for wet AMD
that have proved effective in large-scale randomized
clinical trials. These include laser photocoagulation,
photodynamic therapy with verteporfin, and injec­
tion o f drugs called angiogenesis inhibitors. None
of these treatments is a cure for wet AMD and they
do not improve vision. Each treatment may slow the
rate of vision decline or stop further vision loss, but
the disease and loss of vision may progress despite
treatment. Som etim es treatments may result in an
im m ediate decline in vision, in order to m axim ize
vision in the long run. Treatments may also create
blind spots around the central most part of vision, so
that, for example, one or two letters in a word might
be missing.
Figure 4-7. Amsler G rid. Distortion reported by patient
(Steinman).
Laser Surgery
In the 1990s, m ost A M D treatm ent research
focused on laser photocoagulation. The M acular
Photocoagulation Study Group showed that laser
photocoagulation was effective in the treatment of
neovascularization if the vessels were not too close to
the fovea.23'26 This procedure uses a laser to destroy
the fragile, leaky blood vessels. A high-energy laser
beam is aimed directlv J onto the new blood vessels
and destroys them, preventing further loss o f vision.
However, laser treatment also may destroy som e sur-
rounding healthy tissue and some vision. Therefore,
laser surgery is more effective if the leaky blood
vessels have developed away from the fovea. Only
a small percentage o f people with wet AMD can be
treated with laser surgery, because in most patients
the disease is near the center o f the macula 27 The risk
of new blood vessels developing after laser treatment
is high. Repeated treatments may be necessary. In
som e cases, vision loss may progress despite repeated
treatments.
Photodynamic Therapy
A light-activated drug called verteporfin (Visudyne,
Novartis Pharm aceuticals Corporation, Hast Hanover,
NJ) is injected intravenously and travels throughout
the body, including the new blood vessels in the eye.
The drug tends to "stick'' to the surface of new blood
vessels. Low power, nonthermal laser light is shined
into the patient's eye for about 90 seconds and activates
the drug. The activated drug destroys the new blood
vessels and leads to a slower rate of vision decline.
U nlike laser surgery, this drug does not destroy su r­
rounding healthy tissue. Because the drug is activated
by light, the patient must avoid exposing his or her
skin or eyes to direct sunlight or bright indoor light
for 5 days after treatment.
Photodynam ic therapy has been shown to be effec­
tive in selected patients with certain types of wet
AM D and slows the rate of vision loss.28-29 It is
im portant to understand how "success" or "effective­
ness” is defined in these studies. In photodynamic
therapy investigations, the researchers com pare the
risk o f losing 15 or more letters (3 lines) of vision w ith
the treatm ent versus placebo treatment. The studies
dem onstrating "success" reduced the risk of losing
15 letters from 61% in the placebo group to 33% in
the vcrteporfin-treated group.29 Thus, this treatment
does not totally stop vision loss or restore vision in
eyes already damaged by AMD. Rather, the treatment
slow s the progression of vision loss. Treatm ent results
often are tem porary and may need to be repeated as
often as everv •*
3 months.
A nother im portant finding from these studies is
that the greatest benefits of photodynam ic therapy
can be achieved if the diagnosis is made early and
patients receive therapy before the disease causes too
much destruction of the m acula.30
Injections
I n D ecem ber2004, the Food and D rug A dm inistration
(FDA) approved the latest treatm ent available for wet
AMD, called M acugen (Eyetech Pharm aceuticals Inc.
and Pfizer Inc., New York, NY). M acugen (pegap-
tanib) is a vascu lar endothelial grow th factor (VEGF)
inhibitor. W hen Macugen is injected into the vitreous
hum or of the eye, it has the capability of neutralizing
a specific grow th factor that prom otes the grow th of
abnorm al new blood vessels in eyes with wet AMD.
The result is a decrease of the vascular grow th and
leakage that are together responsible for the visual
loss in wet AMD. M acugen has demonstrated preven­
tion o f visual loss as com pared w ith previous "stan­
dard of care" treatm ents that include photodynam ic
therapy.31 M acugen has broad im plications for treat­
ment because it is effective in m anagem ent of all types
o f new -onset wet AMD. In fact, M acugen has show n
that it can prevent severe visual loss (defined as loss
o f three lines of visual acuity on the Snellen eye chart)
in as m any as 70% of the treated patients during the
period of follow-up.32 Unfortunately, M acugen only
has a tem porary effect and must be readm inistered
approxim ately every 6 weeks. Furtherm ore, only 6%
of patients experienced gain s in visual acuity and the
average patient in the study still lost visual acuity over
the 2 years of treatm ent. N evertheless, M acugen ther­
apy represents a m ajor advance against AMD. It will
prevent severe vision loss in the m ajority o f appropri­
ately selected patients w ith new -onset wet AM D and
has opened the door to further investigation in the
m anagem ent of this potentially devastating disease.
Antioxidants
In a clinical trial called the Age-Related Eye Disease
Study (AREDS), researchers found that high levels of
antioxidants and zinc significantly reduce the risk of
advanced AM D and its associated vision loss.3' In this
study, patients at high risk of developing advanced
stages of AM D lowered their risk by about 25% when
treated w ith a high-dose com bination o f vitam in C,
vitam in E, beta-carotene, and zinc. In the sam e high-
risk group, the nutrients reduced the risk of vision
loss caused bv / advanced A M D bv j about 19%. For
those study participants who had either no A M D or
early AMD, the nutrients did not provide an appar­
ent b e n e fit33 It is im portant to understand that these
nutrients are not a cure for AMD, nor w ill they restore
vision already lost from the disease. However, they
may delay the onset of advanced AMD.
The specific daily am ounts of antioxidants and zinc
used by the study researchers were 500 m illigram s
of vitam in C, 400 international units of vitam in E, 15
m illigram s of beta-carotene (often labeled as equiva­
lent to 25,000 international units of vitam in A), 80
m illigram s of zinc as zinc oxide, and 2 m illigram s
of copper as cupric oxide. Copper was added to the
AREDS form ulation containing zinc to prevent cop ­
per deficiency anem ia, a condition associated with
high levels of zinc intake. People w ho are at high risk
for developing advanced AM D should consider tak­
ing the formulation under the supervision of a retinal
specialist.
It is also im portant to understand that there is no
evidence that this AREDS form ulation is effective for
those diagnosed w ith early-stage AMD. T h e study
did not find that the formulation provided a benefit to
those with early-stage AMD.
Low Vision Rehabilitation
Although vision loss cannot be restored w ith m edi­
cal treatm ent, low vision rehabilitation is an effective
treatment that enables patients w ith dry AM D to
function more effectively in activities of daily living
(ADL) and regain independence in spite o f the visual
deficit. The occupational therapist's role in low vision
rehabilitation includes instruction in the use of opti­
cal and nonoptical assistive devices; m odification of
lighting, contrast, and other environm ental factors;
treatment to learn adaptive eye movement patterns,
scanning, and reading skills; education; and involve­
ment in support groups.
 M any patients w ith AMD may not have had a
recent exam ination and may benefit from a change
in eyeglass prescription. If prescribed in conjunction
with low vision rehabilitation, most patients with
AMD respond well to m agnification at both distance
and near (see Chapter 9). This is especially true with
people who have the dry type of AMD. Because the
loss of vision is gradual, these individuals may d is­
engage from occupations such as reading for pleasure
or sew ing because the tasks become difficult, and are
often not referred because the condition has not stabi­
lized. These clients may develop depression, yet inter­
vention may be as simple as instruction about lighting
and a new set of reading glasses. These treatments are
discussed in detail in Chapters 10 through 12.
D iabetic R etinopathy
Description
Diabetic retinopathy is the most serious vision-
threatening complication of chronic diabetes mellitus.
Although there has been extensive research over sev­
eral decades, knowledge about the etiology of diabetic
retinopathy is still incomplete. Diabetes mellitus is
a chronic, incurable disease with major medical and
social implications. Diabetes occurs when the pan­
creas does not produce enough insulin or when the
body cannot effectively use the insulin it produces.
The vascular complications of diabetes involve all
organ systems, including the eye. Diabetes is a het­
erogeneous group of diseases with different etiolo­
gies and clinical features. The two major categories of
diabetes are insulin-dependent diabetes m ellitus and
noninsulin-dependent diabetes mellitus.
Insulin-Dependent Diabetes Mellitus
Insulin-dependent diabetes mellitus (1DDM), or
type 1, or juvenile onset diabetes mellitus, occurs at
any age but most often before the age of 30 years. It
has an abrupt onset that requires medical treatment.
Only approximately 10% of the patients with diabetes
m ellitus have type 1 diabetes and the rem aining 90%
have type 2 diabetes mellitus.
Noninsulin-Dependent Diabetes
Mellitus
Noninsulin-dependent diabetes m ellitus (NIDDM),
or type 2, occurs at any age but most often in adults.
It has an insidious onset and a subtle progression of
symptoms. People with NIDDM are frequently obese
and sedentary.
*
Diabetes can affect the retinal blood vessels and
cause hemorrhaging and abnormal growth of new
blood vessels into the vitreous (Figure 4-8).
Diabetic retinopathy has four stages:
1. Mild Nonproliferative Retinopathy. At this
earliest stage, m icroaneurysm s occur. They
arc sm all areas of balloon-like swelling in the
retina's tiny blood vessels.
2. Moderate Nonproliferative Retinopathy. As the
disease progresses, some blood vessels that
nourish the retina arc blocked.
3. Severe Nonproliferative Retinopathy. Many
more blood vessels are blocked, depriving sev­
eral areas of the retina of their blood supply.
T hese areas of the retina send signals to the
body to grow new blood vessels for nourish­
ment.
4. Proliferative Retinopathy. At this advanced
stage, the signals sent by the retina for nour­
ishment trigger the growth of new blood ves­
sels. These new blood vessels are abnormal
and fragile. They grow along the retina and
along the surface of the clear, vitreous gel that
fills the inside of the eye. By themselves, these
blood vessels do not cause symptoms or vision
loss. However, they have thin, fragile walls. If
thev*
leak blood, severe vision loss and even
blindness can result. Proliferative diabetic
retinopathy is the more advanced form of the
disease, and in this condition the new blood
vessels hemorrhage and grow into the vitre­
ous. The vitreous may then pull away from
the retina, causing additional hemorrhage into
the vitreous. This blocks transmission of the
light through the normally transparent vitre­
ous, causing significant vision loss. Floaters
or debris in the vitreous may follow along
with retinal detachm ent and additional loss
of vision. Fluid can also leak into the center of
the macula, the part of the eye where sharp,
straight-ahead vision occurs. The fluid makes
the macula swell, blurring vision. This condi­
tion is called macular edema. It can occur at
any stage of diabetic retinopathy, although
it is more likely to occur as the disease pro­
gresses. About half of the people with prolif­
erative retinopathy also have m acular edema.
M acular edema can cause significant loss of
vision along with distortion of vision.

Figure 4 -8 . Diabetes can affect the retinal blood vessels and
cause hemorrhaging and abnormal growth of new blood ves­
sels into the vitreous (Steinm an).
Prevalence of Diabetes and
Diabetic Retinopathy
D iabetes m ellitus affects 18 m illion people (about
6.3% of the population) in the United States.34 An
estim ated 5.2 m illion people in the United States have
d ia b e te s a n d d o n o t k n o w it. D ia b e te s is th e third
leading cause of death in the United States after heart
disease and cancer.34 The prevalence of diabetes var­
ies by age as indicated in Figure 4-9. M en and women
are equally affected. About 1.3 m illion people aged 20
years or older are diagnosed per year w ith new cases
o f diabetes m ellitus.34
Diabetic retinopathy is the leading cause of new
blindness in the 20- to 64-year-old population in the
United States. It accounts for about 12% of all new
cases o f blindness each уyear. In a recent study
у of US
adults 40 years and older known to have diabetes,
the estim ated prevalence rates for retinopathy and
vision-threatening retinopathy w ere 40.3% and 8.2%,
respectively.1 The estim ated US general population
prevalence rates for retinopathy and vision-threaten­
ing retinopathy w ere 3.4% (4.1 m illion persons) and
0.75% (899,000 persons).1 Future projections suggest
that diabetic retinopathy will increase as a public
health problem, both with aging of the US population
and increasing age-specific prevalence of diabetes
over tim e.1 T h e prevalence of diabetic retinopathy
am ong patients w ith diabetes is m ore dependent on
the duration of the disease than the patient's age.1516
Risk Factors
1 laving diabetes (whether type 1 or type 2) puts
an individual at risk o f retinopathy. The risk of d ia­
betic retinopathy increases the longer the person has
the disease. The W isconsin Epidem iologic Study of
Diabetic Retinopathy found that after having diabe­
tes for 20 years, alm ost all people with 1DDM and
more than 60% of those with NIDDM have some
degree of retinopathy.37'39 The duration o f the dia­
betes is also the major determ inant of the severity of
retinopathy and progression. O ther risk factors for
diabetic retinopathy include poorly controlled blood
sugar levels, high blood pressure, high blood choles­
terol, pregnancy, obesity, and kidney disease.
Effect on Vision
Patients w ith d iabetic retinopathy experience
decreased, fluctuating, or distorted vision; focusing
problem s; loss of color vision; and floaters.40 They
frequently have im paired contrast sensitivity (because
of cataracts), cloudy vitreous and retinal edem a, are
very glare sensitive, and are particular about lighting.
Thev may also have a central scotoma due to effects
of the diabetes on the m acular area (maculopathy),
loss of peripheral vision, and difficulty in dim light.
Treatm ents (described below') often leave clients with
a sm all island of good vision. They m ay see individual
num bers or letters but not words. The treatm ents also
produce scotom as in the periphery, or "sw iss ch eese"
vision. Figure 4-10 illustrates the visual problem s o f a
patient with diabetic retinopathy.
Treatment
D uring the first three stages of diabetic retinopathy,
no treatm ent is needed, unless m acular edema is pres­
ent. The current approach in these early stages em pha­
sizes the early recognition of retinopathy, vigorous
control of blood glucose, and direct therapy with laser
photocoagulation and vitreous surgery 41
Proliferative retinopathy is treated w ith laser sur­
gery. This procedure is called laser photocoagulation
treatment. Laser photocoagulation treatm ent helps to
shrink the abnorm al blood vessels. The ophthalm olo­
gist places 1,000 to 2,000 laser burns in the areas of the
retina away from the m acula, causing the abnorm al
blood vessels to shrink. Because a high num ber of
laser burns are necessary, two or more sessions usu­
ally are required to com plete treatment. Although the
patient may lose som e peripheral vision, scatter laser
treatm ent can save central vision.
Laser photocoagulation treatm ent works better
before the fragile new blood vessels have started to
hemorrhage. Thus, patients with diabetic retinopathy

T o ta l P re v a le n c e o f D ia b e te s in P e o p le 2 0 Y e a rs o r O ld e r
U nited S ta te s 2 0 02
(S o u rc e : 1999-2001 N ational H ealth Interview S u rve y)
2 0 -3 9 4 0 -5 9
should bo seen frequently for follow-up appointments.
Even if hemorrhaging has begun, laser treatment may
still be possible, depending on the amount of bleed-
ing.
If the hemorrhaging is severe, the patient may
need a surgical procedure called a vitrectomy. During
a vitrectomy, blood is removed from the vitreous of
the eye. During this procedure, the ophthalmologist
inserts a sm all instrum ent into the vitreous of the eye
and removes the vitreous that is clouded with blood.
The vitreous is replaced with a salt solution.
Figure 4-9. Prevalence of
diabetes by age (Steinman).
□ P e rc e n t
60 +
Figure 4-10. Illustration of visual problems of a client
with diabetic retinopathy (Steinman).
Effectiveness of Treatment
Both laser surgery and vitrectomy are effective in
reducing vision loss.4243 People with proliferative
retinopathy have less than a 5% chance of becoming
blind within 5 years when they get timely and appro­
priate treatment. Although both treatments have high
success rates, they do not cure diabetic retinopathy.
Once a patients has proliferative retinopathy, he or she
will always be at risk for new hemorrhages.

anterior cham ber (Steinman).
Low Vision Rehabilitation
The first step in low vision rehabilitation is an accu­
rate refraction by the low vision optom etrist and mod­
ification of the patient's eyeglasses, if required. O ne
o f the unique problem s that occurs w ith diabetes is
fluctuation of vision due to changes in refractive error
and vitreous debris. This exam ination m ay need to
be repeated if blood sugar levels are unstable. Visual
acuities should be frequently rem easured. Because
diabetes is often associated w ith other conditions
treated by occupational therapists, the occupational
therapist should routinely screen for vision loss, the
onset o f retinal edema with A m sler grid, and insure
the patient has a thorough retinal exam ination by a
eyecare practitioner every 6 months. In m anaging any
client w ith diabetes, even those w ithout diagnosis of
low vision, the occupational therapist should always
be vigilant for visual changes and frequent eye exam i­
nations.
A hallm ark of diabetic vision changes is impaired
contrast sensitivity. The low vision optom etrist may
prescribe special tinted lenses that block blue wave­
lengths in an attempt to improve contrast, elim inate
glare, and reduce sensitivity to light (photophobia).40
Patients often require multiple optical devices for vari­
ous ADL. Because of their fluctuating vision, these
individuals usually respond well to electronic m agni­
V
Figure 4-11 b. Aqueous fluid flowing into anterior cham ber
(Steinm an).
fication, where contrast can be enhanced and m agni­
fication varied. The occupational therapist must often
work w ith the patient to improve eccentric view ing
if the m acula is involved in the disease. Nonoptical
devices such as a glucose m onitor and insulin-syringe
aids are helpful to the patient.40 Chapter 15 covers the
rehabilitation of the diabetic patient in detail.
G lauco m a
Description
Glaucoma is not a single clinical entity, but a group
of ocular diseases w ith various etiologies that cause
an elevation of pressure in the eye (intraocular pres­
sure (IOP]), ultim ately leading to progressive optic
nerve dam age and loss of peripheral visual function.
Figure 4 -lla is an illustration of the front o f the
eye, called the anterior chamber. T h e ciliary body is
the structure that produces aqueous flu id . T h is fluid is
produced on a daily basis and flows to the front o f the
eye as illustrated in Figure 4-1 lb. Because the eye is a
closed structure, if new fluid is produced on a daily
basis, an equal am ount o f fluid must drain out of the
eye to m aintain the proper IOP. Under normal condi­
tions, the amount of aqueous fluid that is produced
is equivalent to the am ount that drains out on a daily
basis, m aintaining equilibrium and normal IOP. In
glaucom a, this equilibrium is disrupted. There are a
num ber of reasons why a person m ay develop glau­
com a; however, regardless of the cause, the ultimate
problem is loss of th is equilibrium , which causes a rise
in IOP. W hen the IOP rises, the nerve fibers exiting
the eye through the optic nerve are compressed and
dam aged. The fibers that are generally affected in the
beginning of the disease are those that carry inform a­
tion about our side vision (peripheral vision). Thus,
in the initial stages of the disease, glaucoma leads to
a gradual loss o f peripheral vision. In most cases of
glaucoma, the disease is painless because the rise in
pressure is very gradual. As a result, a person with
glaucoma may be unaw are of the problem until the
loss o f vision is advanced. Thus, routine eye exam ina­
tions are im portant to rule out this disease, and are
the best way to avoid the consequences of glaucoma.
Glaucoma is classified as prim ary opcn-angle glau­
coma when it is not related to another underlying con­
dition, and secondary when the cause of the glaucoma
is another ocular or system ic disease, trauma, or the
use o f certain drugs. Prim ary open-angle glaucoma
represents about 70% of all glaucom a and is a chronic,
progressive disease causing optic nerve dam age and
subsequent visual field loss. It occurs prim arily in
adults and generally affects both eyes, although one
eye can have more advanced disease than the other.
The m ajority of persons with prim ary open-angle
glaucom a have elevated IOP. As described above, the
elevated IOP observed in prim ary open-angle glauco­
ma usually results from decreased outflow of aqueous
fluid from the eye. T h e cause of this decreased outflow
is not well understood, but may be due to acceleration
and exaggeration of norm al aging changes in the area
o f the eye responsible for drainage of aqueous fluid
(anterior cham ber angle).44,4?
How Is Glaucoma Diagnosed?
Several tests can help the eyecare professional
detect glaucoma. Individuals at high risk for glaucoma
should have a dilated pupil eye exam ination at least
every 2 years. High risk factors for glaucoma include
being an A frican A m erican over 40, having a fam ily
history o f the disease, or for the general population,
being over 60. Those who are very nearsighted, have
a history of diabetes, have experienced eye injury or
eye surgery, or take prescription steroids also have
an increased risk of developing glaucom a. Japanese
ancestry is a risk factor for norm al-tension glaucoma.
Tests involved in the diagnosis of glaucoma include:
1. Tonom etry: M easures the fluid pressure
inside the eye. There are several m ethods
for m easuring eye pressure. The Schiotz and
applanation tonom eter m easure eye pressure
by directly applying pressure on the cornea.
The tonom eter is gently placed against the
eyeball and a pressure reading is then taken
from the instrum ent. These m ethods require
anesthetic drops in both eyes. Eye pressure
can also be m easured by sending a puff o f air
onto the eyeball. No anesthetic eyedrops are
required for this method.
2. Pupil d ilation: Special eyedrops are used
to tem porarily enlarge the pupil so that the
eyecare specialist can obtain a better view of
the inside o f the eve.
J
3. Visual field: T h is m easures the entire area that
can be seen when the eye is looking forward to
docum ent straight-ahead (central) and/or side
(peripheral) vision. The test m easures the dim ­
mest light that can be seen at each spot tested.
The test consists of responding by pressing a
button every tim e a flash of light is perceived.
4. Visual acuity:
¥ This m easures how well the
person sees at various distances. W h ile seated
20 feet away from an eye chart, the person is
asked to read standardized visual charts with
each eye. The test is perform ed w ith and w ith­
out corrective lenses.
5. Pachym etry: This procedure u ses ultrasonic
waves to help determ ine corneal thickness.
Prevalence
Glaucoma is an incipient disease, and can prog­
ress to significant loss in peripheral visual function
before the patient is aw are that there is a problem.
An estim ated 2.5 m illion A m ericans have open-angle
glaucom a,46 although at least half of all cases may be
undiagnosed.47 Prim ary open-angle glaucom a rep­
resents about 70% o f all adult glaucom a cases.48 The
Baltim ore Eye Survey estim ated the prevalence of
glaucom atous blindness to be 1.7 per 1,000 in the
general population, o f which more than 75% was due
to prim ary open-angle glaucom a.49 O ver 11% o f all
blindness and 8% of all visual im pairm ent may be due
to glaucom a.48 Prim ary open-angle glaucom a is 6.6 to
6.8 tim es more prevalent and accounts for about 19%
of all blindness am ong A frican Am ericans, compared
w ith 6% of blindness in Caucasians.49
Risk Factors
Risk factors for glaucoma include general and ocu­
lar factors (Table 4-2). Age is a m ajor risk factor for
the development of glaucoma. The prevalence of glau­
com a is 4 to 10 tim es higher in the older age groups
 Table 4-2.

Risk Factors for Primary Ooen Aiisde Glaucoma

General Ocular Nonocular

Age Elevated or asym m etric levels of IOP Diabetes m ellitus
Race D iffuse or focal enlargem ent of cup Vasospasms
Family history portion of optic nerve System ic hypertension
D iffuse or focal narrow ing of
neuroretinal rim
A sym m etry of cup-to-disc ratios >0.2
Myopia

Figure 4-12. Reduction in visual field caused by glau­

com a (Steinman).

Щ :
H e-;

than in persons in their 40s.50'51 Race is another major Treatment

risk factor for prim ary open-angle glaucoma. A frican
A m ericans develop the disease earlier, do not respond
as well to treatm en t arc more likely to require su r­
gery, and have a higher prevalence of blindness from
glaucoma than Caucasians.51 Finally, a fam ily history
of glaucoma is also a significant risk factor. O cular
factors include high IOP, thinness of the cornea, and
abnorm al optic nerve anatomy.
Effect on Vision
Left uncorrected, glaucom a causes a reduction in
visual field (Figure 4-12), which may progress to total
blindness. Central vision is generally unaffected until
the end stage of the disease.40
Treatment of glaucom a usually begins with m edi­
cations (pills, ointm ents, or eyedrops) that help the
eye cither drain fluid more effectively or produce less
fluid. Several form s of laser surgery can also help
fluid drain from the eve.
¥
Laser Trabeculoplasty
In this procedure, a high-intensity beam of light is
aim ed at the area o f the anterior cham ber of the eye
responsible for drainage of the aqueous fluid. Several
evenly spaced burns are used to stretch the drain­
age holes and allow the fluid to drain better. Laser
trabeculoplasty is a com m on treatm ent if topical med­
ication is not effective. T h e long-term benefits of this
treatment of glaucoma rem ain controversial because
its effectiveness d im inishes over tim e.52
 Eve Dis<vises \ssnciaU \:Ж ilh /сил \ ision
Figure 4-1 3a,h. Illustrations of ,i cataract iSteinman).
Conventional Surgery
Conventional surgery m akes a new opening for
the fluid to leave the eye. T h is often is done after
m edicines and laser surgery have failed to control
pressure.
Conventional surgery is about 60% to 80% effec­
tive at low ering eye pressure. If the new drainage
opening narrows, a second operation m ay be needed.
Conventional surgery works best if the patient has not
had previous eye surgery, such as a cataract opera­
tion.
Surgical intervention, the third level of treatment
for prim ary open-angle glaucom a, is required in many
m oderate or advanced glaucoma patients to lower the
pressure if other treatm ents have not been successful.
T h is surgery is also designed to im prove the drainage
o f aqueous from the eye. Filtration surgery usually
results in a dram atic and stable reduction in ЮР. ^
Although long-term control of IOP is often achieved,
many patients must rem ain on m edications and may
require additional surgery.
Low Vision Rehabilitation
M any patients with AM D may not have had a
recent exam ination and may benefit from a change in
eyeglass prescription. For patients with intact central
visual acuity and peripheral visual field loss, optical
devices that m inify the visual field can be used. This
is the opposite approach used for m acular degenera­
69
tion. Visual scan n in g strategies to com pensate for an
overall field loss, sim ilar to techniques used w ith field
cuts associated with stroke, are used as well. Severe
visual field loss associated w ith end-stage glaucoma
can create problem s w ith orientation and mobility
and referral to an orientation and m obility (O&M )
specialist is often required.40 Electronic m agnification
m ay be useful because it allow s for increased contrast
and brightness.40 The occupational therapist's role in
low vision rehabilitation includes m edication m an­
agement, especially if eyedrops are used; instruction
in the use of optical and nonoptical assistive devices;
m odification of lighting, contrast, and other envi­
ronmental factors; referral for orientation and m obil­
ity; education; and involvement in support groups.
Chronic glaucoma usually responds well to treatm ent
if the patient consistently adm inisters eyedrops. For
this reason, the occupational therapist should care­
fully evaluate medication m anagem ent if a patient
experiences vision loss w ith chronic glaucoma.
C atar ac t
Description
A cataract is an opacification or clouding of the lens
in the eye that affects vision. Cataracts are very com ­
mon in older people and can occu r in either or both
eyes. Figure 4-13 is an illustration o f a cataract.
 Age-related cataracts develop in two ways:
1. Clumps o f protein reduce the sharpness o f the image
reaching the retina. The lens consists mostly of
water and protein. W hen the protein clumps
up, it clouds the lens and reduces the light
that reaches the retina. The clouding may
becom e severe enough to cause blurred vision.
Most age-related cataracts develop from pro­
tein dum pings. W hen a cataract is sm all, the
cloudiness affects only a sm all part of the lens.
Over time, the cloudy area in the lens m ay get
larger, and the cataract may increase in size.
2. The clear lens slow ly changes to a yellow ish/brow n­
ish color. The clear lens slowly changes color
w ith age. At first, the am ount of tinting may
be sm all and m ay not cause a vision problem.
Over tim e, increased tinting may m ake it more
d ifficult to read and perform other routine
activities. This gradual change in the amount
o f tinting does not affect the sharpness of
the im age transm itted to the retina. With
advanced lens discoloration, a person may
have difficulty identifying colors.
How Is a C ataract Diagnosed?
A cataract is easily detected in the course of any
routine eye exam ination. The eyecare provider finds
reduced visual acuity that cannot be improved by
m odifying the patient's prescription. After dilating
the pupil, the eye doctor uses instrum ents that pro­
vide view s of the lens under a variety of m agnified
conditions. This d irect exam ination of the lens allow s
the eyecare provider to detect and diagnose the condi­
tion.
Prevalence
Hye D iseases Prevalence Research Group com ­
pleted a research study in 2004 designed to determ ine
the prevalence of cataract in the United States and to
project the expected change in these prevalence fig­
ures by 2020.54 They collected data from major popu­
lation-based studies in the United States. They found
that an estim ated 20.5 m illion (17.2%) A m ericans older
than 40 years have cataract in either eye. Women have
a significantly higher age-adjusted prevalence of cata­
ract than men in the United States. The total number
of persons who have cataract is estim ated to rise to
30.1 m illion by 2020. They concluded that the num ber
o f A m ericans affected by cataract and undergoing
cataract surgery will dram atically increase over the
next 20 years as the US population ages.54
Risk Factors
The m ain risk for developing cataracts is aging. By
age 65, about h alf of all A m ericans have developed
som e degree of lens clouding, although it may not
im pair vision. O ther significant factors are diabetes,
a fam ily history of cataracts, previous eye injury or
inflam m ation, previous eye surgery, prolonged use
of corticosteroids, excessive exposure to sunlight, and
smoking.
Effect on Vision
A cataract usually develops slowly and causes
no pain. As a result, most people are unaw are of its
development until it begins to interfere w ith everyday
activities. Sym ptom s of a cataract include:
• Blurry vision
• Increasing difficulty with vision at night
• Sensitivity to light and glare
• Poor contrast sensitivity
• Halos around lights
• The need for brighter light for reading and other
activities
• Frequent changes in eyeglass or contact lens pre­
scription
• Fading or yellow ing of colors
• Double vision in a single eye
Figure 4-14 illustrates the effect of cataract on
v isio n .
Treatment
The only effective treatm ent for a cataract is sur­
gery to remove the clouded lens and replace it w ith a
clear lens implant. The lens im plant can correct refrac­
tive error as well. In some cases, one eye is corrected
to focus at near and the other to focus at distance.
Cataracts cannot be cured with m edications, dietarv
supplements, exercise, or optical devices. However,
in the early stages of cataract development, the sym p­
toms may be improved w ith new eyeglasses, brighter
lighting, antiglare sunglasses, or m agnifying lenses.
W hen these m easures are no longer effective, surgery
is necessary. O phthalm ologists treat cataract surgi­
cally when vision loss interferes w ith a person's activi­
ties, such as w orking, driving, reading, or w atching
TV. Typically, if a person requires surgery on both
eyes, the surgery is perform ed on each eye at separate
times, usually about 4 to 8 weeks apart.
Cataract rem oval is one of the most com m on, saf­
est, and most effective types of eye surgery. More
than 1.5 m illion cataract operations are performed

each year. In a study of about 18,000 patients, Desai
et al reported that 92% of patients without other eye
disease achieved 20/40 or better visual acuity.-5 The
main risk indicators associated with visual outcomes
and complications related to surgery were age, other
eye diseases, diabetes, and stroke. Other studies have
reported sim ilar results.'’6'57
There are two types of cataract surgery. The most
com m on procedure is called phacoem ulsification.
During this procedure, the surgeon removes the cata­
ract but leaves most of the outer layer (lens capsule)
in place. The capsule helps support the lens implant
when it is inserted. During phacoemulsification, the
ophthalmologist makes a sm all incision where the
cornea meets the conjunctiva and inserts a needle-
thin probe. The surgeon then uses the probe, which
vibrates with ultrasound waves, to break up (emul­
sify) the cataract and suction out the fragments. The
lens capsule is left in place to provide support for the
lens implant. This procedure is som etim es referred to
as small incision cataract surgery. The other procedure is
called extracapsular surgery. This technique is generally
used if the cataract has advanced beyond the point
where phacoemulsification can effectively break up
the clouded lens. This procedure requires a larger inci­
sion where the cornea and sclera meet. Through this
incision, the ophthalmologist opens the lens capsule,
removes the nucleus in one piece and vacuums out the
softer lens cortex, leaving the capsule in place. With
either procedure, after the lens has been removed, it is
replaced with an artificial lens, called an intraocular
Figure 4-14. Illustration of visual problems of a c li­
cnt with a cataract (Steinman).
lens (IOL). An lOL is a clear, plastic lens that requires
no care and becom es a permanent part o f the person's
eye. If a person cannot have an IOL because of some
other eye disease or problems during surgery, a soft
contact lens, or glasses that provide high m agnifica­
tion, would be required to obtain clear vision.
Although cataract surgery is one o f the most effec­
tive surgical procedures, there are potential risks,
including inflam m ation, infection, bleeding, swelling,
retinal detachment, and glaucoma. Occasionally, cata­
ract surgery fails to improve vision because of condi­
tions such as glaucoma or m acular degeneration.
Another potential complication of cataract surgery
is a condition called posterior capsule opacification.
Common terms for this condition are second cata­
ract or after cataract. This condition occurs when
th e back of the lens capsule (the part of the lens that
isn't removed during surgery) eventually becomes
cloudy and blurs the client's vision. Posterior capsule
opacification can develop months or even years after
cataract surgery and occurs about 25% of the time.
Treatment for posterior capsule opacification involves
a technique called YAC. laser capsulotomy, in which
a laser beam is used to make a small opening in the
clouded capsule to let light pass through. This is a
quick and painless outpatient procedure that usually
takes less than 5 minutes.
Low Vision Rehabilitation
Because visual impairment from cataracts can be
corrected, cataracts rarely are the prim ary diagnosis
of moderate or severe vision loss. A s normal lens
changes in the eyes of clients over 80 years old involve
mild cataracts, in most cases of cataracts, low vision
rehabilitation involves m anaging the m ild im pair­
ment in contrast sensitivity, light sensitivity, and visu­
al acuity in older patients w ith a nonvisual prim ary
diagnosis. In some cases, especially when other visual
pathologies are present, if a client is medically frag­
ile or refuses the surgery, more severe cataracts are
not removed. W hen moderate cataracts are involved,
treatm ent focus is on m anagem ent o f glare, careful
control o f lighting, and environm ental interventions
and electronic devices to m axim ize contrast of read­
ing material and objects with good results. Severe
cataracts left untreated w ill result in profound vision
loss.
Su m m a r y
It is im portant for the occupational therapist spe­
cializin g in low vision rehabilitation to keep updated
about the latest research regarding eye pathology and
treatment. In a m ultidisciplinary low vision reha­
bilitation setting, the occupational therapist often
is involved in helping clients with medication m an­
agement. With clients who have active pathology, a
treatm ent plan usually includes instructing the client
about how to self-m onitor for vision changes and
educating the client regarding the cause, treatment,
and prognosis associated with eye diseases. In a home
care, general ou tp atien t or inpatient setting where the
occupational therapist does not practice w ith eyecare
providers, the occupational therapist w ho special­
izes in low vision plays an active role in insuring
that patients are receiving appropriate eyecare and
insuring appropriate referrals. In inpatient settings
with older persons who typically also have nonvisual
prim ary diagnoses, the occupational therapist often
is the first to identify the need for a referral to a low
vision optom etrist. In these settings, the occupational
therapist may provide stop-gap, nonoptica 1, low vision
interventions necessary to m aintain a rehabilitation
program w hile the patient is w aiting for an eye exam i­
nation.
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 Optics of Lenses, Refraction,
and Magnification

In tr o d u c tio n L enses
O ptical dcviccs are an im portant part of low T hree types ot lenses are used for eyeglass pre­
vision rehabilitation and help clients compensate for scriptions and low vision optical devices: convex,
impaired visual acuity and see objects more effective­ concave, and cylindrical.
ly at near, intermediate, and far distances. These opti­
cal devices include handheld magnifiers, spectacle Convex Lens (Plus Lens)
magnifiers, stand magnifiers, and telescopes. The low
A convex lens is thicker in the middle and thin­
vision eyecare practitioner ultimately prescribes these
ner at the edges (Figure 5-1) and is also referred to
devices. The occupational therapist contributes to the
as a plus lens, because when an optom etrist writes
selection of the device, evaluates these devices with
a prescription for a convex lens the symbol "+ " is
the tasks the client wishes to perform, and plays the
used. Convex lenses are used by eye doctors when
key role in teaching the client how to use the optical
prescribing glasses for hyperopia (farsightedness), as
aids in various activities of daily living (ADL). To teach
described in Chapter 2.
a client how to effectively utilize these devices, how­
A typical prescription for a client with hyperopia
ever, requires an understanding of the basic principles
(farsightedness) would look like this:
of lenses, optics, accommodation, and refraction. The
objective of this chapter is to review these principles
OD: +1.50
so that an occupational therapist can function com­
OS: +1.50
fortably in this role. Chapter 13 provides details about
the devices and instructional methods that can be
In this case, the acronym OD is used to designate
used to teach clients how to use these aids.
the right eye, or oculus dextrus, and O S is the acro­
nym for the left eye, or oculus sinister. Occasionally,
 < > Thick in
the Middle
Thin at
^ the edge
Figure 5-1. A convex lens is thicker in the middle and thinner
at the edges (Steinman).
you will see the acronvm OU used. T h is is used to
refer to both eyes, or oculus uturque.
Convex lenses are also used in most low vision opti­
cal devices such as handheld m agnifiers, stand mag­
nifiers, spectacle m agnifiers, and telescopes (Chapter
13). The therapist can quickly check to see if a client
has been prescribed a plus lens for hyperopia by look­
ing through it. If distance objects are blurred and near
objects clear, it is a convex lens. Note that because the
lens com pensates for hyperopia, it w ill have an effect
opposite to the refractive error, m aking objects clear
at near.
Concave Lens (Minus Lens)
A concave lens is th in ner in the m iddle and
thicker at the edges (Figure 5-2) and is also referred
to as a m inus lens. W hen an optom etrist w rites a
prescription for a convex lens, the m inus sym bol is
used. Concave lenses are used by eye doctors when
prescribing glasses for myopia (nearsightedness), as
described in Chapter 2.
A typical prescription for a client w ith myopia
(nearsightedness) would look like this:
OD: -1.50
O S: -1.50
The therapist can quickly check to see if a client has
been prescribed a concave lens for myopia by look­
ing through it. If distance objects look sm aller and
1 Thin in
the Middle
Thick at
► the edge
Figure 5-2. A concave lens is thicker at the edges and thinner
in the m iddle (Steinman).
are clear, it is a concave lens, opposite to the effect of
myopia.
Cylindrical Lens (Astigmatic
Lens)
W hile a convex or concave lens has only one uni­
form pow er throughout the lens, a cylindrical lens has
two powers and is used for the treatm ent of astigm a­
tism. Most clients have a com bination of hyperopia
and astigm atism or myopia and astigm atism . The
occupational therapist can easily determ ine if a cli­
ent has astigm atism by looking at his or her eyeglass
prescription. A typical prescription for a clicnt with
astigm atism and myopia (nearsightedness) would
look like this:
OD: -1.50 - 1.25 x 180
OS: -1.50 - 1.50 x 180
This would be read as: Right eye, m inus 1.50 w ith
-1.25 axis 180 and left eye, m inus 1.50 with -1.50 axis
180.
An exam ple of a prescription for a client w ith astig­
m atism and hyperopia (farsightedness) would look
like this:
OD: +2.50 - 2.25 x 180
OS: -2.00 - 1.75 x 180

The therapist can quickly check to see if a client has
been prescribed a cylindrical lens for astigmatism by
looking through it and slowly turning the lens clock­
wise or counterclockwise. If the object being viewed
changes shape as it is rotated, the correction has a
cylindrical component to correct for astigm atism.
A c c o m m o d a t io n
Definition and Description
Assum ing that any refractive error has been correct­
ed with eyeglasses, the human visual system is physi­
ologically focused for objects at distances of 20 feet
and greater. If an object is brought closer than 20 feet,
a focusing adjustment must be made or the object will
appear blurred. I his focusing adjustment is referred
to as accommodation. Accommodation is the ability
to change the focus of the eye so that objects at dif­
ferent distances can be seen clearly. Accommodation
occurs by stim ulating the smooth muscle of the ciliary
body in the eye to contract, thereby enabling the lens
to change its shape to become more convex. Optically,
therefore, accommodation is identical to putting a
variable plus-lens in front of the eye. Figure 5-3 is a
cross-section of the human eye show ing the lens and
the ciliary m uscle in its relaxed state. The light rays
Figure 5-3. Cross-section of the human
eye showing the lens and the ciliary
m uscle in its relaxed state (Steinman).
Figure 5-4. C iliary m uscle has contract­
ed and allow s the light rays to focus on
the retina (Steinman).
entering the eye are focused behind the retina, which
would cause blurred vision. In Figure 5-4, the ciliary
m uscle has contracted and allows the light rays to
focus on the retina.
The accommodative ability o f an individual is
inversely related to age. We use the term accom m oda­
tive amplitude to refer to the total am ount of accom­
modation available for a particular client. Young chil­
dren have very large am plitudes of accom m odation,
and this declines with age. This relationship between
age and accommodative amplitude is so consistent
across the population that it is possible for an optom ­
etrist to predict a client's age within several years sim ­
ply by m easuring the amplitude of accommodation.
The accom m odative am plitude declines gradually
with age, and by 40 to 45 years of age the decline is
significant enough to interfere with the ability to see
small print held at a normal reading distance o f 40 cm
or 16 inches. This is referred to as presbyopia.
Presbyopia is a condition in which near visual acu­
ity is decreased because of an age-related decline in
accommodative ability. All adults after the age o f 45
or so have this condition, and require reading glasses
or som e modification of their eyeglasses to account
for it. Reading glasses that supplement accom m oda­
tion position plus lenses in front of each eye. Bifocals
are lenses that add extra plus to a person's distance
prescription, referred to as reading addition or by the
shorthand term add. Sincc most clients will be older,
occupational therapists working in the field of low
vision rehabilitation of adults usuallv deal w ith clients
who have presbyopia and require a reading addition
to focus at near.
In the report from an eyecare practitioner, the read­
ing addition is specified as the num ber at the end of
the prescription for refractive error. It alw ays follows
a plus sign, but should not be confused w ith the cor­
rection for hyperopia. An exam ple for a correction for
1 diopter (D) of hyperopia, 2.25 D of astigm atism , with
2.50 D o f reading addition to com pensate for presby­
opia would be as follows:
OD: +1.00 - 2.25 x 180, +2.50
OS: +1.00 - 2.25 x 180, +2.50
Significance of A ccom m od ation
for Low Vision Rehabilitation
W hen working with optical aids, it is im portant to
consider accom m odation and how it may impact on
the c lie n ts ability to use the device. With som e opti­
cal devices, the client is required to accom m odate and
with others accom m odation is not required. To deter­
m ine if a client must use accom m odation, one must
consider a num ber of factors, including the working
distance, or the distance from the eye to the material
being viewed. T h e working distance is the distance at
which the object being viewed is held from the eye,
always specified in m etric units. If an object is held
at 20 feet (~6 m eters), no accommodation is required.
As the object is brought closer, more and more accom ­
m odation is required. We determ ine the amount
of accom m odation required by using the following
formula:
Accom m odation Demand = 100/working distance
in centim eters
E xam ple 1
If a client holds the reading m aterial al 40 cm , the
am ount o f accom m odation required is:
Accom m odation Demand = 100/distance (cm)
Accom m odation Demand = 100/40 = 2.50 D
E xam ple 2
If a client holds the reading material at 10 cm, the
am ount o f accom m odation required is:
Accom m odation Demand = 100/distance (cm)
Accom m odation Demand = 100/10 = 10 D
Thus, close working distances require a consider­
able amount of accom m odation. In the adult popula­
tion over the age o f 40 years, the ability to accom m o­
date has declined significantly. T h e optom etrist must
consider this when prescribing the optical aid and the
occupational therapist m ust always be aware o f the
issue of accom m odation when instructing clients in
the use of optical devices.
If a client is experiencing difficulty using an optical
device, one of the issues to consider is accom m oda­
tion. This w ill be reviewed in detail in Chapter 13.
O ptics o f L enses
M anufacturers use two different m ethods to label
the power or m agnifying capability of optical devices.
Som e designate the device or lens by its actual power,
w hile others label the device using the term m agnifi­
cation. T h is inform ation, in w hichever form at provid­
ed, tells the therapist how to position the device and
to instruct the client how to use the optical device. It
is, therefore, im portant to understand various param ­
eters of lenses, such as focusing power, focal distance,
and m agnification.
Focusing Power o f a Lens
The unit of m easurem ent of the focusing power of
a lens is called a diopter (D). The definition of a 1 D
lens is one that w ill focus parallel light rays entering
the lens from a distant object to a point focus 100 cm
away (Figure 5-5). We refer to this as a 1 D lens. As
the power of a lens increases, it focuses parallel rays of
light closer and closer to the back surface o f the lens.
We use the follow ing form ula to determ ine the
power of a lens:
D = 100/d (cm)
Exam ples
1. A lens focuses parallel light at 1 m eter - D =
100/100 = 1 D
2. A lens focuses parallel light at 50 cm - D =
100/50 = 2 D
3. A lens focuses parallel light at 33 cm - D =
100/33 = 3 D
4. A lens focuses parallel light at 25 cm - D =
100/25 = 4 D
5. A lens focuses parallel light at 10 cm - D =
100/10 = 10 D (Figure 5-6)
 Figure 5-5. A 1 D lens w ill
focus parallel light rays entering
the lens from a distant object
to a point focus 100 cm aw ay
(Steinman).

Figure 5 -6 . Five exam ples of

convex lenses of varying power
(Steinman).

Many of the optical devices that the occupational Examples

therapist will use with clients will have the power of
the device designated in diopters. Note that the for­
mula for accommodative demand is the sam e because
it measures the required focusing power.
Focal Distance (Length) of a Lens
Another important term used in optics is the focal
distance of a lens. The focal distance of a lens is the
distance at which the lens brings parallel rays to a
sharp focus (Figure 5-5). It is the distance between the
lens and the point focus. The point or plane at which
the lens focuses light is called the focal point of the
lens. The focal distance of the lens is determined by
the power of the lens in diopters.
T h e fo c a l d is ta n c e o f a le n s is c o m p u te d u s in g th e
fo llo w in g fo r m u la :
Focal Distance (cm) = 100/D
Thus, the focal distance of a lens is the reciprocal
of the dioptric power. The greater the power of the
lens, the closer the image is focused to the back of the
lens.
1. The focal length of a 1 D lens - = 100/1 = 100
cm
2. The focal distance of a 2 D lens - = 100/2 = 50
cm
3. The focal distance of a 3 D lens - = 100/3 = 33
cm
4. The focal distance of a 4 D lens - = 100/4 = 25
cm
5. The focal distance of a 10 D lens - = 100/10 = 10
cm
Knowledge of the focal distance is critical for the
occupational therapist because it determ ines the dis­
tance at which the client needs to hold the optical
d e v ice fro m th e w o rk in g m ateria l. W e w ill refer to th is
distance as the lens-to-object distance.
For example, a client is using a 10 D handheld mag­
nifier to read a label on a can of soup. How far from
the can of soup should the client hold the m agnifier
to achieve most m agnification with a sharp focus? To
determ ine lens-to-object distance of this magnifier,
use the formula:
 Lcns-to-objcct distance = 100/D, lens-to-object d is­
tance = 100/10 = 10 cm
In this case, the occupational therapist would
instruct the client to hold the m agnifier 10 cm from
the can o f soup. Thus, if the dioptric power of the lens
is known, the therapist can determ ine the appropriate
lens-to-object distance of the optical device.
Optics o f Magnification
O ne m ethod of describing a low vision optical
device lens is by its dioptric pow er as described above.
For example, a handheld m agnifier may have a power
of 6 D, 10 D, or 20 D. Another method used by m anu­
facturers to describe an optical device is by its degree
of m agnification. A device m ight be labeled as a 5X or
10X m agnifier, for example. Unfortunately, the conven­
tion used to calculate m agnification is inconsistent.
The most com m on form ula used to relate the power
of a lens to its m agnifying ability is:
M = D/4
where M = M agnification
Exam ples
A lens has a power of 20 D. W hat is its m agnifying
power?
M = D/4
M = 20/4 = 5X
O ther m anufacturers may use the formula:
M = D/4 +1
O th ers m ay use the form ula:
M= D/2.5
Thus, the actual m agnification of a device marked
as 4X may d iffer betw een m anufacturers depending
on the definition used to determ ine the m agnification.
In addition, for other devices such as telescopes and
video m agnifiers, m agnification is described as how
much the im age viewed through the optical device is
enlarged. For exam ple, a 4X telescope im plies that the
object size as viewed through the telescope is 4 times
larger than the sam e object viewed without the tele­
scope. This inconsistency in term inology is a source
o f great confusion for therapists. Because of this
inconsistency, in this text we use the term m agnifica­
tion only in a general qualitative sense, as in “to make
som ething appear larg er"
Fortunately, one general convention has emerged
in low vision care that helps resolve this problem . The
m agnification of any near device can be described as
the power "equivalent" to the power o f the near read­
ing addition. T h is is referred to as equivalent power
(EP).1 All m ajor m anufacturers now list the EP of
their devices. In order to understand how EP relates to
m agnification, one must first understand the various
ways that an object can be m agnified to com pensate
for im paired visual acuity.
Methods o f Achieving
Magnification
O ne of the prim ary ways to com pensate for
im paired visual acuity is to m agnify the object of
interest. All methods of m agnification enlarge the
retinal image of an object. There are four m ethods of
achieving this goal. T hese four m ethods are actually
variations of cither relative distance or relative size
m agnification. The relationship betw een relative size
and relative distance m agnification form s the founda­
tion for understanding all interventions, optical and
nonoptical, that involve m agnification of the object of
interest to com pensate for inadequate visual acuity.
Relative Size M agnification
In relative size m agnification, the actual size of the
object is increased. To avoid confusion with the many
other definitions of m agnification, the convention is
to call size m agnification "en larg em en t" T h e concept
is quite simple. If the size of the object is doubled, the
size of the retinal im age is doubled. To achieve 2X
enlargem ent, therefore, we sim ply enlarge the object
twofold. If a client has trouble reading 8 point font,
but can fluently read the 16 point font typical of large
print books, the therapist could print a docum ent on
the computer using 16 point font or use large-print
books typically printed with 16 point letters, as long as
the eye-to-object distance rem ained the same.
This approach is relatively easy and can be an inex­
pensive option that is generally w ell-accepted because
the client does not require any optical aids and can
read at a normal distance. However, as the m agnifi­
cation dem ands grow and the print size for books is
increased, the size and weight becom e issues. This
method of m agnification, therefore, is generally best
suited for clients with m ild to moderate loss of vision.
It is also used in com bination w ith other m ethods of
m agnification.
Relative Distance M agnification
A nother simple m eans o f achieving m agnifica­
tion of an object is to move closer to it. As an object
is moved closer to the eye, the retinal image of the
object increases. If the distance is halved, the retinal
image size doubles and 2X m agnification is achieved.
To achieve 4X m agnification, the therapist would
decrease the distance by one-fourth. If a client is hav­
ing trouble seeing a 20-inch television at a distance
o f 12 feet, the therapist can suggest that the client
move to 6 feet aw ay *
T h is would double the size of the
retinal im age of the television and m agnify the image
twofold.
If a client is having difficulty reading a newspaper
at 40 cm , bringing the newspaper closer to 10 cm d is­
tance would m agnify the print 4X. However, moving
the newspaper this close creates another problem.
Recall the discussion above about accomm odation.
The closer an object is brought to the eye, the more
accom m odation is required. Although decreasing the
working distance from 40 cm to 10 cm achieves 4X
m agnification, the client would experience blurred
vision if he/she is unable to accom m odate for that
distance. W hile a young child would be able to accom ­
modate even at 25 cm, this would not be possible
for an adult, particularly an adult age 40 and older.
To solve this problem in adult clients with limited
accom m odation, the eyecare practitioner prescribes a
reading addition or other optical device that focuses
the light on the retina. In this example, the am ount of
additional plus required to read at 25 cm can be calcu­
lated using the formula described above.
Power (Diopters) = 100/D (cm) = 100/25 = 4 D.
The am ount of relative distance m agnification can,
therefore, be described in term s of the additional plus
power required to see som ething at a given distance,
otherw ise called equivalent power.
Angular M agnification
A ngular m agnification is the m agnification exp e­
rienced when a person looks through a device like a
telescope. A ngular m agnification also increases the
size o f the retinal image just like relative size and rela­
tive distance m agnification. The advantage of angular
m agnification is that it can be used when moving clos­
er to an object or enlarging it is impractical or im pos­
sible. Viewing a sporting event is an exam ple of such a
situation. If an individual sits far from the action, nei­
ther relative distance nor relative size m agnification is
possible. However, the use of a telescope or binoculars
w ill m agnify the object of interest. W hen view ing
objects further than 20 feet, angular m agnification is
an optical method of achieving size m agnification,
and the m agnification specification can be described
as an enlargem ent ratio. A 4X telescope produces the
sam e effect as enlarging an object 4X.
Projection M agnification
Projection m agnification refers to enlarging an
object by projecting on a screen; this is the sam e as
size m agnification. Electronic devices like closed cir­
cuit televisions (CCTV) increase the size of the image
to be viewed through the projection process, and like
size and angular m agnification may be described as
an enlargem ent ratio. A 4X enlargem ent on a CCTV
screen m eans that the 1.5 mm high, 8 point newsprint
being viewed under the cam era o f the CCTV w ill be
enlarged 8X to 12 m m on the screen. A CCTV can
be used to project printed and graphic m aterials to
increase their size.
In low vision care rehabilitation, the type o f m ag­
nification used is dependent on many factors that will
be discussed in Chapter 13. It is not unusual to use a
com bination of m agnification system s. For exam ple,
the eye doctor may prescribe a m agnifier and the
therapist may suggest the use of larger print. How
to com bine m agnification will be discussed in the
advanced optics section o f Chapter 13.
Lovie-Kitchin and W hittaker compared the effect
on reading rates o f adults using relative distance ver­
sus relative size m agnification.2 They found that the
reading rates of the subjects with low vision did not
differ significantly with the two m ethods of provid­
ing m agnification if the m agnification provided was
adequate. They also concluded that for most tasks, it
is more practical to enlarge the image optically, rather
than to enlarge the reading material physically.2
Field of V iew
Field of view refers to the size of the area that can
be viewed through a lens, m agnifier, or telescope.
Typically, when we are reading a book, we are able to
see the entire page at once. Although only the words
we are looking at are clear, the rest o f the sentence,
paragraph, and page are visible in our peripheral
vision. This is im portant because it is this peripheral
vision that helps us know where to move our eyes next
to continue to effectively gather visual inform ation.
W hen introduced to an optical device for the first time,
clients often are pleased that they can now see detail
better but com plain about the reduced field of view.
A com m on question is "C an't I find a m agnifier with
a larger field of view ?" The answer, unfortunately, is
simple. W hen a client uses an optical device, the field
of view will always be sm aller; the stronger the mag­
nification, the sm aller the field o f view. M agnification
is like enlarging on a copy m achine when the paper
size cannot be changed. If the page is doubled in size,
only half the original page will fit onto the copy. At
times, a client may only be able to see a few words or
 factors Affecting the Field of View
Factor Effect on Field of View
D iam eter of the m agnifier A wider diam eter lens w ill have a w ider field of view. The
diam eter is related to the power o f the lens. Stronger lenses
have sm aller diameters.

Power of the m agnifier The greater the power, the sm aller the field of view.

D istance betw een eye and lens The field of view becom es larger the closer the client is to
the lens.

even just a few letters at a time. This, of course, m akes
reading difficult, interfering with speed, fluency, and
com prehension. The reason that larger size handheld
m agnifiers enable people to see with a larger field of
view is generally because larger diam eter lenses gen­
erally have less m agnification.
W hen using optical devices, a num ber of factors
affect the field of view through the device. These are
listed in Table 5-1. Stronger m agnifiers have sm aller
fields o f view because they must be m ade with sm aller
diam eters and must be held closer to the material
being viewed. The field of view also becom es sm aller
if the client moves his or her eyes away from the mag­
nifier.
the use of these devices in ADL. In this chapter, we
reviewed the basic concepts that occupational thera­
pists must know to com fortably work w ith optical
devices.
R eferences
1. Bailey IL. Equivalent viewing power or magnification? Which is
fundamental? The Optician. 1984;188:14-18.
2. Lovie-Kitchin Whittaker S. Rdative-size magnification versos
relative-distance magnification; Effect on the reading perfor­
mance of adults with normal and low vision. / Vis Impairment &
Blind. 1998;16:433-446.

Summary
The use of optical devices is an integral part of
low vision rehabilitation. O ccupational therapists will
routinelv
У need to educate and instruct clients about
 Psychosocial Issues Related to
Visual Impairment

influenced by cognitive and psychosocial factors.3 In

In tr o d u c tio n
An enduring irony of low vision rehabilitation is
that potential beneficiaries of services often resist par­
ticipation. It is not uncommon to find that once clients
discover that interventions do not restore vision, they
drop out of treatment, even though compensatory
low vision rehabilitation is available that mav ¥ restore
nearly all activities of daily living (ADL), most instru­
mental activities of daily living (IADL), and many
leisure and vocational occupations. We feel that this
resistance occurs because psychosocial and cognitive
effects of adventitious (later onset) vision loss can
present unique and substantial complications that
extend beyond functional vision problems.1 It is criti­
cal, therefore, that occupational therapists attend to the
cognitive and em otional impact of the vision loss and
the client's ability to cope when providing low vision
rehabilitation. Clients who do not cope or adapt well
to vision impairment arc at risk for depression, which
may have a negative impact on rehabilitation. O ne of
the very important issues in low vision rehabilitation
is the high prevalence of depression and psychoso­
cial problems associated with vision impairment.2
Occupational therapists are very aware that engage­
ment in occupations and in daily life activities can be
the field of low vision rehabilitation, depression and
other psychosocial problems are important client fac­
tors that must be considered in intervention. Profound
or peripheral vision loss that requires focus on non­
visual compensatory strategies presents additional
cognitive demands as well. A s with other disabilities,
occupational therapists address all aspects of per­
formance (physical, cognitive and psychosocial, and
contextual) when providing low vision intervention3
and this includes consideration of the psychosocial
problems commonly associated with vision im pair­
ment. This chapter is designed to provide background
information about the psychosocial issues related to
vision impairment.
Fa c t o r s A ffecting
A d justm en t t o V ision
Im pa irm en t
Clinical reports and mostly retrospective descrip­
tive research indicates a num ber of factors that affect
the client's adjustment to vision loss and suggests that
information about these factors should be gathered
 _______Common Impediments to a Client’s Adjustment to Vision Loss_________
1. The type of vision loss and stage of coping
2. Cultural and Fam ily reaction: caregiver dependence.
3. The life stage
4. O ther significant life events
5. Patient's expectations and the stigm a of blindness
6. Self-concept
7. Personality
Graboyes M. Psychosocial implications of visual impairment. In: Brilliant RL. Ed. Essentials o f Low Vision Practice. Boston, МЛ:
Butterworth •Heinemann; 1999; 12-17.
during the history and w hile w atching the client
engaged in occupation and activities.1-4'7 These fac­
tors are listed in Table 6-1, are briefly explained below,
and should be considered in every evaluation. Issues
related to any of these factors have the potential to
lim it the overall outcom e for a client.
Type o f Loss
An im portant issue is whether the vision loss is
congenital, adventitious and longstanding or adventi­
tious and recently acquired. Tuttle and Tuttle's review 7
uncovered a sequential pattern of coping with vision
loss (Table 6-2). A review of phenomenological stud­
ies revealed that these stages often overlap and may
occu r in a different sequence.5 Clients w ith recently
acquired vision loss who are in denial m ay still be
hopeful for a cu re that will restore their vision. Many
will also be in stages of m ourning or depression. As
will be discussed below, m any will becom e “stu ck " in
a stage of clinically significant depression. The lack of
initiation, m em ory im pairm ent, and decreased activ­
ity level associated with depression will invariably
have a negative impact on rehabilitation designed to
teach the client how to adapt to vision impairment.
Gradual loss of vision caused by dry m acular degen­
eration m ay be easier to adapt to than the sudden
loss of wet m acular degeneration, especially if early
rehabilitation intervention enables a client to m aintain
habits, routines, and occupations.4
Cultural and Fam ily Reaction
The fam ily's reaction to the person's vision loss
can have a significant effect on the client's adjust­
ment. This reaction will vary with different cultures.
For example, vision loss may cause role changes
w ithin the household, causing anger and resentm ent.1
Stigm as associated w ith vision loss, perceptions of
disability, and expectations of fam ily for recovery of
roles and functions vary w ith different cultures. Since
cultural diversity exists w ithin broad ethnic groups,
we find the best strategy is to explore such expecta­
tions by careful interview of the client and the family.
Som etim es interpreters can help. Vision im pairm ent
often leads to social problems such as nonacceptance,
difficulty sustaining relationships, and attitudes of
pity and overprotection by fam ily m em bers.8
Life Stage
T h e life stage of the client at the onset of the visual
im pairm ent and at the tim e of intervention has im pli­
cations for psychological adjustm ent. For exam ple, the
older adult already faces challenges related to aging
and these challenges can be com pounded by vision
im pairm ent. Low vision rehabilitation involves hard
work and stress. M any older individuals consider
themselves as having retired from stress and hard
work. Vision loss may interfere with m any of the
leisure activities that a retiree expected to enjoy in
the retirem ent years, and for an elderly person living
alone, vision im pairm ent can lead to the end of inde­
pendence.
Significant Life Events
Older age involves m any stresses, especially the
loss of loved ones, other illnesses and the dependence
of others. Interestingly, older adults appear more resil­
ient than their younger counterparts in adapting to
stressful events, a resilience that appears to relate to
social support.5 It is im portant to determ ine if there
have been recent stressful life events. A client who has
recently been challenged to deal with other stressful
situations may not have the energy to adjust to the
vision impairment and em bark on a vision rehabilita­
tion program .9
 Table 6-2.

Tuttle and Tuttle’s Stages of Coping

Trauma: physical and social
Shock and denial
M ourning and withdrawal
Succum bing and depression
Coping and m obilization
Self-acceptance and self-esteem

cessful attempt at adaptation, even if a better solution

Patient Expectations to the problem m ight exist. Avoid corrective feedback
D uring the occupational profile/case history (see and errors by focusing on easily attained goals at first.
Chapter 8), the occupational therapist should ask Educate fam ily
У and friends to do likewise.
about the client's goals and expectations from vision
rehabilitation. Clients who have advanced to later Personality
stages of coping (see Table 6-2) begin to understand
Each client will react to vision loss in a different
the nature of their problem and will have reason­
manner. As will be discussed below, older individuals
able goals and expectations. For individuals who
w ith vision loss are at high risk for depression. Any
have initiated adaptation, vision rehabilitation has a
other factor that predisposes a person to depression,
better chance of success. Clients still in denial, who
therefore, would im pact on low vision rehabilitation
have not fully accepted the vision loss, may still be
outcomes. For exam ple, those people w ith an anxious
seeking the special pair of glasses that will suddenly
personality prone to depression w ill react differently
restore their vision. If the client presents w ith unre­
from an independent, motivated individual.4
alistic objectives, it is im portant to accept the need to
O ccupational therapists should evaluate the seven
advance through the stages of coping and focus. This
factors listed in Table 6-1 and this inform ation should
advance can be facilitated by external routines, roles,
be considered when developing a treatm ent plan.
and social dem ands that gently encourage recovering
perform ance of occupation accom panied by a reha­
bilitation focus on more highly valued, enjoyed, and
easily attained goals. V ision Im p a ir m e n t an d

Self-Concept or Perceived Locus of C ognitive F u n c t io n

Control Treatm ent planning to address d isability from
visual im pairm ent involves consideration of cogni­
A person's self-concept m ay be impacted in a nega­
tion as either a support or barrier to a successful
tive w ay by a vision im pairm ent.1 It is not unusual for
perform ance outcome. Evaluation of cognitive func­
a person w ith vision im pairm ent to get the message
tion and interventions involving consideration of
from others that he or she is unable to perform certain
cognitive function10 have been an integral part o f the
activities and the implied m essage is that the person
repertoire of skills an occupational therapist brings to
is unable to be independent anymore. People differ
any rehabilitation team. Critical for success, a review
in their perception of their own ability to control
of cognitive evaluation and treatm ent is beyond the
outcomes.4'5' A loss of self-esteem and loss of sense of
scope of this book and these topics have been covered
control is observed behaviorally as lack of initiation,
elsew here.10 Low vision and blindness present some
especially w hen problem -solving is required. For
unique cognitive dem ands, including dependence
exam ple, a client m ay "give up" when a handheld
on higher-order processing of other senses, auditory
m agnifier that has enabled reading does not seem to
localization and processing, and hepatic processing.
work, rather than try different m agnifier positions or
Although som e people who are blind have developed
experim ent w ith lighting. Self-perception and self-con­
near normal spatial processing abilities, in general,
cept often are altered by a disability- We feel that locus
spatial perception based on touch and sound is not
of control or hardiness can be learned.5 The effective
as accurate as spatial perception based on vision.
strategy to restore a person's "h ard in ess" is to provide
Exam ples of spatial-perceptual tasks include: recall­
positive feedback when the individual exhibits a suc­
ing where a glass is located during a meal, finding the
door that one entered when leaving a room, recalling
where a throw rug was located in an u nfam iliar loca­
tion, determ ining by touch if a seam being sew n is
straight, or finding the dom inoes on a table. People
w ith adventitious peripheral vision loss acquired
after adolescence or profound blindness where high
contrast landm arks cannot be seen have the greatest
difficulty with spatial perception.6
People w ith long-duration blindness tend to move
few er joints when scan n in g an environm ent, whereas
people w ith recent blindness move the whole arm and
hand.6 This suggests that a strategy for teaching som e­
one to locate objects by feel should include careful,
stereotypic arm positioning. An exam ple is pressing
the elbow s to the body and keeping the w rists rigid so
the hand is moved only by shoulder rotation, and then
increm ental, careful shoulder flexion to reposition
the elbow on a table for a reach. If possible, only the
hand or digits should be moved to scan sm aller areas.
By decreasing the joints involved, we suspect, spatial
localization can becom e more accurate.
Adaptive strategies include use of high-contrast
m arkers to help som eone orient to a room or objects
on a table. If som eone has full visual fields but pro­
found visual acuity loss, sm all bright lights, bright
windows, table lam ps, and streetlights work very well
as markers. Careful organization of objects in the liv­
ing space becom es a critical adaptive strategy.
T h e therapist needs to be careful to respect indi­
vidual organization schem es and carefully evaluate
a person's ability to locate objects after perform ance
has been evaluated to see if som eone can find given
objects. The stacks of paper and jumble of objects
on a table might actually be positioned according
to a person’s premorbid organization schem e; any
change could devastate perform ance. Fam ily needs
to be carefullv ¥ instructed not to alter the environ-
mcnt o f a person with visual impairm ent in any way
w ithout directly involving the person in m oving each
object. Low tables or throw rugs that are normally
considered hazards m ay not present a safety hazard
to som eone w ho is fam iliar with the location of these
items. Indeed, the clicnt may use these objects as
m arkers in orienting to a room.
D uring m obility training, a person w ith low vision
can be alerted to sounds and sm ells associated with
landm arks, such as a food cart, reception desk, escala­
tor, or busy doorway.
Learning to use other senses to perform tasks pro­
vides a considerable cognitive challenge to som eone
w ho has lost vision later in life. For this reason, we
suspect individuals w ith recent vision loss may find
use of visual devices or visual m arkers m ore help­
ful than a counterpart who has lived with impaired
vision for m any years. C are m ust be taken to intro­
duce som eone with low vision to searching, scanning
and localization tasks that may, to a norm ally sighted
person, be very easy.
V isual Im p a ir m e n t and
D epression
There is a significant body of literature dem onstrat­
ing a relationship betw een visual im pairm ent and
depressive illness in adulthood and later life.2'11*18
Horowitz and Reinhardt suggest two possible rea­
sons for this relationship.4'18 The first factor is the
relationship betw een chronic illness of any type and
functional disability.19'20 T h is concept suggests that it
is not the chronic illness itself that causes the depres­
sion. Rather, it is the loss of independence in ADL
caused by the chronic illness that leads to depres­
sion. Studies have dem onstrated that adults w ith
visual im pairm ent are more functionally disabled in
ADL than those without vision im pairm ents.4'21'2^5
W illiam s et al interviewed 86 patients w ith age-relat-
ed m acular degeneration (AM D) and found severe
disabling effects of the disease.25 Patients rated their
quality of life substantially lower than people with
intact vision. These patients were eight tim es more
likely to have trouble shopping, 13 tim es more likely
to have difficulty m anaging finances, four tim es more
likely to have problems with meal preparation, nine
tim es more likely to have difficulty w ith light house­
work, and 12 tim es more likely to have trouble using
the telephone. Rovner et a l16 found that depressive
sym ptom s are more prevalent and persistent am ong
low vision patients and appear more highly correlated
to the disability than to the actual visual acuity loss.
Brody et a l1-1 also found that in the group of patients
they studied, visual acuity had little correlation with
the severity of the depressive sym ptom s. In a study
of 144 subjects, Tolman et a l17 exam ined psycho­
logical adaptation to vision loss and its relationship
to depressive sym ptom atology in older adults. Their
findings support the contention that depressive sym p­
tom atology is m ediated by one's perceived sense of
individual control as it relates to intrapersonal factors
underlying adaptation to vision loss.
There is also evidence that vision im pairm ent
may have a more severe im pact than other physical
disabilities on everyday functioning.4 Furner et al
found that vision im pairm ent and stroke are the most
significant in their effect on instrum ental activities of
daily living.26 Ford et al identified vision im pairm ent
as second only to arth ritis as a cause o f disability
in the elderly.27 Thus, there is convincing evidence
dem onstrating that vision im pairm ent interferes with
occupational perform ance, causing loss of indepen­
dence. It is this loss of independence that may be a key
factor in explaining the high prevalence of depression
in clients with visual impairment.
The second factor that may explain the relationship
between visual impairment and depressive illness
is the subjective characteristics of vision im pair­
ment.-4 Horowitz and Reinhardt4 suggest that the most
unique characteristic of vision impairment is that it is
a particularly feared disability. In 1995, the Lighthouse
surveyed adults 45 and older and found that blind­
ness was more feared than other disabilities.28 A
public opinion poll found that blindness ranks fourth,
following only AIDS, cancer, and Alzheimer's disease,
as the illness most feared by Americans.29 The results
of a Gallup survey in 1988 showed that blindness was
the most feared disability by 42% of adults polled.30
Thus, adults who become visually impaired may have
internalized this attitude, which influences their reac­
tion and adaptation to vision loss.4 Ainlay suggests
that older adults may assum e that vision loss invari-
ably leads to a loss of independence, which then leads
to self-imposed social isolation.31
Another important issue is that vision impair­
ment has a negative impact on driving and read­
ing, two activities that are very highly valued by
most people.18'32 33 For older adults, the inability to
drive affects their sense of autonomy, self-worth, and
independence.18 Losing the ability to drive has been
identified as one of the most feared aspects of vision
impairment.33
Thus, the emotion elicited by vision impairment
plus the relationship between vision loss and func­
tional disability combines to increase the client's
susceptibility to develop clinically significant depres­
sion.
P revalence o f D epression
in A dults W ith V ision
Im pairm en t
In a small pilot study using a convenience sample
of 70 patients at a low vision clinic, Rovner et al found
that 38.7% of the patients were clinically depressed.16
In another study, Rovner et al prospectivelv studied a
group o f 51 older patients with recently acquired bilat­
eral AMD using a depression scale and found clini­
cally significant depression in 33% of the cohort.34
Brody et al performed a sim ilar study and found that
32.5% of the 151 elderly with AMD were found to have
a depressive disorder.14 Higher levels of depression
have been associated w ith more recent onset of the
vision im pairm ent25
These studies indicate that it is reasonable to expect
one out of every three older adult clients with visual
impairment to have a significant level o f depression
that could interfere with rehabilitation. Occupational
therapists should consider the use o f easily and quick­
ly administered questionnaires to assess clients for
depression during the low vision evaluation. A brief
overview of the assessm ent of depression and avail­
able screening tests is reviewed below.
M easures o f D epression
Definition and Background
The gold standard for a research diagnosis of
depression is the Structural Clinical Interview (SC1D),
a clinical interview that uses the DSM-1II-R criteria
for illness.35-36 However, because of the tim e and
level of experience required to adm inister a clini­
cal interview, self-report questionnaires have been
developed that can be used by clinicians who are
not in the mental health professions. Three of the
most popular self-report measures are the Center
for Epidemiological Studies Depression Scale (CF.S-
D), the Beck Depression Inventory (BDI), and the
Geriatric Depression Scale (GDS).
The Beck Depression Inventory
The Beck Depression Inventory (BDI) is a list of 21
sym ptom s and attitudes that are each rated in inten­
sity.37 Examples include: mood, pessimism , sense of
failure, lack of satisfaction, guilt feelings, self-dislike,
etc. It is scored by sum m ing the ratings given to the
21 items. Although originally designed to be adm in­
istered by trained interviewers, it is most often self­
administered and takes 5 to 10 minutes.
The Center for Epidem iologic
Studies Depression Scale
The Center for Epidemiologic Studies Depression
Scale (CES-D) was designed to m easure current level
of depressive symptomatology, and especially depres­
sive affect.38 The 20 items were chosen to represent
all major components of depressive symptomatology.
These include: depressed mood, feelings of guilt and
worthlessness, feelings of helplessness and hopeless­
ness, loss of appetite, sleep disturbance, and psycho­
motor retardation. Each item is rated on 4-point scales
indicating the degree of occurrence during the last
week. The scales range from "rarely or none of the
tim e" to "m ost all of the time."
 T he G eriatric Depression Scale
The G eriatric Depression Scale (CDS) is a self-
report scale designed to be simple to adm inister and
does not require the skills of a trained interviewer.39
Each o f the 30 questions has a yes/no answ er, with
the scoring dependent on the answ er given. A shorter
15-item version of the CD S has been devised and is
probably the most com m on version currently used.40
For an exam ple of th e/ F | e^ ;^ ^ g ;)E )ep ression Scale,
see ww w .slackbooks.com /otvisionform s
As depression responds well to m edication and
counseling, if an occupational therapist suspects a
client is depressed, the client should be referred to a
mental health professional for treatment, and this pro­
fessional should collaborate in treatment planning.
Rehabilitation and Depression
Depressed clients m ay be less likely to use optical
devices and less likely to benefit from vision rehabili­
tation.41 It is, therefore, im portant to try and address
the psychosocial needs of clients as w ell as interven­
tion aim ed at im proving occupation and ADL. Davis
et al reported that despite vision rehabilitation, per­
sons with long-standing A M D are likely to still show-
psychosocial dysfunction well after the on set of vision
loss.42 They recom mend that therapists should con­
tinue to assist clients w ith their psychosocial adjust­
ment as a follow-up to previous intervention because
vision rehabilitation at the» tim e of vision loss does
not fully m eet the client's needs. In another study-
designed to evaluate the im portance of addressing
the psychosocial needs of the client, Horowitz et al
provided vision rehabilitation to 395 older adults with
vision im pairm ent.43 They used a program called
the Adaptive Skills Training Program. T h e goal was
to help clients m aintain them selves independently
using a group intervention model. A fter attending
this program , participants demonstrated significant
im provem ent in adaptation to vision loss and life sat­
isfaction and significantly less sadness or depression.
T h e study had som e design lim itations, such as the
use of unmasked exam iners, short follow-up, and lack
o f a control group. Nevertheless, the study suggests
the im portance of addressing broad goals of rehabili­
tation to include not only specific functional skills, but
fostering global well-being and a better quality of life
for persons with visual im pairm ent.43
Brody et al conducted a random ized clinical trial
o f 92 elderly patients w ith AMD.41 T h e purpose of the
study was to assess w hether a self-m anagem ent group
intervention would improve mood, self-efficacy, and
activity in people w ith central vision loss due to AMD.
The intervention involved six w eekly 2-hour group
sessions providing education about the disease, group
discussion, and behavioral and cognitive skills train­
ing to address barriers to independence.41 H alf of the
patients were assigned to this group, w hile the other
h alf were assigned to a "w aiting list" and received
no intervention during the 6 weeks. They used a
variety of questionnaires and inventories to assess
the patients before and after intervention. The results
demonstrated the value of a brief, behavioral self­
m anagem ent group in reducing distress, enhancing
self-efficacy, and im proving adaptation. In a larger,
randomized clinical trial of 252 older adults with
AMD, Brody et al again studied the effectiveness of
a self-m anagem ent program . Patients were followed
for 6 m onths after receiving a 12-hour self-m anage-
ment program , a series o f 12 hours of tape-recorded
health lectures, or a waiting list. T h e prim ary outcome
m easure was the score on the Profile o f Mood States.
At the 6-m onth follow-up visit, participants in the
self-m anagem ent group reported significantly less
em otional distress compared with control subjects.
The incidence of clin ical depression at the 6-month
follow-up was significantly lower in the self-m anage­
ment group than the control group.44
In addition to interventions that specifically address
an underlying depression, Table 6-3 lists several gen­
eral treatm ent strategies we have found help clients
continue to participate in a rehabilitation program
until perform ance goals are attained. In general, we
have found that a good strategy to encourage resum p­
tion of activity is to ask the patient to start an activity-
according to a routine but stop anytim e when tired or
feeling frustrated. Remember, low vision rehabilita­
tion presents considerable challenges if som eone has
even mild cognitive lim itations.
Summary
This chapter was designed to provide background
inform ation about the psychosocial issues related to
vision im pairm ent. The inform ation provided sug­
gests that an occupational therapist engaged in vision
rehabilitation must attend closely to the psychosocial
status of his/her client. G oals should be established
to address this issue in rehabilitation. If a therapist
suspects that a client is significantly depressed, use of
one of the sim ple questionnaires should be considered,
along with referral to a mental health practitioner.
R eferences
I. CraboyesM. Psychosocial implications of visual impairment. In;
Brilliant RL, Ed. Essentials o f Low Vision Practice. Boston, MA:
Butterworth-Heinemann; 1999; 12*17.
 Table 6-3.

____ Intervention Strategies to Avoid/Address Depression_____________

Speak with fam ily when the client is present and included.

Provide fam ily instruction on "courtesies" with people with low vision:
A lways speak directly to the client.
Do not raise your voice.
Always ask before helping and accept "n o " for an answer.
Do not leave without telling som eone you are leaving.
D escribe your feelings, do not use gestures or facial expressions to com m unicate.
Always introduce people who arrive, som etim es by just saying "H ello Jim".

Provide fam ily instruction to use proper sighted guide techniques.

Provide fam ily instruction to praise success and initiation of activity and to avoid any
negative feedback, com m ents or reference to premorbid activities.

Recommend specific activities that a person can resume, encourage fam ily to gently but
firmly encourage resum ption of these activities and roles at home.

Encourage fam ily involvement in shared activity, reading aloud, fam ily m em bers describing
a TV show, gam es that all can play like Bingo.

Recom mend resum ption of premorbid routines and spiritual activities.

Sm ile, joke, and tease. Encourage the fam ily to do the same.

2. Castor» R) Rovner BW, Tasman VV. Age-relaled macular degen­
eration and depression: a review of recent research. Curr Opin
Ophthalmol. 2004; 15(3): 181 -183.
3. American Occupational Therapy Association. Occupational
Therapy Practice Framework: Domain and Process. Am / Occup
Jher. 2002;56<6):609-639.
4. I lorowitz A, Reinhardt |P. Mental health issues in vision impair­
ment. In: Silverstone B. et al. Eds. The Lighthouse Handbook on
Vision Impairment and Vision Rehabilitation. Oxford: Oxford
University Press; 2000:1089-1109.
5. Ringerini* L, Amaral P. The role of psychosocial factors in adapta­
tion to visum impairment and rehabilitation outcomes for adults
and older adults. In: Silverstone B. et al, Eds. The Lighthouse
Handbook on Vision Impairment and Vision Rehabilitation.
Oxford Oxford University Press; 2000:1029-1048.
(». Hollins M. Vision Impairment and cognition. In: Silverstone
B, et al. Fds. The lighthouse Handbook on Vision Impairment
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Examination and Treatment o f the Neurologically Impaired
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in older persons with low vision. Somatic eye symptoms
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12. Wells KB, Stewart A. Hays RD, et al. The functioning and well­
being of depressed patients. Results from the Medical Outcomes
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13. Shmuely-Dulit/ki Y, Rovner BW, Zisselman P. The impact of
depression on function in low vision elderly patients. Am /
Ceriatr Psychiatry. 1996;3:325-329.
14. Brody BL. Gamst AC, Williams RA, et al. Depression, visual
acuity, comorbidity, and disability associated with age-related
macular degeneration. Ophthalmology. 2001;108(10i:1893-
1900; discussion 1900-1.
15. Rovner BW. Shmuely-Dulitzki Y. Screening for depression in
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16. Rovner BW, Zisselman PM, Shmuely-Dulitzki Y. Depression
I’ ross; a n d d is a b ilit y in o ld e r p e o p le w it h im p a ir e d v is io n : a f o llo w - u p
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17. Tolman |, Hill RD, Kleinschniidl ||, Oegg C H . Psychosocial
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sive affect in older adults with age-related macular degenera­
tion. Gerontologist. 2005;45(6>:747-753.
18. Horowitz A. The prevalence and consequences of vision impair­
ment in later life. Topics in Geriatric Rehab. 2004;20:185-195.
19. Williamson CM , Schulz R. Physical illness and symptoms of
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1992;7:343-351.
20. Zeiss AM. Lewinsohn PM, Rohde P, Seeley |K. Relationship of
physical disease and functional impairment to depression in
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21. Bianch LG, Horowitz A, Carr C. The implications for everyday
life of incident self-reported visual decline among people over
age 65 liv ing in the community. Gerontologist. 1989;29(3):359-
165.
22. Gillman AE, Simmel A, Simon EP. Visual handicap in the aged:
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of public housing for the elderly. / Vis Impairment & Blind.
1986;80:533-590.
23. Heinenunn AYV, Colorez A. Frank S, Taylor D. Leisure activity
participation of eldeily individuals with low vision. Gerontologist.
1988;28<2>:181-184.
24. Salive M, Guralnik J. Glynn RJ, Christen W, Wallace RB, Ostfdd
AM. Association of visual impairment with mobility and physical
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SI. The psychological impact of macular degeneration. Arch
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26. Furner SE, Rudbcrg MA, Cassel CK. Medical conditions differen­
tially affect the development of IADL disability: Implications for
medical care and research. Geromo/og/sf. 1995;35:444-450.
27. Ford AB, Fnlmar SJ, Salmon KB, Medalie )H, Roy AW. Galazka
SS. Health ami function in the old and very old. I Am Geriatr
Soc. 1988;36:187-197.
28. The Lighthouse National Survey on Vision Loss: The Experience,
Attitudes, and Knowledge o f Middle-Aged and Older Americans.
New York: The Lighthouse; 1995:11.
29. National Society for the Prevention of Blindness, Survey
'84: Attitudes towards blindness prevention. Sighi-Savings.
1984;53:14-17.
30. Augusto CR. McGraw JM. Humanizing blindness through public
education. / Vis Impairment <S Blind. 1990;93:397-400.
31. Aintav SC. Aging and new vision loss: Disruptions of the here
and now. / Social Issues. 1988;44:79-94.
32. Ryan EB et al. Coping with age-related vision loss in everyday
reading activities. £duc Gerontol. 2003;29:37-54.
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visual impairments. / Vis Impairment Л Blind. 1994;88:53-68.
34. Rovner BW, Casten RJ, Tasman WS. Effect of depression on
vision function in age-related macular degeneration. Arch
(Ophthalmol. 2002;120(8>:1041 -1044.
35. Williams JB, Gibbon M, First MB, et al. The Structured Clinical
Interview for DSM-III-R (SCID). II. Multisite test-retest reliability.
Arch Gen Psychiatry. !992;49(8):630-636.
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Clinical Interview for DSM-III-R (SCID). I: History, rationale, and
description. Arch Gen Psychiatry. 1992:49{8):624-629.
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Beck Depression Inventory: Twenty-five years of evaluation.
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38. Ensel WM. Measuring depression: The CES-D scale. In: Lin
N, Dean A. Ensel WM, Eds. Social Support, tife fw n ts, and
Depression. New York: Academic Press: 1986.
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dation of a geriatric depression screening scale: a preliminary
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40. Shiekh J, Yesavage JA. Geriatric Depression Scale: recent find­
ings in development of a shorter version. In: Brink I, Ed. Clinical
Gerontology: A Guide to Assessment and Intervention. New
York: Howarth Press; 1986.
41. Brody BL. Williams RA, Thomas RG, Kaplan RM, Chu RM.
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1999;21(4>:322-329.
42. Davis C, Lovie-Kitchin J. Thompson B. Psychosocial adjustment
to age-related macular degeneration. I Vis Impairment & Blind.
1995;88:16-27.
43. Horowitz A, Leonard E, Reinhardt J. Measuring psychosocial
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2000;94(5):328-338.
44. Brodv BL, Roc h-Leveeq AC, Thomas RG, Kaplan RM. Brown
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Ophthalmol. 2005; 123(11:46-53.
Section II

Evaluation
 Overview and Review of the Low
Vision Evaluation
O pto m etric Lo w V ision
E xam ination
It is imperative for occupational therapists involved
in low vision rehabilitation to be fam iliar with the low
vision examination. The following is a description of
the optometric low vision evaluation (Table 7-1). This
evaluation can be performed in a variety of settings,
including a professional office, a rehabilitative facility,
or a personal care facility.
Case History
The history of a visually impaired patient, as with
any other history, is a snapshot of the patient up to the
time of questioning. The general areas that this history
should cover are listed in Table 7-2. This information
may be obtained from a number of sources, including
the patient, family, friends, caregivers, therapists, and
doctors. Among the most common chief visual com­
plaints of visually impaired patients is the inability to
see conventional size print, the inability to drive, and
the inability to recognize people.
It is always important to determ ine the date and
results of the last eye exam ination. In many cases.
Paul B. Freeman, OD, FAAO,
FCOVD, Diplomate, Low Vision
individuals who believe they are visually impaired
may simply require an eye exam ination and con­
ventional eyeglasses. This was demonstrated in the
Baltimore Eye Survey, which found that "the acuity
of about three-fourths of the visually impaired whites
and tw o-thirds of the visually impaired African
A m ericans could have been corrected to better than
20/40 w ith only eyeglasses."1
Once it is established, however, that the patient has
a bona fide decrement in visual acuity that cannot
be corrected by conventional eyewear, the rem aining
questions explore the impact of this visual deficit on
the patient's ability to visually interact with the envi­
ronment and the challenges facet!. During the case
history, the doctor can obtain information about the
patient's understanding of the impact of the visual
impairment, cognitive level, motivation, support sys­
tems, and previous attempts at vision rehabilitation.
Visual Acuity Information
Visual acuity information is generally com m unicat­
ed as a fraction, which can be in either feet (Snellen) or
metric notation. The numerator signifies the actual or
calculated testing distance and the denom inator the
actual or calibrated target size. For example, 10/200
should be recorded if the physical testing distance was
 Components of Optometric Low Vision Evaluation
Case history
D istance visual acuities
N ear visual acuities
A m sler grid testing
Color vision testing
Visual/mobility field testing
Contrast sensitivity testing
Refraction
Binocular vision evaluation
Eye health evaluation
M agnification evaluation

Table 7-2. _

__ Case History Components___________________

C hief complaint
Last eye exam ination
Visual/ocular history
D istance visual abilities (present and past)
Independent travel concerns
Near visual abilities (present and past)
Social/ em otional review
General health review
Environm ental challenges (present and past)
E d u ca tio n an d / o r v o ca tio n a n d a v o ca tio n (p re se n t a n d p ast) n e e d s
S p e c ific v is u a l g o a ls an d d e sire s in a p rio ritiz e d o rd e r

10 feet and the sm allest target size correctly identi­
fied w as a 200 size letter. A ny of the m odifiers listed
in Table 7-3 should be included if there is anything
unusual or pertinent about the m anner in which the
acuity was m easured. These findings are typically
obtained for each eye independently, if possible, both
with and w ithout the patient's current eyeglass or
contact lens prescription.
D istance V isual A cuities
Distance visual acuities are m easured to establish
the patient's baseline ability to see at a specific d is­
tance. Specially designed charts (which allow for bet­
ter quantification of reduced acuity levels) other than
the standard Snellen projected chart can be used, but
when doing so, the specific chart used and actual test­
ing distance should be noted (Figure 7-1). O ther factors
that should be considered, including expressive and
receptive language skills and cognitive functioning
that can also affect this m easurem ent when assessing
visual acuity at distance, are listed in Table 7-3.
There are occasions when a person cannot recog­
nize, identify, or match sym bols. In these instances,
there are other ways the practitioner can establish
what a patient can see. In these cases, a m ore func­
tional approach can be used. For instance, a patient's
ability to fixate and follow a light and/or localize a
specific sized target (without the actual ability to iden­
tify it) at a specific distance can be used to indirectly
assess visual acuitv. *
 Table 7-3.

Factors to Be-ConsideiEd-WJieD-Assessing. Visual Acuity________

Lighting
Contrast
Specific chart used
Num bers of targets at each acuity level
Spacing of the targets
D ifficulty of the targets being identified (ie, letters, num bers, pictures, etc)
Single letter versus reading acuity
Type of letters (block, serif, etc)
Ease with which the targets are identified
Expressive as well as receptive language skills
Cognitive functioning
Eccentric view ing (body positioning, eye/head posture)

Figure 7-1. S pecially designed charts fo r testing

visual a c u ity in v isu a lly im p a ire d patients.

Figure 7-2 illustrates som e of the com m only used near

N ear V isual A cuities visual acuitv charts.

T h e vast m ajority of activities for which visually-

im paired patients require assistance revolve around
near work. Therefore, a m easure o f visual acuity
should be done at n ear as well as distance. This infor­
mation ill not only help the occupational therapist
when tryin g to determ ine an appropriate sized target
to work with, but also helps the optom etrist to evalu­
ate the consistency between d istance and near acuity
m easurem ents. As w ith distance visual acuity mea-
surem ent, all pertinent inform ation about the test (see
Table 7-3) should be made available to anyone review­
ing the data. Additionally, know ing whether the tar­
get size was based on identification (discrim ination)
acuity or actual reading acuity is im portant, as there
can b e a difference. The ability to recognize a letter
does not always equal the ability to actually read.
Amsler Grid Testing
Using an Amsler grid (Figure 7-3) can help to deter­
m ine whether a patient is experiencing distortion or
has (multiple) areas of scotom a. A scotom a is defined
as "an isolated area o f absent vision or depressed sen­
sitivity in the visual field, surrounded by an area of
norm al vision or of less depressed sensitivity."2 The
Amsler grid m easurem ent can provide inform ation
used to identify the onset of a pathology, m onitor a
pathology, or m odify the ultim ate optical device(s)
that m ight be needed by a patient for a specific task.
Functionally, the results can also give guidance as to
whether a patient eccentrically view s or needs to learn
to do so. Figure 7-4 illustrates an exam ple of the d is­
tortion of the A m sler grid that can be experienced by
a patient with m acular degeneration.
Figure 7-2. Com m only used near visual acuity charts.
Figure 7-3. Am sler G rid.
C o l o r V ision T esting
Several tests are available for assessing color vision
(Figure 7-5). The results of color vision testing can
be used to identify the onset of a pathology, monitor
a pathology, or alert a therapist to color deficits that
might im pact a therapeutic regim en for the patient.
Color vision deficits are generally not as detrimental
to functioning as other losses such as visual acu­
ity, visual field, or contrast. However, know ing the
Figure 7-4. Distortion ot Am sler G rid.
patient's color vision status can be im portant in educa­
tional, vocational, and social planning or training.
V isual / M o b ilit y F ield T esting
Perim etry or visual field testing is designed to
evaluate the depth and breadth of an individual's
peripheral vision. Visual field loss can be either abso­
lute or relative. An absolute visual field loss is one in

which no m atter how large and bright the target is,
it will not be seen w ithin the blind area. A relative
visual field loss, on the other hand, is dependent on
the size, brightness, and contrast of the target rela­
tiv e to the e n v ir o n m e n ta l b a c k g r o u n d . T h is tr a n s la te s
functional!) into variations of visual field aw areness
consistency based on environm ental conditions. For
exam ple, a person with a relative peripheral visual
field loss m ight function better under bright illu­
m ination than under dim lighting conditions or at
night. I here are several instrum ents that can formally
quantify the extent of the visual field. However, for
initial screening, confrontation field testing (Figure
7-6) is the method of choice. It is typically carried out
Figure 7-5. Several tests availa ble to r c o lo r vision test­
ing.
Figure 7-6. Illustration of confrontation
field testing.
by the doctor sitting opposite the patient, each cover­
ing the eye on the sam e side, and having the patient
then dem onstrate aw areness of when the doctor's (or
a third person's) hands (or object) are brought in from
th e p e rip h e ry . A s in o th e r te s tin g , n o ta t io n s a b o u t
environm ental conditions should be m ade (see Table
7-3). This type of testing will uncover gross peripheral
visual field deficits and is very useful for determ in­
ing the presence o f a hem ianopia (which is absolute).
Confrontation field testing is not as sensitive for
subtle peripheral field loss or for central visual field
disturbances.
To accurately quantify visual field loss, a formal
visual field study m ust be perform ed. Typically,
Figure 7-7. M anual visual fie ld apparatus.
a com puterized visual field apparatus is used for
this purpose (Figure 7-7). However, for purposes of
determ ining visual disability from a medical-legal
standpoint, a m anual G oldm ann visual field test is
required.3
C o n t r a s t S ensitivity T esting
Contrast sensitivity testing determ ines the patient's
ability to distinguish borders, eg, a gray car against a
foggy background or coffee in a dark cup. It is a m eth­
od of assessing the qualitative aspects of visual func­
tioning. This is particularly im portant when follow­
ing a patient's progress over multiple visits. Patients
som etim es report that their sight has changed, but
on a standard eye chart (which has a m axim um con­
trast of black and white) there may be no measured
difference. These arc patients w ho are noticing real
functional difficulties, even though their measured
visual acuity has not changed. In these cases, contrast
sensitivity m ay dem onstrate a qualitative change in
vision that confirm s the patient's report. T h is test is
also valuable when it is d ifficult to pinpoint a visual
com plaint, especially w ith patients with "good" visual
acuities. Proper lighting is integral to this testing.
R efr a c t io n
Refraction is the term used to describe the evalu­
ation of the optical system of the eye. We use the
term refractive error to describe any deviation from
em m etropia. W hen the optom etrist perform s the
refraction, it can be determ ined w hether the eye
is em m etropic (absence of refractive error), myopic
(nearsighted), hyperopic (farsighted), or astigm atic.
The refraction is the exam ination procedure used to
determ ine if a patient has a refractive error that needs
to be corrected, as well as the exact lens prescription
that is appropriate. A phoropter or a trial fram e with
loose lenses is used to perform the refraction. W hen
a patient is visually im paired, the optom etrist must
also use inform ation about the refractive error when
designing low vision optical devices.
As noted previously, we som etim es encounter
patients who appear to be visually im paired or legally
blind, but a thorough refraction indicates that the
patient simply requires an updated eyeglass prescrip­
tion to regain normal vision. I cannot em phasize
enough the im portance of perform ing a careful refrac­
tion before initiating any low vision rehabilitation
activity. For exam ple, a patient who needs a bifocal
correction and is not w earing it, may not be able to
see clearly through a "sim ple" stand m agnifier. A
m isleading conclusion m ight be that the patient is
unable to cognitively handle the task, when in fact it
is simply the om ission of the appropriate refractive
prescription.
B in o c u l a r V ision
E x a m in a t io n
Binocular vision is the ability of the visual system
to fuse or com bine the inform ation from the right and
left eyes to form one image. For binocular vision to
occur, the inform ation arriving from each eye must
be identical, with approxim ately equal vision in both
eyes. To satisfy these requirem ents, the tw o eyes must
be aligned so that they point at the sam e object at
all times, and the visual acuity, optics, or refractive
error of the two eyes must be approxim ately equal.
Therefore, it is understandable that many patients
 Table 7-4.

_________ Classification of Strabismic Binocular Vision Disorders

Direction
Esotropia An eye turns in toward nose
Exotropia An eye turns out temporally
Hypertropia An eye turns up

Each o f these conditions is also classified based on the follow ing characteristics:

Frequency
Intermittent esotropia or constant esotropia
Intermittent exotropia or constant exotropia
Intermittent hypertropia or constant hypertropia

Laterality (which eye turns)

Right esotropia, left esotropia, or alternating esotropia
Right exotropia, left exotropia, or alternating exotropia
Right hypertropia, left hypertropia, or alternating hypertropia

Comitancy
Com itant
Noncomitant

with vision impairment do not have normal binocular
vision because they lack approximately equal visual
acuity in both eyes.
It is not uncommon for an older adult with low
vision to lose binocular vision, w hich can cause a
m isalignm ent of the eyes; referred to as strabismus.
W hen strabism us occurs, the eyes may drift in, out,
up, or down. Table 7-4 lists some of the common terms
associated with binocular vision problems that an
occupational therapist may encounter in a low vision
exam ination report.
Clinical Assessment of Binocular
Disorders
Som e of the common tests used to evaluate bin­
ocular vision in patients with low vision include the
cover test and tests to assess fusion. Using the cover
test procedure, an optometrist can determ ine many
key binocular vision characteristics, including the
direction, magnitude, frequency, and com itancy of the
strabismus.
Direction o f Strabismus
This refers to whether the eyes turn in, out, up,
down, or a combination of these directions. Table 7-5
lists the various possibilities, including esotropia (eyes
turn in), exotropia (eyes turn out), and hypertropia
(one eye turns up).
M agnitude o f Strabismus
This refers to the am ount of the eve turn. W hen an
¥
eye turn is large, it is quite obvious, even to a nonpro­
fessional. However, it is im portant to be aware that the
magnitude of a strabism us may be moderate or small
and in such cases the eve ✓ turn mav / be not be visible
or detectable without special testing. The magnitude
of the strabism us is recorded in prism diopters. For
example, you might see the following notation in an
optometric report:
25 pd esotropia (or 25.Л)
where pd = prism diopters.
Frequency o f Strabismus
Frequency of the strabism us refers to the am ount
of tim e the eye turns in, out, up, or down (see Table
7-4). For example, it is possible for the eye turn to be
present 100% of the tim e and this would be called a
constant strabismus. In contrast, the strabism us may
 Table 7-5.

Commonly Used Abbreviations in Eye Examinations

Abbrev Term
VA Visual acuity
OD Right eye (oculus dexter)
OS Left eye (oculus sinister)
ou Both eyes (oculus uterque)
XP Exophoria
EP Esophoria
XT Exotropia
ET Esotropia
AA Accom modative am plitude
VF Visual field
PERRL Pupil equal, round, respond to light
WNL W ithin norm al lim its

occur only port of the tim e and would be called an

interm ittent strabismus.
Eye H ealth Evaluation
For example, you m ight see the following notation
An eye health evaluation can include but is not lim ­
in an optom etric report:
ited to the following tests: observation of the external
structures of the eye and adnexa, intraocular pres­
25 pd (or 25Д) interm ittent esotropia, or
sure (IOP) measurem ent, evaluation of the anterior
15 pd (or 15Д) constant esotropia
structures of the eye, and evaluation o f the internal
structures of the eye through a dilated pupil (unless
C om itancy o f Strabismus
contraindicated). The goal of the eye health evaluation
The final variable is referred to as com itancy and
is to determ ine the underlying basis for the visual
refers to the uniform ity of the size of the strabism us acuity, contrast sensitivity, and/or visual field loss.
from one position of gaze to another. A strabism us There are many good texts available for a detailed
is called com itant if it is the sam e size regardless of description of these procedures.4-55 An ocular health
where the patient looks (left, right, up, or down). If
evaluation is indicated prior to beginning any low
there is a significant difference from one position to vision rehabilitation, or if any change in vision or
gaze to another, it is called a nonconiitant strabismus. functioning is noticed by the patient, family, or thera­
For exam ple, if a patient's eyes are aligned when
pist, and periodically as indicated by the patient's
looking straight ahead but deviate when looking to
prim ary eyecare doctor.
the right, it is called a noncom itant strabism us.
A dditional tests m ay be used to evaluate the
patient's ability to "fu se" or use inform ation from
both eyes in a coordinated way. A popular probe of M a g n ificatio n Evaluation
sensory fusion is stereopsis testing. In this test (Figure
D eterm ining the m agnification necessary for the
7-8), the patient wears special polaroid glasses and is
patient to see desired m aterials is another prerequi­
asked if any of the figures on the page appear to be
site for beginning a vision rehabilitation program.
floating off the page in 3D. A nother com m only used
M agnification refers to the process of enlarging the
test is called the W orth 4 Dot test. T h is test is used to
im age on the retina. M agnification of an object can be
determ ine if th e patient has double vision or is sup­
accom plished using four different m ethods: relative
pressing the vision of one eye.
size m agnification, relative distance m agnification,
T h e low vision optom etrist should provide infor­
angular m agnification, or electronic m agnification.
mation about binocular vision to the therapist. This
inform ation will help the occupational therapist to
understand why an optical device w as prescribed for Relative Size Magnification
just one eye versus both eyes. Relative size m agnification refers to enlarging the
target. This is sim ilar to taking conventional size print

Stereogsj^
S t e nmar.
and enlarging it to fit on a billboard. W hen viewing
targets at distance, the patient's appropriate refractive
correction should always be in place. W hen view ing
objects at closer distances, a com pensatory lens for
a specific view ing distance m ust be considered. This
concept is reviewed in detail in Chapter 5. Therefore,
even when using large print, conventional glasses or
bifocals mav be needed to see the print clearly, even
before other form s of optical m agnification are con­
sidered.
Relative Distance Magnification
This is accom plished by bringing the object of
interest closer. It m ight be considered sim ilar to "air­
plane m agnification," where at 10,000 feet houses look
sm all, but the closer one gets to the ground, the larger
the houses appear. Similarly, a target at 2 inches will
give the appearance of being 8 tim es larger than the
sam e target at 16 inches. Rem em ber that when objects
Figure 7-8. Stereopsis test - Random D ot
Stereogram (Steinm an).
are held at a closer working distance, the patient
must exert additional "m u scu lar" effort (if possible)
to accom m odate (focus). T h is effort can lead to d is­
com fort and eyestrain after short periods of time.
Additionally, m any older patients are unable to exert
this effort and, along with discom fort, will not see
clearly. Thus, an appropriate powered lens must be
used for the target to be seen clearly at that distance.
This lens m inim izes or elim inates the need for the
patient to accom m odate (or focus) the eyes.
Angular Magnification
A ngular m agnification is the m agnification expe­
rienced when a person looks through a device like
a telescope. T h is form of m agnification is typical of
a stand m agnifier or a telescope where the relation­
ship betw een lenses in the system creates an enlarged
image. A ngular m agnification also increases the size
of the retinal im age just like relative size and relative
Maiepian. захищений авторським правом
distance m agnification. The advantage of angular
m agnification is that it can be used when moving
closer to an object or enlarging it is im practical or
im possible. View ing a sporting event is an example
of such a situation. If an individual sits far from the
action, neither relative distance nor relative size mag­
nification arc possible. However, the use of a telescope
or binoculars w ill m agnify the object of interest.
Telescopic lenses must be focused properly. To see
clearly through a telescope, the refractive error must
be corrected or compensated for in som e manner.
T h is can be done by using glasses or contact lenses,
or by adjusting the telescope for the refractive error.
It should be noted that focusing the telescope for an
uncorrected eye may m odify the power (or m agnifi­
cation) of the telescope, even though the image will
be clear.
Electronic or Projection
M agnification
T h is form of m agnification uses electronic equip­
ment and is basically a com bination of relative size
and relative distance m agnification considerations.
O nce again, the application of lenses for the near
focusing demand must be considered; otherw ise the
target may be made large enough to see, but will be
out o f focus. Big and blurry is not as easy to see as
big and clear. In som e instances, a clearer image can
be recognized with less m agnification (ie, sm aller on
the screen), thereby allow ing more inform ation to be
displayed on the screen at one time.
D eterm in in g M a g n ificatio n
W hen an individual cannot see to perform a task,
m agnification m ay be necessary. Sim ply stated, the
m agnification required is determ ined by dividing the
patient's actual acuity level by the desired acuity level.
For exam ple: An individual has 20/200 distance visu­
al acuity, sees the 20/200 near target at 16 inches (with
appropriate glasses), and would like to see 20/50 size
print at near. That requires 4X m agnification, and can
be calculated a num ber of ways:
1. Using "b illb oard " m agnification (relative size
m agnification), the target (print size) can be
made four tim es larger.
2. If the 20/200 target is at 16 inches initially, it
can be brought four tim es closer ("airplane"
or relative distance m agnification) to approxi­
mately 4 inches, which would require a lens, or
accom m odation, of approximately +10.00 D.
3. Л com bination of relative size and relative
distance m agnification could be provided with
electronic equipm ent like a closed circuit tele­
vision (CCTV). For example, the target can be
made physically larger on the CCTV monitor,
and the patient can sit closer (or farther) than
16 inches, with the appropriate glasses.
If this individual needed to see the 20/50 sized
target at a 20 foot m easured distance, a 4X telescope,
or electronic equipment that could m agnify four tim es
at distance, could be used. The lim iting physical and
optical factors o f these as well as near devices are the
weight, appearance, field of view, and lighting con­
straints that these system s impose.
These are generalities and should be reviewed
w ith the optom etrist who has prescribed the devices
in relationship to what the occupational therapist has
identified as the visual requirem ents necessary for
the task.
C o n c l u s io n
This chapter reviewed the low vision exam ination
that an occupational therapist should expect to be per­
formed by the eyecare provider. We have also includ­
ed a sample report from a low vision optom etrist,
and Table 7-5 provides a list of comm on abbreviations
used in a low vision exam ination record or report.
W hen receiving such a report, if the occupational
therapist has questions about term inology, test results,
o r a n y o th e r issu e s, it is b e s t to c o n ta c t th e re fe rrin g
optometrist. The team effort stressed in this book is
one that will benefit clients with vision im pairm ent
who most need the integrated services of both the low
vision optom etrist and the occupational therapist.
R eferences
1. Tielsch |M. Prevalence of visual impairment and blindness in the
United States. In: Massof RW, Lidoff L, Eds. Issues in Low Vision
Rehabilitation: Service Delivery, Polk y, and Funding. New- York:
American Foundation for the Blind: 2001:13-26.
2. Cline D, I iofstetter 11W, Griffin )K. Dictionary o f Visual Science.
Newton, MA: Butterworth'Heinemann: 1*197.
3. United States Social Security Administration. Code of Federal
Regulations. 1992.
4. Spalton DJ, Hitchings RA. Hunter PA. Atlas o f Clinical
Ophthalmology. London, England: Gower Medical Publishing:
1984.
5. Harley RD. Pediatric Ophthalmology. Vol I and II. Philadelphia,
PA: W.B. Saunders Co.; 198.3.
spian, захищений авторським правом
 8
Occupational Therapy Low Vision
Rehabilitation Evaluation

vision optom etrist evaluates the client once it is deter­

In t r o d u c t io n
T h e objective of this chapter is to present an orga­
nized evaluation approach for the adult low vision
client. In 2002, the Am erican O ccupational Therapy
A ssociation (AOTA) published the O ccupational
Therapy Practice Framework: Domain and Process.1 The
Framework w as developed to articulate occupational
therapy's unique focus on occupation and daily activi­
ties and the application of an intervention process
that facilitates engagem ent in occupation to support
participation in life.1 In regard to the occupational
therapy evaluation, the Framework states that "the
evaluation process is focused on finding out what
the client wants and needs to do and on identifying
those factors that act as barriers to perform ance".!
The evaluation that we present below follows these
guidelines.
O v er v iew
In the model of low vision care we proposed in
Chapter 1, the ophthalm ologist diagnoses and treats
the eye disease responsible for the vision loss. The low
mined that additional m edical/surgical treatm ent will
not be useful. The role of the optom etrist is to try and
m axim ize the client's visual function using a com bi­
nation of traditional eyeglasses plus low vision optical
devices. The occupational therapist's role is to deter­
m ine what the client wants and needs to do, identify
factors that act as barriers to perform ance, and devel­
op a treatm ent plan to m eet the client's specific needs.
It is also im portant for the occupational therapist to
interact with the low vision optom etrist. The occupa­
tional therapist can provide im portant inform ation to
the optom etrist about the client's physical capabilities,
living environm ent, and needs. T h is inform ation can
then be used by the optom etrist to determ ine the
appropriate low vision optical aids.
Thus, although the occupational therapist's exam i­
nation screens for changes in an underlying pathology,
the occupational therapy evaluation is not designed to
be diagnostic in term s o f identifying the disorder.
T h is inform ation should be available from the oph­
thalm ologist and optom etrist. Rather, the objective
of the occupational therapy low vision rehabilitation
evaluation is to understand the client's functional
ability before the vision loss, to define his/her current
goals, to evaluate the client s ability to participate in
activities of daily living (ADL), leisure, work, play,
and social and spiritual occupations. In addition, the
occupational therapist evaluates social, cultural, and
physical context as well as client factors other than
vision, including m usculoskeletal process and m en­
tal/cognitive factors. Although the low vision optom e­
trist typically provides the initial device selection and
estim ation of m agnification, the occupational thera­
pist evaluates devices in the context of occupational
perform ance and may recomm end m agnification and
different devices. The low vision therapist may need
to estim ate the m agnification required for perfor­
m ance of som e tasks. It is also im portant to remember
that under M edicare Part В guidelines, the initial
evaluation completed by the occupational therapist is
used to determ ine w hether there is medical necessity
for low vision rehabilitation.2
To accom plish these goals, the occupational therapy
vision rehabilitation evaluation consists of four com ­
ponents:
1. O ccupational profile/case history
2. Evaluation of visual factors
3. Environm ental evaluation
4. Evaluation of occupational perform ance
O f course, som e clients may have other physical
disabilities/issues that need to be addressed and the
traditional occupational therapy evaluation proce­
dures should be used to assess these problems.
The Veterans A ffairs Low-Vision Visual Functioning
Q uestionnaire [VA IV VFQ-48) and an evaluation
form can be found on www.slackbooks.com/otvi-
sionform s
O c c u p a t io n a l P r o file / C ase
H isto ry
T h e occupational therapy evaluation of an adult
w ho is suspected of having low vision begins with
the occupational profile/case history. The occupa­
tional profile/case history is the form alized process
o f asking relevant questions to elicit inform ation that
will contribute to an understanding of the client's
problem s. Specifically, the objectives of this part of the
evaluation are to gather inform ation about the client's
vision and health status, previous eyecare and low
vision treatm ent, to understand the client's functional
ability before the vision loss, and to define his or her
current goals.
An integral part of the evaluation, the occupational
profile/case history offers a rich source of data for
case form ulation that is not available from other forms
of assessm ent. The occupational profile/case history
w ill shape the evaluation strategy, developm ent of the
m anagem ent plan, and the form ulation o f the rehabili­
tation prognosis. In addition to contributing to better
diagnostic and therapeutic decisions, the foundation
for a good client-therapist relationship is established
during this time.
O ne im portant issue for occupational therapists is
tim e managem ent. In alm ost all clinical settings, the
am ount of tim e available for the occupational therapy
evaluation is limited to about 1 hour. This lim itation
may be based on high client census or insurance
guidelines and protocols. It is, therefore, im portant
to design an evaluation that can be completed in a
reasonable period of time. To facilitate this objective,
we suggest the use of a low vision visual function­
ing questionnaire. Visual functioning questionnaires
include a series of questions that assess the perfor­
m ance of ADL.3 Stelm ack et al recently J described a
self-report questionnaire designed to m easure the
difficulty visually im paired persons have perform ing
ADL.4 The questionnaire, called the Veterans A ffairs
Low-Vision Visual Functioning Q uestionnaire (VA LV
VFQ -48), was found to be a valid and reliable m easure
of visual ability in low-vision clients with moderate to
severe vision loss. This questionnaire is not only used
to m easure perform ance ability, but can also be used
to tailor rehabilitation program s to m eet individual
client needs and to m easure outcom es of rehabilitation
program s 4 T h e VA LV VFQ -48 has a strong research
basis and its validity and reliability have been estab­
lished. The questionnaire can be scored and the occu­
pational therapist can, therefore, obtain a num ber that
can be com pared to norm ative data. T h is score can be
used to docum ent the need for rehabilitation. In addi­
tion, the VA LV VFQ -48 can be readm inistered at each
reevaluation to docum ent functional improvement.
Thus, in addition to stream lining the evaluation, it is
an effective tool for M edicare docum entation.
The VA LV VFQ -48 can be adm inistered over the
phone or can be sent to the client, and the client is
asked to bring the completed form to the occupational
therapy low vision rehabilitation evaluation. The
questionnaire was not designed for the low vision
client to complete independently. Rather, a fam ily
m em ber or friend would have to help the client com ­
plete this questionnaire because it is not available in
large print size. The occupational therapist can review
the questionnaire and elaborate on pertinent issues
raised by the client's responses using the Low Vision
Rehabilitation Evaluation form included in the appen­
dix. It is im portant, however, to understand that the
VA LV VFQ-48 is not a substitute for interaction with
the client. The O ccupational Profile/Case History
interview is an excellent tim e to establish rapport
w ith the client, to dem onstrate interest in the client as
 Occupational Therapy Lov\ Vision Rehabilitation Evaluation 105

Table 8-1.

Courtesies and Considerations When Dealing With the Adult Client With Low Vision
1. Announce yourself when entering or leaving the room or when beginning or ending a
conversation so the person does not continue to speak after you leave.
2. Speak directly to the person, using a normal tone of voice.
3. Call the person by name or touch him or her lightly on the arm.
4. Always explain what you are going to do before you begin.
5. Request permission to touch the person when necessary.
6. Be specific in directions. Avoid expressions like "over there" or "right here." Use phrases
such as "your m agnifier is on the left side of the lamp."
7. If in doubt about how to help, just ask the client.
8. Do not rearrange the space of a person with a visual impairment.
9. Avoid safety hazards. Keep doors fully opened or closed. Push in chairs.

Adapted from Sokol-McKav DA, Michels D. Facing the challenge of macular degeneration: therapeutic interventions for low vision.
О Т Practice. 2005;10(9):10-15.

a person, and thereby to establish a basis for effective
communication.
Interviewing the Client
The rapport established betw een the occupational
therapist and client will influence the accuracy of the
information obtained during the interview as well as
the client's confidence in the assessm ent and his/her
response to later recommendations. Therefore, the
occupational therapist's attitude should be one of
interest, w illingness to listen, and empathetic concern.
A m anner that is friendly and informal will lessen
any anxiety associated with the visit. A hurried,
indifferent, detached, or unempathetic presence is a
barrier to effective communication, which in turn may
have a deleterious effect on the interview process.5
Breakdowns in communication frequently result in
failure to comply with a professional's recom m en­
dations.6 Because of the client's visual impairment,
interaction is different from that typical of a case his­
tory with a normally sighted person. Sokol-McKay7
em phasized the importance of implementing certain
courtesies and considerations when evaluating an
adult client with low vision. Examples of these courte­
sies are announcing yourself when entering or leaving
the room or when beginning or ending a conversa­
tion, speaking directly to the person, using a normal
tone of voice, and requesting permission to touch the
person when necessary. Table 8-1 is a list of these sug­
gested courtesies.
Using the VA LV VFQ-48 as a basis for explora­
tion of particular areas of concern, the occupational
therapist can begin with broad-based questions with
a progression to more focused inquiries. The strategy
is to scan potentially important areas and focus in
when appropriate, w hile m aintaining sensitivity and
flexibility in listening and pursuing.5
The key areas to be investigated are listed in Table
8-2 and included in the Low Vision Rehabilitation
Evaluation form. These are only suggested start­
ing points. The occupational therapist will need to
ask additional questions based on the client's initial
responses.
The Low Vision Rehabilitation Evaluation form can
be found on www.slackbooks.com/otvisionforms
Im portant Areas to Be Addressed
in the Occupational Profile/Case
History
Vision History
It is im portant to determ ine the client's under­
standing of his or her eye disease and v ision prob­
lem. The therapist should ask questions about onset
(when did the problem begin), duration (how long
has the client been visually impaired), the date of the
last exam ination, and questions to probe the client's
understanding of the diagnosis, prognosis, and effects
on performance (Table 8-3). Even if a complete report
is available from the referring doctor, it is worthwhile
to gather this information from the perspective of a
client. A client's answ ers to these questions will indi­
cate stage of coping, expectations, and many aspects
of cognitive functioning. O ne of the critical factors
determ ining the effectiveness o f vision rehabilitation
is a motivated, educated client. The more the cli-
 Suggested Additional Questions for Occupational Profile/Case History_____

Living Situation
• Prior Level of Function
• Marital Status
• D escription of residence
• Assisted living
• Nursing home
• O ne floor/multifloor

Prior Level of Function

(Goal is to determ ine how client functioned in home/work prior to visual im pairm ent)
• Driving
• Meal preparation
• Finances
• C leaning home
• Leisure activities
• Shopping
• M obility

Medical History
• H earing loss
• H earing Aid
• Diabetes
• Dialysis
• Stroke
• Hypertension
• A ngina
• Cardiac problem s
• A rthritis
• Respiratory problems
• Cognitive and em otional health
• M edications

ent knows and understands about his or her vision
problem s, the more likely rehabilitation will be effec­
tive. After discussing the onset and duration, ask the
client about previous and current treatment. We are
prim arily interested in the treatm ent of the resulting
disability, not the im pairm ent or eye disease itself. By
definition, this client has been sent to the therapist
because the underlying eye disease has caused per­
m anent vision loss.
We need to know the optical or nonoptical devices
that have been prescribed or purchased by the client
on his or her ow n, and if the client is able to use these
devices. Have there been any previous attempts at
vision rehabilitation? If so, w ho provided these servic­
es and were these services helpful? It is also im portant
to determ ine if the client is aware of support groups
and other opportunities in the com m unity to receive
help, support, and education about low vision.
H ealth History
The health history is an im portant com ponent of
the occupational profile/case history. An understand­
ing of the client's other medical problem s is neces­
sary when planning vision rehabilitation. Nonoptical
and optical device selections are contingent on the
client's physical and health status. Com m on exam ples
include: peripheral sensation problem s secondary to
diabetes that lim its the use of tactile devices, hand
 Table 8-3.

Suggested Initial Questions About Vision Loss for Occupational Profile/Case History
W hat happened and why are you here?
Do you know the nam e of the eye disease that has caused your vision loss?
Can you tell me when this eye disease first becam e a problem for you?
W hat are some things you cannot do now that you did before your vision loss?
W hat do you m iss the most?
How long have you experienced trouble seeing?
Do you know your visual acuity?
W hat is most difficult to see?
Do people treat you differently now than before the vision loss?
Have you ever had a low vision evaluation? W hen? Where?
Do you use any m agnifiers or special glasses?
Who gave the m agnifiers or special glasses to you?
Have you had any previous vision rehabilitation services? If so, describe.

trem ors that might interfere with the use of optical
devices, hearing problems that may preclude the use
of assistive devices such as liquid level alert and books
on tape, and arthritis that may lim it movement and,
therefore, the ability to use certain optical devices.
O f course, most occupational therapists w ill not
be treating clients w ith only low vision problems.
Because the population of clients seen by the occupa­
tional therapist will generally be the older adult, many
clients will have multiple medical conditions requir­
ing occupational therapy. It is, therefore, important
to question the client about general health status. The
occupational profile/case history, therefore, should
include questions about hearing loss, diabetes, dialy­
sis, previous stroke, hypertension, cardiac problems,
arthritis, and respiratory ailments.
It is also important to obtain a complete list of the
client's medications. The therapist should review the
medications for potential side-effects that m ight be
im portant when planning vision rehabilitation. Some
drugs affect pupil size and function and can cause
blurred vision and photophobia (sensitivity to light).
Prem orbid Occupational
Perform ance an d History
The importance of occupational history has been
sum m arized in the ЛОТА Practice Fram ew ork1 A
person's expectations about vision rehabilitation are
often closely associated with his/her previous level of
activity, occupation, habits, routines, and roles. Clients
typically want vision to be the way it was before the
eye disease caused the vision loss, rather than focus on
lost occupation and roles. In some cases, improvement
in vision may be possible using optical devices with
mild vision loss, or lighting changes, but treatment
often focuses on compensatory strategies, assistive
devices, and vision rehabilitation that enable occupa­
tional perform ance using different sensory modalities
or strategies. In most cases, therefore, the client will
need to realize that some significant changes will be
required in lifestyle. Information should be gathered
about work, sports, and leisure activities.
To understand a client's expectations and to insure
that the client's chief concern will be addressed, one
should begin with a general question such as: "W hy
are you here? W hat is it you want us to do for you?"
Typical responses include the following:
• "I have som ething wrong with my eyes and
want to see better" (the focus is on the im pair­
ment).
• "I have m acular degeneration, I can't read, I
want to use a computer again'' (the focus is on
occupation).
• "M y [doctor, daughter] sent me here" (no clear
goals, client education needs, psychosocial
im pairm ent with coping, cognitive im pair­
ment, or family/caregiver education needs).
The client's initial response will indicate education
needs, level of insight, as well as the general stage
of coping with the disability. Since the most effec­
tive interventions are often compensatory, a skilled
clinician will focus this segment of the evaluation
on recovery of occupational perform ance with ques­
tions such as: "W h at did you do before vou vision
loss that ^vou can't do now ?" "W hat do /vou m iss the
m ost?" "D o people treat you differently now ?" These
questions will begin to reveal im portant occupational
 _____ List of Questions to Determine a Client’s Goals for Vision Rehabilitation_____

Close-up Vision
As you go about your daily household chores, what do you need to read (m ail, cooking controls, medical
prescriptions, etc)?
How m any of these chores are essential for continuing the sam e level of independence you currently experi­
ence?
W hat, if any, are you professional reading requirem ents (journals, m agazine, memos, com puter work)?
W hat are your leisure reading activities?
W hich of these activities are im portant for your continued happiness?
W hat other daily household chores require close-up vision (sorting laundry, housecleaning, preparing
m eals)?
W hat chores could you confidently perform without sight?
Nam e your recreational activities that require close-up vision (cards, sew ing, and music).
W hich of these could you perform without sight?

Distance Vision
N am e the daily distance tasks you do that require sight (driving, seeing signs, lights, landm arks). W hich of
these activities could you confidently undertake if your vision deteriorates?
W hich of your leisure activities require good distance vision (television, attending shows, m ovies, sporting
events)? W hich of these activities could you perform without good vision?

goals and lost roles that could be restored using com ­
pensatory strategies.
Client's N eeds an d Goals
Finally, it is im portant to let the client tell you what
he/she hopes to achieve through vision rehabilitation.
A s discussed above, it is not unusual to hear some
unrealistic expectations from clients. Rem ember that
the prior experience of this client w as that new glasses
always restored clear vision. Clients often expect the
sam e result even when the vision loss is caused bv
¥
disease. They either fail to understand that the vision
loss is perm anent or refuse to accept this prognosis.
By the tim e the clicnt is being exam ined by the occu­
pational therapist, he/she m ay have had num erous
exam inations with an ophthalm ologist and perhaps
a low vision optom etrist. The client has been told that
there arc no m iracle glasses, devices, or drugs that
will restore norm al vision. Yet, it is not unusual for the
client to say, "I want to be able to see well again" or "I
am hoping you can prescribe glasses that w ill help me
see well again".8
Low vision treatm ent and vision rehabilitation are
designed to help clients w ith low vision fulfill realistic
vision-related goals.8 Freem an indicates that the two
prim ary ingredients that determ ine success or failure
are: 1) the client's acceptance of the need to use opti­
cal and nonoptical assistive devices, and 2) motivation
to take an active role learning how to use his or her
rem aining vision.8
Table 8-4 lists a series of questions modified from
a "personal eyesight evaluation" developed by Paul
Freeman, OD. These questions allow the therapists to
help the client system atically develop a list o f realistic
goals for vision rehabilitation. Before m oving on to
the next part of the evaluation, the therapist m ust have
a list developed by the client o f his or her goals for
vision rehabilitation.
Exam ples of com m on, realistic perform ance goals
arc:
• I want to be able to read the sports page.
• 1 want to be able to follow a recipe and cook
meals for my family.
• 1 want to be able to enjoy a m ovie in a movie
theater.
• 1 want to be able to find products m yself at the
superm arket.
• 1 want to be able to w rite letters to my grandchil­
dren and read their responses.
• I want to be able to independently read mail,
w rite checks, and handle my finances.
 Occupational Therapy Low Vision Rehabilitation Evaluation
Table 8-5.
Recommended Tost of Visual Function
Visual Function Recommended Technique
Home l iealth Setting
Visual acuity at distance Feinbloom Distance Test Chart
Reading acuity at near MN Read test
Peripheral visual field Confrontation Field Testing
C ontrast sensitivity Mars Letter Contrast Sensitivity Test
Scotom a assessm ent Clock Face scotoma assessm ent
Reading assessment/ Pepper Test, MN Read test
reading speed
Psychosocial an d Cognitive
Issues
Vision loss is one of the most em otionally devastat­
ing physical problem s that one can experience, and its
im pact extends beyond functional vision problems to
many psychosocial issues.9 It is critical, therefore, that
occupational therapists attend to the em otional impact
of the vision loss and the client's ability to cope when
providing low vision rehabilitation. In Chapter 7, we
outlined seven key factors9 that should be reviewed
by the occupational therapist during the occupational
profile/case history. These include: the type of vision
loss, the fam ily's reaction to the vision loss, the client's
life stage, significant life events, the client's expecta­
tions, the client's self-concept, and personality. In
addition, if the occupational therapist is concerned
about the client's mental health, we suggest using one
of the self-report questionnaires described in Chapter
7. T hree of the most popular self-report m easures are
the Center for Epidemiological Studies Depression
Scale (CES-D), the Beck Depression Inventory (BDI),
and the Geriatric Depression Scale (GDS). We recom ­
mend using the GDS because it can be easily adm in­
istered in a very short period of time. There is no cost
for th is test b e c a u s e it w a s d e v elo p ed w ith fed eral
fu n d s.
Low vision, especially severe and profound vision
loss, creates unique and substantial cognitive demands,
especially w ith spatial perception and use and inter­
pretation of other senses. A person with a long-stand­
ing visual im pairm ent m ay have developed an ability
to interpret vision differently, eg, using a hairline and
a person's gait to recognize him, or using blobs of color
to orient in a room. These skills are som etim es infor­
m ally called "blur interpretation." Introducing visual
109
Recommended Technique
Hospital/Nursing Home/Outpatient
Settings
ETDRS Chart
MN Read test
Confrontation Field Testing
Mars Letter Contrast Sensitivity Test
Tangent Screen
Pepper Test, MN Read test
devices (optical or electronic) may confuse individu­
als w ith long-standing visual im pairm ent at first, but
acceptance m ight follow w ith repeated practice.
Ev a l u a t io n of V isual Fac to r s
For the occupational therapist to determ ine the
needs of a client and develop a treatm ent plan, he
or she must have a thorough understanding of the
client's visual status. Im portant visual factors include:
visual acuity at distance and at near; the specific eye
disease; visual field; contrast sensitivity; presence,
size, and location of the central scotom a; reading skill;
and reading speed. Depending on the occupational
therapist's practice setting, much of this inform ation
may be readily available from the referring oph­
thalm ologist or optom etrist. O ccupational therapists
working in an ophthalm ology office, a low vision
practice, or any other facility in which an ophthal­
m ologist and/or an optom etrist is working, will have
full access to the client's eye records and the required
inform ation. Even if the occupational therapist is not
working directly with an eyecare professional, this
inform ation can be requested from the referring doc­
tor. We have included a form in the Appendix that
can be used for this purpose. However, there may
be situations in which the necessary data are ju st not
available. In such cases, the occupational therapist
will need to perform specific testing to gather this
inform ation. The recom m ended areas and tests are
listed in Table 8-5. Background inform ation for these
tests is reviewed in Chapter 3. It should be noted that
visual acuity testing should be repeated every session
to monitor for changes in vision and in cases o f active
pathology.
Figure 8-1. Feinbloom Distance
A cu ity Chart.
O ne additional issue that w ill determ ine the actu­
al test selection is the therapist's practice setting.
Therapists working in the client's home will need
portable tests that can easily be transported and set
up in a variety of home settings. Therapists working
in hospitals, nursing homes, and outpatient settings
should be able to establish som e dedicated space in
w hich all of the necessary equipm ent is perm anently
set up and available. Thus, in the following discussion
and in Table 8-5 we m ake recom m endations based on
practice settings.
Visual Acuity at Distance—
Feinbloom C h art
Practice Setting
Recom m ended for hom e health setting or any set­
ting in which portability is im portant.
E quipm ent Required
Feinbloom D istance Test C hart
Occluder
Description
T h is chart (Figure 8-1) is widely used.10 The char­
acteristics of the chart are reviewed in Chapter 3.
The Feinbloom chart w as calibrated for 20 feet but is
typically used at a 10-foot distance, w hich m eans the
acuitv values listed above would be doubled. At a 10-
¥ bers.
foot distance, the acuity range extends from 20/1400
to 20/20.
If a client cannot even see the large " 7 " at 10 feet,
the chart can be moved to 5 feet. At this distance, the
acuity range is extended from 20/1400 to 2800 because
each tim e you decrease the distance bv half you dou-
ble the denominator.
A nother major advantage of this visual acuity chart
is that because of the large visual acuity range that can
be assessed, alm ost all clients with low vision w ill be
able to read at least some letters on the visual acuity
chart. This is im portant from a psychological stand­
point. Many clients w ith low vision have had negative
experiences during visual acuity testing if they were
unable to even see the large "E ." T h is can be depress­
ing. The client feels that there is no hope if he or she
couldn't see the eye chart at all. With the Feinbloom
chart, however, most clients are able to read quite a
few lines on the chart, leading to a much more posi­
tive experience.10'11
Setup an d Procedure
1. The client should wear his/her usual glasses.
The exam iner should be careful to m ake sure
glasses are clean (clean with cotton cloth and
water) and adjusted so the client is looking
through the top half of the lens for distance
testing.
2. The Feinbloom chart is positioned 10 feet away
and the client's left eye is covered w ith the
occluder.
3. The occupational therapist opens the chart to
the largest num ber (num ber 7 = 20/1400 at 10
feet) and asks the client to call out the num ­
ber.
4. The occupational therapist proceeds until the
client can no longer read the num bers correctly
at 10 feet and records the last level at which
the client can read m ore than 50% of the num ­
5. The occluder is then held before the client's
right eye and then neither eye so that binocular
visual acuity
✓ is tested.
6. If the client is unable to see the largest number
at 10 feet, the chart should be moved to 5 feet
and testing should be attempted again.
7. If the client is still unable to see the largest let­
ter, test at a 2.5 foot distance.

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-.1 S Z R D N
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Interpretation
T h e visual acuity should be recorded as 10 (testing
distance)/last size num ber identified. For example,
if the testing was performed at 10 feet and the client
could identify the 350 size num bers, the visual acuity
would be reported as 10/350. To convert this to the
more traditional 20/20 notation, the clinician multi­
plies both the top and bottom of the equation by 2.
Thus, 10/350 is equivalent to 20/700.
It is appropriate to encourage guessing, eye move­
ments, and eccentric view ing to see the num bers10 as
a m eans of determ ining the prognosis for rehabilita­
tion. However, when determ ining the visual acuity
for M edicare docum entation and coding, the chart
should be placed at 20 feet and eccentric view ing and
tu rning o f the head should not be perm itted.
Shortcomings o f the Feinbloom
C hart
O ne m ajor problem w ith the Feinbloom chart is
that it does not have an equal num ber of optotypes
per acuity level. There is onlv one num ber at the
20/700, 20/600, 20/400, 20/350, 20/300, 20/225 levels,
and only three per line from 20/200 to 20/60. Also,
the letters are not standard, so acuity measured with
the Feinbloom chart m ay not m atch acuity measured
w ith another chart. Because of these shortcom ings,
the Early Treatment Diabetic Retinopathy Study Chart
(ETDRS) described below should be used when the
therapist can establish a perm anent work area.
Figure 8-2. ET D R S Chart.
80
бо
50
40
32
25
16
12.5
10
Visual Acuity at D istance— ETDRS
C hart
Practice Setting
Recommended for any setting in w hich the equ ip­
ment can be setup permanently.
Equipm ent Required
ETDRS Chart
Occluder
Description
T h is chart provides five letters per line and also
standardizes the separation between letters (Figure
8-2). A unique aspect of this chart is its geom etric
progression of size differences betw een lines, referred
to as logM AR progression. O ptotypes on each line
are 0.1 log unit or 25% larger than the previous line.
This format results in every three lines representing
a halving or doubling of visual acuity at any given
view ing distance, for example, if one starts at 100 and
goes down three steps (step 1 = 80, step 2 = 80 to 63,
and step 3 = 63 to 50), which is one-half o f 100. These
ch aracteristics allow s for consistent and accurate
evaluation of visual acuity.
The standard test distance is 4 m eters, but for low
vision evaluations the test distance is usually halved
to 2 m eters to insure a client can read the largest let­
ters.

Setup an d Procedure
1. The client should w ear his or her usual glasses.
The exam iner should be careful to m ake sure
the glasses are clean (clean w ith cotton cloth
and water) and adjusted so the client is looking
through the top half of the lens for distance
testing.
2. The ETDRS chart is positioned at 4 meters
and the client's left eye is covered with the
occluder.
3. The occupational therapist asks the client to
call out the letters on the top line.
4. T h e occupational therapist proceeds until the
client can no longer read the letters correctly at
4 m eters and records the last level at which the
client can read more than 50% of the letters.
5. The occluder is then held before the client's
right eye and neither eve so that binocular
visual acuitv is tested.
6. If the client is unable to see the largest letters
at 4 meters, the chart should be moved to 2
m eters and testing should be attempted again.
Interpretation
Testing distances are typically 2 m eters or 4 meters.
At the 2-m eter working distance, the acuity obtained
can easily
у be converted to standard Snellen 20-ft
notation by just adding a zero to the num erator and
denom inator. For example, a 2/10 acuity measurement
becom es 20/100; an acuity of 32 M at 2 m eters corre­
sponds to a 20-ft equivalent of 20/320.
A s w ith the Feinbloom chart, it is appropriate to
encourage guessing, eye movements, and eccentric
view ing to sec the num bers as a m eans of determ in­
ing the prognosis for rehabilitation.
Reading Acuity (Visual Acuity at
N ear W ith Continuous Text)
Practice Setting
Appropriate for any practice setting.
E quipm ent Required
M innesota I.ow-Vision Reading Test (MN Read
Test)
Description
If a client is going to regain independence in ADL,
he or she will need to be able to read again. We also
know that near visual acuity for single letters (let­
ter acuity) is often different than near visual acuity
for reading phrases and sentences (reading acuity).
Therefore, to better understand the impact of the low
vision on reading, it is im portant to assess both let­
ter and reading acuity. W hile low vision specialists
routinely adm inister both types o f tests, most eye doc­
tors onlyr
evaluate near letter visual acuity./
Thus, the
occupational therapist m ay need to evaluate reading
acuitvУ at near.
A popular test for assessing continuous reading
acuity is the M innesota Low-Vision Reading Test (MN
Read Test) illustrated in Figure 8-3. An advantage of
using this test is that it not only provides an assess­
ment of near visual acuity with continuous text, it
also allows the therapist to evaluate the client's read­
ing speed. Unlike visual acuity, which is not expected
to improve with vision rehabilitation, reading speed
is one function that can be improved. Thus, reading
speed is one of the areas for which the occupational
therapist may be able to docum ent improvements
with treatment and justify additional vision rehabili­
tation in M edicare docum entation.
The M N Read acuity chart can be used to provide
a sensitive and reliable m easure o f reading acuity.
Each sentence has 60 characters, which correspond
to 10 standard length words, assum ing a standard
word length of 6 characters (including spaces). The
reading level of each line is controlled as well. An esti­
mate of reading acuity is given by the sm allest print
size at which the client can read the entire sentence
without m aking significant errors. (U sually reading
perform ance deteriorates rapidly as the acuity limit
is approached, and it is easy to determ ine the level
where reading becom es impossible). The exam iner
uses a stopwatch to record the tim e required to read
each paragraph and this allow s a determ ination of
reading speed. A modified graph that can be used for
recording results can be found in the Appendices.
The therapist's goal with this test is to determ ine
the best print size for reading at a given distance.
Typically, there are tw o distances at which clients
often must read. The most com m on distance for con­
tinuous text reading is 16 inches or 40 cm. The second
com m on distance is about 32 inches or about 80 cm
(arm's length), the usual distance o f stovetop dials and
shelf labels.
Two endpoints should be noted with this test:
1. Continuous text reading acuity: T h is is the
sm allest print the client can read.
2. Critical print size: The print size just before
reading starts to slow, ie, the sm allest print that
results in m axim um reading rate.
Setup an d Procedure
1. The client should wear his or her usual read­
ing glasses. The exam iner should be careful
to make sure the glasses are clean (clean with
cotton cloth and water) and adjusted so the cli­
ent is looking through the bottom h alf o f the
 Occupational Therapy Low Vision Rehabilitation Evaluation
U N R E A D A C U I T Y CHART 1
Mtuo
8.0
M y father takes me
to school every day
in his big green car
Everyone wanted to
go outside when the
rain finally stopped
They were not able
$.0 to finish playing the
game before dinner
lenses for near testing if it is a bifocal or pro­
gressive lens (no-line bifocal) design. Л client
is usually tested under binocular conditions
if he or she typically reads w ith both eyes, or
with the better eye if he or she reads with one
eve.
2. The usual distance for the MN Read chart is
40 cm from the eyes. If the patient is reading
with stronger reading glasses, the test should
be measured at the correct distance for the
prescribed glasses. T h is can be calculated
from the reading addition in the report from
the eyecare provider (see Chapter 13). This
inform ation must be accurate before testing
proceeds. Make sure the test distance is m ain­
tained throughout the testing.
3. Allow the client to move the card side to side,
but be careful to prevent the client from bring­
ing the chart closer as the print size becom es
smaller.
4. Instruct the client to begin reading the para­
graphs from top to bottom of the chart. Note
the critical print size, the print size just before
the line where reading starts to slow.
113
S o o lo n kxjWAW
2 0 .4 0 0 1)
2IV2SO 1.1
5. As the client reads sm aller print, encourage
him to keep reading until he starts m aking
m istakes. The sm allest print at which the c li­
ent can read w ith no more than one error is
continuous text reading acuity.
6. Using a stopwatch, the exam iner also records
how long it takes to read each paragraph. This
inform ation is used to determ ine the client's
reading speed. The MN Read Test com es with
a conversion table that allow s the exam iner
to convert the stopwatch m easurem ent into
words per minute.
Interpretation
The critical print size is the last paragraph read
before reading starts to slow. T h is is recorded using
"M " notation. The client continues reading even if he
or she slows down, and the sm allest print at which the
client can read with no more than one error is continu­
ous text reading acuity. T h is would also be recorded
using "M " notation as above. Typically, critical print
size is 3 lines above continuous test acuitv. If distance
visual acuitv indicated that the vision in the left eve
was better than the vision in the right eye, the left eye
should be tested separately. If the last paragraph read
before reading starts (critical print size) was 1 M at a
test distance of 40 cm , the result would be recorded
as:
Critical print size: 0.4/1 M (OS) or “ 1 M at 40 cm "
Acuity: 0.4/ 0.5 M (OS) or "0.5 M at 40 cm "
Note that acuity, reading perform ance, and critical
print size m ust alw ays include a specification of test
distance as well as target size.
Peripheral Visual Field
Practice Setting
Appropriate for any practice setting.
E qиipm en t R eqиired
None.
Description
Visual field testing is designed to evaluate an
individual's peripheral vision. Visual field loss can be
either absolute or relative. An absolute visual field loss
is one in w hich no m atter how large and bright the
target is, it w ill not be seen w ithin the blind area. A
relative visual field loss, on the other hand, is depen­
dent on the size, brightness, and contrast of the target,
relative to the environm ent. This translates function­
ally into variations of visual field consistency based
on environm ental conditions. For example, a person
w ith a relative peripheral visual field loss might
function better under bright illum ination than under
dim lighting conditions or at night. There are several
instrum ents that can form ally quantify the extent of
the visual field. These instrum ents are expensive and
the testing is tim e consum ing. A good alternative for
the occupational therapist is confrontation field test­
ing. No equipm ent is necessary for this testing. The
exam iner sits opposite the client, and the client has to
indicate when he or she can see the exam iner's fingers
or hands brought in from the periphery.
W hen eye doctors assess a client's visual field, the
testing is done monocularly, first with the right eye
and then with the left eye alone. However, for the
occupational therapist perform ing peripheral field
testing under norm al view ing conditions w ith both
eyes open is more practical. The occupational thera­
pist is trying to determ ine if a visual field deficit exists
under normal seeing conditions and how it might
affect ADL.
Setup an d Procedure
Part 1 - Testing fo r a H em ianopsia
(Field C ut)
1. The exam iner sits an arm 's length away from
the client, or about 80 cm (32 inches).
2. The exam iner's hands should be h alf the d is­
tance betw een him and the client, or about 40
cm (16 inches).
3. The exam iner and the client w ill see the sam e
thing, except the exam iner's right is the client's
left.
4. The exam iner instructs the client to "look
directly into my eye and tell me how many
fingers you see out o f your side vision. Do not
look at my hands, only at mv
* eye".
/ «/ J
5. M ake sure the background is not cluttered. For
example, a uniform wall or curtain should be
behind the exam iner.
6. The exam iner positions her fingers about 40
cm from the client and presents 1, 2, or 3 fin­
gers together, one hand at a time, until the cli­
ent counts them reliably
✓
7. The exam in er tests the client's peripheral
vision using three positions on the right and
three positions on the left (ie, presenting his
fingers at 2, 4, 6, 8, and 10 o'clock positions).
Interpretation
A visual field loss is indicated if the client is unable
to see the target on one side. If the client is unable to
see the target when presented on the right side until
the target is essentially at the m idline, the deficit is
called a right hem ianopsia. The sam e problem on the
left side is called a left hem ianopsia.
C ontrast Sensitivity and Lighting
Evaluation
Practice Setting
Appropriate for any practice setting.
Equipm ent Required
M ars Letter Contrast Sensitivity Test.
Description
The M ars Letter Contrast Sensitivitv
у
Test is a set
of letter charts for testing peak contrast sensitiv­
ity (Figure 8-4). The more fam iliar visual acuity test
assesses the ability to see sm all, high-contrast objects
or print. Symbol contrast sensitivity with sym bols that
are well above acuity threshold relates to a person’s
ability to see large, lower contrast objects such as
m agnified but lower contrast print, or larger lower
contrast shapes like the last step on carpeted stairs. As
such, it is a useful instrum ent in the clinician's arsenal
of assessm ent tools. The test consists of three printed
charts for independent left eye, right eye, and binocu­
lar testing. The three forms are identical except for the
sequence of letters chosen. Figure 8-5 is a sam ple score
sheet.
The test itself consists of 48 letters arranged in
eight rows of six letters each. The contrast of each
letter gradually decreases reading from left to right,
and continuing on successive lines. The client simply
reads the letters across lines and down the chart, as
in standard letter acuity measurement. Instead of the
letters decreasing in size, however, they decrease in
contrast.
Setup an d Procedure
1. For best results, the chart should be illum inat­
ed uniformly. The patient is tested with both
eyes or the preferred eye as w ith near acuity.
2. The view ing distance should be selected to
insure that the letters arc at least 2 tim es acu­
ity threshold and more. This is easily done by
starting far away and m oving the chart closer
until the client can barely recognize the dark­
est letter. Move the chart h alf that distance and
start testing.
3. Clients should wear their appropriate eyeglass
correction for the test distance and an occluder
or patch on the untested eye.
4. To speed up test time, have the patient read
down the left side of the chart. W hen reading
slows, ask the client to read the letters from
left to right across each line of the chart. If
the client responds with a letter other than
C, D, H, K, N, O, R, S, V, or Z, do not score
the response as incorrect. Instead, inform the
client of the restricted letter set, and ask for
a n o th e r resp o n se .
5. Encourage the client to guess, even when the
letters seem too faint.
6. O n the score sheet (see Figure 8-5), mark in
the grid corresponding to the chart form used,
an X for each letter incorrectly identified. Stop
testing only when the client m akes two con­
secutive errors or reaches the end of the chart
7. Do not term inate the test because the client
has given up and has stopped responding. If
this happens, encourage the client to guess,
and score the guesses as ordinary responses.
This will help to insure that the score is based
on what the client can see and not on what the
client believes he or she can see.
8. The score is given by the contrast sensitivity
value of the lowest contrast letter just prior to
tw o incorrectly identified letters, m inus a scor­
ing correction.
9. The letter just prior to the two consecutive
m isses is called the final correct letter.
10. If the client reaches the end of the chart w ith­
out m aking tw o consecutive errors, then the
final correct letter is sim ply the final letter cor-
rectlv identified.
11. If the client does not achieve contrast threshold
of 2% or better after the lighting m odifications
described below, decrease the distance in half
once again, and start testing at the last line
tested above. Record the results as contrast
threshold at 4X acuitv.У
Interpretation
Table 8-6 is used to determ ine the contrast sen­
sitivity
w for the client. T h is can then be converted to
contrast threshold. Contrast threshold is defined as
an object with the lowest contrast that a client can
recognize. A client with norm al vision can usually see
objects with as little as 2% to 3% contrast. If the con­
trast of an object is less than the contrast threshold of
the client, the object cannot be seen. Contrast sensitiv­
ity is the reciprocal of the contrast at threshold, ie, one
divided by the lowest contrast at which form s or lines
can be recognized. If a person can see details at very
low contrast, his or her contrast sensitivity is high and
vice versa. A client w ith a contrast threshold of 2% has
higher contrast sensitivity (1/2 = 50) than a client with
a contrast threshold of 10% (1/10 = 10).
O n this test, the contrast o f the final letter before
which the client m isidentifies two consecutive let­
ters, w ith a correction for earlier incorrect responses,
determ ines the log contrast sensitivity. Normal values
of m onocular log CS are about 1.8 (1.6% contrast) in
children and young adults, and about 1.68 (2.0% con­
trast) for older adults (over 60 years of age). Table 8-7
can be used to interpret the results o f contrast sensi­
tivity testing.
Effect o f Lighting
For patients with vision im pairm ent, lighting can
have a significant effect on perform ance. Therefore,
when perform ing these visual acuity or contrast sen­
sitivity tests, it is useful to m odify the lighting condi­
tions and determ ine the effects o f these changes.
Figure 8 -4 . M ars Letter Contrast
S ensitivity Test (rep rinte d w ith
perm ission fro m th e M ars
P erceptrix C o rp o ra tio n ).

Figure 8 -5 . Sam ple Scoring

Sheet fro m M ars Letter Contrast The Mars Letter Contrast S ensitivity Test
S ensitivity Test (rep rinte d w ith
Score Sheet
l>ermission fro m th e M ars
P abent. ___________________ A d m in ist er ed b>-___________________
P erceptrix C o rp o ra tio n ).
Date C o rr ec ti on T est d i s t a n c e

C o m m e n ts

Q u ic k In s tru c t i o n s I n s tr u ct p a b « n t to re a d l e t te r s left to n g h t for e a c h line , from to p to b o tt o m o f the

c h a r t Mark m i s s e s with a n " X ‘ S t o p t e s t on 2 c o n s e c u b v e m i s s e s .

I m p o r t a n t : Allow олГу th e lette rs C O H K N O R S V Z a s r e s p o n s e s

С 0 0 4 »• * -i=. V 1 0 12 o n o i s s : o ? o М П 0 24 Value o f fi n *! c o r r e c t lette*

0 1 . 0 .2 0 . S ; : 0S2 Z 'J A n ; o * j R -J 4-1 к / ; о до
Num ber o f m i s s e s prior to
M □ □ 056 r :о б о H 0 54 v r ; o 6 8 z; 0 72 S t o p p i n g ______ X 0 04
C " 0 i'G- S . ; C % о C o w К ;о.У2 Н 1 0 9 в
K 1cc N □ 1 0 4 v . j \ c e О П 1 12 s ; 1 is R 1 2C
S u b tr a c t
2 L _ t 24 К ' o z i *J2 к П i >з m l ; i 4'j o z 1 44
h \ ; i 4£- Z D 1 5 ? С Г ] 1 5€ V ( j 1 « R C 1 6 4 K ' J 1 6 8
s z i ?2 C D l 7 6 Z Z 1 8 0 O D 1 j8 4 V D 1 Ы 0 1 3 1 9 2 log C o n t r a s t Se nsi tiv ity

FORM 2 Left R igh t eye B in oc u lar

C o w sQ oos H _ 0 12 o Q o .16 N □020 С П 0 .24 V alue d final c o r r e c t letter:
7 D 0 32 С :• v . V U 044 0 D C 4.5 Number o f m i s s e s prior to
с 0 S2 к ]озб о ;о б о n Q og4 « □ o s e SQ 072 s t o p p i n g ______X O.W
N □076 sD o e o Z Q 084 кП овв H Q 092 D D 096
hZ * со N _ 1 0 4 d i 0 8 O U I ' 2 r Q i te Z D i 2 0
S u b tr a c t
V 1 ;•* К S 1 32 >J : ?.F. " p. ; i
К 1 46 R ~ 1 6 2 V I 1 5 6 z D i . e c o D i 6 J s Q i e e
V 1 72 1 ’ 76 C C l 8 0 D Q 1 B 4 V D 1 8 8 « □ 1 97 l o g C o n tr a s t Se nsitivity

FORM 3 Left eye R igh t eyo Binocular.

H 0 0 4 R lTIO O e Z : •2 V . 0 16 С H 0 24 Value o f final c o r r e c t letter.
*, ...
O D O . 3 2 К Г - JO :• . -. R Q 0.44 SZ 04S
Number o f m i s s e s prior to
К Ц О 52 D D 0 5 6 C D o .e o V " Z 0 6 4 o D o e e HZ 0 72 stoppmQ X 0.04
S ' 0 S> •• z :• CQ 092 dZ 0 9 6
R E 100 Н Ц 1 0 4 N Q 1 0 6 K Q 1 12 z Q i 16 o Z i ?o
С 1 ?< R * ?3 s i . ; i 32 V • 35 K ' J 1 40 nZ i 44 S u b tr a c t

S 1 ДЗ К |1 5 2 R l T l l . 5 6 N 6 0 H. 1 64 D 1 68
c Q l 72 v Q l 76 h Q i e o o n 164 o D i . a a Z 1M l o g C o n t r a s t Se nsitivity

mors porc^ptrix

Я О Х С * r f V . •» * N TH «H ift* i
*1 M HI« V *»I C M t M r*«f bm .«■ Я «
 Table 8 -6 .

Converting Log Contrast Sensitivity to Contrast Values (From the Mars Letter
__________________Contrast Sensitivity Test Manual)__________________

log log log log log log

CS C o n tra s t CS Contrast CS Contrast CS C o n tra s t CS C o n tra s t CS C o n tra s t
0.04 0.912 0.08 0.832 0.12 0.759 0.16 0.692 0.20 0.631 0.24 0.575
0.28 0 .5 2 5 0 .3 2 0.479 0 .3 6 0.437 0.40 0 .3 9 8 0.44 0.363 0 .4 8 0.331
0.5 2 0.302 0.56 0.275 0.60 0.251 0.64 0.229 0.68 0.209 0.72 0.191
0 .7 6 0.174 0.80 0.158 0.84 0.145 0.88 0.132 0.92 0.120 0.96 0.110
1.00 0.100 1.04 0.091 1.08 0.083 1.12 0.076 1.16 0.069 1.20 0.063
1.24 0.058 1.28 0.052 1.32 0.048 1.36 0.044 1.40 0.040 1.44 0.036
1.48 0.033 1.52 0.030 1.56 0.028 1.60 0.025 1.64 0.023 1.68 0.021
1.72 0.019 1.76 0.017 1.80 0.016 1.84 0.014 1.88 0.013 1.92 0.012

8. D ecreasing test distance is equivalent to

Procedure
1. To determ ine the effect of lighting, place the
M ars Letter Contrast Sensitivity
¥ Test at a dis-
tance at which the letters are at least 2 tim es
the visual acuity threshold.
2. If at this distance the contrast threshold is
worse than 4%, vary the am ount of light to
determ ine the range of light levels and type of
light that produces contrast threshold at better
than 4%.
3. We recommend the use of an illuminometer,
which is an inexpensive device that measures
light levels in units called Lux or footcandles.
This allows the therapist to reproduce accept­
able light levels accurately under various treat­
ment situations and make appropriate home
modifications.
4. To system atically modify lighting, the thera­
pist first finds the type of light (fluorescent,
incandescent, natural light) that produces best
vision.
5. O nce the best type of lighting is determined,
the therapist varies the intensity by varying
the distance of the light from the material
being viewed.
6. If an illum inom eter is unavailable, report type
of light, wattage, and range of distances that
produce contrast threshold better than 4% to
5%.
7. If contrast threshold better than 4% to 5% can­
not be achieved, decrease test distance to the
4X distance.
increasing m agnification of the print. If accept­
able contrast threshold is achieved by relative
distance m agnification, this indicates the client
will not only require careful control of light­
ing, but may require more m agnification than
is typical of someone with his or her visual
acuitv.
j
9. If contrast threshold never improves to a level
better than 7%, this indicates that electronic
magnification that enhances contrast may be
more effective than optical magnification.
10. A severe loss (contrast threshold worse than
10%) indicates that fluent reading is unlikely
even under optim al visual conditions.
This lighting assessm ent provides an excellent
opportunity to determ ine the effect of usual glare
sources, and educate the client. For example, the thera­
pist can move the light source so that it shines directly
into the client's eyes and measure any changes in
contrast threshold, as well as directly illustrate to the
client the effects of bad lighting.
Sunlens Evaluation
Som eone w alking outside on a sunny day, driving
into the sun, or trying to recognize a fam iliar place
in a brightly lit fluorescent dining hall must try to
optim ize lighting using sunglasses or sunlenses. An
important component of the occupational therapy
evaluation, therefore, involves having the client try
on and select sunlenses under simulations of the
conditions that cause problems. The general approach

Interpreting Contrast Sensitivity Test Results
Mars Log Contrast Sensitivity Score
0.60 or less
0.64 to 1.00
1.04 to 1.28
1.40 to 1.60
1.64 or greater
to a sun len s evaluation involves a trial-and-error
approach under simulated conditions. The "getting
started " evaluation equipm ent for a therapist should
include an assortm ent of wrap-around style sunlenses
to dem onstrate (see Chapter 16).
The sunlens evaluation involves selecting the style,
d e n s i t y a n d c o lo r o f th e s u n l e n s e s . In g e n e r a l, th e
best style of sun len s w raps tightly above and around
the eyes (w w w .noir-m edical.com ) to block glare and
reflections around the lenses. Relatively inexpensive
or more stylish m odels can be purchased to fit over
conventional eyeglasses. With standard com m ercial
sunglasses, this glare can be blocked with a hat brim
or visor.
The density of the sunlens describes the amount of
light transm itted through the lens, usually described
as a light transm ittance percentage w here 100% is
clear and 0% would be completely opaque. Typically,
the lightest sunlenses have transm ittance values of
50% to 60% ; very dense sunlenses have transm ittance
values o f approxim ately 10%. Sunlenses also vary in
color. Most clients will respond best to polarized yel­
low or orange sunlenses that decrease glare, or color
neutral lenses (Polaroid Gray). Some, however, prefer
green hues, and occasionally red and blue. Colored
lenses will degrade color vision, but the yellow hues
will improve perceived contrast and decrease glare.
The sunlens evaluation is tim e consum ing and will
require about 30 m inutes in a separate session. One
must wait for a sunny day, and evaluate the lens by
having the client attempt to identify an object or per­
son next to a glare source, such as reflections off of a
Table 8-7.
Interpretation
25% or higher— severe loss in contrast sensitivity
Reading unlikely unless contrast enhanced and w ith very
careful light control.
10% to 24% — oderate/severe loss in contrast sensitivity
Fluent reading unlikely
5% to 9 % — moderate loss in contrast sensitivity
Contrast enhancem ent (electronic m agnification) usually more
effective than optical devices. Lighting evaluation indicated.
2.5% to 4 % — mild loss in contrast sensitivity
Increased sensitivity to light intensity level and glare
1.25% to 2.4% — norm al contrast sensitivity
car. The therapist provides lenses in pairs for the client
to com pare and choose w hich is better, taking care to
allow the client to adjust after he dons each sunlens.
To save time, the lighting evaluation should reveal the
approxim ate sunlens density required. If a light meter
is used, one can hold the m eter behind the lens to
quickly locate those lenses that will provide best light
levels in a given environm ent; otherw ise the therapist
may use gray sunlenses first and then com pare colors
at the selected transm ittance values. O ne should also
perform a sunlens evaluation indoors under lighting
conditions where the client has a problem, typically
in brightly lit fluorescent room s with shiny tile floors.
O ne might also use the selected high transm ittance
sunlens to cut glare during reading, or with a white
on black CCTV.
Assessment of Central Scotom a/
Eccentric Viewing
There are several ways to evaluate the central
scotom a and eccentric view ing. The complexity, cost
of equipment, and accuracy varies dram atically from
one technique to another. For exam ple, the m ost accu­
rate method uses an instrum ent called the scanning
laser ophthalm oscope. The scanning laser ophthalm o­
scope takes a picture of the patient's retina, and is able
to map exactly where scotom as exist and w hich areas
are used for fixation. The benefits of this procedure
are its accuracy and that it does not rely on the client's
responses. However, it is very expensive and usually
only used in large eve clinics. Most private practice
scotoma/eccentric viewing.
ophthalmologist and optometrists would not have
this instrument available.
Fortunately, less expensive techniques requiring
m inim al equipment are available. We recommend
that the therapist use either the clock face technique
or the Tangent screen.
Clock Face Technique
Practice Setting
Recommended for home health setting or any set­
ting in which portability is important.
Equipment Required
Clock drawn on 8.5 by 11-inch sheet of paper.
Description
As described in Chapter 4, macular degeneration is
alm ost alwavs associated w ith a macular scotoma or a
blind spot in the center of the visual field. This creates
major difficulty for the client when engaged in any
ADL requiring vision. During vision rehabilitation,
the occupational therapist will teach the client how to
look off to the side or to eccentrically view to improve
performance. Therefore, it is important during the
evaluation to determine if there is a scotoma and the
best position for eccentric viewing.
Setup an d Procedure
Wright and W atson12 describe the following tech­
nique used to teach clients how to eccentrically view.
scotoma/eccentric viewing with scotoma covering ccntrnl
star.
We believe that this is also a valuable evaluation tool.
1. Draw a clock (numbers 1 to 12) with a star in
the middle with a black marker on a sheet of
paper (Figure 8-6a).
2. Occlude the client's left eye and place the clock
about 2 feet awav from the client.
j
3. If the client has eyeglasses, these should be
worn for this procedure.
4. Ask the client to look at the clock and so that
the scotoma or unclear area is obscuring the
star in the middle of the clock (Figure 8-6b).
The star should either be unclear or m issing at
this point.
5. W hile the client m aintains this position, he or
she should see that some of the numbers on
the clock are clearer than the star in the middle
(Figure 8-6c).
6. Instruct the client to move his or her eye so that
the star is most clear. The client should do this
sy stem a tica lly b y lo o k in g up and tow ard the
right at the number 1 on the clock, and contin­
ue clockw ise. The client should be able to find
at least one position in which the star is now
clearer than when looking straight ahead.
7. Once this position is established, instruct the
client to look directly at the star again and
notice that it is now blurred or disappears.
Then repeat either eye movement required to
regain better clarity.
 to do in every setting, but is more sensitive to small
scotom as that could be m issed w ith the Clock Face
technique and actually perm its the scotom a to be
m easured.11 Eyecare providers use the Tangent screen
to evaluate the central visual field of patients. It is a
black piece of felt with a white fixation target mounted
on a wall (Figure 8-7). T h e screen usually has circles
of black thread stitched into it to indicate the degrees
from the center of the fixation target.
The procedure we suggest com bines testing for
scotom as with instruction, so that scotoma aw are­
ness and eccentric view ing training are combined.
T h is procedure is discussed in more detail in Chapter
10. The results o f Tangent Screen testing are useful
diagnostically and indicate how to begin the eccentric
view ing training.
Procedure
1. The tangent screen method involves first posi­
tioning the fixation target in the center o f a
1-meter-square tangent screen. The fixation
Figure 8 -6 c. C lo t к face used fo r e va luatio n o f central target is usually a letter large enough for a
sco to m a /e cce n tric v ie w in g w ith central star vis ib le and
patient to recognize in the center of a felt board
scotom a d o w n and to left.
(see Figure 8-7). The letter is positioned in the
center of a large cross.
2. It is im portant for the therapist to be positioned
Interpretation to allow careful observation o f the patient's
• A scotoma below fixation can present a safety eyes.
problem, as clients might m iss sm all obstacles, 3. The client is asked to "look at the letter so that
trip, and fall. it is the clearest." It is im portant that the client
• A scotom a to the right of fixation m ay impair continue to hold the eye in this position dur­
reading. ing testing. Individuals w ho have had central
• Inconsistent responses indicate inconsistent fixa­ field loss for several m onths or more may have
tion and the need for instruction on eccentric already started developing eccentric view ing
fixation (see Chapter 10). Inconsistent fixation or fixation. If so, the client m ay position his
often results soon after a client has a central or her eyes so that the eyes appear to be1 look­
scotom a. These individuals will see som ething ing above, below, or to one side o f the letter
out of the corner of their eye, only to have it d is­ and the client reports seeing the whole letter.
appear when they look at it, a frustrating experi­ This behavior is acceptable as long as the cli­
ence. Client education and use of other senses ent m aintains this eye position throughout the
are the best im m ediate interventions. Training testing.
som eone to develop adaptive eccentric view ing 4. W hile w atching carefully that the eyes do not
is an im portant aspect of low vision rehabilita­ move, the therapist moves a 5-m m w hite testing
tion. spot at the end o f long black wand around the
fixation area in an attempt to find a scotoma.
Tangent Screen At this stage, the therapist is em pirically trying
to find the location of the scotoma.
Practice S etting
5. W hen the white spot enters the scotom a, the
Recommended for any setting in w hich the equip­ client w ill report that it disappears. W hen this
ment can be setup permanently. occurs, the therapist explains to the client that
E qu ip m e n t Required the scotoma has been found and its size will
now be m easured.
Tangent screen
6. To m easure the size of the scotom a, the white
D escrip tio n target is moved until it is first seen and the
The tangent screen method is less convenient, takes edge of the scotom a is marked w ith a low-con-
more practice to becom e skilled, and is not possible trast mark or pin (not visible to the client), and

quickly moved from nonseeing to seeing and
the border of the scotoma is marked several
times. Typically, the clinician maps at least 4
points: 12 o'clock, 6 o'clock, 3 o'clock, and 9
o'clock (Figure 8-8).
7. Some clients may shift fixation, eg, from look­
ing above to looking below the fixation letter.
1 he therapist can detect these shifts by looking
at the eyes and noting inconsistency in where
the target is seen. It is important to instruct the
client to try not to shift the position of his or
her eyes.
8. W hen the scotoma is mapped, the edges are
more clearly marked (with white yarn wrapped
around the push pins in the felt board). The
patient is instructed to move his or her eyes to
see the outlined scotoma (Figure 8-9).
9. I he therapist should instruct the client to look
into different positions and with another let­
ter or the wand, to demonstrate where the
scotoma has moved.
10. The client may be coaxed with verbal instruc­
tions ("look further to the right"). Som etim es
one needs to give the client a target to look
towards, such as waving the testing spot to the
right of the fixation target to encourage eccen­
tric fixation to the right.
j Figure 8-7; Tangent screen (screen only).
In Chapter 10, we describe the use o f this procedure
to teach eccentric viewing, which is often incorpo­
rated into this testing procedure.
Reading Assessment/Reading
Speed
Practice Setting
Appropriate for any practice setting.
Equipm ent Required
The Pepper Visual Skills for Reading Test (Pepper
VSRT)
Description
The Pepper VSRT is a test in which clients read
unrelated words aloud (Figure 8-10). T h e words
increase in length as the reader reads down the
chart. The exam iner records reading rate and also
the occurrence and type of errors. W hen comparing
reading perform ance with different optical devices,
or m onitoring changes in reading perform ance after
vision rehabilitation, the Pepper VSRT is the reading
evaluation instrum ent o f choice. The Pepper test has
exceptional test-retest reliability and is very sensitive
to sm all changes in reading perform ance in clients
 о
Figure 8-9. Tangent screen showing white yarn used to out­
line the scotoma.
with a 9th grade or higher reading level. A change
in reading rate of about 10 words per m inute is sta­
tistically significant when measured by the Pepper
test. In addition, m any compound words are used,
so readers m ay m iss either the beginning or end of
the words. T h is would lead to certain error patterns.
The exam iner can m ake inferences about underlying
visual im pairm ents on the basis of the error patterns
based on an analysis of these errors. For example, a
tendency to om it the end of words indicates a scotoma
in the right field.
The Pepper VSRT engages the client in reading pro­
cesses that depend solely, or in part, on visual sources
of inform ation, including: word recognition ability,
saccade control, return-sw eep eye movement control,
and scotom a placem ent w hile reading.14
O ne of the three form s of the Pepper VSRT is
illustrated in Figure 8-6. Word recognition ability
is required because unrelated letters and words are
presented. T h e absence of contextual inform ation
forces clients to rely on vision to identify the items
presented. The test becom es increasingly more dif­
ficult from top to bottom because line delineation and
spacing, word length, and word spacing change as the
client reads successive lines. Both saccadic and return
sw eep eye m ovem ents are also increasingly more dif­
ficult because of system atic decreases in either spac­
Figure 8 -8 . Tangent screen showing therapist holding the
target, client view ing the screen, and 4 pins showing size of
scotoma, w h ich is to the right of fixation.
ing betw een successive items on a single line or the
spacing betw een successive lines.
Setup m id Procedure
1. The exam iner should select the appropriate
test size based on the reader's acuity. The
appropriate VSRT size is at least one size larger
print than the reader's acuity. T h e authors rec­
ommend using tw o sizes larger or more than
acuity for best perform ance. Therefore, if the
reader's acuity is 2 M, the 3 M test is appropri­
ate, but 4 M may give better reading ability.
2. If the reader is using an optical device to read
the test, then the appropriate test size is one
or two sizes larger than the aided acuity. That
is, if the reader is using a 5X m icroscope with
an aided acuity o f 0.8 M, the 1 M or 1.5 M test
should be adm inistered.
3. To stim ulate the reader to do his or her best,
and to reduce the stress o f the testing situation,
encouragem ent can be given consistently at the
end of each line read, or when the reader asks
for feedback. Such com m ents as, "G ood, keep
going," "You arc doing w ell," or "That's fine"
are effective. However, praise can be overdone.
Most adults know when they У are beyond
У their
skills. The sensitive exam iner will strive to
 yonn in Figure 8-10. Pepper VSRT.

# correct percent
Line # item correct

1 x g a j p m u 1 с d s b r h о /15 . . . %

2 f w z i t b k e n q v у a m r /15

3 yes so j pop sat d at с am h in so _______ /12 dummy

4 oh of n to am g k in u do of s b /13 ______

5 fire side past gold fish own sky help . /« %

6 advice badger slide anyone table mirror /6 ____________ %

7 understudy sportsman campground fenders /4

8 bad z navy specific g show dog amber /8 dummy

9 narrow today penny cream hopped honest /6

10 meantime upbringing summertime splendid _______ /4 __ ъ

И quick sand spiteful outlast stops winds /6 %

12 side w alk tracking readily overshadow employ /6 %

13 story milk bunny college crayons idea gotten _______ /7 dummy

•Total Number Correct (add lines 1-13)»

•Mean Percent Correct (sum of percentages / 10)= %
•Total Test Tim e»___ nun. sec (Time in Minutes)*
•Corrected Reading Rate = Total # Correct/Total Time (in min)»

•Error Codes-
Misidenlification .... .... substitution written лЬnve ite m .
Repetition ,.~..w..^.«.................wavy line placed below item re p lie d ... e.g. S £ t-
SpHU W ord----------------- - ..... "»р* placed above word item sp^?I!eH w f
Omission---------------circle item omitted - ..................... . ............ - ....— eg. C D
Insertion. ...------------c u t* placed where insertion occurs ....... e8 <%
C a n t'd * Words------ --------------tine underneath indicating connection... "Ч1М.ПИ eg tear
Separate» Woixb..~-----------------slash indicating separation . .......... ■eg cv^ight
Clwinging Word O rder.............. arrow to where item was read . e.g.
Uxte S kip------- — ---------arrow to Skipped lilH* -— ^

Test Termination ..... 1. 10 consecutive errors. 3 . fa tig u e o f r e n te r

2. skipped line twice i e x ce e d e d tim e lim it

learn the appropriate amount of encourage­ Also, the exam iner should be careful not to let
ment to elicit maximum performance from a the reader know when she is right or wrong
particular reader. either by a glance, expression, tone of voice, or
4. Before the test is begun, the exam iner should the sound of the m istake being marked on the
tell the reader that the test cannot be discussed score sheet.
until it is completed, and it is important that 5. The reader should be handed the appropri­
the reader keep reading until the test if fin ­ ate test, provided the best illum ination, and
ished. These procedures are important both to instructed to call the letters and words aloud.
motivate the reader, and to allow spontaneous If the reader is using a low vision device,
changes in answers, which are accepted. The insure that he or she knows the correct focal
exam iner should be as responsive and posi­ distance before adm inistering the VSRT. The
tive with incorrect as with correct responses. client should be instructed to hold the card as
 close or far away as needed to see the sym bols
clearly. If necessary, the exam iner should point
out the beginning of the first line as a localiza­
tion clue.
6. The exam iner should sav
¥ to the reader:
"I am going to show a card to you with unre­
lated letters and words on it. The letters and
words are not sentences; they have no m eaning
when read together. The first line has a black
border around it as a visual guide, but the rest
of the lines do not. 1 would like you+ to sav
у
the letters and words aloud as you see them.
Please read the entire test. The first two lines
will be letters, and on the third line there will
be words. W hen you see a word, please say the
word, do not spell it. W hile you are reading
the test, I cannot answ er questions about how
you are doing, but as soon as you finish, we
will talk about how Гyou did. Do Фvou have any w
questions before we b egin ?"
7. Tim ing for speed using a stopwatch begins as
soon as the reader has the card in focus and is
fixing on the b egin nin g letter.
If a reader asks about the correctness of an
answ er or how she is doing on the test, the
exam iner should give an am biguous, noncom ­
m ittal response, such as, ’’You are doing a fine
job, keep going."
9. The test has a coding schem e for recording
errors. For exam ple, if the reader spells the first
word instead of saying the word, the instruc­
tor should indicate that the item is a word
and asked the reader to pronounce the word
instead of spelling it. If the reader is able to
pronounce that word, no error is scored. After
this, however, if the reader spells the word
instead of saying it, the exam iner should score
a "spells word" error.
Readers should be encouraged to guess test
items if they are not im m ediately recognizable.
If there is no response to an item after 10 sec­
onds, the exam iner should say, "Even if you are
not sure, just tell me what it looks like". If the
reader is still struggling, made such a remark
as, "That is difficult, go to the next item". If the
reader did not read the item, it is considered
an om ission error and is scored as such (check
score sheet).
The last answ er given is the one that is scored.
Thus, if the reader spontaneously corrects an
incorrect answer, even after leaving the item,
credit is given. Also, if the reader changes to a
w rong answ er, the item is scored as incorrect.
12. The VSRT should be adm inistered in one sit­
ting. There is a m aximum tim e limit. It is not
useful to adm inister the test in more than one
sitting. If the reader is tired, or for any other
reason unable to finish the test, the exam iner
should decide w hether to readm inister the test
at another tim e (because of extenuating cir­
cum stance), or score the rem ainder of the test
as errors and count the adm inistration as the
pretest, and indicative o f the reader's best per­
form ance at the time.
13. As soon as the reader pronounces the last word
on the test, or the test is term inated, the tim ing
of the test is completed.
Interpretation
At the end of the scoring, the exam iner should have
a profile of the readers perform ance that contains the
following:
• A ccuracy of perform ance (mean percent cor­
rect)
• Reading rate (num ber correct words/minute)
• Line m astery for sym bol length, sym bol spacing,
line spacing
The reading rate m easure has exceptional test-retest
reliability and sensitivity to sm all changes in perfor­
m ance; change in reading rate o f about 10 w ords per
m inute is statistically significant. Four form s of the
test are available to enable repeated testing. This test
has been used, therefore, to docum ent im provem ent
in perform ance w ith therapy or provide justification
for the effectiveness o f reading devices using an objec­
tive m easure of perform ance.
An evaluation o f both the accuracy and rate scores
for each reader can provide the clinician with infor­
mation to m ake a prelim inary categorization o f the
reader's reading perform ance. Typically, low vision
readers will be reading:
• inaccurately and slowly
• accurately but slowly
• with both speed and accuracy
T h e VSRT suggests guidelines that may aid the
low vision therapist in m aking these categorizations.
O bservations of the VSRT perform ance o f individuals
with m acular disease suggest that accuracy scores
below 75% correct may be indicative of inaccurate
perform ance and rate scores below 20 words/minute
may be considered slow perform ance
T h e VSRT scoring m anual also has an extensive
discussion of interpretation and analysis of com m on
reading errors, line m astery issues, problem s with
word length, sym bol spacing, om issions, insertions,
 Occupational therapy Low Vision Rehabilitation Evaluation
repetitions, jumping or changing word order, and a
variety of other important issues.
E n viro n m en tal Evaluation
Even a well-developed treatment plan will fail
unless the therapist considers the location where the
client will habitually perform the goal performance
in question. For example, a client may successfully
perform a task in an office setting using an optical
device, while sitting at a desk with a task light and
a reading stand. However, when the client takes the
prescribed device home and sits in his favorite chair
with inadequate lighting, poor support for materials,
and disabling glare, he may be unable to perform the
identical task. Fortunately, outpatient low vision reha­
bilitation is a covered service under M edicare В and
occupational therapists can provide these services in
the client's home. This allows the therapist to evaluate
the client's environment.
As individuals age, they often tend to perform
tasks in the same place, eg, bill paying is performed
on the dining room table, knitting and reading in the
stuffed chair in the living room. Indeed, as people
age, the space within which they perform most activi­
ties decreases to a favorite chair, referred to as the
"personal surveillance zone."1’ This is a sacred place.
Individuals resist moving from this place or changing
the layout of the space. An environmental assessment,
therefore, should focus on the preferred living spaces.
Careful consideration should be given to:
• The available lighting and glare sources
• Possible positioning of task lights, reading
stands, and tables
• Possible organizational schemes
• Placement and storage of devices
• Ergonomics when performing a task
• Escape and emergency response
Evaluation o f O ccupational
P er fo r m a n c e
T he final portion of the occupational therapy low
vision rehabilitation evaluation is designed to evalu­
ate occupational performance. Occupational perfor­
mance is defined as the ability to carry out activities of
daily life, including basic and personal ADL, instru­
mental activities of daily living (IADL), education,
work, play, leisure, and social participation.1 Table 8-8
sum m arizes these activities. During the evaluation
125
process, the performance skills and patterns used
in performance are identified, and other aspects of
engaging in occupation, such as client factors, activity
demands, and context are assessed.1 The occupational
perform ance evaluation involves discussion, observa­
tion, and evaluation of the client's use of vision in
ADL and IADL.
The occupational profile/case history assessm ent
establishes what the client wants and needs to do. This
part of the evaluation is designed to identify deficits
in perform ance or specific disabilities. By considering
the results of the above evaluation of visual and non­
visual client factors, the therapist then identifies client
factors that act as barriers to perform ance— perfor­
mance lim iting factors. T he perform ance evaluation
com bines questioning the client as well as observing
the client engaged in the activities of interest. This
inform ation will be used to develop a treatment
plan that attempts to remove the barriers and enable
occupational performance, thus meeting the client's
specific needs.
An excellent starting point for this phase is the eval­
uation driven by the client's results on the Veterans
Affairs Low-Vision Visual Functioning Questionnaire
(VA LV VFQ-48). As discussed earlier in this chapter,
this has been found to be a valid and reliable m easure
of visual ability in low vision clients with moderate to
severe vision loss. After review ing this questionnaire,
the therapist should evaluate the client's actual per­
formance in the areas of concern and also concentrate
on what the client has identified as im portant goals.
If paying bills is an im portant goal for the client, the
therapist should have the client demonstrate w'here
and how he or she pays the bills. The therapist should
carefully observe lighting, contrast, glare, and other
environmental issues.
It is also wise to routinely ask clients to perform
several basic activities that are almost uniform lv J
necessary for all individuals, such as pouring liquid,
reading labels on m edicine bottles, food containers,
reading the newspaper, reading mail, or using the
microwave.
The location of the evaluation is an im portant issue
to consider. Ideally, the occupational performance
evaluation should take place in the client's home or
current living situation. This allows the therapist hi
explore the various areas of occupation and actually
observe the client engaged in these activities in the
client's real environm ent (perform ance context). This
is particularly im portant because for the low vision
client, context issues such as lighting, contrast, glare,
home design, appliance setup, and organization are so
critical to an analysis of occupational performance. In
addition, one should observe perform ance o f fam iliar
tasks under somewhat unfam iliar circum stances to
Areas of Occupation Assessed in QT Low Vision Rehabilitation Evaluation____
Activities of Daily Living (ADL): These activities are oriented toward taking care of one's own body.
Bathing, show ering
Bowel and bladder control
Dressing
Eating
Feeding
Functional m obility
Personal device care
Personal hygiene and groom ing
Sexual activity
у
Sleep/rest
Toilet hygiene

Instrumental Activities of Daily Living (IADL): Activities that are oriented toward interacting with the
environment and that are often complex and generally optional in nature.
Care of others
Care of pets
Child rearing
Com m unication device use
Com m unity m obility
Financial m anagem ent
Health m anagem ent and m aintenance
Home establishm ent and m aintenance
Meal preparation and cleanup
Safety procedures and em ergency responses
Shopping

Education: Includes activities needed for being a student ands participating in a learning
environment.
Form al educational participation
Exploration of inform al personal educational needs or interests
Inform al personal education participation

Work: Includes activities needed for engaging in remunerative employment or volunteer activities.
Employm ent interest and pursuits
Employm ent seeking and acquisition
Job perform ance
Retirem ent preparation
Volunteer exploration
Volunteer participation

Play: Any spontaneous or organized activity that provides enjoyment, entertainment, amusement, or
diversion.
Play exploration
Play participation
_______________________________________________________Continued
 Table 8 -8 , Continued.

__ Areas of Occupation Assessed In QT Low Vision Rehabilitation Evaluation_____

Leisure: Any nonobligatory activity that is engaged in during discretionary time.

Leisure exploration
Leisure participation

Social Participation: Activities associated with organized patterns of behavior that are
characteristic and expected of an individual interacting with others in a given social system.
Community
Family
Peer, friend

Adapted from American Occupational Therapy Association. Occupational Therapy Practice Framework: Domain and Process. Am J
Occup Ther. 2002;56(6):609-639.

evaluate cognitive functions such as problem solving,
insight, reasoning, and frustration tolerance.
Another important issue to consider when evaluat­
ing the client's performance is how much effort and
energy is expended. Warren states that the prim ary
issues to consider regarding performance of ADL are
safety and effort.16 She states that most people with
vision loss are technically independent, but expend a
great deal of mental and physical effort with question­
able safety and little margin for error. They perform at
their maximum capability at all times, leaving them
with little energy to enjoy what else life has to offer.16
A ssessment o f
R ehabilitation P otential
As the therapist performs the evaluation described
in this chapter, he or she is not simply gathering bits
of unrelated information to be analyzed at the very
end of the evaluation. Rather, during the evaluation
process, the therapist is already thinking about how
this inform ation relates to rehabilitation potential and
the actual treatment plan. Experienced clinicians tend
to follow a basic clinical reasoning process, which we
have outlined below:
To determ ine rehabilitation potential, the basic rea­
soning process is as follows:
1. Define the specific performance goal.
2. Look first to evidence-based research and then
to clinical experience to ascertain the visual
and nonvisual requirem ents to perform the
goal task.
3. Consider visual perform ance of the task and
ascertain if the visual, movement, and cogni­
tive requirem ents can be met by available
devices or interventions to enhance vision.
4. Consider nonvisual perform ance of the task
and ascertain if other modalities, movement,
and cognitive requirements can be met by
available devices or interventions.
5. Evaluate and document the pre- and postmor-
bid specific perform ance deficits or disability.
O ne must be careful to consider visual and non­
visual options and keep the focus on what the client
requires to recover roles, essential function, and qual­
ity of life, rather than just visual criteria. For example,
arranging for a sighted reader or books on tape for
someone who wishes to read again is a successful
rehabilitation outcome even if the client is unable to
read visually. Too often, a clinician may be so focused
on the visual aspects of the task and visual solutions,
that he or she ignores a much more simple nonvisual
adaptation or solution.
After completing the evaluation, the therapist must
make a decision about the client's rehabilitation poten­
tial. The information gathered from all four com po­
nents of the evaluation should be used to m ake this
decision. Ultimately, alm ost anv client with low vision
has the potential for im proving his or her ability to
more effectively engage in ADL. To m ake the determ i­
nation of rehabilitation potential, however, the thera­
pist must first define the specific perform ance goal
and then follow the other four steps listed above.
D eterm ining the
P r im a r y D iagnosis
A fter determ ining that the client has the potential
to benefit from vision rehabilitation, the therapist
m ust determ ine the prim ary diagnostic code that will
be used for billing M edicare. M edicare considers low
vision rehabilitation services reasonable and necessary *
only for clients w ith a clear medical need. To estab­
lish th is need, clients m ust have a moderate visual
im pairm ent or worse not correctable by conventional
eyeglasses and clients must have a clear potential for
significant improvement in function follow ing reha­
bilitation over a reasonable period of time.
Please note that the prim ary diagnosis is not the
eye disease that caused the vision loss. T h e occupa­
tional therapist does not treat m acular degeneration or
diabetic retinopathy. Rather, it is the visual disability
that is treated. Table 8-9 can be used to determ ine the
prim ary diagnosis. These codes periodically change
and it is im portant for therapists to check frequently
for updates.
Step one: Relate the visual acuity in each eye to one
of the categories in the left hand column.
Example:
Visual Acuity:
Right Eye 20/300
Left Eve
* O S 20/800
20/300 falls into the category of severe im pairm ent
(20/200 to 20/400)
20/800 falls into the categorv of profound im pair­
m ent (20/500 to 20/1000)
Step two: Find the intersection betw een the two
categories.
Begin in the left colum n and locate the row that cor­
responds to the right eye acuity (severe im pairm ent).
Move left to right across that row until it intersects
w ith the colum n corresponding to the left eye acu­
ity (profound im pairm ent). In this case, the prim ary
diagnostic code would be 369.14.
Four other codes that can be used relate to visual
field loss and include:
368.41—Visual field defects, scotom a involving
central area
368.45— Visual field defects, generalized contrac­
tion or constriction
368.46— Homonvmous bilaterial field defects
368.47— H eteronym ous bilateral field defects
In som e cases, visual acuity may be better than
20/60 but field loss m ay be present and the field loss
codes apply. The secondary code is determ ined based
on inform ation received from either the ophthalm olo­
gist or optom etrist. Som e o f the com m on codes are
listed in Table 8-10.
Summary
The objective of the occupational therapy low vision
rehabilitation evaluation is to understand the client's
functional ability before the vision loss, to define his
or her current goals, to evaluate the client's ability to
participate in ADL, and assess the his or her social
and em otional health. In this chapter, we described an
evaluation consisting of three com ponents, including
the occupational profile/case history, the evaluation
of visual factors, and the evaluation occupational per­
formance.
 Table 8-9.

ICD-9CM Codes for Visual Imoairment - Primary Disability (Hart. 2000)

Normal N ear normal Moderate Severe Profound N ear total Total
vision vision im pairm ent im pairm ent im pairm ent im pairm ent im pairm ent

Normal vision
20/20- 20/25 369.76 369.73 369.69 369.66 369.63
Near normal vision
20/30-20/60 369.75 369.72 369.68 369.65 369.62
Moderate impairment
20/80-20/160 369.76 369.75 369.25 369.24 369.18 369.17 369.16
Severe impairment
20/200- 20/400
or V F =<20 degrees 369.73 369.72 369.24 369.22 369.14 369.13 369.12
Profound im pairm ent
20/500- 20/1000
or VF <=10 degrees 369.69 369.68 369.18 369.14 369.08 369.07 369.06
Near total impairment
20/1250-20/2500
or VF<=5 degrees 369.68 369.65 369.17 369.13 369.07 369.04 369.03
Total im pairment
NLP
(no light perception) 369.63 369.62 369.16 369.12 369.06 369.03 369.01

CD
3-
3
Cl
О
13
to
&>
ID fso
•O

о
"O'
CD
 _____ Secondary Diagnostic Codes_______
362.01 — Diabetic retinopathy, background
362.02 — Diabetic retinopathy, proliferate
362.35 — Central retinal vein occlusion
362.51 — M acular degeneration, dry
362.52 — M acular degeneration, wet
362.74 — Retinitis Pigmentosa
365.10 — Glaucoma, open angle, unspecified
365.20 — Glaucom a, primary, angle-closure, unspecified
366.10 — Cataract, senile, unspecified
368.46 — Field deficit hom onym ous, bilateral
377.10 — O ptic nerve atrophy
377.41 — O ptic neuritis

Sidebar 8-1: Resources for Equipment

Equipm ent Company Contact Inform ation
Feinbloom Visual Acuity Lighthouse Professional 800-826-4200
C hart Products www.lighthouse.org/prodpub_procat.htm
M N Read Test Lighthouse Professional 800-826-4200
Products www.lighthouse.org/prodpub_procat.htm
M ars Contrast Sensitivity M A RS Perceptrix www.ma rspercept r i x.com /
test
Tangent screen Bernell Corporation 800-348-2225
www.bernell.com/
Pepper Test Lighthouse Professional 800-826-4200
Products www.Iighthouse.org/prodpub_procat.htm
Veterans A ffairs Low- See w w w.slackbooks.com/ot vision form s
Vision Visual Functioning
Q uestionnaire (VA LV
VFQ-48)
G eriatric Depression Scale See w w w .slackbooks.com /otvisionform s

R eferences
1. American Occupational Therapy Association. Occupational
Therapy Practice Framework: Domain and Process. Am f Occup
I her. 2002;56{6):609-639.
2. Warren M. Providing low vision rehabilitation services with
occupational therapy and ophthalmology: a program descrip­
tion. Am f Occup I her. 1995;49<9>:877-883.
3. Massof RW. Rubin CS. Visual function assessment question­
naires. Si/rv Ophthalmol. 2001;45(6>:531'548.
4. Stelmack JA, Szlvk JP, Sielmack TR, et al. Psychometric prop­
erties of the Veterans Affairs Low-Vision Visual Functioning
Questionnaire. Invest Ophthalmol Vis Sci. 2004:45(11):3919-
3928.
5. Colter SA, Scharrc IE. Optometric assessment: case history.
In: Scheiman M, Rouse M, Eds. Optometric Management o f
learning Related Vision Problems. St. Louis, MO: C.V. Mosbv;
1994.
r>. Korsch BM. Negrete VF. Doctor patient communication. Si r Am.
1972;227:66-74.
7. Sokol-McKav DA. Facing the challenge of macula degen­
eration: therapeutic interventions for low vision. 0 7 Practice.
2005;10(9>:10-15.
Й. Freeman P. Mendelson K. Believing Is Seeing: Hope for Those
Victimized by Macular Degeneration and Other Conditions
that Cause Low Vision. 1st ed. Pittsburgh, PA: Freeman and
Mendelson; 1996.
9. Graboyes M. Psychosocial implications of visual impairment. In:
Essentials o f Low Vision Practice. Brilliant R l, Ed. Boston. MA:
8 utterworth-Hei nemann; 1999:12-17.
10. Freeman PH. Jose RT. The Art and Practice o f Low Vision. 2nd ed.
Boston. MA: Butterworth-Heinemann; 1997.
11. Brilliant RL. Essentials o f Low Vision Practice. Boston: Butterworth-
Heinemann; 1999.
12. Wright V, Watson CR. team to Use Your Vision for Reading
Workbook. Lilburn. GA: Bear Consultants; 1995.
13. Greer R. Evaluation methods and functional implications:
children and adults with visual impairments. In: Lueck AH,
Fd. Functional Vision: A Practitioner's Guide to Evaluation and
Intervention. New York: American Foundation for the Blind;
2004.
14. Watson GR. Baldasare J, Whittaker S. The validity and clinical
uses of the Pepper Visual Skills for Reading Test. / VJs Impairment
H Blind. 1990;84:119-123.
15. Rowles GD. Beyond performance: being ir> place as a compo­
nent of occupational therapy. Am / Occup Ther. 1991;45(3):265-
271.
16. Warren ML, Lampert J. Assessing daily living needs. In: Fletcher
DC, Ed. Ophthalmology Monographs: Low Vision Rehabilitation:
Caring for the Whole Person. San Francisco. CA: American
Academy of Ophthalmology; 1999:89-125.
Section III

Treatment
 191
Overview of Treatment Strategy
M o d e l o f C are f o r Low
V isio n R e h a b ilita tio n
In Chapter 1, we reviewed our proposed model of
care for low vision rehabilitation and included a d is­
cussion o f the four terms for defining im pairm ent and
disability proposed by the World Health O rganization
(W H O ).1 This term inology is illustrated in Figure 9-1.
A disorder is an anatom ical deviation from normal
and can be congenital or acquired. Exam ples of visual
disorders causing low vision arc age-related m acular
degeneration (AM D), diabetic retinopathy, glaucoma,
and cataract.
Impairment is a loss or abnorm ality in function. The
im pairm ent can be either physiological or psychologi­
cal. Visual im pairm ents include decreased visual acu­
ity, reduced contrast sensitivity, central scotom as, and
constricted visual fields.
Disability refers to a restriction or an inability to
perform a task in the normal way. Examples are d if­
ficulty reading newspaper print, recognizing faces,
and driving a car.
Handicap is a disadvantage that prevents or limits
the fulfillm ent of a role that is norm al for the client.
Exam ples are the inability to work or engage in hob­
bies, and restricted social interactions.
In the low vision rehabilitation model presented
below, the ophthalm ologist and optom etrist are pri­
m arily interested in the disorder and impairment,
w hile the occupational therapist and other vision
rehabilitation professionals m anage the d isability
and handicap, although there may be overlap in some
areas.
Role of the Ophthalmologist
T h e role of the ophthalm ologist is to diagnose and
treat the eye disease. This might involve the use of
m edication or surgery. W hen it is clear that vision has
been perm anently impaired due to the eye disease,
the ophthalm ologist refers the client to a low vision
optom etrist for evaluation and treatment. In many
cases, optom etrists m anage diseases with medical
interventions as well.
Role of the Low Vision
O ptom etrist
T h e role of the optom etrist is to evaluate the patient
and determ ine w hether a change in the traditional
eyeglass prescription m ight be o f benefit. The low
vision optom etrist also perform s a detailed evaluation
of distance and near visual acuity, contrast sensitivity,
 Definition
Anatomical deviation from normal.
whether congenital or acquired
Loss or abnorm ality of function,
w hether phsyiological or psychologi­
cal
Restriction or inability to perform a
task in a m anner considered normal
Disadvantage that prevents or limits
fulfillm ent of a role that the indi­
vidual would consider normal
Figure 9-1. W o rld H e alth O rg a n iz a tio n te rm in o lo g y fo r im p a irm e n t a n d d isa b ility. W H O . International classification o f impair­
m ents, disabilities, a n d h andicaps: A manual o f classification relating to the con seq u en ces o f disease. G eneva: W H O ; 1980.
assessm ent of central scotom as, and peripheral visual
field. Based on the results of this evaluation and the
case history, the optom etrist begins the process of
determ ining the m agnification needs of the client for
various activities of daily living (ADL) and selects and
prescribes appropriate low vision optical aids. The
optom etrist then refers the client to the occupational
therapist for training in the use of the prescribe devic­
es in various ADL. A few ophthalm ologists specialize
in low vision rehabilitation .is well.
Although the scenario described above represents
current th in kin g about the interaction between the
optom etrist and occupational therapist, we suggest
that to provide optim al care for clients, the ideal work­
ing relationship could be modified as detailed in the
section below.
Role of the Occupational
Therapist
T h e role of the occupational therapist is to determ ine
the cognitive, psychosocial, and physical needs of the
client. The evaluation process described in Chapter 8
allows the occupational therapist to evaluate visual
and nonvisual client factors, history, roles, physical
environm ent, and occupational performance.
Based on the evaluation, the occupational therapist
designs a vision rehabilitation program to teach the
client how to function more effectively in ADLs in
spite of the vision loss. Rehabilitation includes edu­
cation about low vision, m anaging the psychosocial
issues, referral to com m unity resources, teaching the
client how to eccentrically view and read more effec­
Term Examples
D isorder Cataract, Age-related m acular
degeneration, Glaucoma
Visual acuitv
* loss
Im pairm ent
Reduced contrast sensitivity
w
Constricted visual field
Inability to read
D isa b ility
Inability to recognize faces
Inability to drive a car
H andicap Inability to work
Restricted social interaction
G iving up hobbies
tively, the use o f both optical and nonoptical assistive
devices in ADLs, and in som e cases sensory substitu­
tion. M anagement of lighting, contrast, and glare arc
also critical roles. The occupational therapist may
need to refer the client back to the low vision optom ­
etrist if he/she finds that the prescribed optical device
is not as effective as desired. O ther potential referral
sources include professionals such as the orientation
and m obility (O&M ) specialist, a psychologist or psy­
chiatrist, and the social worker.
O ther Vision Rehabilitation
Professionals
In Chapter 1, we described the background, edu­
cation, and history o f vision rehabilitation thera­
pists, O &M specialists, and teachers of the visually
impaired. Until 1990, these three professions supplied
all of the vision rehabilitation services in the United
States through the chronically underfunded blindness
system. This system has had to prioritize services gen­
erally favoring children and young adults of working
age. In addition, the limited num bers of rehabilitation
professionals in the blindness system prim arily tend
to work in m etropolitan areas. Thus, for many older
clients and for those not living in large m etropolitan
areas, low vision rehabilitation has not been readily
available through the blindness system .2 Teachers of
the visually impaired work with children and are not
involved in the care of the older client with low vision.
However, vision rehabilitation therapists and O&M
specialists w ill continue to be actively involved in low
vision rehabilitation of the older adult. Although these
two professions are unable to bill Medicare or other low vision. Social workers can participate in the
insurers directly for their services, in the spring of psychosocial assessment, and help assess the client's
2006 the Centers for Medicare and Medicaid Services coping and adaptation to the vision loss. Studies show
(CMS) initiated a 5-year Low Vision Rehabilitation that we can expect about one of three older adults with
Demonstration Project that w ill allow these two pro­ vision impairment to be clinically depressed.3’5 Thus,
fessions to provide these services under the supervi­ an important role for the social worker in rehabilita­
sion o f a physician. tion is to provide counseling services to these clients.
Thus, we can expect that in the traditional medical The social worker is also knowledgeable about com ­
settings in which occupational therapists currently munity and government resources as well as potential
work (acute care hospitals, rehabilitation hospitals, financial assistance. Providing guidance and educa­
long-term care facilities, home health, outpatient reha­ tion about these issues may lead to more effective
bilitation), occupational therapists will provide the adaptation and coping with the vision impairment.
bulk of the vision rehabilitation. In other settings,
such as private practices of ophthalm ologists and
optometrists, large eye clinics, and state-funded agen­ Low V ision R e h a b ilita tio n —
cies, occupational therapists, low vision therapists,
vision rehabilitation therapists and O&M specialists G e n e ra l C o n ce p ts
may compete as service providers. One strategy for
occupational therapists to avoid competition is to join
the ranks of these other professionals. Just as many Remediation
occupational therapists continue their education to
Professionals involved in low vision rehabilitation
become certified hand therapists, many occupational
know that the loss o f visual acuity and visual field
therapists have acquired a dual professional certifica­
is related to a disease process that is almost always
tion and become low vision therapists (see Chapter 16
irreversible. Although remediation may be an integral
for certification requirements).
part of physical, psychosocial, and cognitive rehabili­
A typical collaborative continuum of care would
tation, vision rehabilitation generally is not designed
be as follows. The occupational therapist would begin
to improve visual acuity or visual field. Rather, the
the vision rehabilitation process working in a medical
goal of the occupational therapist is to provide thera­
rehabilitation outpatient setting or home-care setting,
peutic intervention to enable the client to function
collaborating with a low vision optom etrist from a
effectively in spite of the presence of the disability.
distance. Often occupational therapists work in the
W hile this essential concept is well known by low
offices of low vision optom etrists as well, sometimes
vision professionals, clients with low vision often have
with other low vision therapists who are not occupa­
difficulty understanding and accepting this idea. In
tional therapists. As part of this initial intervention,
the client's previous experiences with blurred vision
the occupational therapist would cncourage the client
and other vision disorders, the problems were always
who meets eligibility criteria to apply immediately to
solved quite easily with a new set of eyeglasses. It is
state and regional blind associations and vocational
easy to understand the clients asking "W hy can't the
rehabilitation services, often staffed by vision rehabili­
doctor just prescribe stronger lenses?", or "W hy can't
tation teachers and O&M specialists. These agencies
the doctor just give me a different eye drop ?" This
and organizations often provide equipment and addi­
difficulty accepting the chronic nature of vision loss is
tional services as well. A client who has severe vision
one of the most significant obstacles to successful low
loss may benefit from Braille instruction and intensive
vision rehabilitation.6
instruction on blind techniques and would be best
Many clients spend years looking for a miracle
served by a vision rehabilitation teacher. A client
that will restore their vision and valuable tim e is lost.
who might require instruction on use of a white cane,
Studies show that vision rehabilitation tends to be
g u i d e d o g , o r m o b ility in s t r u c tio n sh o u ld bo referred
more successful when initiated soon after the vision
to a certified O&M specialist. As a result of such col­
loss and when visual acuity or visual field are not
laboration, the services available to a client with visual
too severely impaired/ There is no doubt that you
im pairm ent might be greatly extended and the costs
will encounter the frustration of clients who do not
o f assistive devices funded.
enthusiastically embrace your attempts at vision reha­
bilitation because they simply have not yet accepted
Role of the Social Worker the fact that the vision loss is permanent. In such situ­
The social worker can play an important role in ations, the role of the occupational therapist is to pro­
both the evaluation and treatment of the client with vide understanding, education, and guidance through
the stages of coping discussed in Chapter 6. O ne of
the most effective ways to deal with this issue is to
encourage the client to attend local support groups.
T h ese support groups not only have educational
presentations, but also provide opportunities for the
person to interact with other people who have lived
with low vision for m any years.
The one area where remediation is possible is read­
ing rehabilitation (see Chapter 10). Patients with low
vision generally struggle with reading, particularly
when the underlying disease affects the m acula and
causes a central scotom a. Effective reading is very
closelv*
linked to the ability to fixate
*
and m ake accu-
rate, rapid eye movem ents called saccades. Both fixa­
tion and saccadic ability are negatively affected after
m acular disease such as AMD. Studies demonstrate,
however, that in spite of the perm anent visual acuity
loss and central scotom a, reading speed and com pre­
hension can indeed improve, even though the visual
characteristics of the print or a p ersons visual acuity
does not improve. Indeed, as clients develop skills
in using their rem aining vision in functional tasks,
m any areas of visual perform ance improve consider­
ably w ith practice. Although some clients m ight claim
their vision improves, these improvements are likely
higher order perceptual changes or visual scanning
skills, not changes in basic sensory function such as
visual acuity, contrast sensitivity, or visual fields.
Com pensatory Approaches
Low vision rehabilitation has been successfullyУ
practiced for many years w ith an em phasis on com­
pensatory techniques. Com pensatory rehabilitation
strategies include the use of optical and nonoptica 1
devices; treatm ent of visual skills such as fixation,
eccentric view ing, saccades, and scanning; m odifica­
tion of the environm ent; and education. The research
supporting low' vision rehabilitation is reviewed
below.
Early Intervention Is Critical
O ne o f the kev
у factors in the success of low vision
rehabilitation is earlv у intervention.7 W hen treatment
is initiated earlier in the disease process, visual acuity
and visual field loss are generally less severe. With
better visual acuity, lower m agnification optical aids
can be prescribed and it is easier for clients to learn
how to use lower power devices because the work­
ing distance is closer to normal and the field of view
is wider. In addition, the use of nonoptical assistive
devices is more effective because less m agnification
is required and a wider variety of appropriate devices
are available. Sim ple rehabilitation strategies such as
organization of the environm ent, improved lighting
and contrast, and elim ination of glare are more effec­
tive in the early stages o f visual loss. Even if the client
eventually progresses to more serious vision loss, he
or she has already experienced success in low vision
rehabilitation and is more likclv to be motivated to
continue treatment. As a result, earlv ¥
intervention
encourages people to begin applying relatively easy
com pensatory techniques to m aintain occupations,
routines, and roles.
M cllw aine et al7 found that there was a relation­
ship between age and success w ith low vision aids. In
their study, there was a significant difference in use
of aids between clients less than 65 *years and those
greater than 65 years old. O ver one-third of clients
over the age of 65 never used their low vision aids,
compared w ith only one-sixth of clients under the age
of 65 years.7
J
The obstacle to early intervention, however, is that
many clients are not em otionally ready for rehabilita­
tion after initially sustaining visual loss.6 They may
still not accept that the vision loss is perm anent.
Patients often schedule appointm ents with other doc­
tors for additional options, hoping that there m ay be a
conventional way of restoring vision.
Determ ine Patient Goals
It is im portant to have the client actively involved
in development of the specific perform ance goals
of the treatm ent plan. T h is process actually occurs
during the low vision rehabilitation evaluation. As
we stated in Chapter 8, the objectives o f the occupa­
tional profile/case history part of the evaluation are to
gather inform ation about the client's vision and health
status, previous eyecare and low vision treatm ent, and
understand the client's functional ability у before the
vision loss to define his or her current goals. We sug­
gest the use of the Veterans A ffairs Low-Vision Visual
Functioning Q uestionnaire (VA LV V FQ -48).8 This
questionnaire not only m easures perform ance ability,
but can also be used to tailor rehabilitation program s
to m eet individual client needs.
O f course, it is im portant for the therapist to guide
the client through the process o f establishing goals.
Patients will typically require guidance because they
may not know what rehabilitation strategies are pos­
sible.9,10 Q uillm an and G oodrich state that people
with recent and severe vision loss m ay not have been
able to think about vision goals as yet.10 They state
that "It is never a good idea for a practitioner to set a
goal for a client; it is appropriate to help the client set
his or her own goals." Watson suggests using check­
lists or perform ance assessm ent system s to negoti­
ate betw een felt needs and ascribed needs.9 In some
cases, the client may be depressed and reluctant to
establish his or her own goals. In such cases, it is criti­
cal for the therapist to acknowledge that a significant

4 ■•■a
Figure 9-2. C lin ical reasoning process.
loss has occurred, w hile encouraging the client about
proper intervention and motivation. Much can be
done to help the client becom e more independent in
ADL.10 O nce the goals are established, the sequential
treatm ent program outlined below can be planned
and initiated.
Clinical Reasoning Process
The occupational therapist uses the results of this
four-part evaluation to develop a treatm ent plan,
w hich is described in detail in Chapter 8. We suggest
the clinical reasoning process illustrated in Figure 9-2.
Perform ance goal definition involves consideration of
occupational history, habits, roles and culture context,
dem and, and finally, the results of current occupa­
tional perform ance assessm ent.1 It is im portant to
define observable and m easurable perform ance goals
w ithin context, not in the clinic. For example, Ms.
Jones, a 72-year-old, w ishes to read a novel fluently
and com fortably in her favorite chair by the window.
O ne then refers first to evidence-based research and
then to clinical experience to ascertain the visual, cog­
nitive, and other physical requirem ents to perform the
goal task. In the case of Ms. Jones, the visual require­
ments for fluent reading are presented in Chapter 10.
O ne then considers context, social and environm ental
context, visual function, motor skills, cognitive and
com m unication skills in order to define perform ance-
lim iting factors. Perform ance-lim iting factors may
include environm ental com ponents (available print
size) and client factors (visual acuity). In the case of
Ms. Jones, the evaluation o f visual and nonvisual fac­
tors reveals inadequate visual acuity to read the 1.2 M
print novels, and mild contrast sensitivity im pairm ent
also lim its reading perform ance. In addition, she has
no social support and has a severe hearing im pair­
ment. The proposed treatm ent plan addresses the
lim iting factors by physical and social environm ental
m odification and prescription and instruction to use
assistive devices. In the case of Ms. Jones, the treat­
ment plan includes m oving the ch air or shading the
window to elim inate glare, adding a task light, con­
sideration of regular size and large print books, and
referral to a low vision optom etrist for recom m ended
trial optical m agnification devices to try in order
to read 1.2 M (regular print) and 2 M (large print).
The treatment plan includes instruction first under
controlled clinical conditions with different devices
and finally in a sim ulation of her home context, w ith
a report and recom m endations for a final device pre­
scription.
S eq u en tia l T reatment
A ppr o a c h
The seven-step sequential treatm ent approach for
low vision rehabilitation is sum m arized in Table 9-1,
and each phase of this treatm ent approach is described
in detail in Chapters 10 through 15.
Recall that m any clients begin therapy skeptically
and need to be convinced o f the value of therapy. The
therapist should always begin the rehabilitation pro­
gram with a careful discussion of perform ance goals
and, if possible, dem onstrate to the client that achieve­
ment of a perform ance goal is possible. Som etim es
this might be done during an initial evaluation. The
therapist w ill spend tim e discussing the client's par­
ticular eye disease and the expected course o f the
disease, but care must be taken not to discourage the
client. The goal is to encourage the client to focus on
the end, a perform ance goal, rather than the means.
For example, a client with AM D might hope for the
day when she will be able to read mystery novels
again. This client is expecting to read visually. A s will
be discussed in Chapter 10, fluent visual reading is
 Table 9-1.
Vision Rehabilitation: Seven-Steo Seauential Treatm ent Plan
Education
Nature of eye disease
O utlook for the future
Expectations of vision rehabilitation
Therapeutic Activities
Eccentric Viewing
Scanning
Reading skills
Environmental Modifications
Lighting
Contrast
G lare
usually not possible with AMD, although spot read­
ing is possible after considerable instruction. In the
first session, one m ight introduce the client to a tape
recorder and an audiotape from Recordings for the
Blind (a free service) as a place to start, em phasizing
that norm ally sighted people use books on tape and
that with rehabilitation she will likely read again but
it will be very difficult at first. The therapist might
also show the client how to perform a simple cook­
ing activity, dial a phone, or find the right cell in her
m edication dispenser— a task that requires little or no
vision to perform.
A large percentage of the clients seen in vision
rehabilitation have A M D and, therefore, have a central
scotom a. W hen dealing with a client with a central
scotom a, it is best to begin therapy with eccentric
view ing techniques. O nce the client is comfortable
with eccentric view ing, he or she can use these skills
throughout the rest of the rehabilitation.10 Eccentric
view ing, scanning, eye movement training, and read­
ing skills training are covered in depth in Chapter 10.
O ne o f the easiest and most econom ical treat­
m ent approaches is the use of environm ental m odi­
fications. A client can often achieve substantial gains
w ith improved lighting, contrast and elim ination of
glare. Therapists will need to evaluate these aspects
of the client's environm ent, educate the client about
the im portance of optim al lighting and contrast,
and then dem onstrate the possible im provem ents by
m aking appropriate changes. O ther strategies, such
as changing the working distance and enlarging
Nonoptical Assistive Devices
Visual
Tactile
Auditory
Optical Magnification
Computer Technology in Low Vision Rehabilitation
Resources/Handouts
target size, are used in this phase o f the rehabilita­
tion. These approaches are described in Chapter 11.
If one is providing services in an outpatient setting,
at least one home visit early in the treatm ent is highly
recom mended not only for treatm ent planning, but
also because several simple home m odifications can
be highly effective and easy to implement. O ne often
finds that removing glare and seating a client closer
to the TV will easily enable one perform ance goal to
be met.
O ccupational therapists just becom ing involved in
the field of low vision are som etim es intim idated bv
the need to develop a knowledge and understand­
ing of low vision optical devices. New terminology,
an understanding o f optics, and the impression that
there are so many aids available can potentially cre­
ate an obstacle to getting involved. WTe feel that it is
im portant to understand that the use of low vision
optical devices, although very im portant, is just one
aspect of low vision rehabilitation. In m any cases,
very sim ple environm ental m odifications and the use
of nonoptical assistive devices can be of great benefit
to a client. These nonoptical assistive devices include
visual devices and also devices that utilize sensory
substitution, such as tactile and auditory assistive
devices. O ccupational therapists should acquire the
various catalogs that are available and include a wide
variety of available nonoptical assistive devices. This
topic, along with inform ation about resources, is cov­
ered in Chapter 12.

Optical Magnification
The use of optical m agnification is, of course, criti­
cally important in low vision rehabilitation. Almost
all clients with low vision will be able to perform bet­
ter with the prescription of appropriate optical aids.
These aids will typically be prescribed by the low
vision optometrist. In the ideal professional environ­
ment, however, the occupational therapist will also be
involved in the early phase of selection of optical aids.
The occupational therapist can assist in this process
by providing critical information about the clients'
ADL problems and goals. If the client has other physi­
cal problems that could interfere with the use of some
types of aids, the therapist can make suggestions
about optical aids selection based on these needs as
well. Chapter 13 covers this topic.
just as computer technology has become impor­
tant in so many aspects of our lives, it is also gaining
importance in the field of low vision rehabilitation.
Every year, more elderly present in the clinic with
premorbid fam iliarity w ith computers. For some,
computer use is as fam iliar an activity as cooking.
Once a specialty skill, every low vision therapist now
needs to understand how to adapt computers for use
by people with low vision. Computers themselves
have become important assistive devices that enable
shopping, leisure, and functional written com m unica­
tion regardless of the level of vision loss. This genera­
tion will want and need to continue using computers
and will feel com fortable with computer-assisted
technology for low vision rehabilitation. Thus, the
use of computer technology will become a vital part
of the sequential rehabilitation treatment plan and is
described in detail in Chapter 14.
Review o f R e s e a r c h o n Low
V ision R e h a b ilita tio n
Research studies have been published report­
ing on the effectiveness of low vision rehabilitation.
However, this research has been impeded by a lack of
standardized measurement tools, and a lack of quality
research.11-12 Some of the design flaws in the available
research include retrospective design, lack of placebo
groups, the use of unmasked exam iners, lack of stan­
dardized measurement tools, and sm all sample size.
Most of the available research is limited to investiga­
tion of the use of low vision aids with limited train­
ing sessions,7'13'14 and the use of low vision aids with
additional training.15- ’ Few studies have reported
on the benefits of other services such as occupational
therapy and O&M training.2425 O ne study reported
on the effectiveness of a self-management interven­
tion program for clients with AMD.26
An interesting problem when designing research
to study the effectiveness of low vision rehabilita-
tion is what to use as an outcome measure, or how
to measure the effectiveness o f treatm ent Various
strategies have been used, including measurem ent of
reading speed,ч-1л1‘Л23 duration,15'19 and com prehen­
sion;19 adm inistration of questionnaires that assess
quality of life;20'21'23 compliance with the use of low
vision aids;7' 13'14'22,26 satisfaction with treatm ent;7'1*’-18
independence in A D L;13'20'21'24'26 and psychological
adjustment to vision loss.20'26 Even among studies that
have used questionnaires as outcome measures, the
actual questionnaires have differed from one study to
another. These significant variations in study design
are problematic and make it challenging to compare
the results of one study to another. Nevertheless, the
research that is available generally suggests that low
vision rehabilitation is indeed beneficial and allows
clients to read faster and for longer periods of time,
and leads to improvement in independence in ADL
and psychological adjustment to the vision loss.
There are numerous studies that demonstrate that
the use of low vision aids is helpful when actually
used by clients.13'19'22*24 O f critical importance, how­
ever, is the finding that many clients either never use
the low vision aids that have been prescribed or fail
to use them properly. Hum phry27 studied a sample
of visually impaired clients who received low vision
devices with no training and found that 75% reported
that they never used them. Another study7 found
that 33% of clients who were prescribed aids without
training never used their devices. Training or rehabili­
tation designed to teach clients how to use prescribed
aids in ADL may, therefore, be an im portant com po­
nent of low vision rehabilitation.
The outstanding question is one o f dosage. How
many therapy sessions are necessary? The number
of training sessions required to achieve m aximum
effectiveness is an im portant question because o f its
implications for healthcare costs. Several studies have
been designed to compare limited to more exten­
sive training.7'15' 19-2* Goodrich et a l19 performed two
experim ents and all clients received eccentric view­
ing training before starting the research. In the first
experim ent, they found that five sessions o f optical
device training were as effoctivc in im proving reading
speed as 10 sessions of training, and seven sessions
of training to read with a CCTV were as effective as
15 sessions. In the second experim ent, they compared
very short training typically used in private practices
(one session of optical device training) to five sessions,
and two sessions of CCTV training to seven sessions
of CCTV training. In this study, the shorter number
of sessions was not as effective as the longer treating
approach for improving reading speed. They con­
cluded that extended training sessions beyond what
is typically provided in private practice is beneficial
for the rehabilitation of reading ability in clients with
central vision loss. However, they also found that a
moderate am ount of training (five sessions versus 10
sessions w ith optical aids, and seven sessions versus
15 sessions with a CCTV) w as as effective as longer
am ounts of training. A problem w ith this study was
that the outcom e exam ination was not performed by
a masked exam iner. A sim ilar study was performed
com paring 1 hour to 5 hours of low vision device
training.24 The outcom e m easures were reading speed
and accuracy and quality of life m easures. T h is study
also used an unm asked exam iner who knew the
clients' treatm ent assignm ents. They found that the
extended training tim e made a significant difference
in reading ability as w ell as the clients' perceptions of
the quality of their lives.
In contrast to these studies, a random ized clinical
trial with m asked exam iners was performed com ­
paring the effectiveness of conventional low vision
rehabilitation, conventional low vision rehabilitation
enhanced w ith home training sessions, and a control
group.20 The conventional low vision rehabilitation
included dem onstration of low vision aids, use and
handling of low vision aids, advice about lighting,
providing large print m aterials w ith inform ation
about lighting, use of low vision aids, and other
services. The enhanced group also received this
basic care plus three home visits from a rehabilita­
tion therapist. D uring these visits, the rehabilitation
therapists provided additional training with the low
vision aids, dem onstrated additional or alternative
low vision aids, and provided additional client sup­
port. Patients assigned to the control group received
the sam e conventional care plus three home visits
from a com m unity care worker. This individual did
not provide any low vision rehabilitation. Instead he
o r she discussed the client's ability to cope w ith daily
activities, leisure activities, and any other problems
raised by the participant. The trial found no evidence
o f benefit from enhanced low vision rehabilitation.
T h e authors conclude that researchers should be cau­
tious about advocating m odified or supplemental
interventions w ithout more in-depth evidence of their
effectiveness.
La Grow21 also com pared traditional com m unity-
based treatm ent from private optom etrists or ophthal­
m ologists to enhanced treatment. The enhanced or
com prehensive treatm ent consisted of train in g in the
use o f low vision aids (1.5 to 2 hours) and nonoptical
assistive devices. The results revealed no significant
differences betw een the two groups on visual fu nc­
tion questionnaires, quality of life questionnaires, and
m easures of independence in ADL.
Thus, there is no consensus at this point in the lit­
erature about the benefits of additional training visits
and more research is necessary to clarify this issue.
Nevertheless, conventional wisdom suggests that cli­
ents are more likely to use prescribed optical aids and
perform more effectively in ADL when they receive
additional rehabilitation from a low vision therapist.
Because occupational therapy has only recently
becom e involved in the field of low vision rehabilita­
tion, there is lim ited research in which occupational
therapists played a significant role in the treatm ent.24
A study conducted at the M assachusetts Eve & Ear
Infirm ary tested the hypothesis that vision rehabilita­
tion using optometry, occupational therapy, and social
work services increases clients' functional ability. The
study also investigated whether involving fam ilies
in the intervention resulted in more successful out­
comes. N inety-seven subjects w ere studied and were
randomized into either individually focused or fam ily
focused intervention. Table 9-2 lists the services pro­
vided by each profession.
All clients received the services listed in Table 9-2.
For those clients assigned to the individual protocol,
their family m em bers were excluded from all sessions.
Rehabilitation intervention focused solely on the cli­
ent. If the fam ily had questions, these were answered
in the w aiting room or hallw ay as the clicnt was
entering or leaving the service. In contrast, the fam ily
focused group had fam ily m em bers included with
the clicnt in all stages of the rehabilitation process. A
functional assessm ent questionnaire and a functional
vision perform ance test were used to m easure the
outcom e of the study.
T h e re su lts o f th e stu d v
J d e m o n stra te d th at a v isio n
rehabilitation plan involving optometry, occupational
therapy, and social work services increased the client's
level of function as m easured by both an objective
observation of perform ance of daily tasks and a self-
report of difficulty and independence in perform ­
ing ADL and social activities. The gain s in function
applied to even predom inantly frail elderly clients.
The study did not support the hypothesis that fam ily
involvement in vision rehabilitation increases the level
of functional improvement.
Summary
This chapter presented an overview o f the seven-
step sequential treatm ent plan for vision rehabilitation
as well as a review of the research on the effectiveness
of low vision rehabilitation. There is an urgent need
for additional research to study the im portance and
effectiveness of occupational therapy intervention for
low vision im pairm ent. This need should be a priority
for the profession o f occupational therapy.
 Overview o f Treatment Strategy 143

____________________Services Provided by Profession______________________

Optometry Services
• History
• Assessm ent of visu al acuity, contrast sensitivity, visual field, color vision, glare
sensitivity, refraction
• Recom m endations for rehabilitation
• Education and em otional support
• D eterm ination of optical and nonoptical system s
• Follow-up to ensure progress

Occupational Therapy Services

Evaluation and training in:
• Prescribed optical devices
• Nonoptical devices
• Adaptive techniques
• Environm ental m odifications
• Vision substitution techniques
• System atic organization
• Energy conservation
• Work sim plification
• Postural alignm ent
• Joint protection

Social Work Services

• Psychosocial assessm ent
• Supportive counseling
• Referral to com m unity services
• Registration with state agencies
• Referral for financial assistance
• Advocacy

Adapted from McCabe P, Nason F, Demers Turco P, Friedman D, Seddon |M el al. Evaluating (he effectiveness of a vision rehabilitation
intervention using an objective and subjective measure of functional performance. Ophthalmic Epidemiol. 2000;7(41:259-270.

•1. Rovner BW, Zisselman PM. Shmuelv-Dulitzki Y. Ltepression

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2 Warren M. An overview of low vision rehabilitation and the
role of occupational therapy. In: Warren M, Fd. tow Vision
Occupational Therapy Intervention With the Older Adult.
Bethesda, MD: American Occupational Therapy Association;
2000:3-21.
3. Brody BL. Gamst AC. Williams RA, et al. Depression, visual
acuity, comorbidity, and disability associated with age-related
macular degeneration. Ophthalmology. 2001;108(10):1893-
1900; discussion 1900-1901.
and disability in older people with impaired vision: a follow-up
study. / Am Geriatr Soc 1996;44<2>:I8I-184.
5. Rovner BW, Casten Rl. Tasman WS. Effect of depression on
vision function in age-related macular degeneration. Arch
Ophthalmol. 2002;120(8):1041-1044.
6. Graboyes M. Psychosocial implications of visual impairment. In:
Brilliant RL, Ld. Essentials o f lo w Vision Practice. Boston, MA:
Butterworth-Heinemann; 1999:12-17.
7. Mcllwaine G G , Bell |A. Dutton G N . Low vision aids: is our ser­
vice cost effective? Eye. 1991;5:607-611.
8. Stelmack |A, Szlvk |P, Stclmack IR, et al. Psychometric prop­
erties of the Veterans Affairs Low-Vision Visual Functioning
Questionnaire. Invest Ophthalmol Vis S<i. 2004;45( 111:3919-
3928.
 9. Watson GR. Older adults with low vision. In: Corn AL. Koenig
Al, Eds. Foundations o f lotv Vision. Clinical and Functional
Perspectives. New York: American Foundation tor the Blind;
2000:363-390.
10. Quillman RD, Goodrich GL. Interventions tor adults with
visual impairments. In: Lueck AH, Ed. Functional Vision: A
Practitioner's Guide to Evaluation and Intervention. New York:
AFB Press; 2004:423-474.
11. Stelmack |. Emergence of a rehabilitation medicine model for
low vision service delivery, policy, and funding. Opfomefry.
2005;76<5>:318-326.
12. Vision rehabilitation: care and benefit plan models. Literature
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13. D'Allura T, Mclnernev R. Horowitz A. An evaluation of low
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15. Goodrich GL, Mehr EB. Quillman RD. Shaw HK, Wiley
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16. Nilsson UL, Nilsson SE. Rehabilitation of the visually handi­
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University of Linkoping. Doc Ophthalmol. 1986;62<4):345-367.
17. Nilsson UL. Visual rehabilitation of patients with advanced
diabetic retinopathy. A follow-up study at the Low Vision Clinic,
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Ophthalmol. 1986;62(4»:369-382.
18. Nilsson UL. Visual rehabilitation with and without educational
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 Foundation Skills and
Therapeutic Activities
C om pensating f o r C entral
F ield Loss
This chapter includes the foundation skills for low
vision rehabilitation. In Chapter 9, we stressed the
general rule th.it rehabilitation for vision impairment
is not remedial. Low vision rehabilitation improves
performance of activities that typically depend on
vision, rather than improve vision itself. The one
important exception to this rule is the area of reading
and localization of objects in space. Clients with low
vision generally struggle with reading, particularly
when the underlying disease affects the macula and
causes a central scotoma. Clients with peripheral field
loss or unilateral field loss struggle with spatial local­
ization, finding and localizing objects in their im m e­
diate surroundings, and avoiding tripping hazards.
Effective reading and scanning of one's environment
is very closely linked to the ability to fixate and make
accurate, rapid eye movements called saccades. One
often must relearn saccade control and scanning in
order to recover reading and localization of objects in
space. Studies demonstrate, however, that in spite of
the permanent visual acuity loss and central scotoma,
a person can learn to fixate more accurately and make
more accurate saccades after vision rehabilitation.
Thus, reading and localization of objects in space
can indeed improve after vision rehabilitation as the
client learns to more effectively use the rem aining
vision. This chapter is designed to present a system ­
atic approach to rehabilitation of eccentric viewing,
fixation, scanning, and reading and is the second
step of the seven-step sequential treatment approach
for low vision rehabilitation that was sum m arized in
Table 9-1.
In occupational therapy, occupation is used as a
means for developing necessary foundation skills and
abilities. For example, reading and finding an object
in a store provide engaging activities that help build
foundation visual scanning skills for other activities
as well. In occupational therapy, the development
of m eaningful occupation is not only a means, but
an end, the ultimate outcome. Towards this end, the
occupational therapist will readily consider nonvisual
as well as visual solutions to enable som eone to enjoy
a book or find som ething in a store.
Central Field Loss and M acular
Degeneration
Macular degeneration ranks as the most common
cause of low vision in developed countries.1 As the
disease progresses to the end stage, m acular degen­
eration usually restricts dam age to the central visual
field, the macula and imm ediately surrounding area,

A C e n tra l F ixation
I Learning Eccentric Viewing
в E c c e n tric V iew ing
Figure 10-1. A . Illustration of central view ing. B. Eccentric
view ing vv/ Noillson technique ndded. Th e letter 'A" is the
fixation target and the cross indicates the scotoma center
(Steinman).
creating a central scotom a. A scotom a is a “blind spot,"
an island in the visual field with reduced or no vision
that is surrounded by better vision. T h e central por­
tion of our visual field, the m acula, com prises the
central 15 to 20 degrees of visual angle, an area about
tw ice the width of a fist at arm 's length.1 With m acu­
lar degeneration, this central region is damaged and
creates a central scotoma surrounded by functioning
more peripheral retina. Investigators have measured
scotom a sizes to about 30 degrees,2 an area about the
size o f three fist widths. In addition to m acular degen­
eration, central field loss also occurs w ith untreated
d iab etic retinopathy and cortical blindness. With
these conditions, the central field loss m ight be larger
than the central field loss associated with m acular
degeneration.
There are tw o types of m acular degeneration. With
the exudative (wet) type of m acular degeneration,
retinal sw elling m ight distort the shape of objects
being viewed and the person might have multiple
scotom as or islands of vision rather than one large
central scotom a. W ith exudative m acular degenera­
tion, onset of vision loss occurs suddenly w ith more
extensive vision loss at first due to hem orrhaging at
the retinal level. As blood in the vitreous dissipates,
the m easured scotoma will stabilize and shrink and
contrast sensitivity will improve somewhat. Atrophic
(dry) m acular degeneration usually begins with a
relative scotoma, ie, an area of reduced visual acuitv.
*
This area gradually increases in size and density,
allow ing the affected individual to adapt to loss of
central vision. In some cases, people will experience
active hallucinations in the scotom a, referred to as
the Charles Bonnet syndrom e.3 Medical treatm ent for
m acular degeneration due to retinal pathology, at best,
slows the progression of the disease; rarely is vision
improved.1 The functional problem s associated with
central field loss, however, have responded well to
rehabilitation interventions.
Vision loss is usually restricted to a relatively small
percentage of visual field; however, unm anaged m ac­
ular or central field loss severely disables perform ance
of most visual tasks that require resolution of detail,
such as reading, finding objects in a room, or recogniz­
ing a face. T h is is because the m acula represents the
region of our retina that provides the best resolution
of detail and color. Som eone with a m acu lar scotoma
often does not visualize the scotom a as a dark spot
and may not even be aw are of a central blind spot. For
example, som eone might see a person norm ally in his
or her peripheral vision, then look over at the person
only to find that the face, or part of the face seem s to
disappear. Indeed, people with recent onset central
field loss often com plain that "th in gs appear and d is­
appear." If the m acular problem is left unm anaged,
reading becom es impossible, as even w ith magnified
text, words or parts o f words appear and disappear.
Not surprisingly, nearly one out of four o f those with
this frustrating and confusing im pairm ent develop
clinically significant depression.4 '
Several studies and clinical experience indicate
that a person with central field loss can learn to use
his or her peripheral vision rather than central vision
to view objects (Figure 10-1). Research indicates that
people who have adapted to central field loss will
prefer to use one or more patches of functioning retina
outside of m acula called Preferred Retinal Loci or
PRL.8' 1-'’ Som eone using a PRL rather than the fovea
will appear to be looking above, below, or to the side
of a target rather than directly at it. M any use the
term s eccentric viewing or eccentric fixation to describe
how a person's eyes appear when h e or she uses a PRL
(eccentric m eans "off center"). Learning to use a new
 Table 10-1.

______________Eccentric Viewing (EV) Instructional Sequence_______________

1. Scotoma awareness training, and evaluation of scotoma and eccentric view ing skills.
2. If no or inconsistent eccentric viewing. Eccentric viewing training with central fixation cue that is faded
out and replaced with verbal cues.
3. If consistent eccentric viewing. Verify client can shift eccentric view ing positions with verbal cues.
4. Eccentric viewing training under natural viewing conditions—without central fixation cue. Identify the
best eccentric viewing position.
5. Patient ready for device evaluation and prelim inary recommendation by optometrist.
6. Reading training with the scrolling technique and introduction to m agnification device.
7. Final prescription of m agnification device— home program with device.
8. Tracking with and without a handheld device.
9. Scanning without optical devices.
10. Finding the best eccentric view ing position.

patch of retina to see som ething develop is much like
relearning a tennis or golf swing after many years of
using another technique. Learning the new task is
conscious and clum sy at first, becoming automatic
and smooth later after considerable practice with feed­
back. At first, if someone sees som ething to the side
and quickly looks directly at it using the fovea, it will
disappear. With practice, people with central field loss
will learn to directly look at som ething using the PRL,
but not as quickly or efficiently as someone with intact
central vision.16 People also can learn to use different
eccentric view ing positions that optim ize vision for
different conditions.1■
Instructional protocols have been shown to rather
quickly and effectively teach a person with central
field loss to develop a PRL that substitutes for loss
central retinal function.18*20 These instructional pro­
cedures have improved functional reading as well as
clinical measures of viewing performance. The meth­
ods described below are a blend of those reported by
Nilsson with methods developed by Gale Watson21-22
and personal clinical experience. How the therapist
teaches eccentric view ing depends on the client's level
of skill when started, as many learn some eccentric
viewing without instruction. These steps are sum m a­
rized in Table 10-1.
Scotoma Awareness Instruction
an d Evaluation o f Vision and
Skills
The first and most important step in eccentric view­
ing training has tw o objectives. The first objective is to
determ ine if the client has already developed adaptive
eccentric view ing or still has nonadaptive central fixa­
tion. The second goal is to teach the client to become
aware and in some cases visualize the central scotoma.
As this instruction is best done by demonstration, the
therapist can instruct the client and evaluate eccentric
viewing and scotoma size at the sam e time. T h e client
also requires education regarding the expected prog­
nosis and reassurance that by learning a new way of
looking at things, vision will once again become more
predictable, although m agnification will be required
to read and recognize faces and TV again. Learning
to eccentrically * fixate is difficult and can be frustrat-
ing. Care must be taken to carefully grade activities to
insure early success, to be positive, and to keep train­
ing sessions short.
O ften the visual system "fills in " the central
scotom as; the person with a central scotoma cannot
see the blind area but can be instructed to become
aware of it. W hen asked to look at a target "so you can
see it clearly," the beginner who has not yet developed
eccentric view ing will tend look directly at the target
and it will disappear, but he or she can still see objects
to the side. Scotoma awareness training requires dem ­
onstration com bined with explanation. At the end of
scotoma awareness training, the client should be able
to describe the shape of his central blind spot and why
things appear and disappear. At the end of eccentric
view ing training, the client will voluntarily move the
blind spot to m ake isolated targets disappear as well
as to position his eye to see an object most clearly.
The client who has developed eccentric view ing will
be able to position the eye eccentrically, that is look­
ing above, below, or to the side so the target that is
straight ahead can be visualized. One case that illus­
trates this skill involves an attractive young woman
who had adapted to a juvenile macular degeneration
she acquired at age 16. She described one advantage
of m acular degeneration: at a party she could m ake
unattractive guys “go aw ay" just by looking at them,
w hile chocking out the cute ones from the “corner of
her eye." O ne might say she had m astered scotoma
awareness.
There arc several m ethods to approach scotoma
aw areness training. We describe tw o useful proce­
dures, the tangent screen and clock face methods.
Ideally, instruction should include both techniques.
The clock face method is quickly adm inistered; the
tangent screen m ethod might require approxim ately 5
m inutes. Early in the instructional sequence, a larger
tangent screen is required and m ay not be practical in
a hom e-based therapy setting.
The C lock Face M e th o d
Wright and Watson developed m ethods available
in a workbook that provides excellent worksheets
and resources for eccentric view ing instruction.21 The
clock face method involves the use of a picture of a
clock (Figure 10-2) w ith a star at the center of the clock.
T h e therapist tells the client to "look at the center of
the clock so that you can see it." If the client still has
central fixation tendencies, the client will report that
center star w ill disappear and that all of the num bers
can be seen. If the client cannot see the num erals, the
therapist can move the clock closer until the numeral
shapes can be seen, or use a larger picture of a clock.
If the client has developed eccentric view ing, when
asked to describe the shape at the center of the clock,
the client w ill report that a star can be seen but that
som e o f the num bers are m issing. The m issing num ­
bers w ill indicate the location of the scotoma and
direction of eccentric view ing. For example, if the
num bers 2, 3, and 4 are m issing, the client is eccentri­
cally fixating to the right (see Figure 10-2). If all of
the num bers can be seen and the client reports seeing
the star, then one of three possibilities exist. O ne is
that no scotoma exists. The most likely option is that
the client is not steadily fixating; rather, the client is
looking around with searching eye movements. The
therapist should carefully observe the client's eyes to
insure view ing is stable. If the client has steady view­
ing, the third possibility is that the scotoma m ight be
sm all or might be a relative scotom a (reduced central
vision but enough vision to see shapes). In this case,
the therapist moves the clock fu rther away until the
client reports that the star fades from view (central
fixation) or som e num bers disappear (eccentric view­
ing). D uring this testing, scotoma aw areness train­
ing involves explaining to the client about the center
"blind sp ot" and pointing out how it can be moved by
looking in different directions.
The T angent Screen M e th o d
The tangent screen method (see Figure 10-3 and
Chapter 8) also can be used to com bine central field
testing and eccentric view ing evaluation w ith scotoma
awareness training. The view ing target is usually a
letter large enough for a client to recognize in the cen­
ter of a felt board. The tangent screen method involves
first positioning the view ing target in the center o f the
1-meter square tangent screen. The letter is placed in
the center of a large cross. The client is instructed to
“look at the letter so that you can see it most clearly."
With a large screen, the therapist is able to sit or stand
betw een the client and the screen to carefu lly observe
the client's eyes. The client who has not developed
eccentric view ing and is still centrally fixating will
fixate the center of the cross and report that the letter
disappears. The person with adaptive eccentric view­
ing will report that she sees the letter in the center of
the cross and if the scotoma is large, eccentric view ing
should be evident by looking at the eyes. If the client
generates random searching type movements, gently
instruct the client to “look directly at the center of the
cross— don't worrv J
about the letter." If the client cen-
trally fixates the cross, the letter will disappear into
the scotoma.

If the client has nonadaptive central fixation, while
the client continues to fixate and position the scotoma
in the center of the cross, move a dot attached to the
end o f the wand away from the center until the client
sees it (Figure 10-4). Mark the spot where the wand
dot "appears" w ith a pin, and then start at the center
and quickly move to the edge of the scotom a in all
directions. The pins should be sm all or low contrast so
they are not visible. O nce all of the pins are in place,
a thick high-contrasl yarn can be placed around the
pins to illustrate the size and location of the scotoma.
Individuals w ho have had central field loss for
several m onths or more may have already started
developing eccentric view ing. The client who has
already developed stable eccentric view ing will posi­
tion the eyes to be looking above, below, or to one
side of the letter and the client will report seeing the
whole letter. The client may also move his head. The
therapist should be able to predict w here the scotoma
is expected to be located based on where client's eyes
appear to be looking, observing the eyes and not the
head because often the head is moved in the d irec­
tion opposite to the eyes. Based on this prediction,
Figure 10-3. Tangent screen method. The E
is the eccentric view ing target. The client is
looking at the center of the cross, the central
fixation cue. Th e clicnt reports w hen the dot
stimulus at the end of the w and appears and
disappears. O ften the cross is eliminated to sim ­
plify the task visually.
Figure 10-4. A . Tangent screen
w ith scotoma w ith central fixa­
tion. B. U pward view ing w ith
w ord stimulus w ithout a central
fixation cue. C . U pw ard view ing
w ith a central fixation cue.
the therapist moves a white testing spot at the end of
a long black wand to where the client appears to be
looking (see Figure 10-3). It is essential that the thera­
pist carefully watch the client's eyes to be sure that he
does not move during this procedure. W hen the white
wand dot enters the scotom a, the client w ill report that
it disappears. Explain to the client that you have found
the scotom a and that you will now be m easuring how
large it is. Move the wand dot until it is first seen and
mark the edge of the scotoma w ith a low-contrast
mark or pin (not visible to the client). Q uickly move
from nonseeing to seeing and mark the border o f the
scotoma so that it is mapped in a couple of minutes.
The outline of the scotoma should be above, below',
or to the side of the letter indicating the direction of
eccentric view ing and the size o f the scotoma.
It is not unusual for a client with eccentric view ing
to shift eye position, for example, from looking above
to looking below the view ing letter. The therapist can
detect these shifts by looking at the eyes and not­
ing inconsistency in where the target is seen on the
screen. If this occurs, illustrate the new location of the
scotoma by positioning the white spot in the scotoma's
new location. This dem onstrates to the client that the
scotom a moved. Gently coax the client back to his
original position and com plete mapping. W hen the
scotoma is mapped, more clearly mark the edges (with
white yarn wrapped around the push pins in the felt
board) and have the client move his eyes to see the
outlined scotoma.
Eccentric Training With a
C entral Fixation Cue
This phase of instruction should be done w ith cli­
en ts who have not developed adaptive eccentric view­
ing (see Table 10-1). The purpose of this instruction
is to teach the client to look in a particular direction
above, below, or to the side of a target, ie, to eccentri­
cally fixate in order to sec a target that is positioned at
the center of the screen. Note that to avoid confusion
we use the term eccentric viewing target as the word or
shape that the client is tryin g to see using eccentric
view ing. The term central fixation cue refers to targets
used to encourage the client to look in a particular
direction. Central fixation cues are used w ith begin­
ners who have not yet developed eccentric view ing,
and still tend to look directly at objects using the
m acula even though the m acula no longer functions.
T h e central fixation cue is used in conjunction with
an eccentric view ing target to stim ulate the client to
position the eyes in a particular direction so that the
client m ight better sec the eccentric view ing target.
For example, when asked to identify the letter E on
the screen, the beginner will tend to look directly at
it and w ill report that the E disappears. To encourage
eccentric view ing, the therapist asks the client to look
at the cross above the E using a large cross as a central
fixation cue. W hen the client then looks at the cross,
the center of the cross disappears, but the E now can
be visualized and recognized using eccentric view ing
(Figure 10-4C). Since the client intends to identify the
letter E, it is an eccentric view ing target. T h e cross
is a central fixation cue. Note that clients who have
becom e well adapted to a central scotom a will auto­
m atically
w eccentrically
#
fixate even if instructed to look
directly at a target.
C lock Face M e th o d
T h e client is asked to first look at the center of the
clock w here a star is positioned. If the client tends to
centrally fixate, then the client will report the center
star disappears. The clock distance should be posi­
tioned so the shapes of all of the num bers can be seen,
bringing it closer if the num bers cannot be seen. The
therapist then directs the client to "look a t" differ­
ent clock num erals; the clock num erals act as central
fixation cues. W hen the client directs central fixa­
tion to a num eral, he should report that the numeral
disappears and the center target appears. Using the
disappearing num erals on a clock face for feedback,
the client becom es aw are of the direction of eccentric
view ing as well as how to control the scotom a position
in order to see the central star.
Now ask the client which num erals can be seen
most clearly w hile he fixates at the m iddle of the clock.
This report indicates the area if the retina w ith best
visual acuity. M oving the eye in the direction opposite
to the numeral most easily seen (area of best vision)
will bring the retinal locus o f best vision to the center
and the star or shape in the center of the clock will be
seen most clearly (see Figure 10-2). Again, note that
the therapist needs to vary the distance o f the clock
face from the eye depending on the expected size of
the central scotoma. For those with better vision and
a sm aller scotoma the clock should be held further
away.
Tangent Screen M e th o d
Frennesson, Jakobsson, and N ilsson2-* described a
different method that is well-suited for a person in the
early stages of adaptation with a strong tendency to
centrally fixate. T h is method keeps the eccentric view­
ing target, a letter or number, stable in the center of
the screen and uses a com puter program to move the
cross above, below, or to the side o f the letter on a com ­
puter screen. A high-contrast cross made out o f thin
dowels attached to the end of a wand m ight work as
well with a tangent screen. The client is instructed to
always direct central fixation and the scotom a to the
center of the cross. The cross is then moved until the
client reports being able to see the letter. By moving
the cross above, below, or to the side of the eccentric
view ing target, the therapist encourages the client to
redirect the line of gaze eccentrically so that the letter
can be seen w ith side vision (see Figure 10-4C). O ne
might think of this technique as enabling the therapist
to slowly drag the client's gaze into a desired position.
The letters m ay be replaced with three to four letter
words placed in the center o f the screen and different
eccentric positions attempted until the eccentric view­
ing position that produces the best word recognition
is found.
Fading Out the Central Fixation
Cue an d Introducing N atural
Eccentric Viewing Targets
T h is step is quickly perform ed w ith individuals
who have demonstrated eccentric view ing during
initial evaluation. It should be used to verify that the
client can voluntarily adopt different eccentric view­
ing positions in response to verbal instruction. With
cognitively or linguistically impaired individuals, one
might just em pirically determ ine the best view ing
 Tabic 10-2.
Instruction on Compensatory Scanning
Compensatory scanning:
Search tasks for expected objects.
Search with unexpected objects.
Behavior m odification of right-left scanning.
Holding fixation in the direction of the deficit.
position, and instruct the client to always adopt this
one position.
T angent Screen M e th o d
In this stage of instruction, the tangent screen
m ethod is most suitable. The purpose of this step of
the instruction sequence (Table 10-2) is to enable the
clicnt to follow verbal instructions to look to each side
of the target or above and below the eccentric view­
ing target without a central fixation cue. Instruction
begin s w ith a central fixation cue that is faded out and
replaced by verbal cues or no cues. D uring this instruc­
tion, different m eaningful eccentric view ing targets
are used— three to four letter w ords for som eone who
wishes to read, pictures of loved ones, or a TV. Thus,
during instruction, the therapist can ascertain the
eccentric view ing position that is best for a particular
goal task. At first, a central fixation cue is used such as
a cross at the end of a wand or a laser spot to encour­
age the person to eccentrically view in a particular
direction. T h e central fixation cue is positioned at
different points around the eccentric view ing target,
encouraging eccentric view ing above, below, and to
each side of the eccentric view ing target w ith verbal
instruction. The therapist should place a word on the
tangent screen and instruct the client to “look at the
center of the cross (the central fixation cue) until it d is­
appears" and determ ine the position that allow s the
words to be seen clearly. Then repeat the movement
without the wand. As one teaches the client to move
in different positions, one will determ ine the position
most suitable for reading. Occasionally, one finds a cli­
ent w ith one PRL with a larger field of view more suit­
able for reading, and another PRL that allow s isolated
letters to be seen more clearly. This tangent screen
m ethod could be perform ed on a computer screen or
any near card. Variations on the tangent screen can
be im provised by using a w all, laser pointer, and a
drawn or real life eccentric view ing target. The eccen­
tric fixation target is centered and a central fixation
cue (laser spot) is positioned as needed to the side and
If also unilateral inattention, add the following:
Forced fixation on the side of the deficit.
Cued fixation to the side of the deficit.
Use cued fixation to the side o f the deficit.
evcntuallv* faded out so a client can follow directions
such as "look up" and eventually eccentrically fixate a
centered target without any cues.
A nother therapeutic activity that can be used at
this stage of training w ith either the tangent screen or
the clock involves the use of a telescope or sm all d iam ­
eter tube. The client looks through a tube of about 1
cm (0.5 inch). If the person w ith a central scotom a cen­
trally fixates through the tube, nothing w ill be seen.
If the person eccentrically views, then som ething will
be seen. T h is exercise may be done with a telescope
and provides salient feedback as to w hether adaptive
eccentric view ing has been achieved or not.
C lock Face M e th o d
Recall that during the initial evaluation, when the
client with adaptive eccentric view ing w as asked to
look at the center star he would report seeing the
center star and that som e clock num erals would d is­
appear. At this point, the client who has just received
completed instruction should also be able to do the
same.
Eccentric Viewing Under
N atural Viewing Conditions
Home exercise or practice also may be performed
w ith pairs of large-print playing cards positioned
so that w hile “looking a t" one card, the other card
becom es visible. Com puter program s that act like flash
cards might also help a client practice eccentric view ing
by them selves (M agnim aster, Hunstad M agnim aster
Reading Improver SMC, Paradis, Norway). The fixa­
tion tube, computer program , and clock face m ay also
be sent hom e for practice as a home exercise program .
At this stage of instruction, the client should be able to
practice by w atching TV, taking care to insure the TV
is close enough to sec.
D uring this training, a client m ay turn his head. This
head turn may be in the direction opposite the direc­
tion to which the client moves the eves* to eccentrically
view. There is no evidence that head turning presents

Figure 10-5. A . Steady eye te ch n iq u e at a reading
stand w ith m o u n te d han dheld m agnifier. B. Steady
eye te ch n iq u e seated w ith han d-over-ha nd assistance.
a problem except to the therapist trying to observe eye
position. Head turning may present ergonom ic prob­
lems and clients can be taught to eccentrically view
without head tu rning during advanced instruction.
Research needs to be done to better understand the
effect of head position. However, eccentric view ing is
a difficult skill to learn, and we feel that focusing too
much on technique may be discouraging.
Reading With Scrolled Text
Once the client dem onstrates the ability to eccen­
trically view and identify a single stationary object
like playing cards or short w'ord cards, large-print
text should be used. The print size used should be at
least tw ice the visual acuity level of the client. The cli­
ent might also require a m icroscope (strong reading
glasses), a mounted handheld m agnifier, or a closed
circuit television (CCTV) for this training period.
W hen practicing with printed text, the client should
be sitting at a table in front of a reading stand with
the text m ounted on a card that slides horizontally on
the lip of the stand (see Figure 10-4A). The client is
then directed to eccentrically *
view the first word. In
most cases, looking above the line is best for reading.
Once the client can see the w'ord, slowly scroll the text
from right to left w hile he tries to keep the eye in the
sam e position. T h e eye and the head should not move.
Watson calls this the steady eye technique.21 Starting
w'ith hand-over-hand assistance, the client holds the
text affixed to a clipboard and scrolls the text (Figure
10-5). In addition to reading lines of text, the client
needs to learn to return to the beginning o f the line.
T h is is accomplished by m arking the beginning o f the
line w ith a finger and follow ing the line just read back
to the beginning and moving down. T h is is called the
retracing technique. The therapist gradually withdraws
assistance until the client is able to read without assis­
tance. The client can practice scanning m ultiple lines
and finally more complex activities such as reading
bills and bank statem ents. The key to this technique
is that the client slow ly moves the m aterial being read
from right to left rather than the eyes and head.
People with more normal visual acuity read by gen­
erating left to right eye movem ents (saccades) to look
from one word to the next. Visually guided saccades
are comprom ised in people without central vision.24
W hen using the steady eye technique, a person with
central field loss can more easily shift gaze from word
to w'ord using a reflexive eye movement, the quick
phase of optokinetic nystagm us rather than visually
guided saccades.2=i
Tracking an d Viewing Through
a H andheld M agnifier
A fter the client has demonstrated good steady
view ing and mastered reading scrolled text, tracking
and scan n in g techniques are used along w ith mag­
nification devices. The procedure begin s with steady
view ing. The client attem pts to identify playing cards
as the therapist pulls each card off the top o f the deck.
Index cards w ith num bers and short words (four let­
ters or less) can also be used. O nce the client can per­
form well with steady view ing, the therapist should
add movement to the procedure. To do so, the thera­
pist holds the cards w hile carefully observing the cli­
ent's eves. The stack of cards is then slowlv moved and
the client should track the cards. M aintaining view'ing
with a slowly m oving target w ith a predictable motion
is relatively easy. Recovering eccentric view ing when
view ing is lost presents the greater difficulty, espe­
cially if the target disappears into the scotom a. If
the client loses visibility of the target during this
procedure, the therapist should stop until he recovers
and then continues. At first the characters should be
at least three tim es the client's visual acuity. Starting
from the card position that allow s most consistent
eccentric view ing, slowly m ove the cards in various
directions (up and to the right, down and to the right,
up and to the left, down and to the left), starting with
movement awav J from the scotoma because movement
toward the scotom a w ill present the most difficulty.
Increase task difficulty by increasing the speed of the
target m ovement and then m oving the tracking stim u­
lus unpredictably. To further increase the level of d iffi­
culty of the task, decrease print size. Note that people
will som etim es switch from one eccentric view ing
position to another. Let your client know when you
observe this happening. Rapid alternation between
eccentric view ing positions slows reading and should
be discouraged for reading; this strategy, however,
may be adaptable when scan n in g during mobility.
A practical extension of tracking a large stim ulus
is to have the client read through a handheld m agni­
fier or stand m agnifier held at about 20 to 40 cm (16
inches) from the eye. Begin with the client seated, and
once he can m aster reading w hile seated instruct the
client to attempt reading through a handheld m agni­
fier or stand m agnifier w hile standing. Recall that
the handheld m agnifier and the head should rotate
together with the lateral movement of the head as the
m agnifier moves across the page, as if an im aginary
rod connects the m agnifier through the eye and the
head. Scanning with telescopic m agnification can also
be introduced at this point in the therapy.
Localizing an d Scanning
The most advanced task is to have the client scan a
room using saccadic eye movements. The goal of scan ­
ning training is to enable the client to m ake an accu­
rate saccade to an object seen peripherally without the
object disappearing into the scotom a. Although this is
a sim ple task for a person without a central scotom a,
this type of saccadic control is irreversibly com pro­
m ised with the loss of central vision. A person with
a central scotoma requires increased tim e to m ake a
saccade to an object seen peripherally because these
eye movements are inaccurate and several saccades
m ay be required to scan from one object to the next.8
To practice scanning, a large, high-contrast eccentric
view ing target can be presented in the periphery
such as a waving hand, a person, or a light in regular,
predictable positions at first. Eventually the targets
sh o u ld b e p re se n te d in u n p re d icta b le p o sitio n s. Л
laser light, flashlight, or flash card works well as an
eccentric view ing target at this stage.
A more advanced technique used by individuals
learning to use optical devices is localization. With
localization, the client scans a room or page of text
until he fixates a spot where he expects to see som e­
thing o f interest. Without breaking eccentric view ing,
the client positions a m agnification device in front of
the eye so that the object of interest is m agnified. For
exam ple, he might scan a bill and localize where some
num bers are printed that are likely to be the am ount
due by the layout of the text. The client then positions
the m agnification device in front of the eye to read
the number. Localization will be described in detail in
Chapter 13 when discussing optical devices.
Researchers have found that som e well-adapted
people with central vision loss use different eccentric
view in g positions after saccades.8 T h is advanced
technique can be taught if the evaluation reveals dif­
ferent functional ability for various eccentric view ing
positions, such as one PRL that has better acuity, and
another with a larger horizontal field of view for read­
ing.
Finding the Best Eccentric
Viewing Position
To teach people to use different PRLs, the therapist
should select targets that are typically involved in
real-life tasks. Targets should be carefully selected so
that a different visual skill is required to best identify
the chosen target. For exam ple, one target might be
more easily identified with a PRL that works well
with longer words, w hile another target (picture of a
face) might be more easily identified w ith a PRL that
has better acuity. O ften different PRLs have different
visual acuity ability, requiring a change in required
m agnification. It is im portant to understand that for
mobility, the use o f inferior view ing is dangerous
because a scotoma in lower central field puts people at
risk for tripping on objects on the floor.26 Positioning
the scotom a above the text is generally thought to be
better for reading.
Equipment for Eccentric Viewing
Training and Home Exercise
Program
Ideally, eccentric view ing instruction involves a d is­
play for stim uli and a method for the therapist to view
the client's eye w hile he is attem pting to eccentrically
fixate. A 1 m eter (3 foot) felt screen that will accept
pins will work for most techniques, although sm aller
and improvised tangent screens may becom e neces­
sary when a large tangent screen is not practical.
A com puter can also be used for eccentric view ing
training. The therapist can generate a graphics display
on a computer screen using a draw program such
as the draw feature in M icrosoft Word. O ne draws
the four lines of a cross and then uses the "group"
feature to connect them so that one can click on one
line and drag all four. O ne or two view ing letters or
words might be w ritten in a "text box" that can be
dragged and placed anyw here on the screen with the
mouse. Template word docum ents are provided in the
Appendices.
 The procedures described above using playing
card s or the clock face can easily be perform ed
C o m pen sa t in g f o r P eripheral
at home. W orkbooks are available that provide a F ield Lo ss
sequence of progressively more challenging home
exercises for read in g 21 Indeed, even if reading is
not the c lie n ts prim ary goal, the skills developed for Basic Functions of Peripheral
reading should transfer to other tasks as well. The
M agnim aster is a computer program that flashes Vision
m agnified w ords on a screen for a limited period of A key to the rehabilitation o f clients with periph­
tim e for a client to identify, functioning much like the eral field loss is an understanding o f the three basic
deck of cards in training steady eccentric view ing. The functions of peripheral vision: organization of visual
client can be set up to work on this program without scanning, w arning, and night vision.
one-on-one assistance as w e ll27
A nother challenge is providing the client w ith a Organize Visual Scanning
m agnification device sufficient to identify the targets
The first basic function of peripheral vision is to
or text used to practice the steady eye technique.
help an individual organize visual scanning. W hen
Several options have been developed to provide mag­
som eone with normal visual function "looks a t" a
nification. Handheld m agnifiers that arc relatively
larger scene or area such as a room or a restaurant
inexpensive are often prescribed and dispensed for
menu, he generates a sequence of quick saccades at a
spot reading tasks. These devices can be mounted to
rate of three to four saccades per second. Each saccade
allow the client to practice the scrolled text technique
ends with a period of view ing on som e part of the
described above. A CCTV is ideal because the m agni­
scene. D uring this view ing, the visual system samples
fication can be adjusted as the client's skill improves.
a different area w ithin the scene. During the approxi­
A nother option includes a "lo an er" program where
mately one-quarter second fixation period, the visual
full field m icroscopes or loupes can be loaned to the
system uses the macula w ith its high resolution and
client during the exercise program , although this is
color rendition to collect detail about som e patch of
costly to equip and difficult to manage. A final option
the im m ediate surroundings. Using this sequence of
is to have the client attend office-based treatm ent
saccades, the visual system rapidly pieces together a
sessions and practice before or after the scheduled
detailed and complex perception of the scene or area.
therapy session in the clinic with a borrowed device.
For example, when a person w ith norm al visual func­
tion enters an u nfam iliar room for the first time, his
Eccentric Viewing W ith Cognitive peripheral vision with its lower acuity detects larger,
Im pairm ent higher contrast and moving objects. T h e person may
detect people m oving to the left and glance over to see
Learning to eccentrically view requires consider­
w ho they are, then check the doors, signs, tables, and
able practice even in clients w ith normal cognitive
chairs seen in the periphery. W ithin a few seconds,
function. Eccentric view ing training proceeds much
using three to four saccades per m inute, this person
more easily if the client understands complex, mul­
has gathered critical inform ation that will allow him
tistep instructions, can perform ideational problem
to interact w ith the other people, know where the
solving, and has good sem antic as well as procedural
doors are located, avoid obstacles in the room , as well
memory. If a client is capablc of follow ing one-step
as read the sign that indicates which doorway to enter.
com m ands and dem onstrates learning w ith practice,
O rganization of visual scanning involves not only
eccentric view ing training may proceed if a helper is
peripheral vision, but also m em ory and other sensory
present who understands the process and can assist
modalities. A person entering a room m ay glance over
with practice. T h is client is unlikely to learn how to
to a radio playing music, or to the person talking to
shift eccentric view ing with verbal cues, but might
her left. The next tim e this person enters the room,
learn one eccentric view ing position with training.
she can use memory of the room layout, and m ay look
O ne should skip trying to teach this client how to
directlv
/ to the door that leads to the desired destina-
voluntarily shift eccentric view ing positions and use
tion and eventually could navigate the room , and even
m ultiple PRLs.
know where to look for the faint outline o f obstacles
if the lights are out. If this person developed a field
cut, she may becom e aw are that she is not seeing on
one side just as one is generally aware of the lim its of
typical visual fields.
However, dam age to the parietal cortex and cer­
tain areas in the frontal cortex may com prom ise this
scanning process.28 This problem may m anifest as
a unilateral visual inattention or visual neglect. For
exam ple, a client named M ary has had a right cerebral
vascular accident. We assum e she has an intact left
field because she responds to a bright light, a waving
hand, or a ball thrown to her on the left. However,
she does not spontaneously glance in that direction or
notice signs to her left when looking around the room
or when her attention is divided. We would conclude
that M arv ✓ has intact visual fields but a unilateral
inattention or visual neglect. In som e cases, people
will have both a unilateral inattention and unilateral
field loss. These individuals cannot sec anything on
one side and are not aw are of the vision loss or that
objects exist on the side of the vision loss. Note that
w ith unilateral field loss or inattention, the pattern of
eye movements will be abnorm al, but basic eye move­
ment control such as saccade control by itself is not
necessarily com prom ised. The abnorm al pattern of
saccades is secondary to a basic deficit in the neuro-
physiological and/or the sensory system that organiz­
es the pattern of saccades required for scanning eye
movements. The focus of therapy, therefore, should be
on the visual and attention deficit, not directly on the
eve movements themselves.
Use o f the Visual Periphery as a
Warning System
The second basic function of peripheral vision is the
use of the visual periphery as a w arning system. This
is im portant for driving, w alking in crowds, or mobil­
ity in general in busy areas. O ur ability to respond
to high-contrast moving objects is a phylogenically
ancient system that allow s creatures to detect and
respond to high-contrast m oving objects approaching
from the side. That flash of fear we all experiences
when som ething unexpected darts rapidly in from
the side illustrates this w arning system. In hum ans,
this orienting response includes a saccade toward the
suspected threat.29 In our m odern era, these threats
m ay be a child running in front of the car, a car sud­
denly approaching an intersection that we arc trying
to cross, suddenly noticing and avoiding a rolling ball,
or an anim al running in front of us. These events may
occu r very quickly while we are looking som ewhere
else. If a client has a peripheral field loss and is look­
ing straight ahead, the early w arning system w ill not
alert him or her to unexpected danger.
Role o f Peripheral Vision in
Night Vision
The final basic function o f peripheral vision is
the role peripheral vision plays in night vision. The
peripheral retina has much greater sensitivity to dim
light than central retina. Loss o f peripheral vision,
therefore, leads to night blindness, a severe loss of
vision w'hen the light levels drop.30 A person with
an overall peripheral vision loss due to advanced
glaucoma or retinitis pigm entosa, for example, may
report little problem during the day but severe visual
disability at night.
Overall Field Loss
The retinal conditions that lead to overall visual
field loss or "tunnel vision" usually have a gradual
onset, allow ing the client to progressively adapt w ith
com pensatory scanning. If som eone with restricted
visual fields reports problem s bum ping into objects
or difficulty finding things, he should be taught com ­
pensatory scanning (Figure 10-6), described below.
The usual progression includes searching tasks for
objects graded from salient objects, such as bean bags
on a table, to searching for objects in a cluttered area,
such as a room. The comm on challenge in m anaging
people with peripheral loss is addressing the loss of
the "w arn in g system ." Even when using good scan ­
ning technique, a person with an overall peripheral
field loss will m iss an unexpected, quickly moving
hazard from the "blind side." People w ith overall
peripheral vision loss often experience night blind­
ness. As peripheral visual field loss has a gradual
onset, these clients may deny functional problems
because of occupational disengagem ent. People with
peripheral visual field loss m ay not go out at night,
may avoid crowds or new environm ents, and may
be in denial if the prognosis is total blindness. The
best com pensation for loss o f the w arning system is
to use a white cane or guide dog, at least to signal to
others to be careful. M obility training, especially if it
involves the use of a white cane, should be performed
by a certified orientation and m obility (O &M ) spe­
cialist. T h e vision rehabilitation therapist, however,
can and should introduce the client to sighted guide
techniques, use of nonvisual cues, environm ental
adaptations, and trailing techniques (sliding the back
of the hand along a wall w hile w alking), and convince
the client to seek training on the use o f the w'hite cane.
The denial process that occurs w ith recent on set low
vision com plicates the introduction of techniques
associated with blindness.7 The therapist often must
subtly introduce blindness strategies. Better accep-
 Figure 10-6. Com pensatory scanning left-right with
hom onym ous hem ianopia (Steinman).
tance m ight be expected if the therapist introduces a
sighted guide or the need for a white cane for “walk­
ing at n ig h t" when the client is less likely to deny the
problem. People w ill gradually becom e accustomed to
the advantages of using the m ethods, and begin using
many of these techniques at all tim es and w hen vision
further declines.
Unilateral Field Loss
Unilateral field loss results from brain injury to
tracks or cortical areas post optic chiasm , often asso­
ciated w ith cerebral vascular accident. Dam age to the
right side of the brain may lead to blindness in the
left visual field of both eyes. Dam age to the left side
of the brain may lead to blindness in the right visual
field of both eyes. If the blind area com prises nearly
h alf o f the visual field, starting approxim ately at the
m idline of both eyes, the condition is called hom ony­
mous hem ianopia (Figure 10-7). If a quarter of the visual
field is affected, the condition is called homonymous
quadrantanopia.
To develop effective treatm ent, sensory deficits
m ust be differentiated from perceptual, attention,
Figure 10-7. Unilateral field loss w ith and without
central sparing during confrontation field testing
(Steinman).
linguistic and other cognitive deficits. Brain injury
affects a variety o f cognitive and linguistic functions
that might affect visual function such as letter iden­
tification and reading. People may have difficulty-
reading because o f dam age to linguistic processing
areas. They may not respond to objects in the periph­
ery because of im paired visual attention or unilateral
inattention and neglect.28'31 Since unilateral field loss
in often associated w ith unilateral inattention, the
treatm ents often address unilateral attention as well
as unilateral field loss.
Unilateral field loss usuallv
j does not cut the field
down the m iddle but rather leaves central vision intact,
called central sparing (see Figure 10-7). Functionally, an
individual with a unilateral field loss w ith central
sparing will see m ost of a person's face at about 1
m eter (3 feet), but see nothing to one side or the other
of the face. People with field cuts and central sparing
usually have normal acuity and only m inor problems
with reading. These individuals w ill read a single
line of text norm ally but m ight lose their place when
reading, or m ay have difficulty scanning a page for
inform ation. In som e cases, people have a unilateral
field loss that also bisects the central field (see Figure
10-7). These individuals will report that one h alf of
the exam iner's face can be seen during field testing.
People w ith "split central fields" w ill only see half of a
letter or words they are tryin g to identify as well. The
resultant loss of basic shape, letter, and face recogni­
tion may be confused with higher-order perceptual
deficits. People with a right unilateral field loss w ith a
split central field will have severe problems w ith read­
ing, even though other linguistic functions are intact.
Functionally/ people with unilateral field loss will
present w ith disabled visual scanning and periph­
eral w arning system, often w ith the functional effects
compounded by an overlay of unilateral visual inat­
tention. In addition, a person w ith unilateral field loss
may present with "w ayfinding deficits," and often
cannot even retrace his steps. A person may have basic
problem s with w ayfinding, prim arily due to a unilat­
eral field loss rather than cognitive deficit. For exam ­
ple, if a client w ith a left field loss w alks down a hall
for the first time, he will see one side of the hall to his
right. W hen he turns around to retrace his steps, the
formerly right side of the hall will now be to his blind,
left visual field. The side of the hall that is now in his
intact right field would never have been seen before.
In effect, he has never seen the route he is retracing.
This problem is exacerbated for people who have split
central fields and/or unilateral inattention.
Dam age to the optic chiasm , most often associ­
ated with pituitary tum or but som etim es associated
w ith traum atic injury, will cause field loss that causes
binasal or bitemporal field loss. With binasal deficit,
the client cannot sec objects nasal to the fixation
objects with each eye and the temporal fields are
intact. With bitemporal field loss, the client cannot
see temporal to the fixation target in each eye and the
nasal fields are intact. If one overlaps the visual fields,
it appears that the fields are full because one eye
w ill see what the other does not. For example, w ith
binasal defects, the left (temporal) field of the left eye
is intact, and the right (temporal) field of the right eye
is intact. At least in theory, if the two eyes look at the
sam e fixation target, the client has an intact right and
left field and should have full binocular fields. There
are, however, subtle but disabling problems. A person
with binasal deficits will not see som e objects closer
than the fixation target because closer objects might
fall into the nasal field of each eye. O ne can dem on­
strate this by positioning a finger at arm's length and
another a few inches from the nose on the midline.
Fixate the far finger w ith both eyes, then close each
eye to see how the proxim al finger falls into the nasal
field of each eye. If a client had a binasal field deficit,
he would not see the closer object. With bitemporal
defects, one will not see som e objects further than
the fixation target, which can be dangerous. If central
vision is cut, a client will also have difficulty fixating
an object w ith both eyes at the sam e tim e and will
report double vision.
R em ediation
O ne training technique has been reported to actu­
ally decrease the size of the blind a r e a '2 5 to 10
degrees in people with a presum ably stable field loss
of 18 months to several years. T h is instructional tech­
nique involved having clients detect flashing lights
presented at the edge of the scotoma for 1 hour for 3 or
more days a week for 3 to 6 m onths as part of a home
program involving specialized training equipm ent.
The results have not been replicated in studies con­
trolling for com pensatory scan n in g eye m ovem ents.33
Therefore, the evidence for this procedure is question­
able at th is time.
The method that seem s to produce the largest and
functionally greatest increase in peripheral aw are­
ness is called com pensatory visual scanning. In this
technique, the therapist teaches the client to look
with quick saccades in the direction o f the blind
hem ifield 32 Com pensatory visual scanning docs not
actually increase the size of the intact field.
C om pensatory Visual Scanning
To com pensate for a unilateral field loss, the cli­
ent must change habitual eye movement patterns.
Norm ally we look at an object and depend on our
peripheral vision to see on either side. Compensatory-
visual scanning involves frequently and consistently
looking in the direction of the blind hem ifield, much
like a driver uses a rear-view and side-view m ir­
rors when driving to get a sense o f what is going on
around the car and beyond the range o f peripheral
vision. As with any therapeutic intervention, the cli­
ent must be educated about the deficit and provided
with an explanation for the com pensatory strategy.
Understanding and verbalizing the problem or dem ­
onstrating im proved perform ance during in stru c­
tional protocols is not sufficient. The client must
dem onstrate com pensatory scanning as an ingrained
habit during real-life activities when attention is on
the activity, not the eye movement.
S canning W ith Expected Then U ne xpe cte d
O b je cts
We suggest a three-step sequence for teaching this
skill.
Figure 10-8. Tw o techniques to
facilitate adaptive scanning into
an affected hem ifiekl. A . Partial
lens occlusion forces the eye to
look into the affected hem ifield.
B. The Sarah Appel technique
uses a colored translucent til­
ler to cue the client w hen he is
looking in the correc t direction
(Steinman).

S te in m a n

1. Step O ne in the direction of the field loss until he sees

The first stage in treatm ent is to engage the cli­
cnt in various search tasks: looking for speci­
fied objects in a room , looking for cooking or
self-care items, sim ple puzzles, dom inoes, or
com pleting cancellation and draw ing tasks.
Exam ples of these treatment strategies have
been well described in the occupational thera­
py literature.31'34 This step is quickly mastered
by people with intact visual attention, and
less easily recovered with clients w ho have
¥ trying to find hazards in a kitchen or picking
attention deficits. W hen grading the activities,
easier tasks should be fam iliar and m eaningful
activities such as brushing teeth. Using tasks
w ith expected objects (the brush, toothpaste,
and glass) w ill encourage the client to continue
looking until all the com ponents in the visual
task are found.
To rem ediate inattention deficit, first one might
force fixation to the side where there is inatten­
tion by sm earing Vaseline or taping one-half
of each lens on the intact side with translucent
tape (Figure 10-8). This forces the client to
look past the m idline in the direction of the
visual field loss, if the head is straight ahead.
Nonvisual or extravisual cues might be added
to direct attention to the affected side as well.
A classic strategy is to place a brightly colored
line and tactile m arker down the edge of the
page or field being scanned and cueing the
client to keep looking until the line is seen.
T h e next stage in this step is to use a method
described by A ppel35 that involves placing a
colored filter on one-half of each lens or cut­
ting the lenses of inexpensive sunglasses (see
Figure 10-8). W hen the client looks in direction
of the field loss he w ill see a color change (see
Figure 10-8A). The client is instructed to look
the color (see Figure 10-8B). T h is cues the client
that he is looking in the correct (compensatory)
direction. Once the client can consistently scan
for objects even w ith less fam iliar tasks, the
searching and scanning function has been
restored.
2. Step Two
Step two involves having the client scan a room
where unexpected objects m ight be found, eg,
up objects on the floor.
3. Step Three
Step three re-establishes the w arning function
of the peripheral retina. T h is step presents
a greater challenge because responding to
approaching objects from the affected side
usually requires perform ance during divided
attention, which is often im paired with brain
injury or in older individuals. O ne approach
we have successfully ¥ used involves behavior
modification of scanning eye movements. T he
goal is to establish the habit of frequently and
quickly looking in the direction o f the field
defect. Com puter program s and equipm ent
has been developed that allow the client to
be set up to perform this task independently.
T h is author has found any num ber of com ­
puter gam es where objects fly in unexpectedly
from all directions (eg, "Squ ares," w hich is a
free gam e found on the Web) that provide an
engaging opportunity for hom e-based practice
as well.
Laser tag transitions the client to m ore real-life
situations. The therapist and client each hold a
laser pointer. The therapist presents the laser
spot on a surface such as an uncluttered wall.
 The client responds by pointing to the light
and tagging the spot w ith his laser pointer.
At first, the light is flashed at tw o predictable
points in the right and left field. The task is
graded to become more challenging and real­
istic by moving from predictable positions in
an uncluttered area to unpredictable locations
in a cluttered area. To further increase dif­
ficulty, the laser spot targets can be presented
at different distances. Finally, the task is per­
formed when the client's attention is divided,
such as in a visually busy environment with
people w alking around. During this task, the
therapist gradually decreases the frequency of
presentations and varies the interval between
laser spot presentations as well, pausing up
to a minute or two between presentations. At
this point, the client should be w alking with
frequent automatic glances into the affected
hemifield, so that when the light eventually
appears, she detects it within 2 seconds. T his
instructional sequence should result in the
client frequently and habitually looking in the
direction of the field deficit.
Holding fixation in the direction of the deficit
is another strategy that provides early warning
in the direction of the field loss. In this proce­
dure, the client must look over and m aintain
fixation in the direction of the field deficit,
using peripheral vision in the intact field to
look straight ahead and to see into the unaf­
fected hemifield. The sunglasses procedure or
a colored filter on glasses (see Figure 10-8) can
be used effectively to cue the client to look and
maintain the eve ¥
in one direction. The client
could be encouraged to play two-on-one ball
gam es such as soccer or basketball, practice
w alking in crowds, practice crossing intersec­
tions with supervision, and when walking
down the street, a partner might intermittently
and unexpectedly veer into the client and play­
fully bump shoulders if not detected. Success
is achieved if the client automatically / main-
tains most of the fixation between straight
ahead and the affected side so as to detect an
approaching target within a second or two.
Instructional Strategies With
Central Field Cut
A person with a central field cut needs to develop
eccentric view ing in the direction of the field deficit
and use side vision to expand the field of view. Since
the region of highest visual acuity has been compro­
mised, some magnification, usually under 2X or 5 D
of equivalent power, is required. Strategies for read­
ing rehabilitation with central field cut are discussed
below.
Field Expansion Devices
The use of field m irrors and prism have been
advocated for many years and purportedly work as
an early warning system, allow ing clients to detect
the approach of som ething on the affected side.36*38
Prism, usually Fresnel-type prisms (sec Figure 10-
8), are pressed onto one spectacle lens with the base
of the prism in the direction of the field defect. The
prism displaces an image awav from the base toward
the point of the prism. (Think of the prism wedge as
an arrow that points in the direction in which the
person's view will move.) This prism is attached to
one lens so that when the client looks into the blind
hem ifield or to the edge o f the blind area, double
vision will be experienced. O ne image is the normal
view as seen by the eye looking through the plain
lens. The eye looking through the prism will see the
other image, actually a scene displaced from the blind
area by the prism usually by no more than about 20
degrees.
A major problem with the use of prism is that it
causes double vision, and we have found it might dis­
courage compensatory scanning toward the affected
side. To m inim ize this problem, Peli suggested that
the prism be attached in the superior field above the
pupil so the double vision is seen peripherally where
it is less bothersom e (Figure 10-9).48 In theory, the cli­
ent should detect objects in the blind field before the
object enters the intact visual field.
R eading
People with low vision often present upon ini­
tial evaluation with perform ance goals that involve
reading. The visual requirements and perform ance
demands of a reading activity vary considerably-
depending on the particular task. Reading a medicine
bottle, finding the total on a credit card invoice, medi­
tating on a very fam iliar passage in the Koran alone
during morning prayer, reading the Torah in Hebrew
in front of synagogue, locating a sign on the street cor­
ner, and enjoying the latest Tom Clancy novel involve
substantially different assistive devices, motor skills,
and visual demands. School sy'stems, state offices of
vocational rehabilitation, and medical insurance com ­
panies must recognize literacy as medically, vocation­
ally, and educationally necessary'. Not surprisingly,
reading has become the cornerstone therapeutic activ­
ity as one develops a treatment plan for a variety of
visual impairm ents and perform ance goals. Reading
Figure 10-9. The position o f the Fresnel prism
on spectacles and a sim ulation of the visual
effects. Note the double image of a potential
obstacle approaching from the blind hemifield
becom es visible before contact (Steinman,-.
is so often the focus of treatm ent because the skills
apparently transfer to other tasks as well.
Although reading is alm ost universally identified
as a visual task, successful rehabilitation requires
the therapist to move beyond the process of typical
reading to appreciate the m eaning of reading as an
"occupation" to each individual. The act of reading
m ight be viewed as purely functional, the process of
transm itting inform ation from the printed page into
the brain. From this functional perspective, whether
the reader uses vision, hearing, or touch to "read"
becom es less significant. A person can acquire the
inform ation printed in a new spaper visually with an
optical device, tactilely using a Braille transcription,
listening to som eone read, or as auditory reading
using a com puter equipped w ith a screen-reader that
reads Web pages aloud. For students, those employed
w ith productivity dem ands, people who w ant to read
quickly, or people who read for pleasure, even with
m oderate vision loss, the most efficient solution often
is text-to-speech. For many, however, the perform ance
goal m ight focus on the process. How one reads a spir­
itual text often becom es a focus in religious ritual, as
with unison recitations in a church or synagogue, the
reading of a young m an during his bar m itzvah, or the
recitation of the Divine O ffice by a priest. Productivity
m ight be less im portant than the process, or hoiv we
read. In this case, treatm ent planning should consider
the process as well as speed and efficiency of inform a­
tion acquisition.
Steinm an
Reading Evaluation
Overview
The steps for evaluation and treatm ent for read­
ing rehabilitation are sum m arized Table 10-3. The
evaluation begins w ith consideration o f the context
in which the reading will occur and the instruction
ends in the natural context. If one does not consider
context, a successful dem onstration o f good reading
perform ance in the clin ic will not carry over into the
home or workplace. The evaluation of context begins
w ith the physical and social settings. Then one consid­
ers the font characteristics of the reading m aterial and
availability in other media. Is the material available in
large print or as a recording of som eone reading the
text? Next one considers the task dem and. Does the
client need to read a few words on a label, or relax and
enjoy a novel? Does a lawyer need to scan and read
hundreds of pages all day long?
O nce the task dem and has been ascertained, it is
usually advisable to discuss the nonvisual options
first, as text-to-speech options often are the easi­
est to implement. The use of sighted assistants or
Recordings for the Blind can quickly enable the goal
task w hile the more difficult rehabilitation of visual
reading is undertaken. Next the therapist perform s an
evaluation and with the consulting low vision optom ­
etrist decides if the visual requirem ents for reading
can be met, and if so how. The evaluation identifies
 Table 10-3.

____________________ Steps for Reading Rehabilitation________________

Evaluation
• Determ ine reading context (lighting, glare, seating, ergonomics).
• Determ ine font characteristics and availability of alternative media (Braille and recordings).
• Ascertain reading task demand (duration, rate, comprehension requirements).
• Consider and present available nonvisual options to client.
• Evaluate visual requirements for reading: identify perform ance lim iting factors to address in
treatment.
• Evaluate reading performance.

Treatment (if visual requirements can be met)

• Address perform ance-lim iting factors:
Inadequate acuity reserve, use assistive devices
Inadequate contrast reserve, use assistive devices
Inadequate field of view
Central field loss and compensatory scanning strategies
• Provide initial instruction under idealized settings.
• Transition to natural context and perform necessary environmental modifications.

the visual impediments that must be addressed in
the treatment. Instruction begins out of context, in a
setting where ergonom ics and visual conditions can
be carefully controlled to remove the impediments,
m eeting the visual requirements. For example, in
home-based therapy, reading is often best started on
a table. If one performs all of the instruction in the
preferred context, such a person's favorite easy chair,
the therapist will not be able to demonstrate environ­
mental m odifications that might make reading easier.
The final phase of instruction moves to the client's
preferred context, where environmental modifications
permitted by the client are performed.
Context
In general, one first ascertains where each goal
reading task will be performed: reading tags in a
grocery store, reading a novel in л favorite chair in the
living room, or m anaging medications at a table in the
bathroom. The therapist usually starts instruction on
a table that encourages good posture, and support for
the upper body required for finely controlled move­
ment of text, optical devices, and the head. A table also
provides for easy repositioning of a directional task
light. During this phase, the therapist must reassure
the client that the task will eventually be adapted to
his preferred, habitual context. As the therapist transi­
tions from the ideal setting to the habitual setting, the
client will becom e aware of the effects environmental
changes have on reading ability. For example, a client
might stubbornly refuse to move his chair so that it
does not face a window. Once the client has recovered
reading in the clinic with directional lighting from the
side, and then struggles in a simulation of the position
of his favorite easy chair in the clinic, he appreciates
the impact of glare on performance. The clicnt might
now accept the therapist's suggestion and move the
chair. Evaluation o f context should include attention
to lighting and potential glare sources, the potential
for mounting reading stands or positioning assistive
devices, and ergonomics. Often, optical devices for
reading are more easily used if the client stabilizes the
material being read and his upper body on a table.
Font Characteristics and
A va ilabili ty o f A Iternati ve
M edia
Once goals for treatment of reading problems have
been developed, the occupational therapist should
establish the media and form ats in which the read­
ing material is available (Table 10-4). For example,
most bills, checks, legal docum ents and many m aga­
zines and books are available in large (2 M or 14-16
 Typical Print Sizes and Acuity Requirements41

Text Size Sample Text Acuity Usually

Required
N scale (points) M scale Approxim ate; point size varies
with font type
3 pt 0.4 M
4 pt 0.5 M
Ad*, bibk *
5 Pt 0.6 M 0.3
6 to 8 pt 0.8 M Telephone book 0.4
8 to 10 pt 1.0 M Newspaper 0.5
10 to 12 pt 1.25 M M agazines, books, computer 0.6
12 to 14 pt 1.6 M B o o k s , t y p e w r it e r 0.8
16 to 18 pt 2.0 M 1.0
Child & large print
18 to 20 pt 2.5 M 1.2
Large print

point) print. Inform ation is also available as speech,
for example, telephone com panies and utilities must
provide inform ation by phone at no additional charge
if a client can certify his disability. Automated Teller
M achines (ATMs) have jacks for headphones so users
can hear as well as see the display. Books, m agazines,
and daily newspapers are available in Braille, on tape,
or on C D in a listening format by free services such as
Radio Services for the Blind, and the National Library
for the Blind. M ajor new spapers and m agazines are
available on the Web and are accessible bv J Web brows-
ers equipped w ith softw are that reads the display
aloud, m agnifies the print, and im proves contrast.
Font characteristics must be considered. Print size
is expressed in N notation (points) or M notation. The
M scale refers to the test distance in m eters where the
lower case letter w ith no extender (eg, x or m) sub­
tends 5 m inutes of arc on the retina, approxim ately
the distance w here the print is barely seen w ith nor­
mal vision. N notation refers to the printer's standard
for sizing print w here 1 point equ als 1/72 of an inch;
however, the actual print size in points varies from
font to font because it dates to the days w hen lead
type was set and refers to the slug" size, not the letter
itself. M ehr and Fried's37 survey of fonts found N8 (8
pt) lower case and N5 (5 pt) upper case to be approxi­
mately equivalent to 1 M. Print characteristics also
influence reading.
Font characteristics include type of font (Times
New Rom an, A rial), font size (discussed above),
boldness, spacing betw een characters, and spac­
ing between lines. Font characteristics significantly
affect the visibility of individual letters (Figure 10-10).
Unfortunately, the earliest research on the effects of
font characteristics on visibility of print did not report
how distance was controlled, if at all. M ore recent,
controlled research has revealed one general find­
ing: increasing letter spacing increased the visibility
of individual letters.39'40 Different font types can be
categorized as serif and sans serif (no serif). Serifs
are little enhancem ents in letters (illustrated in Figure
10-10). The effects o f using serif versus sans serif fonts
have not been found to consistently affect the visibil­
ity of print, although as with the use of colored filters,
we have found strong individual preferences. Figure
10-10 also dem onstrates how the sam e size font (in
points) can have different visibility by varying font
characteristics. Com puter system s and newer screen
reading electronic system s allow font characteristics
to be modified (see Chapter 14).
Reading Task D em an d
The visual requirem ents for reading vary depend­
ing on the fluency demands.41 The perform ance goal
m ight be categorized as spot reading, low fluent and
high fluent reading. Reading a few words such as a
label or short passage requires "spot reading", read­
ing about 40 wpm. Reading a longer passage such as
a letter or instructions requires "fluent reading of 80
wpm". High fluent reading of 160 wpm is an average

Look at tho X’s. road the words
X X
GROW GROW
Figure 10-10. Fixate the Xs and attem pt to read the w o rd
below . Font characteristics in san serif (Arial) w ith heavy
stroke w id th and increased p rint spacing (left) is m ore visible
than w ith regular serif font typ e (Tim es N e w Roman) and
typ ica l spacing.
sixth grade reading rate. Normal reading rates are
approximately 250 wpm.42
O ne must consider the required reading rate, endur­
ance, and comfort. Reading for pleasure requires that
a person read comfortably for a relatively long time,
enabling endurance. Speed is an individual prefer­
ence. Students and many professionals often also
need to read for long periods of time and at speeds
consistent with the normal visual reading. Som e may
need to skim and scan for critical information, such as
a purchasing agent scanning a catalog for products.
O thers may wish to read slowly and carefully, such as
an actor memorizing lines or someone reading poetry.
People, even older individuals with moderate hearing
loss, can read from slower to normal reading rates,
quickly and comfortably with text-to-speech (listen­
ing to someone with normal vision or a computer read
a newspaper).43
Nonvisual Options
It is generally advisable to introduce text-to-speech
options first. For som eone with a vision impairment,
fast, comfortable "reading" is usually easily achieved
by listening to the passages being read. Sighted assis­
tance should be considered if the client is socially iso­
lated. People with long-standing visual impairment
often have not read for a long time, and have lost basic
literacy skills from disuse. People with poor literacy
skills will benefit more from text-to-speech systems,
at least at first.
Books on tape, and CD and Braille transcriptions
of printed material are free and easily accessed ser­
vices through the National Library for the Blind and
Visually Handicapped and the private organization
Recordings for the Blind, and can be easily located by
a Web search. Note that these services are available to
anyone who has a physical or cognitive disability that
might disable visual reading. Tape recorders are pro­
vided at no cost. Recordings are mailed with postage-
free return boxes that are easy for som eone to handle,
even if totally blind. The tape recorders, however, have
various settings that are not used in conventional
tape recorders and often require careful instruction
to learn. Using computer softw are that m agnifies and
reads the display aloud requires considerable skill
and practice, but can be relatively easy to start using
if someone has premorbid fam iliarity with computers
and can touch-type. Chapter 14 presents a variety of
electronic system s that will read Web pages, computer
screens, even print aloud to individuals or convert the
text into printed Braille or a Braille display.
The text-to-speech options should be presented
prior to the evaluation and incorporated throughout
the evaluation. Indeed, it is our practice to intro­
duce Recordings for the Blind to anyone who is eli­
gible, even those who have an excellent prognosis for
recovering fluent visual reading. Clients should be
reminded that normally sighted people often listen to
books on tape and CD, and these options can be used
as an addition to visual reading, not a substitution.
Introducing these options at the end of the session
as "a last resort" after attempts to read visually have
been rejected or failed tends to discourage clients
from using nonvisual options.
Although the focus of this book is on vision reha­
bilitation with people who have usable vision, federal
law requires that one consider nonvisual options such
as Braille for younger people who are unlikely to
acquire fluent reading visually. Braille reading has
become an important rite o f passage into the culture
of the blind. Associations and federations bv J and for
blind people are com m unities interwoven into other
cultures around the world that have and will con­
tinue to fortify people who have "different" rather
than "low " vision with a network of friends, leisure
activities, employment opportunities, and a sense of
pride. Introduction of Braille to a client requires spe­
cialized certification as a vision rehabilitation teacher
or a certified educator for the blind. The occupational
therapist however, should have a sample of the Braille
alphabet and numbers in order to assess whether a
client with hand impairment or cognitive im pair­
ment might have the capacity to learn Braille. Braille
is typically read scanning left to right with one, two,
or som etim es three fingers. Good tactile sensitivity
is required. We have had adults and teens pursue
Braille literacy, although this is not common in our
experience.

Evaluation o f Visual
Requirem ents
T h e occupational therapy evaluation is described in
detail in Chapter 8. W hat follows is a brief review with
a focus on special considerations for a reading assess­
ment. Evaluation of central and peripheral field loss,
and secondary oculom otor dysfunction was described
J J
previously in this chapter. The therapist must know or
m easure the reading acuity, letter contrast sensitivity,
and visual fields in order to undertake reading reha­
bilitation (see Chapters 7 and 8).
V isual A c u ity and C ritical P rin t Size
Assessm ent
Under a com m on practice model, clients may have
already been prescribed a m agnification device by the
low vision optom etrist. Reading speed w ith different
print sizes m ust be evaluated with an assistive device
that m ay be used, such as strong reading glasses or a
handheld m agnifier without an optical device. If the
device is not providing the predicted m agnification
(Chapter 13), or if visual acuity tends to fluctuate as
it does with diabetes, reading acuity and critical print
size should be frequently re-evaluated.
The evaluation and treatm ent for reading requires
an appropriate near reading acuity chart. An appro­
priate reading acuity chart includes a logarithm ic
progression of print sizes starting at 0.4 M up to 8
to 10 M. A log progression is as follows: 0.4, 0.5, 0.63,
0.8, 1.0, 1.25, 1.5, 1, 3.2, 4 M, ctc. A chart design must
control linguistic difficulty (reading level) of the text,
m aintaining a level that is relatively easy (third to
fifth grade level). Several popular near ch arts are not
suitable for a functional reading evaluation because
the passages used w ith sm aller print are at a higher
reading level. More difficulty reading sm aller print,
therefore, might be due to vision or com prehension.
Estim ates of critical print size will directly indicate the
m agnification required for fluent reading (see below).
With the appropriate reading chart, the therapist can
m easure critical print size by having the client read
down the chart without m agnification, then predict
reading speed for print sizes on or above critical print
size using the principles described in Chapter 7.
W hen the therapist evaluates functional reading
with a continuous text reading test, the client begins
reading with the largest print. T h e client reads each
line as quickly as possible. Fluent reading of the
first line quickly establishes basic literacy, and a
good prognosis for recovering fluent visual reading.
Normally, reading will remain relatively stable as
print size decreases, then reading speed w ill slow as
the decreasing print size approaches acuity threshold,
usually about 3 lines above threshold print size. The
sm allest print size just before reading slows is the criti­
cal print size. This is the sm allest print size that should
be used with the client who wishes to read fluently. J
As an additional significant convenience, charts such
as the MNRead have been designed so that each line
is of the sam e length.44 With a stop watch, the thera­
pist tim es how long it takes to read each line (reading
time) and quickly determ ines the critical print size
as the sm allest print size before reading tim e begins
to increase. In cases where a person has a restricted
field of view, reading speed w ill be slower with larger
print, then increase in speed som ewhat, then decrease
again when print size approaches acuity threshold.
Table 10-3 indicates the print size of different reading
m aterials and the visual acuity threshold that is typi­
cally required in order to read these m aterials fluently.
Instruction should begin with print that is a line or
two above critical print size.
Case Study
In an illustrative case, Ms. Jones w as diagnosed
with early atrophic m acular degeneration and aspired
to read the newspaper fluently as she always had in
her big chair by the window. In the clinic, testing was
conducted at 20 cm (8 in) rather than the usual 40 cm
because her optom etrist had suggested that stronger
reading glasses be tried and used at 20 cm . A table
w as used and cues provided to encourage her to m ain­
tain the test distance. The clicnt read the largest size
(8 M) in a few seconds with recom m ended reading
glasses, indicating a good prognosis for recovering
fluent reading visually. The client read the succes­
sive lines on the chart at about the sam e speed. At
1.2 M print size, the reading tim e increased, indicat­
ing that reading slowed, and she started to stum ble
over words. The critical print size w as 1.6 M at 40 cm
(0.4/1.6 M ), the last line read at the m axim um reading
rate. The client continued to read until at 0.8 M read­
ing was slow and one w ord w as m issed. T h e reading
acuity threshold was 0.8 M at 40 cm (0.4/1 M). Because
fluent reading was achieved w ith print m agnification,
and the critical print size w as about three to four lines
above acuity threshold, typical of norm al reading, the
therapist concluded that no other visual im pedim ents
existed. Since fluent reading wfas achieved w ith print
m agnification alone, additional visual testing was
unnecessary. D uring instruction, the therapist varied
lighting to determ ine the best lighting for reading.
In this example, reading instruction began with
print that was 2.0 to 2.5 M to insure early success. As
instruction progressed, the print size was reduced
and reading acuity testing repeated at the sm aller
print sizes to see if critical print size might change
w ith practice. It is wrise to retest reading near visual
acuity after a few sessions. If after instruction critical
print size w as 1.2 M, the therapist would recommend
additional m agnification or larger print.
 Table 10-5.

__________ Typical Print Contrast and Contrast Threshold Requirements11__________

Contrast Threshold Requirements

Text co n trast o f U ses S e v e re lo ss M o d erate loss
rea d in g m aterial (10:1 contrast reserve). Can usually fully com pen-
C annot fully com pensate sate w ith optim ized lighting
>95% Com puter and CCTV dis- Greater than 10% con- 5% to 10% contrast threshold
play w ith no reflections trast threshold
85-95% Good quality print Greater th an 8% contrast 4% to 8% contrast threshold
threshold
60-70% Newsprint, telephone Greater than 5% contrast 2.5% to 5% contrast thresh-
directory, paperback threshold old
books
50% Cash register receipts, US Greater than 2.5% con- 1.2% to 5% contrast thresh-
paper m oney trast threshold old

This client returned a year or tw o later with com-
plaint of difficulty reading even w ith newer, stronger
glasses. The reading acuity test was perform ed at a
closer working distance and revealed that reading
began to slow at 6.3 M and progressively slowed until
reading acuity was achieved at 1.6 M, although she
could m ake out a few words at 1.2 M. This result indi­
cated a reduction in visual acuity, and also a need to
test for the other possible visual im pedim ents to read­
ing, such as im paired contrast sensitivity or a central
scotoma.
C o n tra st Threshold Assessm ent
For reading, contrast sensitivity should be m ea­
sured with a letter contrast chart. For functional read­
ing testing, the most relevant results are m easured
with the test distance chosen so that letter size is at
about 2X to 4X acuity threshold (see Chapter 7). Table
10-5 indicates the contrast of typical reading that we
have m easured in a survey, and the contrast threshold
requirem ents to read these different m aterials. In the
cases of more advanced atrophic m acular degenera­
tion, glaucoma, or diabetes, often contrast sensitivity
is im paired as well as acuity, indicating a need for
higher contrast print, and careful evaluation of light­
ing.
Assessm ent o f Field o f V ie w
If a client has a reduced field of view, the therapist
should estim ate and m onitor field of view throughout
treatm ent.45 D uring an evaluation of central visual
fields described above, the therapist can assess the
characteristics of eccentric view ing, and the size and
location of the central scotom a. Field of view can be
directly m easured by having the client attem pt to read
using w ords of different lengths w hile fixating the
first letter of the word. It is im portant to select the font
size the clicnt intends to read. Alternatively, the client
can fixate the first letter on a row o f a near visual acu­
ity chart and m easure how many adjacent letters can
be identified at once without shiftin g fixation. A ther­
apist can infer field restrictions from actual reading
perform ance. Clients with restricted fields will tend
to spell words or hesitate or om it the end of longer
words, or m iss the last letters on a line when reading
a near visual acuity chart. The Pepper Visual Skills for
Reading Test (see Chapter 8) was designed to enable
users to m easure reading speed w ith different word
lengths and score errors to estim ate field restrictions
and scan n in g problems 46 It is im portant to attem pt to
estim ate field of view during reading because people
with central field loss may use different view ing posi­
tions for reading words rather than individual letters
because these retinal positions m ay have different
fields of view.
The Visual R equirem ents fo r Reading
The visual requirem ents for reading depend on the
visual demand of the task and font characteristics.41
T h e perform ance goal m ight be categorized as spot
reading, low fluent, and high fluent reading. Reading
a few words such as a label on a m edicine bottle or
short passage requires spot reading— reading about
40 w pm . Reading a longer passage such as a letter or
 Table 10-6.
T h e Visual Recuirem ents for Readine
The Visual Requirements for Various Reading Rates
Visual Factor Reading Rates
Spot (40 wpm) Fluent (80 wpm)
Acuity Reserve 1:1 (0 lines) 1.25:1 (1 line)
Contrast Reserve 3:1 4:1
Field o f View 1 character 2 to 5 cha.
Scotom a Size No lim it defined <22°
instru ctions requires fluent reading of 80 wpm. 1 ligh
fluent reading of 160 wpm is an average sixth grade
reading rate, with norm al reading speed at about 250
wpm.
The visu al requirem ents for each reading rate
depend on the client's visual function and character­
istics o f the print. For example, the print size required
for a particular reading rate depends on the client's
visual acuity and the print size being read. In order
to take both the client factor and print characteristics
into account, the size print required to read at a given
rate is specified as acuity reserve (see Figure 10-10).
A cuity reserve is a ratio of the actual print size being
read divided by the print size at threshold. Typically,
a person w ith 20/20 acuity, 0.4 M threshold at 40 cm,
reads new sprint, 1M with a 2:5:1 acuity reserve, or
print that is tim es acuity threshold. A 2:1 acuity
reserve m eans that the print size is tw ice threshold.
If som eone with low vision can barely read regular
new sprint, he likely has an acuity threshold of 1 M
(8 point) at 40 cm (16 in), reading large print, 2 M (16
point), provides an acuity reserve of 2:1, usually suffi­
cient for fluent reading (Tables 10-3 and 10-6). If a log­
arithm ic acuity chart is used, reserve can be specified
more sim ply in term s of lines on the chart. With a 2:1
acuity reserve, a person is reading a print size that is
3 lines above threshold. Table 10-5 indicates the acuity
reserve requirem ents for different reading rates. Table
10-4 indicates an approxim ation of the visual acuitv
requirem ents to read different com m on print sizes.
In general, som eone can read slowly and w ith dif­
ficulty print that is at threshold or 1 line above acuitv
threshold. If a client needs to read fluently, the print
size should be at least 3 lines above threshold, or a 2:1
acuity reserve. Additional acuity reserve is required
for those with m acular degeneration, media opacities
like cataracts, and individuals whose acuity might be
expected to fluctuate (diabetic retinopathy).
Table 10-5 indicates the contrast threshold required
High Fluent (160 M axim um
wpm )
1.5 to 2.5:1 (2 to 4 2.0 to 3.0:1 (3 to 5
lines) lines)
10:1 >30:1
5 to 6 cha. 16 to 20 cha.
<4° No scotoma
for different reading rates. For fluent reading, print
contrast must be at least 10 tim es contrast threshold
(>10:1). High quality print is about 90% contrast.
Contrast threshold must be better than 9% . For con­
trast enhanced print w ith an electronic device, print
m ust be better than 10%.
A surprising finding in our review o f the research
on vision and reading is that people can read flu­
ently with a rather narrow five to six character field
of view.41 This assum es that the client is reading by-
scrolled text, slowly m oving the line of print from
right to left w hile looking straight ahead— the steady
eye technique— (described earlier) rather than scan­
ning left to right with typical e\re movement patterns.
W hen som eone reads with m agnification, he typically
moves scrolled text from right to left in front o f the nar­
row field of a m agnification device or under a CCTV.
T h e m ajor problem created by a restricted field of
view is w ith scan n in g a page for relevant inform ation,
and losing one's place when reading. O nce the line of
text is found, however, it can still be read fluently as
long as acuity and contrast reserve are high enough.
Based on this concept, electronic and computer-based
devices have been developed that scan several lines of
text and present the text as one continuously scrolling
line (like the m arquee on Tim es Square) in front o f the
eye so that the client docs not have to look from line to
line. These devices are discussed in Chapter 13.
Central field loss, generally resulting from m acular
degeneration, has a particularly devastating effect
on visual reading. Although people with any level
of central field loss can recover visual spot reading
sufficient for activities of daily living (ADL) with
appropriate m agnification, recovery of high fluent
reading cannot be recovered with significant central
scotom a unless nonvisual reading strategies are used
(see Table 10-6).
Clients with visual im pairm ent generally benefit
most from increased m agnification. Increased m agni­
fication enables the acuitv
¥
reserve and contrast reserve
requirem ents to be met, usually without approaching
the field of view lim itations of a few characters. As
described below, clients can be taught to com pensate
for a narrower field of view resulting from higher
m agnification, but cannot progress to faster reading if
inadequate m agnification is prescribed. Clients w ith
central field loss larger than 4 degrees (about 2 to 3
fingers' width at arm's length) cannot recover high
fluent visual reading and must use text-to-speech or
Braille to read fluently.
Possible N onvisual Im pedim ents
T here are other nonvisual requirem ents for read­
ing. Good motor skills are required to precisely move
the text and position the devices. These requirem ents
depend on the device being used (see Chapter 12). The
cognitive and linguistic requirem ents are certainly a
consideration, and these aspects arc often the focus
o f treatm ent by educators for college and high school
students, and speech therapists for adults treated
in m edical rehabilitation settings. People with long­
standing visual im pairm ent often have not read for
a long tim e, and have lost basic literacy skills from
disuse. If it has been established that som eone must
read visually, a reading evaluation requires that one
establish premorbid literacy and the cognitive ability
to read. T h is can be easily done w ith larger, high-con­
trast print that is easy for the client to see.
Evaluation o f Reading
P erform ance
Performance is evaluated before and during treat­
ment and as part of an ongoing evaluation of inter­
vention strategies. It is useful to have num erous short
reading passages of relatively easy to read, engaging
reading m aterial for nonstandardized evaluation d ur­
ing this process (see Appendices). The Pepper Visual
Skills for Reading Test is valuable for a standardized
reading46 evaluation (see C hapter 8). This test uses
unrelated words that increase in length and line spac­
ing. This test has exceptional test-retest reliability, has
been validated, and might, therefore, be used to docu­
ment changes in reading perform ance as a bench­
mark test for docum enting the efficacy of devices and
therapeutic intervention. The test also has diagnostic
value in revealing scan n in g difficulties in people w ith
central field loss. Also designed for adults w ith low
vision, the Morgan Test of Reading Comprehension
allow s one to docum ent literacy lim itations using a
validated instrum ent.47' 49
Finally, one might need to com pare reading perfor­
m ance w ith optical devices and electronic devices. It
becom es essential to provide objective perform ance
data to agencies or insurance com panies to justify
purchase of devices. O ne com pares reading speed
after the devices have been configured for m axim um
reading perform ance. Since devices often must be
purchased w ith justification before instruction on use
of the device can com m ence, the user is also provided
with assistance to insure perform ance is only lim ited
visually, not by his fam iliarity with the device, which
will improve w ith training using the device. In the
A ppendices, we have included a continuous text
reading test that allow s one to com pare reading with
text-to-speech, w ith print reading using paragraphs.43
To evaluate text-to-speech reading, one m ust play a
recording of the MP3 files. T h e different paragraphs
are of approxim ately the sam e visual and phono­
logical length, and linguistic difficulty (fifth to sixth
grade level). The recording w ill read the paragraph at
increasing speeds until com prehension drops below
tw o out of three questions correct. Likew ise, clients
read paragraphs silently as quickly as possible, with
com prehension validated at the sam e level or higher.
The Pepper test is recommended to com pare visual
reading using a test w ith better sensitivity to sm all
changes in perform ance.
R e-evaluation
Once the visual requirem ents arc met, clients often
require special instruction to recover reading skills.
O ften people with low vision have not read for a
long period of time. T h e client m ay need additional
instruction w ith a new device or the new device might
create problems w ith lighting or glare. W hen people
w ith lowr vision use optical and electronic devices,
the appearance of text, eye m ovement scan n in g strate­
gics, and the ergonom ics of the reading task change
substantially.
Strategies fo r M eeting the V isual
Requirements fo r Reading
O nce perform ance-lim iting factors have been iden­
tified, one must develop treatm ent plans to address
these im pedim ents to reading.
In adequ ate Acuity Reserve:
M agnification
T h e most comm on method to increase acuity reserve
involves a m agnification assistive device. An assort­
ment of optical devices are available to m agnify the
im age of print on the retina (see Chapter 12), includ­
ing handheld devices and strong reading glasses that
enable relative d istance m agnification. Under the
more comm on practice managem ent model, the low
vision optom etrist may have already been prescribed
these devices. Ideally devices are recom m ended, and
not prescribed until after the occupational therapy
Oops, page PA170 was not yet downloaded :(
Oops, page PA172 was not yet downloaded :(
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Blind. 2004;98:389-409.
51 Fosse P, Valberg A. Contrast sensitivity and reading in subjects
with age-related macular degeneration. Vision Impairment
Research. 2001;3:111-124.
52. Higgins KE, Wood JM. Predicting components of closed
course driving performance from vision tests. Oprom Vis Sci.
2005; 8218 >:647-656.
53. Racette L, Casson E|. The impact of visual field loss on driv­
ing performance: evidence from on-road driving assessment.
Opfom Vis Sci. 2005;82(8):668-674.
54. Clay О et al. Cumulative meta-analysis of the relationship
between useful field of view and driving [KTlormance in
older adults: Current and future implications. Optom Vis Sci.
2005;82(81:724-731.
Oops, page PA177 was not yet downloaded :(
 Vision Rehabilitation: Seven-Step Sequential Treatment Plan
/. Education
Nature of eye disease
Outlook for the future
Expectations of vision rehabilitation

2. Therapeutic Activities
Eccentric Viewing
Scanning
Reading skills

3. Environmental Modifications
Size
Distance
Color
Lighting
Contrast
Glare

4. Nonoptical Assistive Devices

Visual
Tactile
Auditory

5. Optical Magnification

6. Computer Technology in Low Vision Rehabilitation

7. Resources/Handouts

1. The nam e of the disease or condition, and the com ponents. The use of w ritten m aterials and expla­
part of the eye that is affected. nations should be considered to allow the client to
2. The functional im plications of the condition. review this inform ation at home.

3. The functional im plications of the visual acu­

ity, contrast sensitivity, and visual field loss.
4. The refractive error and why eyeglasses that
previously corrected the client's vision are still
im portant but will no longer restore vision.
5. Discussion of any devices recommended by
the low vision optom etrist.
6. The ways in which any recom mended devices
will help the client achieve his/her perfor­
m ance goals.
7. Illum ination needs, preferences, and problems
indoors and outdoors.
At the end of this phase of rehabilitation, the cli­
ent should have a good understanding of all of these
M o d ific a t io n o f the
E n v ir o n m e n t
D uffy et al7 stress the im portance o f a careful
environm ental assessm ent before attem pting to mod­
ify the environm ent. They describe environm ental
assessm ent as the process o f system atically analyz­
ing the area and surroundings in w hich individuals
with low vision will be living, working, or attending
school. To be effective, the environm ental evaluation
should encom pass tw o broad areas: the individual's
general environm ent and surroundings, and specific
tasks that the individual will be perform ing within
those environm ents.7
 Figure 11-3. Pill boxes w ith large prim (reprinted with Figure 11-4. Large-print address book {reprinted w ith permis­
permission from LS&S Products). sion from LS&S Products).

Г г 22 43 52 7 l l
25 33 58 7 5 1
18
FREE

I
18 6759 46 6 8 1
1 3
SPACE

21 39 59 731 Figure 11-6. Large-print playing cards

1 7

I 3 31 51 72 | (reprinted with permission from LS&S

21 Products).

Figure 11-5. Large-print Bingo cards.

clients w ith limited accommodation, the optometrist

prescribes a convex lens or other optical devices that
M anipulation o f C o l o r
focuses the light on the retina.
Color is a key factor to consider when assessing
Lovie-Kitchin and W hittaker compared the effect
and m odifying the environm ent.7-8 Patients who are
on reading rates of adults using relative distance ver­
visually impaired may have difficulty distinguishing
sus relative size magnification.9 They found that the
between groups of colors, such as navy blue-brown-
reading rates of the subjects with low vision did not
black, blue-green-purple, and pink-yellow-pale green.
differ significantly with the two methods of provid­
By paying careful attention to color, however, it is still
ing magnification if the magnification provided was
possible to use color to enhance physical safety, acces­
adequate. They also concluded that for most tasks, it
sibility, and independent participation in activities of
is more practical to enlarge the image optically, rather
daily living (ADL).' The three characteristics of color
than to enlarge the reading material physically.9
that must be considered are defined in Table 11-4.
Nevertheless, in clients with mild to moderate loss of
Duffy recomm ends the following general prin­
vision, these relatively simple environmental modi­
ciples for m anipulating color in environm ents to help
fications should alwavs be tried and mav be used in
# •
clients with low vision: 7
combination with other forms of magnification.
 Table 11-4.

________________ Characteristics of Color__________________________

Hue: A color's "hue" describes w hich wavelength appears to be most dom inant. The term s
"red" and "blue" for example, are prim arily describing hue.

Satu ration : A fully saturated color is one w ith no m ixture o f white, l’ink may be thought o f as
having the sam e hue as red but being less saturated.

B rig h tn ess: How lum inous or full of light the color appears.

• Bright colors are generally the easiest to see
because of their ability to reflect light.
• Solid bright colors, such as red, orange, and
yellow, are usually more visible than pastels
because they are m ore saturated.
• Lighting can influence the perception of color:
dim light can “wash ou t" some colors; bright
light can intensify others Colors can be best seen
using more recent "n atu ral" lamps that simulate
sunlight.
• Color can also provide im portant safety cues: an
indicator of change in surface or level; a w arning
for potential hazards, such as steps or construc­
tion; a m eans of coding for location or identi­
fication; and a crucial factor in judging depth
perception.
Exam ples of the m anipulation of color to help cli­
ents with low vision are listed in Table 11-5.
M o d ific a t io n o f L ighting
Before discussing the assessm ent and m odifica­
tion of lighting, it is im portant to understand that in
people with norm al vision, light levels can change
considerably from shade to bright sunlight on a snowy
day, without significantly affecting visual function.
O ne effect of most eve diseases that cause low vision is
to narrow the range of light over which som eone has
best vision. There is no ideal or best lighting solution
for all people with low vision.10'11 Different causes
o f low vision create different sensitivities to differ­
ent aspects of lighting. Som etim es people w ith the
sam e diagnosis respond differently to light, especial­
ly m acular degeneration and diabetic retinopathy.12
Therefore, the appropriate m odification of lighting
will varv from individual to individual.
There are two aspects of lighting to consider: the
am ount of light (brightness, illum ination or lumi­
nance) and glare. Glare, which should alw ays be
avoided, generally results w hen light scatters w ithin
the eye so the light from one object interferes with
one's ability to see another object. For exam ple, a
bright light or reflection from a w indow in the room
off of the screen m ight interfere w ith som eone's abil­
ity to sec a television. Unfortunately, increasing the
brightness of an object also increases glare. To create
the largest change in brightness, one should change
the distance of the light source. To m inim ize glare, the
light source should be a directional, have a shade, and
be directed from the side. Light behind or above tends
to reflect off of the material being viewed.
Boyce and Sanford stress the concept that various
causes of low vision may affect the significance or
benefits from m odification of lighting.10 These causes
include diseases that:
• Reduce transm ission of light and require more
light to see best
• D iseases that cause scatter w ithin the eve or sen-
sitivity to glare (cataract and optic atrophy)
• D iseases in w hich there is m inim al effect on
transm ission of light but destruction of parts
of the retina and neural transm ission (retinitis
pigmentosa)
• D iseases that are a com bination of both (m acular
degeneration).
Generally, the lighting of the visual environm ent
will always be im portant in determ ining how well a
client can use his or her rem aining vision when the
cause of low vision alters the optical characteristics
of the eye, such as with cataract. W hen the cause of
the low vision prim arily affects the retina and neu­
ral transm ission, changes in lighting are less likely
to be helpful.10 Finally, in situations where there is a
 Table 11-5.

Examples of Modifying Color to Help Patients With Low Vision______

• Use bright colors for light switches, elevator buttons, call buttons, and other critical safety
features.
• Mark the leading edge of the first and last steps w ith bright paint or reflecting tape that
contrasts w ith the background color of the flooring.
• Use solid, brightly-colored hallway or stair runners to clearly define traffic flow and
w alking spaces.
• Use brightly-colored index cards to mark clothing on hangers.
• Use brightly-colored dots/labels to mark appliances (oven, microwave).

combined effect, such as m acular degeneration, care­
ful attention to lighting will be helpful.13 Boyce and
Sanford, however, emphasize that this distinction
between causes of low vision and the importance
of lighting should be used only as a guideline.10
Lighting modifications should always be attempted
and will generally lead to some improvement in
function. In an experim ent to determine the effect
of lighting on object perception, investigators found
that all subjects, regardless of the cause of low vision,
showed improvement in ability to recognize objects
as illum inance was increased. However, the amount
of illum inance at which improvement ceased varied
significantly among subjects.11-12 This again suggests
that there is no optimal amount of light for all indi­
viduals. Rather, clinicians must empirically determine
the optim al lighting for each client.
Visual acuity, contrast sensitivity, and color dis­
crim ination improve as the amount of light increases,
but only up to a point. At a certain level, functional
improvement plateaus and further increases in the
amount of light may be detrimental. Тею much light
(glare) can cause discom fort or even disrupt vision.
G lare is usually divided into two categories: discom ­
fort and disabling glare.
Discomfort Glare
Discomfort glare refers to the sensation one expe­
riences when the overall illumination is too bright,
and comm only results from excessive amounts of
illum ination and/or reflections w ithin the visual
field. Surroundings including sand, water, snow,
or polished surfaces can produce discom fort glare.
Discomfort glare does not generally degrade vision;
however, it is distracting and may cause discom fort
and eye fatigue.
Disability Glare
Disability glare refers to reduced visibility of a
target due to the presence of a light source elsewhere
in the field. It occurs when light from the glare source
is scattered by the ocular media. This scattered light
forms a veil of luminance that reduces the contrast
and thus the visibility of the target. An exam ple of
disability glare would be the fam iliar experience of
being bothered by oncoming headlights while driving
at night. One form o f disability glare, called starburst
glare, is particularly disabling when som eone is
view ing white objects against a dark background. A
light against the dark tends to alm ost explode like a
starburst. O ncom ing headlights in the fog at night
also simulate a starburst glare effect.
Assessment of Lighting
The occupational therapist should perform an eval­
uation of the lighting in the client's general living
environment w hile the client is engaged in specific
ADL within that environment. In many cases, it will
become apparent that the amount of light or type of
light available is not appropriate for the client. It is not
uncommon to find that the home of an elderly person
with low vision is poorly illum inated even for a per­
son with normal vision. As stated above, som e clients
benefit from additional lighting while others require
less, and the therapist must em pirically determ ine
what will be best for each client. Table 11-6 lists the
lighting requirements and light sensitivity expected
for clients with common eye diseases causing low
vision in the elderly population.
A light meter is an instrument that provides infor­
mation about the illumination com ing from a light
source to the task and can be used by the therapist to
accurately assess the am ount of light available in the
client's environm ent.14 A light meter is very useful
because it is verv *
difficult for som eone with normal
vision to judge absolute brightness. The therapist can
evaluate lighting during the occupational therapy low
vision evaluation during contrast sensitivity or visual
acuity testing as described in Chapter 8. The therapist
varies lighting by varying the distance of a directional
 Table 11-6.

Lighting Requirements and LighLSensitivity for Clients With Common Eye Diseases
Eye Disease Preferred Lighting Sensitivity to Light
Cataract High High
D iabetic Retinopathy Moderate Moderate
Glaucoma Moderate Moderate
M acular Degeneration Varies usually Brighter High
Retinitis Pigm entosa Moderate to bright High

Modified from Flom R. Appendix: Visual consequences of most common eye conditions associated with visual impairment. In: Lueck AH,
Ed. Functional Vision: A Practitioner's Guide to £valuation and Intervention. New York: AFB Press; 2004:475-481.

task light from the task and uses a light meter to mea­
sure the range of illum inance that produced best con­
trast sensitivity or visual acuity. This sam e light level
can then be reproduced in the clinic or the home. In
addition, once the therapist finds the best brightness
for one task, it can be measured and used to guide
lighting w ith sim ilar tasks. The final test will be the
client's perform ance and preference in context, as the
best light m ay be task specific as well. Using a light
meter, however, w ill save considerable time.
After a general assessm ent of lighting conditions
in the house or living environm ent, it is im portant to
observe the client perform ing various ADL. O bserve
activities such as reading, check w riting, reading
mail, reading m edicine bottles, cooking, groom ing,
sorting and folding clothing, selecting clothing, etc.
For each activity, m ake observations about the am ount
o f lighting, contrast, and glare. After this assessm ent,
the therapist should alter the lighting conditions by
changing locations for the task, increasing brightness
by changing bulbs, m oving the light source closer,
reducing glare, and im proving contrast.
There are five different types of light that should be
considered when evaluating and m odifying the envi­
ronm ent.715 Table 11-7 lists the different types of light
and their advantages and disadvantages. To properly
evaluate and m odify lighting, the therapist will typi­
cally have to bring an assortm ent of bulbs and various
desk and floor lamps to the clients' living environ­
ment. T h e therapist can try different com binations of
lam ps and bulbs w hile the client is engaged in various
ADL. Exam ples of som e of the popular types of lamps
are illustrated in Figures 11-7 to 11-9.
Regardless of the type of lighting used, one of the
very im portant concepts that is used routinely when
m odifying lighting is the inverse square law.14 This
law states that the intensity of light observed from a
light source falls off as the square of the distance from
the object.
I = 1/d2
I = intensity of light
d = distance from the bulb to the working surface
Thus, if a therapist decreases the distance of a
75-watt bulb by one-half, he or she w ill increase the
intensity four tim es the bulb's original value. Thus,
the intensity of the bulb becom es 300 watts instead
of 75 watts simply by halving the distance. T h is law
is the foundation for the very effective environm ental
m odification of moving the light source closer to the
clien t’s reading m aterial, rather than increasing the
wattage of the bulb.
Figures 11-10 and 11-11 illustrate tw o comm on
exam ples of possible use of lighting to enhance a
client's ability to participate in ADL. In Figure 11-10,
the client is working on finances at his desk and a
gooseneck lamp is placed very close to the client's
work. In Figure 11-11, a floor lamp w ith a com bination
bulb is place behind the shoulder o f the better-seeing
eye w-hile the client is reading.
M odification of Contrast
W hen we discuss contrast, we often use the term
contrast sensitivity. This topic is discussed in detail
in Chapter 3. W hile visual acuity tests m easure the
sm allest high-contrast object that can be recognized,
contrast sensitivity m easures the lowest contrast an
object or pattern must have to be recognized. Contrast
and contrast sensitivity are im portant factors to con­
sider because they are intim ately related to perfor­
m ance in ADL and provide inform ation that is not
as easily captured by visual acuity m easurem ent.16
For example, contrast sensitivity is strongly associ­
ated with reading perform ance,17 m obility,18*19 driv­
ing, 20,21 facc recognition,21-22 and ADL.22'23 In vision
rehabilitation, occupational therapists can help clients
 Table 11-7.

Contrast of Common livervdav Objects

Type O f Light Advantages Disadvantages
Natural Light Most natural type of light Inconsistent
Appropriate for most tasks Creates glare
Creates shadows

Incandescent Readily available in a large variety of wattages Not recommended for general room lighting
New er full-spectrum incandescent bulbs (Chrom alux bulbs) Can create shadows and glare
are closer to natural sunlight As wattage increases, heat also increases

Light is concentrated
Better for "sp ot" lighting on near tasks
Light does not "flicker" like fluorescent light

Fluorescent Better for general room lighting Light is not stable; can flicker
Illuminates a w ider area than incandescent light C an't be dim m ed as easily as incandescent light
Docs not create shadows
Cooler than incandescent
New compact fluorescent bulbs fit into regular lamp
sockets with less heat and use less energy

Combination Most natural and com fortable type of artificial light May require the purchase of additional lamps
Incandescent and Approximates natural light Specialized lighting fixtures can be expensive
Fluorescent Some lamps com e w ith socket for both types o f bulbs

Halogen Brighter than incandescent light
Gives more illum ination and uses lower wattage
More energy-efficient than regular incandescent light bulbs
Light is hotter, more focused, and requires a shield
Not recom m ended for prolonged close work
Bulbs need to be replaced frequently and are more
expensive than comparable incandescent lights
May be dangerous for low vision clients because
of potential for burns

со
V-ri
 • Use trays to create contrasting background on a
kitchen counter.28
• Color code recipe cards (one color for meat
dishes, one for poultry, another for desserts).28
• Rew rite favorite recipes in large print w ith thick,
black felt-tipped pen.26-28
Finances
• Install a sw ing-arm lamp and gooseneck lamps
in areas where client w ill be paying bills, read­
ing, and w riting.7'26
• W rite w ith m edium to w ide felt-tip pens on lined
white paper.28
• C olor code household files and docum ents with
fluorescent sticky notes.26
• If desk is shinv, cover it w ith a desk pad.26
• O rder large-print checks w ith black print on yel­
low background.
• U se large-print calendar.
• Use large-print address book.
Bathroom
• Experim ent w ith d ifferent light bulbs, such
as full spectrum incandescent bulbs or com ­
pact fluorescent bulbs, or increase wattage of
bulbs.26
• Install sw ing-arm lam ps for additional light­
ing. 7,15,26
• Use m agnifying m irrors to help when shaving
or applying m akeup.24
• W hen choosing a show er curtain, clear plastic
(with design) allow s more light to be transm itted
than an opaque solid color.28
• C ircle the handle of a transparent plastic hair­
brush w ith brightly colored electrical tape.28
• Lighting should be spread out evenly through­
out the room .2:1
• Toothbrushes, cups, and bottles should be bright­
ly colored.25
• W hen towels, w ashcloths, and bath m ats need
replacem ent, purchase solid colors that contrast
w ith the tub, floor, and w all tile.7
• O ne wall should be dark, another light to pro­
vide contrast for different tasks.15-25
• Place items such as com bs and brushes on a con­
trasting colored tray.
• Wrap the grab bar with bright tape to create a
barber pole effect.7
• To avoid glare, use low -gloss or flat paint.1-''
Dining Room
• The color of the furniture should contrast the
color of the floor and w alls, and the colors of
table and chairs should co n tra st23
• Food, dishes, and the tabletop should contrast
w ith each other.15'25
• A white dinner plate is m ore visible against a
brown or navy blue table covering.7-28
• If the tabletop is dark, use light-colored place-
m ats or dishes.28
• Use a tablecloth that contrasts with tableware.28
Living Room
• M ini-blinds or vertical shades control direct
sunlight, and can be adjusted for variable light­
ing conditions according to the w eather and
tim e of day.7'15
• Lighting should be spread out evenly through­
out the room .25-26
• Light fixtures that provide little overall light
and create bright spots and shadows should be
avoided.25'26
• The door fram es should be in a color that con­
trasts with the wall color.15'215
• Space should be provided for the person to move
closer to the television.25'26
• A large-screen television should be considered.
• Use of a flexible-arm lamp for auxiliary lighting
for crafts or reading.7-15'25'26
Safety
• Place colored tape around a wall socket.28
• Lighting should be bright and spread evenly.7'25
• W alls and steps should be free o f clutter.25
• Use solid, brightly colored hallw ay or stair run­
ners to clearly define traffic flow and w alking
spaces.7
• Put contrasting strips o f tape on the bottom and
top of steps on a flight of stairs.7'8-23'28
• O utline electrical outlets w ith m asking tape of a
contrasting color.7-28
 11. Cornelissen FVV, Bootsma A, Kooijman AC. Object perception
Summary by visually impaired people at different light levels. Vis Res.
1995;35:161-168.
In this chapter, we emphasized the importance 12. Fosse P. Valberg A. Lighting needs and lighting comfort during
reading with age-related macular degeneration. I Vis Impair
o f environm ental modifications. In our experience,
Blind. 200-1;98:389-409.
these modifications, along with the use of nonoptical 13. Eldred KB. Optimal illumination for reading in patients with age-
assistive devices described in Chapter 12, should be related maculopathy. Opt Vis Sci. 1992;69:46-50.
attempted very early in the rehabilitation process 14. Carter K. Assessment of lighting. In: lose RT. Ed. Understanding
and in many cases will be more effective in enabling Low Vision. New York: American foundation for the Blind;
1999:403-414.
recovery of more home-based activities than optical
15. Kern T, Miller ND. Occupational therapy and collaborative inter­
devices. In addition, most of the suggestions pre­ ventions for adults with low vision. In: Gentile M, Ed. Functional
sented in this chapter are easy and inexpensive to Visual Behavior in Adults: An Occupational Therapy Guide to
implement and are rehabilitation strategies that all Evaluation and Treatment Options. Betliesda, MD: ЛОТА Press;
occupational therapists can begin using with their 2005:127-165.
16. I laegerstrom-Portnoy G , Schneck ME, Lott LA. Brabyn JA. The
clients with vision impairment.
relation between visual acuity and other spatial vision measures.
Optom Vis Sci. 2000;77:653-662.
17. Whittaker SG, Lovie-Kitchin ). Visual requirements for reading.
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636.
 Nonoptical Assistive Devices
In t r o d u c t io n
This chapter continues our presentation of the
seven components of the sequential vision rehabili­
tation treatment plan reviewed in Table 12-1, and is
designed to present a systematic approach to the use
of nonoptical assistive devices to m axim ize a client's
ability to engage in occupational performance.
The suggestions described in this chapter are not
remedial. Rather, they are designed to improve a
client's functional ability in spite of his or her visual
impairment. Som e of the nonoptical assistive devices
are designed on the principle of relative size magni­
fication, some provide better contrast, and others are
a combination of the two. In addition, this chapter
reviews som e of the available resources that utilize
sensory substitution. In some cases, it is more efficient
for a client with visual im pairm ent to use the tactile
and auditory sensory modalities to accomplish a
visual task.
O rganization o f R eso u r c e s /
M aterials
As suggested in previous chapters, the occupa­
tional therapist will typically visit the client's living
environment to both assess and treat the client. This
may be in the client's home, nursing home, hospi­
tal environment, or an assisted living facility, it is
important to have samples o f the various nonoptical
assistive devices available for demonstration in the
client's environment. We suggest the use of the follow­
ing organizational schem e that allows the therapist
to efficiently provide low vision rehabilitation care.
Divide the various nonoptical assistive devices into
the following categories:
1. W riting and communication
2. Kitchen
3. Self-care and leisure
4. Labeling
These m aterials can be organized by placing them
in large plastic bins that can easily be transported
to the client's living environm ent, or can be easily
accessed in a practice or hospital setting (Figure 12-1).
This is in addition to a sim ilar plastic bin with a vari­
ety of lightbulbs discussed in Chapter 11.
Please be aware that there are frequent new addi­
tions to the available nonoptical assistive devices. This
chapter is designed to introduce the reader to a selec­
tion of commonly used and popular dev ices, but is
by no m eans comprehensive. O ccupational therapists
should order the catalogs listed in Sidebar 12-1. These
catalogs will provide therapists with a comprehensive
resource of available devices for low vision rehabilita-
________ Vision Rehabilitation: Seven-Step Sequential Treatment Plan
1. Education
Nature of eye disease
O utlook for the future
Expectations of vision rehabilitation
2. Therapeutic Activities
Eccentric Viewing
Scanning
Reading skills
3. Environm ental M odifications
Size
Distance
Color
Lighting
Contrast
G lare
4. Nonoptical Assistive Devices
Visual
Tactile
Auditory
5. O ptical M agnification
6. Com puter Technology in Low Vision Rehabilitation
7. Resources/Handouts

Sidebar 12-1: Resources

Independent Living Aids, 800-537-2118 www.independentliving.com

Inc.
Lighthouse International 800-829-0500 ww vv.lighthouse.org
LS& 5 Group, Inc. 800-468-4789 w w w. 1ssgrou p.com
Maxi A ids Catalog 800-522-6294 www.m axiaids.com
 Nonoptical Assistive Devices: Writing and Communication
• W riting guides
Signature guides
Letter guides
Check-w riting guides
• Bold line paper
• Felt-tip pens
• Enlarged print
• Reading stands
• Telephone/computer
• Large-button phones
• Talking watches/clocks

Table 12-3.

Nonoptical Assistive DericesJ&ldien

Eating/Meal Preparation Aids
Large-print tim ers
Boil Alert
Liquid level indicators
M easuring cups/spoons
Cutting boards
Talking kitchen scale
Long oven mitts
Bright Dish Brush
Large-print recipes

improve eccentric viewing, scanning, and reading
skills as discussed in Chapter 10. In addition, it is
essential to first insure that lighting and contrast are
optim ized.
Table 12-2 lists som e of the nonoptical assistive
devices com m only used for w riting and com m unica­
tion. A sim ple approach for helping the client w ith low
vision to perform w riting tasks is the use of w riting
guides illustrated in Figure 12-2. These guides pro­
vide better contrast and also work on the principle of
sensory substitution. The client can use his/her tactile
sense to substitute for poor vision. The popular guides
illustrated in Figure 12-2 include a signature guide, a
letter-w riting guide, and a check-w riting guide. The
use of bold-lined paper and thick felt-tip pens are also
useful for helping a person with low vision to write
more effectively (Figure 12-3).
The use of reading/w riting stands is im portant for
clients w ith low vision for two reasons (Figure 12-4).
The use of a stand frees the hands so that the person
can hold the low vision optical device being used. It
also m akes it easier to provide consistent and appro­
priate illum ination for the task at hand by creating
stability and an appropriate view ing angle.
For people who intend to w rite extensively, typing
or word processing should be considered because
computer system s can be sim plified and adaptive
softw are employed to enable the client to see or hear
what is being typed (see Chapter 14).
 Nonoptical Assistive Devices: Sdf-Care/Leisure
Personal Care
Sock holders
Iron Guides
jum bo plastic pill box
Talking Rx
M agnifying pill cutter
M agnifying clippers
Double-sided lighted makeup mirror
Tweezer magnifier
Item locator
Iron safety guide
Talking Scale
Needle threader

Leisure
Large Bingo
Large symbol playing cards
Giant print Bible
New York Times large-print crossword puzzles
Large remote
Playing card holder

Table 12-5.

Nonoptical Assistive Devices: Labeling

Labels/Identifiers
Bump on tactile markers
Loc dots
Spot and liner
Buttons for labeling
Index cards
Vegetable/fruit identifiers
Puffy paint/Hi Marks

Table 12-6.

________________________ Getting Organized_______________

• O rganize belongings and items into predictable groupings.
• Store equipment, supplies, and other items near the activity for w hich they are used.
• Always return things to the sam e place.
• Elim inate clutter whenever possible by disposing of unnecessary items.
• Establish a comfortable workplace for each activity.
• Establish good lighting and contrast at each workplace.

Adapted from Duffy MA. M a kin g Life M o te Livable. New York: American Foundation for the* Blind; 2002.
Figure 12-2. W ritin g guides
(rep rinte d w ith perm ission from
LS&S Products).

Figure 12-3. B o ld p a p e r and felt tip pen

(re p rin te d w ith perm ission from LS&S
P roducts).

Figure 12-4. Reading stand

(re p rin te d w ith perm ission from
LS&S Products).
Figure 12-8.
Large num eral
in lo w e r right
hand c o rn e r o f
US currency.
to many with low vision. In Canada, the bills have
Braille m arkings to help the visually im paired.
W ithin the United States, there is a long history of
groups advocating changes to the US banknotes to
m ake them more user-friendly. However, m inim al
changes have been made to m ake paper currency
more accessible. At this time, the features that have
been designed to help visually im paired people are
the addition of different colors for different denom i­
nations and a large dark-colored num eral identifying
the note's denom ination in the lower-right corner of
the back of the bill. The size of this num eral is about
20/300 to 20/400 (Figure 12-8). Notes also include
a denom inating feature readable by special devices
designed to help those who are blind verify denom i­
nations.
Finally, bank debit cards or credit cards may be
used as a substitute for using cash. The client needs
to alw ays carry a signature guide and ask the cashier
to position the guide. The store and card receipts
can be folded together and verified later by a sighted
assistant.
Telephone
A nother im portant aspect of com m unication is the
telephone. An obstacle for the client with low vision
is being able see the num erals and then dial the tele­
phone numlx'r. O ne of the trends in technology is
to m ake new models sm aller and more portable. Of
course, this is problem atic for clients w ith low vision.
Fortunately, telephones w ith large num erals/letters
(Figure 12-9) are still available in the catalogs listed
in Sidebar 12-1. These telephones not only have large
print, but high contrast as well. It is im portant to teach
Figure 12-9. l arge num eral te lep hone (rep rinte d w ith perm is­
sion from LS&S F’ roducts).
the client who has sufficient tactile sensitivity to find
telephone buttons by feel because this will enable this
client to use any telephone.
O ne im portant benefit of new technology is pro­
gram m able telephones that allow people to program
a large num ber of com m only used phone numbers.
Phones are also available that allow the individual to
program num bers and use a photograph of the person
when selecting the number. This is ideal for clients
with low vision. They would simply need to program
all the num bers com m only used and then use a one-
or two-num ber com bination to call the telephone
number. The therapist, a fam ily member, or friend
could program the telephone num bers for the client.
In 2006, newer mobile phones and telephones were
available with voice recognition system s that allowed
the dialer sim ply to say the nam e of a person in their
directory, and the phone repeats the nam e of the per­
son dialed and dials the number. Certain brands of
mobile phones and caller ID system s also had features
that announce the nam e of the caller. As this technol­
ogy rapidly changes, one will need to search for the
latest technology with these features.
For persons who are visually im paired, most tele­
phone com panies offer a service in which the person
simply speaks the nam e of the person or business and
the num ber is dialed for the person. This is useful for
those clients with significant loss of vision and is an
exam ple of sensory substitution.
It is im portant for the therapist to know that
Congress amended US telecom m unications law in
1996 to require telephones and telephone services to
be more accessible. Thev enacted Section 255 to ensure
that new telephones would be designed for use by
 Sidebar 12-2: Websites

T h e Federal Com m unications Com m ission (FCC), Consum er & Governm ental A ffairs Bureau:
www.fcc.gov/cgb/d ro

The A m erican Foundation for the Blind also m aintains a web page w ith links to companies'
Section 255 web pages:
www.afb.org

Figure 12-10. Alarm clock for

clients w ith low vision (reprinted
w ith permission Irom LS&S
Products).

people with disabilities, including people who are com m onplace that the next generation o f elderly with
blind or visually im paired. Section 255 applies to all low vision will require com pensatory solutions that
telephone equipm ent and services. will enable them to continue to use com puters and
Section 255 requires com panies to do all that is the internet. We have, therefore, devoted Chapter 14
"readily achiev able ' to m ake each product or service to this topic.
accessible. As phones becom e more complex, Section
255 ensures that clients with low vision should be Telling Time
able to use cordless, w ireless, business, or traditional
Telling tim e can also be challenging for clients with
telephones to m anage telephone calls just like sighted
low vision. Relative si/.e m agnification, contrast, and
users can. Telephone m anufacturers and service pro­
sensory substitution can all be used to help clients.
viders are legally required to be able to explain access
C locks and watches are available from catalogs with
features. The therapist can help by determ ining an
high contrast and large num erals. In addition, sensory
appropriate contact num ber for the client. The Federal
substitution using talking w atches and clocks is an
Com m unications Com m ission (FCC), Consum er &
excellent com pensatory approach. These watches and
Governm ental A ffairs Bureau m aintains a web page
clocks are readily available, and inexpensive. Figure
w ith contact inform ation for most m anufacturers and
12-10 illustrates an exam ple o f an alarm clock that is
service providers. T h e websites in Sidebar 12-2 contain
available for clients w ith low vision.
a lis t o f a v a ila b le e q u ip m e n t . U s e t h e s e a r c h t e r m s to
find service providers.

Computers
T h e use of computer technology for com m unica­
tion, learning, gathering inform ation, and recreation
is a topic of great im portance. Although only a sm all
percentage of clients with low vision currently use
com puters, this num ber will grow dram atically in
the near future. The use of com puters has becom e so
K itchen
T h e ability to prepare m eals and eat independently
are ADL that are essential for a client's ability to func­
tion independently, and many nonoptical assistive
devices are available.
 F igure 12-11. M agnetic labels for
cans (reprinted w ith permission
from LS&S Products).
Organization
O rganization is particularly im portant in the kitch­
en and d in in g room. The food pantry, refrigerator,
spices, pots and pans, flatware, and cooking utensils
should all be well organized. This not only allow s
the client to know where to find necessary items, it
also enables the client to keep track of inventory and
develop shopping lists (see Table 12-6). Remem ber
to be respectful of the client's fam iliar organization
schem e; if it is changed, care must be taken to teach
the new scheme.
Labeling pantries, drawers, the refrigerator, spices,
and food item s can be very helpful. M agnetic labels are
available (Figure 12-11) and other labeling approaches
are discussed later in this chapter.
Meal Preparation
Large-print recipes and cookbooks can be found
at any bookstore or online through the Internet. In a
recent Internet search, we were able to find 15 popular
titles in large-print sim ply by searching for "large-
print cookbooks." W hen clients have favorite fam ily
recipes, a fam ily m em ber or the therapist can copy
the recipe onto a large index card using large print,
or print it out using a com puter and a font of 16 point
or larger. These cards can then be lam inated. W hen
using these recipes or cookbooks, it is best to place
them on a cookbook holder or reading stand. The
use o f a gooseneck lamp positioned near the reading
stand will further improve the client's ability to read
the recipes.
1 5
Nonoptical devices can be helpful with food prepa­
ration tasks, such as m easuring, pouring, w eighing,
cutting, boiling liquid, and w ashing utensils and
dishes. Som e of the more com m only used devices are
illustrated in Figures 12-12 through 12-16 and include:
large-print tim ers (Figure 12-12), Boil Alert (Figure 12-
13), liquid level indicators (Figure 12-14), large-print
m easuring cups/spoons (Figure 12-15), dark- and
light-colored cutting boards (Figure 12-16) to improve
contrast, a talking kitchen scale (Figure 12-17), long
oven mitts, and a bright dish brush.
Know ing w hen water or other liquid is boiling can
be a challenge. It is dangerous to get too close to the
stove to m ake this determ ination, and if the client's
hearing is im paired, listening for the sound of boil­
ing water m ay not be effective. A device illustrated
in Figure 12-13 called Boil Alert can be used. T h e Boil
A lert solid disk m arker rattles against the sides of the
pan when liquid is boiling. W hen pouring liquids,
it may be difficult for a client to know when to stop
pouring. The Liquid Level Indicator (Figure 12-14) is
a device that easilv determ ines when a container of
liquid is filled to w ithin approxim ately 1 inch of the
top. The device is hung over the lip of the cup, glass,
or container. W hen the liquid reaches the alert height,
a buzzer sounds and the unit vibrates. A nother simple
m ethod of m onitoring liquid levels for cold liquids
is the use of a ping-pong ball.3 T h e ping-pong ball is
placed in the cup and the client can feel the ball when
the liquid rises to about an inch from the top o f the
cup. A client pouring for herself m ight simply place
her finger over the side of the cup and feel when the
top is reached.

л . , ■ i •i
Figure 12-12. Large-print tim e r (reprinted w ith perm ission
from I.S&S Products).
Figure 12-14. Liquid level indicator reprinted with permis­
sion from LS&S Products'.
Large-print measuring cups/spoons (Figure 12-15),
dark- and light-colored cutting boards (Figure 12-16),
and a bright dish brush m ake use of the concepts of
relative size magnification and contrast to help the
client. A client may benefit from having both light-
colored and black m easuring spoons and cups. Dry
m easuring cups designed to level off to the top can
be used with liquids as well without need to visually
align a liquid level to a mark. The cup is filled over
som ething that will catch the spill. Another aid for
m easuring is a talking kitchen scale, as illustrated in
Figure 12-17.
гохГПТП
Figure 12-13. Boil Alert.
Figure 12-15. Large-print measuring cups/spoons
(reprinted w ith permission from I.S&S Products).
Duffy suggests attaching light and dark sheets of
c o n t a c t p a p e r to th e c o u n t e r o r o n th e w a ll n e a r th e
food preparation area,1 or use cutting boards that are
light on one side and dark on the other. The client can
hold up dark ingredients against light-colored sheets
and light ingredients against dark to improve contrast
and the ability to m easure things.
The use of flame retardant, elbow-length oven
mitts when removing pots and pans from the stove or
oven m akes sense from a safety standpoint.1
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 Table 13-4.

Masnifier Devices and Tvoical Aoolications

Device Up Close Far Distance Arm's Length Hands-Free Example

Handheld Spot No Spot Possible w ith table Reading labels,
and mount menus, fixing
som ething

Stand Extended No No No Reading a letter

or catalog

Spectacle Extended No No Yes Reading a book

reading or newspaper
addition

Telescope No Yes Spot w ith cap Yes, if mounted Fixing som ething,
on spectacles reading music,
w atching TV'

Electronic No Extended if Yes Yes, if worn on Reading book,

remote camera head seeing blackboard
is used

short duration--spot, long duration—extended

that Ms. Jason may be able to use a 10 D illum inated
handheld device to w rite large-print checks and keep
a register, and since she is already nearsighted, she
could hold it to her eye without her glasses for extra
m agnification, if needed.
6. G rade the Task: The Success-
O riented Approach
In the success-oriented approach, evaluation and
initial instruction should em phasize successful per­
form ance of a goal task.1 Starting with the device most
likely to enable successful task perform ance, have the
client try the device in a situation that requires little if
any learning or skill on the part of the client and with
m axim um assistance if necessary. This will convince
the client that success is possible from the beginning.
The client should experience what it is like to
perform the task with a device before facing the chal­
lenging task of learning to use it. In the exam ple of
Ms. Jason, before trying needlepoint, the therapist
might begin by having her w atch television w ith the
telescope since this is easier to accom plish and gen­
erally successful. Bill paying would be started with
the CCTV because success is more likely, and then a
handheld device could be attem pted later because it is
more difficult to use.
If the result with a particular device is unsuccess­
ful, attem pt to identify other perform ance-lim iting
factors such as lighting or other visual or physical
im pairm ents. Ideally, the eyecare provider partici­
pates in this problem solving. In the case o f Ms. Jason,
if her initial attem pts to use the telescope were unsuc­
cessful, larger stitches with less m agnification and
better lighting m ight be attempted. D uring this pro­
cess, the client is often able to decide if she wants the
device. The therapist should try to find one device that
m eets several needs. In the case o f Ms. Jason, w ith task
m odification (using larger stitches) she could use the
 Figure 13-12. A . V isor lo u p e
m a g n ifie r generally provid es som e
glare co n tro l. В. A s p e c la c le -c lip
lo u p e to r near m a g n ifica tio n
(p h o to courtesy o f Eschenbach
O p tik o f A m e rica , R idgefield, CT).

bccause they easily flip up out of the way, and the

shroud blocks extraneous light from producing glare.
For users w orking in a shop, these devices afford some
degree o f eye protection as well. These are stronger
than typical reading glasses.
Relative distance m agnification and m icroscopes
require that the client learn to perform a task at a closer
than normal working distance. Stronger m icroscopes
also require precise motor control or some external
support to m aintain the lens-to-object distance and to
carefully move the material being read.
Im p o rta n t P roperties o f H igh N ear
A d d itio n o r M icroscopes
• High reading addition, m icroscopes, and loupes
are often preferred to a handheld m agnifier for
extended reading.
• If the client is unable to accom m odate (focus at
near), lens-to-object distance in centim eters is
fixed. A person younger than 40 can bring an
object closer to achieve additional m agnification
and still keep it in focus.
• With higher m agnification, w orking distance is
a few inches and the object can go out of focus if
not held at the exact distance. External support
or good fine motor skills are required.
• With higher m agnification, m aintaining good
lighting becom es more of a problem.
• Because the lens is close to the eye, the client's
visual field through the device is not restricted
by optics.
F igure 13-13. M e th o d s fo r m o u n tin g lenses fo r hands-free
use. A . "G e rry -rig g e d " ho ld e r fo r a m agnifier fro m an o ld
la m p stand. B. Ches! m a g n ifie r (courtcsy o f Eschenbach
O p tik o f A m e rica , R idgefield, CT). See also Figure 13-2C.
• If a handheld m agnifier is held against the read­
ing addition, the power of the lenses w ill add
together.
H an dheld M agnifiers
Most clients w ill be fam iliar w ith handheld m agni­
fiers (see Figure 13-2), more com m only called mag­
nifying glasses. Handheld m agnifiers are the least
expensive and most versatile m agnification device.
Handheld m agnifiers might also be m ounted to a
table or on a string around the neck to allow a client
to use both hands (Figure 13-13). A client can hold
the m agnifier at any distance from the eye, bringing
it closer to increase the field o f view. W hen held close
to the eye, the handheld m agnifier functions just like
a m icroscope. Like the m icroscope, the stronger hand­
held m agnifier requires a close lens-to-object distance,
and good fine-m otor control to m aintain this distance
and to control the position of the m agnifier to avoid
losing one's place.
Handheld m agnifiers are usually used for short
periods of time. Exam ples include spot reading, such
as reading price tags, bills and labels, checking m edi­
cation, checking skin or fingernails, or reading menus.
For sustained tasks, the user often quickly fatigues
because the m agnifier must be held at the precise
distance from the objects being viewed. For more
sustained work, such as sew ing, using near addition,
spectacle clip-ons, visors, or stand m agnifiers is pre­
ferred.
Im p o rta n t P roperties o f H andheld
M a g n ifie rs
• Handheld m agnifiers are usually used for spot­
ting rather than extended use.
• Lens-to-object distance is fixed and can be deter­
mined by liftin g the lens away from a page until
it focuses the im age of a distant light onto the
page, or m axim izes m agnification and focus of
an object view ed through the lens. If the power
o f the device is known, lens-to-object distance in
centim eters also can be estim ated as 100 cm/D.
For example, a handheld m agnifier labeled as a
20 D lens would have a lens-to-object distance of
100/20 = 5 cm.
• D ecreasing eye-to-lens distance increases the
field of view (see Figure 13-9).
• If the m agnifier is held away from the eye, the
client looks through the distance (upper) seg­
ment of eyeglasses, or w ithout glasses if he or
she does not w ear correction for distance.
• The client looks through the bifocal addition or
reading addition if the lens is held close to the
eye. T h e com bined effect of reading addition and
the m agnifier w ill increase overall m agnifica­
tion.
• A lens w ith a larger diam eter has a lower
power. Larger diam eter lenses have a larger
field of view, m ostly because of lower power.
Rectangular m agnifiers arc available to increase
horizontal field of view, but these are available
only for low power m agnification.
• Ixnver power handheld devices are quite forgiv­
ing if not positioned correctly; higher power
devices are not forgiving and should not be used
for people w ith trem ors, apraxia, incoordination,
or if hand function is lim ited by problem s such
as severe arthritis.
• Lighting should ideally be directed from the side
and aim ed betw een the m agnifier and the m ate­
rial/object being viewed.
• Illum inated handheld m agnifiers w ith built in
LCD light sources are generally recom m ended,
especially with stronger m agnifiers. Therapists
are cautioned to avoid inexpensive illum inated
handheld m agn ifiers w ith poor sw itches or
regular bulbs and should caution users against
them. Broken sw itches and problems w ith bat­
teries easily consum e considerable clinical time,
disable perform ance, and irritate everyone
involved.
Stand M agnifiers
A stand m agnifier (Figure 13-3) can be used if a cli­
ent does not have the endurance or fine motor control
to hold the handheld m agnifier at the correct distance.
Stand m agnifiers usually require that the client work
on a table or hard surface. Stand m agnifiers are used
for reading. O ne sim ply rests base o f the stand mag­
nifier on the page and the stand itself m aintains the
correct object-to-lcns distance. The stand m agnifier,
however, is not as versatile as the handheld m agnifier.
Stand m agnifiers require a flat surface. These devices
are usually designed so that user can easily m aintain
a given distance from the m agnifier to keep the print
in focus.
Im p o rta n t P roperties o f Stand M a g n ifie rs
• The client looks through the bottom half of
bifocals or reading eyeglasses w ith the stand
m agnifier positioned at a prescribed eye-to-lens
distance. The prescribing optom etrist should
provide inform ation about eye-to-lens distance
and what reading glasses to use. Calculating
these distances is addressed in the Advanced
section of this chapter.
• These devices are generally preferred if som e­
one with impaired motor control needs to use a
higher m agnification.
• These devices are generally preferred over hand­
held m agnifiers for extended reading.
• Higher m agnification devices should have built-
in illum ination. Lower power stand m agnifiers
(Figure 13-14) are available as bar readers or
Some are adapted for w riting as well as reading.
Telescopes an d Telemicroscopes
D evices that are used for seeing sports events,
theater, the television at distance or recognizing faces
or reading signs arc distance devices. Telescopes and
binoculars can be handheld or spectacle-m ounted (see
Figures 13-4 and 13-5). Spectacle-m ounted telescopes
may also be mounted on the top o f the lens so the
client can look through the bottom h alf of the lenses
w hile m oving about, then stop and look through
the lens to read a sign or identify som eone. This is
referred to as a bioptic mount (Figure 13-15). In many
states, people w ith low vision can legally drive w ith
bioptic-mounted telescopes. Spectacle-m ounted tele­
scopes stabilize the device and allow both hands to be
free. Spectacle mounting, however, positions the tele­
scope further from the eye and, thus, reduces the field
F igure 13-16. Various telescope config urations that are m ore
c o s m e tic a lly accepted. Л. H a ndhe ld, note c lip b e tw e e n index
and lo n g finger (courtesy o f Eschenbach O p tik o f A m erica,
R idgefield, CT). B. B eecher-M ir.ige using a hat fo r glare c o n ­
tro l and to h id e the d e vice fro m others d u rin g sailing c o m p e ­
titio n . C. An O c u te c h Keplerian telescope in a b io p tic (photo
co u rte sy o f O c u te c h i.
• For people w ith significant astigm atism , the
tclcscopc should be viewed through corrective
eyeglasses or contact lenses, or special telescopes
can be m ade to correct refractive error.
• For those w ith tremor, arthritis, or im paired fine
m otor control, telescopes should be mounted on
eyeglasses or a headband.
• G alilean type telescopes have m agnifications
up to about 4X, are smaller, lighter, and have a
sm aller field of view.
• K e p le r ia n t y p e te le s c o p e s h a v e m a g n if ic a t io n s
g r e a t e r t h a n 3X , a r e o f te n la r g e r a n d h e a v ie r , a n d
h a v e a la r g e r f ie ld o f v ie w .
• Telescopes reduce the am ount of light. The larger
the objective lens (far lens), the more light is
transm itted through the telescope.
• Telescopes can be focused closer to about 1 M.
A special cap can be purchased that fits over
th e objective lens to allow the telescope to focus
closer, tu rning it into a telemicroscope.
Electronic Devices
Electronic versions o f several optical m agnification
devices are em erging in the marketplace. Exam ples
discussed in Chapter 14 include head-mounted CCTV
devices that focus at distance and near like telescopes.
H andheld devices act much like stand m agnifiers,
except the m agnified im age is displaced on a screen
on top of the device. The advantage of electronic
devices is the potential to enhance contrast as well as
m agnify the object being viewed.
Figure 13-17. Low er p o w e r spectacle telescope ideal for TV
w a tch in g (p h o to courtesy o f Eschenbach O p tik o f A m erica,
R idgefield, CT>.
Instruction on Device Use
G eneral Strategies for Success-
O riented Instruction
• Com plete eccentric fixation training or training
on specific com pensatory scan n in g strategies
(see Chapter 9) before recom m ending devices or
providing instruction w ith those devices. O ften
a person's functional visual acuity will change
as a result o f this instruction. In som e cases,
devices may be used as part of eccentric fixation
instruction.
• It is often, but not always, advisable to begin
instruction at the full m agnification that the cli­
ent will eventually be required to use. Grading
the activity by gradually increasing device power
requires that working distance, focusing, and
lighting strategics be relearned as well. Grade
the activity by gradually w ithdraw ing assistance
with the m anipulation of the device or materials.
If the client resists the m agnification, consider
m odifying the task to decrease m agnification
demand, using large print for exam ple. O ne
m ight later return to the more dem anding task
and increased m agnification once the skills w ith
a lower power device are mastered.
• Instruction is not com plete unless the client is
taught not only how to use the device for a goal
task, but how to m aintain the device, store it for
ready access, and solve com m on problem s with
a device such as how to change batteries.
 head and hand movement. In som e cases, the
clients skim text by quickly follow ing lines of
text, stopping and reading a couple of w ords at
a time, then skim m ing over several w ords until
the inform ation they arc looking for is found.
Scanning and tracing w ith a telescope requires
the client to recognize and follow contours, such
as follow ing a sign-post up to the top where the
street sign can be read.
• Moving. A n advanced technique is to have the
client practice using a device on an unstable sur­
face, holding the object of interest in one hand
w hile standing. Clients may also need to learn
to spot through a bioptic telescope w hile driving
a w heelchair or car, or w hile w alking without
stopping.

Specific Strategies fo r N ear

Additions, M icroscopes, Visors,

E rgonom ics and C o m m o n A p p lica tio n s

Ergonom ics becom es a significant issue with closer
lens distances that require people to lean forward, and
requires precise m aintenance of lens distance. This is
especially true for a client who is som ewhat decon­
ditioned or frail because fatigued m uscles becom e
unstable and lose precise control. In general, the thera­
pist should attem pt to m aintain the approxim ately 90-
90-90 posture for m axim um stability and minim um
m uscle strain during reading. If the client reads or
works at a table, the use of a reading stand and direc­
tional lighting w ill enable the clicnt to hold the m ate­
rial steady and sit up straight (see Figures 13-14 and
13-19). If the user leans forward, one hand might be
used to support the head with an elbow on the table
to relieve neck and back strain. Users often prefer to
read w ith these devices in a favorite easy chair. Lap
trays may be used and other form s of elbow support
m ight help the client steady the material and m aintain
support for the head and spine as one transitions from
the artificial instructional setup to a sim ulation of the
client's hom e situation.
O ptim ize lighting by turning off overhead lights.
Introduce directional lighting from the side aimed
betw een the lens and paper, being carefu l to avoid
reflections and glare. Use a hat brim or visor to elim i­
nate reflections from the optical surfaces of the glasses
from overhead lights.
Oops, page PA224 was not yet downloaded :(
cal lenses or reading glasses will actually decrease
m agnification when compared with looking through
the upper distance segment of the lens.
Stand m agnifiers are usually designed to be used
at an intermediate distance while the client is look­
ing through the reading addition or bottom half of
bifocals.
Device S tabilization Strategies
For clients who wish to perform craft or sewing
activities, table-mounted m agnifiers, usually with light
incorporated, are available commercially. Weak hand­
held devices are readily available in sewing stores that
can be hung around the neck to enable hands free use
(see Figure 13-13). Smaller, stronger lenses arc often
incorporated into the larger lens. Com m ercially avail­
able devices are usually low power (under 5 D).
Mounts for handheld devices are limited, however,
only by the creativity of the therapist. The low vision
clinic should be equipped with a bin of salvaged table
clamps, flexible arm s and tubing, and splinting m ate­
rial (see Figure 13-13). With a hot glue gun, the thera­
pist can quickly develop a prototype of a lens mount,
custom ized to a client's particular application. Hot
glue can be peeled off to m odify a design but is not
usually durable enough for permanent use. The final
product could be fabricated using splinting material
to hold the handle of the device to the arm.
In stru ctio n fo r H andheld M a g n ifie rs
1. Set up and lighting. Start in an artificial work
setting most likely to produce successful task
perform ance and allow sufficient control to
identify specific impediments. Have the cli­
ent sit at a table with good (90-90-90) posture
using a reading stand. Use a typoscope. Teach
the client how to position the light.
2. Grade the task. Begin with enlarged samples of
the materials that the client wishes to read and
use an uncluttered layout. Initially provide
hand-over-hand assistance. Start by laying
the lens on the material and providing a slow,
controlled increase in lens-to-object distance to
well beyond the focal distance and describing
the visual effect.
3. A lign, focus, and fixate. Instruct the client to
control lens distance and align his or her line of
sight with the center of the optics. Intentionally
position the magnifier incorrectly and have
the client correct the problem. Since hand­
held m agnifiers are often used under varied,
uncontrolled situations such as shopping, the
client should be taught how to solve problems
with these devices. To teach the client to hold
the device parallel to the paper, have him or
her perform controlled rotations of the lens
so that it is no longer parallel to the paper.
Demonstrate how failure to view through the
center of the lens produces optical distortions.
Contrive incorrect lens-eye-material position­
ing and have the client correct the position­
ing.
4. Device m anagem ent. Gradually withdraw
hand and w rist supports. If such support is
necessary, consider stand m agnifiers or head-
mounted devices such as loupes or m icro­
scopes.
5. Spot ting/localizing. Instruct the client on how
to spot inform ation w ith the device. Orient the
client to the lines o f print or borders of col­
um ns and ask him/her to estim ate where the
information might be by first looking where
it is expected to be located and then, without
averting his gaze, placing the m agnifier over
that spot (see Figure 13-20).
6. For scanning, start with hand-over-hand assis­
tance. Slowly have the client scan a line of text
with a coordinated hand and head movement
from left to right. Gradually withdraw assis­
tance and finally increase task demand bv
perform ing tracing/skim m ing type tasks such
as finding the total number o f simple words
(eg, "th e" or "it") in a paragraph, a number in a
phone book, or a dosage on a medicine label.
C o m m o n D ifficu ltie s and Solutions w ith
H andheld M a g n ifie rs
T h e c li e n t n e v e r r e s o lv e d th e o b je c t o r r e a d p r i n t
a s p r e d ic t e d
• Check focus by checking alignm ent of glass­
es, and determ ine whether the client views
through distance segment.
• C h e c k th e fo c u s o f th e h a n d h e ld d e v ic e b y
g r a d u a lly l i f t i n g it f r o m th e p a g e t o a l i t t l e less
t h a n th e fo c a l d is ta n c e .
• Check for optical distortion, and try better
quality optics.
• Turn off overhead lights and adjust lighting.
• Recheck near acuity.
• With certain conditions, such as vitreous float­
ers, acuity may vary w ithin a session or with
diabetes, from session to session.
I n t e r m i t t e n t o b je c t o r p r i n t r e c o g n it io n
• Check lighting.
• Check for central scotom as or floaters.
• Check to make sure the clicnt is view ing
through center of lens.
 sure, stop immediately. These sym ptom s are
precursors to nausea associated w ith motion
sickness.
• Reduce head motion during reading.
• Reduce irregular im age m otion, a shaking
image, by working on a firm surface and using
a handheld magnifier.
Loses place w hen reading
• Use a typoscope, contrasting ruler, or finger to
keep one's place.
• Slide the device along a straightedge, and
secure page being read.
Specific Strategies fo r Telescopes
O ve rall In s tru c tio n a l S trategy
In general, users of telescopes or binoculars, w heth­
er handheld or mounted, should be w-arned to always
stop moving before looking through the device. These
devices are more stable if som eone stops and supports
the device or his head. For example, if a client is spot­
ting a street sign, he could lean against som ething
w hile spotting. As an exception to this rule, users
may be taught how to use a bioptic during driv­
ing or pow'er w heelchair use as a special advanced
technique. A person w earing center-m ount "sports
glasses" to watch television often reduces motion
through the telescope if he reclines slightly and rests
his head on a headrest. Again, ergonom ics is critical
for near tasks. For example, Ms. Jason would perform
her needlework more com fortablv if the work were on
a raised table so she could sit up straight. The head
is more stable if aligned with the spinal colum n, and
she would be more com fortable and the device more
stable.
1. Setup. Reassure the client that the task will
eventually be adapted to the preferred work
environment. Start in an artificial wrork setting
m ost likely to produce successful task perfor­
mance and allow sufficient control to identify
specific impedim ents. Have the client sit at a
high table with good (90-90-90) posture, rest­
ing the elbows on the table w hile holding the
telescope in front of the eve. The user should
face a la rg e b o a rd w ith lin e s o f seq u en tial
num bers that are large enough to be seen
through the telescope. Without the telescope,
the client should ideallv*
see the num bers as
blobs. T h e poster board should be positioned
against a contrasting w all w ith an uncluttered
background at a distance greater than 3 M (9
feet) from the user. This allow s the user to
locate the object if out of focus and identify
wrhere the telescope is pointed. If quick learn­
ing is anticipated, a television can be substi­
tuted for the poster board.
2. Lighting. A s telescopes often reduce light,
the target should be w ell lighted. Instruct the
client to use a hat brim or visor to shade opti­
cal surfaces of the glasses and telescope from
overhead lights.
3. Device fam iliarization. Have the client learn to
identify the ocular, objective lens, the focusing
knob and w-hether it is focused all the way to
distance or near without looking through it. If
used w'ith glasses, fold the eye cup back so it
can be pressed against the lens of the glasses.
Have the client describe a strategy for storing
and cleaning the device. Have the client set the
focus for distance before starting.
4. Align. The user should first m aster alignm ent
and positioning. The ocular end of the tele­
scope should be held in the w'ebspace, not the
fingertips, for m axim um stability. It should be
held as close to the eye as possible to m axim ize
field of view. If properly aligned, the telescope
should have a round view', as a crescent view'
indicates m isalignm ent. With a light shining
on the eye, the therapist should be able to look
through the objective lens and visualize the
user's eye looking back through the telescope-
—if the telescope is aligned w'ith the eye. Note
that a client w ith m acular scotoma may report
no view because he or she is not eccentrically
view ing properly; central fixation will result in
no vision. M astery o f this step requires the cli­
ent bring the telescope to the eye, quickly align
it, and report what he is view ing.
5. Focus and fixate. Begin w ith the telescope
focused at distance. By changing the distance
from a board w ith high-contrast letters, have
the client refocus after he has aligned the tele­
scope with the board.
6. Localization/spotting with real life tasks. Ask
the client to look to the spot where he would
expect to find a particular num ber on the
board without the telescope (see Figure 13-18).
The therapist can assist the client by pointing,
then having the client bring the telescope in
front of the eye without averting gaze and
focus the telescope. W hen the client m asters
this procedure, the therapist can begin train­
ing w ith real-life goal tasks such as spotting
and recognizing people, a television screen,
and a piece of furniture at different distances.
Repeat these tasks with the client using hear­
ing to estim ate the location of a target.
point, clipping fingernails, bill paying, and reading
a book. The HP is a universal term that describes the
m agnification of all near devices as well as strategies
for near work. The term "equivalent pow er" describes
the m agnification as "equivalent" to the accommoda­
tive demand required for particular eye-to-object dis­
tance. For example, a manufacturer m ight specify the
m agnification of a stand m agnifier used with 20 cm
eye-to-lens distance, as "20 D of equivalent power".
This means that the stand m agnifier has m agnifica­
tion "equivalent" to someone using a 20 D of near add
with a lens-to-object distance of 5 cm, even though the
actual power of the lenses and distances may differ.
This now allows us to use the sam e term for describ­
ing the magnification of all near devices. Essentially,
the term equivalent power describes magnification
that is equivalent to the accommodative demand at a
particular distance.
The formula for EP is different from the formula
for accom m odative demand above. M agnification
requires that we also consider enlargement of the
object being viewed. As described above, the therapist
might enlarge print or use larger objects, as well as
decrease working distance. Som e devices, such as tele-
m icroscopes or stand magnifiers, enlarge the appear­
ance o f objects as well as Ihc distance of an object. EP
can be calculated by simply multiplying the accom­
modative demand (100/d) by the enlargement ratio
(ER). The formula for calculating EP is as follows:
EP(Diopters)=100/d (cm) * ER
This important formula can be used to approximate
the FP of all optical devices or viewing situations at
near. For example, if a client requires that regular print
be doubled from 1 M (8 point) to 2 M large print (t6
point) to read comfortably, the ER is 2.0. If he is read­
ing at the custom ary reading distance of 40 cm, the
accommodative demand is 100/VD or 2.5 D, and this
would be multiplied by an FR of 2 to calculate the EP
of 5 equivalent diopters. This would be equivalent to
reading the 1 M print at 20 cm, a distance at which the
actual accommodative demand is 5 D. Note that even
when print is simply enlarged or a CCTV is used at
a normal reading distance, EP increases even though
reading addition or optical devices do not change.
In the case of Ms. jason, she wished to read and pay
bills. Initially, the therapist found with a continuous
text she required 8 M print to read fluently at 40 cm.
To read 1.0 M print fluently, she required an ER = 8X.
She would use the 2.5 D bifocal in her regular reading
glasses to view the card at 40 cm (16 in). EP would
equal 2.5 D multiplied by 8 or 20 D. O ne strategy
would be to keep the print size at 1 M, and enlarge­
ment ratio of 1.0 and recommend a 20 D reading addi­
tion or use a 20 D handheld device. Vis. Jason could
not m aintain the precise working distance of 5 cm and
was too close to write. O ne could double the working
distance from 5 to 10 cm, decreasing the accom m oda­
tive demand (lOO/lOcm) to 10 D. The therapist could
also double the size of the print from 1 M to 2 M (stan­
dard large-print checks and books), increasing the ER
from IX with regular print to 2X w ith large print. The
EP would be 10 D multiplied by 2X, preserving an EP
of 20 D.
In summary, for working distances less than about
1 M, the m agnification of any optical device or just a
change in object size can both be described as equiva­
lent power (EP) using equivalent diopters (ED) as the
measurement units. Knowing EP allows one to com ­
pare several different methods of m agnification with­
out changing the overall m agnification. Equivalent
diopters is calculated using relative size m agnification
and relative distance magnification.
A S horthand A pproach
To apply the above form ulas to estim ate EP would
typically require the therapist use a calculator to
multiply and divide. Table 13-5 describes an alterna­
tive way to perform the calculations that allow one
to more easily perform these calculations without a
calculator by adding and subtracting.
Estimating Required
M agnification
To estim ate the m agnification required for a task,
the general strategy is to use relative size and relative
distance m agnification to m agnify text or an object
until the client is able to perform the task. If it is a
near task, performed at less than about 1 M or 3 ft, one
would use the formula for EP to describe the magni­
fication required to perform the task. The therapist
must generally perform an evaluation to determine
m agnification needs at distance by changing the size
of the object. At distances greater than about 1 M, the
therapist can usually estim ate the required enlarge­
ment bv changing the distance of objects.
E stim ating Required M a g n ific a tio n a t Near
The occupational therapist estim ates the required
magnification at near by changing the size of the
object or text being viewed. In general, an occupa­
tional therapist does not have the ability to correct
for different working distances at near because such
changes require a different near correction. It is essen­
tial that the image be in focus on the retina, ie, that the
client is wearing corrective eyeglasses for the specific-
working distance. For reading, one can maintain near
test distance using a continuous text reading card
where sentences are printed at a progression of print
sizes (see Chapters 8 and 9). The client starts reading
 Table 13-5.

A Shorthand Approach for Performing Magnification Calculations

This approach can save considerable tim e, because as a low vision rehabilitation therapist, one frequently
perform s these calculations. The follow ing method allow s one to m ore easily calculate print size, distance,
or changes in the power of m agnification optics. For exam ple, if a reading evaluation indicated that 1M print
is needed to m agnify to 5 M for best reading at 40 cm , one could quickly calculate the decrease in distance
from 40 cm that would provide the equivalent m agnification, as well as the equivalent diopters (D) required
by sim ply counting steps rather than multiplying or dividing. Adding or subtracting the "steps" of a loga­
rithm ic progression of a num ber sequence is equivalent, respectively, to m ultiplying and dividing num bers
that fall on a standard arithm etic progression.

The first step is to m em orize 10 steps of a logarithm ic progression from 1 to 10. Note that these num bers
correspond to the num bers on a log near acuity chart so one can easily refer to an acuity chart to recall this
progression. The 10-step logarithm ic progression: 1.0,1.25,1.6, 2.0, 2.5, 3.2, 4.0, 5.0, 6.4, 8, (10). T h e progres­
sion of letter sizes in a log near acuity ch a rt w ill typically be as follows:

Print Size: 0.32 M, 0.4 M , 0.5 M, 0.6 M, 0.8 M, 1.0 M, 1.25 M, 1.6 M, 2.0 M, 2.5 M, 3.2 M, 4.0 M, 5.0 M, 6.4 M,
8 M.

Note that 10 steps from 1 to 10 equal a 10-fold increase. Note that 3 steps equal a 2X increase and that each
step is 1.25X larger than the previous step. Note in Table 13-6 we can put print size, power, and distance on
this sam e progression by sh iftin g the decim al place.

To trade working distance (relative distance m agnification) against ER (size m agnification) involves count­
ing steps and m aintaining the sam e total num ber of steps.

Round to the nearest step and count the steps from SI to S2. Using the above exam ple, there are 7 steps from
1 M to 5 M, 1.25,1.5, 2.0, 2.5, 3.2, 4, 5. To calculate the decrease in eye to print distance that would provide a
m agnification equivalent to increasing print size 5X, we count 7 steps starting at the test distance of 40 cm to
8 cm . To calculate equivalent diopters, we start at 2.5 D accom m odative demand at 40 cm and count 7 steps
up to 16 D of equivalent power. T h is allow s us to easily trade size increase against decreasing distance. For
exam ple, 1 step increase in size is equivalent to 1 step decrease in distance. If we use large 2 M print, then
we count 3 steps from 1 M to 2 M, and would decrease distance from 40 cm for the rem aining 4 steps to 15
cm , a total of 7.

Print size
(M ) 1 1.25 1.6 2.0 2.5 3.2 4.0 5.0 6.4. 8 10

Distance
(cm) 4.0 5.0 6.4 8 10 12.5 16 20 25 32 40

Demand
(D) 25 20 16 12.5 10 8 6.4 5.0 4.0 3.2 2.5

at the largest print size and reads down the chart until
reading starts to slow. The sm allest print size before
reading slow s is critical print size. T h e sm allest print
that som eone can read and still understand the text is
reading acuity threshold. The required m agnification
depends on the task dem ands and available print size.
If a client w ishes to read print fluently, one calculates
EP by dividing critical print size by the desired print
size. If som eone desires only spot reading, then the
ER can be som ewhat smaller. O ne then uses the for­
mula for EP and m ultiplies the ER by accom m odative
demand of the test distance, 100/d.
For example, assum e a client wants to read 1M
new sprint fluently, and the m easured critical print
size at 40 cm is 4 M. The required equivalent power
would be calculated by dividing 4 by 1 and multiply
at 40 cm w ith her reading glasses, the accom m odative
demand would be 100/40 or 2.5 D. The EP would be
8 tim es 2.5 or 20 D. O ne m ight not know whether an
"8X " handheld m agnifier should enable Ms. Jason to
read the 1 M fine print on her m edicine bottle. On the
other hand, if the m anufacturer imprinted 16 D on the
device, one would im m ediately know that it would
not have enough power. O ne could use the above for­
m ulas for EP to find a 20 D magnifier.
The convention of som e m anufacturers is to cal­
culate m agnification of a handheld m agnifier or
m icroscope by dividing the power of the lens by 4,
others divide power of the lens by 4 then add 1, so
a 4X from one m anufacturer m ight be equivalent to
a 5X from another. These sam e devices might have
different angular m agnification, depending on how
far they were held from the object being viewed and
w hether a person w as w earing reading glasses while
using the device. Rather than attempt to describe the
assortm ent of conventions used by m anufacturers we
will describe how to estim ate EP for each near device.
If the prescribed device does not fit the task require­
ments, using the formula for EP, the therapist can
select different devices w ith the sam e m agnification.
Fortunately, m anufacturers of optical devices have
generally adopted the convention of also including EP,
or the inform ation that allow s the therapist to calcu­
late EP, into the specifications for a device.
Special Considerations: N ear
Additioriy M icroscopesy and
Loupes
In te ra c tio n W ith R efractive Error and
Presbyopia
A person who is already myopic (nearsighted)
w ill require a w eaker near addition lens to achieve
a required EP of m agnification if the myopia is not
corrected (client is not w earing corrective glasses).
Uncorrected myopia is equivalent to w earing a plus
lens in front of the eye. For example, if a client has 5
D of myopia w ithout his distance glasses, he needs
only an additional 5 D to achieve 10 D of EP. People
with high myopia som etim es are able to focus up
close by taking off their glasses. If w earing glasses for
distance, however, the m inus lens acts like a reverse
telescope, m inifying the image and reducing visual
acuity. For these individuals, w earing a contact lens
correction for distance w ill result in better visual acu­
ity than w earing glasses.
A client w ith uncorrected hyperopia (farsighted­
ness) has insufficient plus in his or her lens and cor­
nea and extra plus must be added to achieve an EP
if the client does not wear his spectacle correction.
Distance correction in glasses in som eone with sig­
nificant hyperopia will have just the opposite effect as
the m inus lens in myopia. If som eone has hyperopia,
corrective spectacles w ill act as a w eak telescope and
provide distance m agnification. In som e cases, when
clients use near addition lenses and view binocu-
larlv (both eyes open), binocular vision (eye muscle)
problems m ay occu r and cause eye strain or double
vision. If occluding one eye relieves these sym ptom s,
the eyecare provider should be inform ed. The eyecare
provider may address this issue when prescribing
near addition lenses for low vision by adding prism
to the lens.
Special Considerations With
H andheld M agnifiers
Most clients are fam iliar with handheld m agnifiers
or "m agnifying glasses". Handheld m agnifiers are
simply plus lenses mounted in a handle. Better mag­
nifiers include thin lens optics and special compound
lenses that reduce chrom atic aberration that occurs
around the edges of the lens. Many have built-in light
so they can be used to read menus or price tags in a
dark store.
Since the therapist often must estim ate the power of
handheld m agnifiers that clients have obtained from
a variety of sources, the method for calculating the
power of the m agnifier w ill be discussed.
In theory, if the m agnifier is held at the focal d is­
tance from the page of text being read, or object being
viewed, the m agnification w ill not change as the cli­
ent moves closer to the m agnifier (see Figures 13-2,
13-9). Thus, one need only specify the m agnification
of the handheld m agnifier like the spectacle add or
m icroscopes described above as diopters (D).
The em erging convention is to include dioptric
value of a handheld m agnifier on the handle of the
device with other specifications. Calculating EP is
very simple and the power of plus lens can be mea­
sured as follows. The therapist should look at an
object and move the m agnifier forward and backward
until the object appears to be in focus. M easure the
distance betw een the object and the back of the lens
and use the following formula from Chapter 5 to
determ ine the power:
D = 100/d (cm)
For example, if the object being viewed is in focus
when the m agnifier is held at 10 cm , the pow er would
be:
D = 100/d (cm)
D = 100/10 = 10 D
 In general, since most users hold handheld magni­
fiers away from the eye for spotting, the general rule
is to teach the client to look through distance correc­
tion (upper half of bifocals) or without glasses if they
do not require glasses for distance. The client should
not use reading glasses and handheld m agnifiers at
the sam e tim e because using both when the lenses are
far apart actually decreases m agnification.11 If, on the
other hand, the handheld m agnifier is held close to the
eye, then looking through the reading glasses or lower
segment of bifocals actually increases magnification.
To explore these types of multilens interactions, trial
and error with working distance seem s to be the best
strategy for solving task-related problems. If someone
has stronger reading glasses and a handheld magni­
fier, one strategy for providing a client w ith an extra
high m agnification is to teach him or her to use the
tw o together with the m agnifier against the lens of the
reading glasses.
Special Considerations With
Stand and B ar Magnifiers
Unlike handheld magnifiers, stand m agnifiers are
designed to be used at a more typical reading dis­
tance while someone looks through reading glasses
or the lower half of bifocals designed for a particular
distance. A stand m agnifier is essentially a handheld
m agnifier set into a stand that rests on the page being
read to maintain the lens distance. A bar magnifier
(see Figure 13-14) is a low power stand m agnifier that
m agnifies vertically. Some stand m agnifiers maintain
the lens distance (the distance from the lens to the
page) at the focal length of the m agnifying lens; like
handheld magnifiers, these are used while someone
is looking through distance correction. Most stand
magnifiers, however, maintain a lens distance that is
som ewhat shorter than the focal distance of the lens.
For a perfectly focused image, one must view the
device within a prescribed range of distance and, if
presbyopic, through reading glasses prescribed for a
particular distance.10'11 In some cases, stronger read­
ing glasses will require that the eye-to-lens distance
decreases, with an increase in magnification and field
of view.
H o w M a g n ific a tio n Is Specified
One would first look at the m anufacturers specifi­
cation for the ER of the device. This simply describes
the "apparent" size or angular size of an object viewed
through the device (S2) when compared to the angu­
lar size of the object without the device (SI), ER =
S2/S1. Note that ER is often different than the manu­
facturer's m agnification specified on the handle. The
stand m agnifier also optically increases the apparent
distance of the object. Even though the actual distance
of the object might be 3 cm from the lens, the optical
distance might be 20 cm. The optical distance is speci­
fied as "L " bv
J the manufacturer. O ne then estim ates
how far the clicnt will be holding the lens o f the mag­
nifier from the eye and adds this eye-to-lens distance
to the value of L, an equivalent to the eye-to-object
distance (d). Using the now general formula for EP
described above for all devices, one calculates EP of
the device as follows.
EP(Diopters) = 100/d(cm) * ER
In the exam ple above where a client was reading
with a 20 D stand m agnifier set 4 cm from the page,
the HR provided in the specification sheet is 5X. The
value of L = 20 cm. If the client holds the m agnifier
20 cm from his reading glasses, the total view ing d is­
tance (d) is 40 cm. Using the above formula, the EP
would be 100/40*5= 12.5 D. This device will interact
with a c lie n ts refractive error much like a handheld
magnifier. In general, these devices are designed for
use with a client's near addition, which, of course,
fully corrects for this error. If the client places his
eye against the magnifier, EP will increase to 25 D.
However, without correction for a 20 cm view ing d is­
tance, the image will be somewhat blurry (if this client
cannot accommodate), although the amount of blur is
insignificant.
Specific Considerations fo r
Telescopes an d Telemicroscopes
When focused at distance, the telescope has no
power and therefore, unlike the other devices and
reading situations above, m agnification cannot be
specified in terms of EP. Telescopes are described in
terms of ER. The convention is that the ER is described
by the m agnification specification etched on the
device as, for example, 2X. When focused closer than
1 M, a telescope technically becom es a telemicroscope
and power can be specified in term s of EP using the
general formula for ER and thus directly compared to
other near devices (see Figure 13-5).
Two types of telescopes exist: G alilean and
Keplerian (see Figure 13-19). Both telescopes have two
lenses. The lens closest to the eye is called the ocular
and the lens at the other end is the objective. Galilean
telescopes are simpler and less expensive with only
two lenses. Keplerian system s involve two plus lenses
spaced further apart than Galilean telescopes. In
addition to the two lenses, a prism or m irror must be
incorporated into the telescope to "right" the image.
Galilean telescopes have a sm aller field of view than
a Keplerian telescope of the sam e m agnification.
Typically, the sm aller and less expensive Galilean tele­
scopes are prescribed for m agnification up to 4X.
Since the late 1950s, telescopes have decreased in
size and weight, while optical quality has improved.
M iniature telescopes con be mounted on spectacles,
allow ing hands-free, easier use and a decrease in
movement.
Normally, just like a set of binoculars or a cam ­
era, the user must refocus a telescope when looking
at objects at different distances. As w ith binoculars
and cam eras, an auto focus feature is available with
som e telescopes. Because electronic auto focus often
becom es "confu sed " and m ight focus at a different
distance than the user intends, auto focus is only rec-
om m ended if there is a m anual override and the user
has the ability to "lo ck " the focus at a given distance.
A lthough telescopes have becom e sm aller and
lighter, the necessary cost of m iniaturization is a
decrease in the am ount of light through the telescope.
Light transm ission depends on the diam eter of the
objective lens. The convention is to specify the size of
the objective after the ER. For example, a 7X50 has an
ER o f 7X and the size of the objective lens is 50 mm.
Telescopes can also be mounted in the bottom of
lenses where the bifocal segm ent is located (see Figure
13-5). The telem icroscope is focused at near, allow ing
one to look down to perform a near task w ith m agnifi­
cation w hile m aintaining a normal working distance.
The cost of this greater w orking distance, however, is a
narrow er field of view than can be achieved by a sim-
pie m icroscope (near add). Note that m ost telescopes
can be converted to telem icroscopes by purchasing
caps that are plus lenses that fit over the objective (far)
lens of the telescope. Like near reading add, the value
o f the cap in diopters is calculated using the formula
for accom m odative demand:
D = 100/d
where D is the value of the cap in diopters, and
d is the distance from the telescope to the object in
centim eters.
Typically, 2 to 2.5 D caps are used.
Since the working distance used w ith telem icro­
scopes is less than about 1 M, m agnification is speci­
fied in term s of EP. To calculate the EP of a m icroscope,
one uses the general formula for F.P. The F.R is speci­
fied on the telescope as, for example, 4X. To calculate
EP, ER is multiplied bv accom m odative demand for
the particular distance (d) that the telescope is being
used. A ccom m odative demand in diopters is 100/d
(cm). If a 4X telescope were used at 40 cm, the EP
would be 4 multiplied by 2.5 D, or 10 D of EP.
Special Considerations
Restricted Visual Fields
M agnification by any m eans m ight lim it perfor­
m ance because the client sees a sm aller piece of the
text or object being view ed. For exam ple, a client with
a visual field restricted to 4 degrees would read text
m agnified to 1 degree letters more slowly because
she would see just about 4 letters at a time. In people
with normal visual fields, field of view is limited
by the optical device (see Chapter 3). In som e cases,
retinal or neurological disease restricts a client's
visual field to less than the field through the device.
Too much m agnification might slow reading because
fewer letters can be seen at one time. U sing a continu­
ous text reading acuity test w ithout a m agnification
device, a clinician can estim ate the m agnification
at w hich perform ance is limited by a client's visual
field. Normally, reading slows as the print decreases
in size to approach acuity threshold. With significant
field restriction, reading also slows as the print is
enlarged beyond a given size. O ne needs to select an
optical device m agnification based on the print sizes
or object that produce m axim um reading rate because
too much m agnification might im pair perform ance as
much as too little m agnification.
Clients w ith field restrictions often have progres­
sive d iseases such as retinitis pigm entosa or glau­
coma. W hen these diseases progress to the point
that visual acuity is im paired, the residual field of
view is often very sm all. Contrast sensitivity often is
impaired as well. In general, these individuals b en ­
efit more from electronic devices than optical devices
because electronic devices enhance contrast and opti­
m ize lighting, allow ing acceptable perform ance with
less m agnification. Computer system s that afford text
to speech, allow contrast enhancem ent and controlled
lighting, and the future capability to use nonsighted
strategies are ideal m ethods to introduce as alterna­
tives to optical devices with clients w ho often resist
nonvisual strategies.
Central Field Loss
People with central field loss will present with
inconsistent reading and visual perform ance, even
with enlarged text rather than an optical device. T h is
condition should be evaluated and the client should
be taught com pensatory scan n in g and view ing tech­
niques such as eccentric view ing before optical devices
arc prescribed. Learning eccentric view ing is difficult
and com plicates learning new optical devices. As with
introduction of any new technique, learned eccentric
view ing strategies may regress w ith fatigue. A client
who has successfully completed eccentric view ing
instruction and is learning to use a telescope for the
first tim e may suddenly complain that nothing can be
seen through the telescope because he has regressed
to central fixation. Although use of optical devices
might be incorporated into the instruction, these
devices often are different than the device that will
eventually be prescribed. Chapter 9 provides detailed
instructions about eccentric view ing strategies.
Poor Contrast Sensitivity
In general, people w ith impaired contrast sensitiv­
ity as well as impaired acuity w ill benefit more from
electronic m agnification where contrast of print may
be enhanced as well as m agnified. Avoidance of glare
and reflections from lenses becom es essential if som e­
one with impaired contrast sensitivity uses an optical
device. Careful control of lighting becom es critical as
well; too much light will produce glare. Use of a typo-
scope where the client reads through a window cut
out of a black card will decrease glare reflecting off of
a white page. Matte rather than high gloss paper will
reduce glare as well. Tinted lenses or colored overlays
may enhance visual function as well.
Cognitive Im pairm ent
Use o f optical devices generally require the short­
term m em ory sufficient to learn new m aterials, and
the capacity to problem solve. As with any rehabilita­
tion program with som eone with impaired memory
and problem solving, one must consider a person's
premorbid skills and historical roles and activity.
A typically complicated low vision com puter sys­
tem may / be relatively
/ easy
/ to som eone who worked
with com puters for 30 years. With assistance, often
people m ay use devices such as telescopes to watch
television or a gradual increase in reading add as
a visual impairment progresses. Clients often have
premorbid fam iliarity w ith low powered handheld
devices that may enhance learning if sim ilar devices
are prescribed, but com plicate learning to use stronger
m agnifiers or stand m agnifiers. In general, sim ple size
m agnification (using large black m arker on a large
yellow pad) or relative distance m agnification (mov­
ing closer to a television) usually are the best solu­
tions. Use of sighted assistance, eg, som eone to read a
book, provides the client w ith socialization as well as
an easy way for tw o people to spend tim e together.
Im paired Fine M otor Control
People w ith tremor or incoordination, in general,
respond better to stand m agnifiers, external mounted
handheld m agnifiers, and spectacle-m ounted tele­
scopes. Com puter system s w ith screen m agnifica­
tion and modified keyboard input becom e excellent
alternatives to optical devices for reading and w riting
tasks (see Chapter 13).
F ield E n h a n c e m e n t D evices
A variety of optical devices have been developed
to help people w ith restricted or narrow fields com ­
pensate for a reduced field of view. Reverse telescopic
arrangem ents m inify a view of the world, but also
lead to greater difficulty seeing d etails.12' 14 Use of
fresnel prism s mounted on half of the lens (on the
affected side) of spectacles have been attempted that
move the view through the prism toward the apex
of the prism that is pointed nasally. In theory, the
prism moves the visual scene from the blind field
into the sighted field.15-16 If the client scans toward
the affected size into the prism , the client experiences
double vision — the displaced view superim posed
on the normal view. T h is allow s him or her to see
som ething approaching unexpectedly from the blind
side. Although these interventions have expanded
clinical m easurem ent of the client's visual field, per­
form ance-based improvements (obstacle avoidance)
rem ain unconvincing. This author has observed the
opposite effect: clients avoid scanning into a fresnel
prism to avoid diplopia, thus discouraging adaptive
com pensatory scanning. Rather than using optical
devices, use of com pensatory scan n in g techniques are
thus generally recom m ended for peripheral field loss
(see Chapter 9).
R eferences
1. Mehr LB, I-reid AN. Low Vision Care. Chicago, IL: Professional
Press; 1975.
2. Demer |L, Porter FI. Goldberg I. el al. Predictors of functional
success in telescopic spectacle use by low vision patients.
Investigative Ophthalmology and Visual Science. 1989;30(7):
1652-1665.
3. Beliveau M, Smith A. Training for visual efficiency without low
vision aids. In: Beliveau M, Smith A, Eds. The Interdisciplinary
Approach to Low Vision Rehabilitation. Stillwater, O K: National
Clearinghouse of Rehabilitation Training Materials: University of
Oklahoma: 1980:224-256.
4. Bailey IL. Equivalent viewing power or magnification? Which is
fundamental? The Optician. 1984;186:14-18.
 ______________________ Types of Electronic Devices_________________________
1. Closed Circuit Televisions (CCTV)
a) Table top— cam era and display in one unit
b) Com ponent— separate camera and display
c) Com puter component—cam era is hooked through computer that can process image
d) Split screen— both computer and CTTV share display but CCTV cam era does not connect to
computer
2. Com puter systems
a) Screen m agnifiers: m agnify and enhance computer display
b) Screen-reader: reads display aloud or converts to refreshable Braille
c) Com bined screen m agnifiers and screen readers
3. Docum ent readers: reads printed docum ents aloud
4. Personal organizers: portable devices with text-to-speech or Braille output, keyboard or Perkins-Braille
input
5. Books on tape or M P3 player: read books aloud from audio tape, CD, or digital files
6. Digital readers: read books aloud from digitized files that include natural voice and text

num erical inform ation as quickly as som eone with to vary the image m agnification, and to increase and
m ore typical vision. reverse the im age contrast so that the faded black
print on a new spaper can be seen as large bright white
Case Study 2 letters on a dark black page. The user m ust move the
material being read under the cam era, and can easily
Ms. W assel refused to move in w ith her daughter.
lose place with a slip of the hand. CCTVs usually are
She loved her house, and the m orning w alk to the cof­
packaged w ith special tables that can be moved hori­
fee shop. She was close to her fam ily in spirit, but they
zontally and vertically under the cam era, enabling the
had all moved away and were living in various loca­
reader to move along a line o f text or down a colum n
tions around the world. Ms. Wassel had alw ays loved
of num bers with relative ease. Color CCTVs allow
to write, and even published a short book of poems
users to sec im ages in natural color and add color
after she retired. As this 80-year-old woman painstak­
contrast enhancem ents that soften glare, such as using
ingly read a handw ritten note from her best friend,
light yellow letters on a dark blue background.
she m om entarily m issed the flow and beauty of hand­
O nce only available as tabletop devices, CCTVs
writing. She still added a word or tw o in her own
have becom e sm aller and lighter and are nearly as
handw riting before signing her printed letters. How
portable as optical devices (Figure 14-3). The cam eras
she struggled to learn that "darn com puter"! Now
can be pointed at distant objects, such as a blackboard,
with the daily em ails from friends and family, Ms.
converting the CCTV into a telescopic system, and can
W assel was able to keep in touch with her network of
even be head-mounted with the im age displayed on a
fam ily and friends. T h is benefit had m ade the effort
m iniature screen in front of the client's eyes (Figure
worthwhile. Ms. Wassel had m acular degeneration,
14-3A). Some CCTVs have split screens and two cam ­
but unlike m any with her condition, w ith the help of a
eras so that the user can quickly move from one image
therapist w ho had sim plified com puter access and the
to another, avoiding the tim e consum ing process of
com puter class organized by her therapist, she could
scan n in g with high m agnification to find inform ation
once again read and write.
(Figure 14-5).
Historically, electronic assistive devices for blind­
Screen m agnifier com puter program s provide the
ness and low vision included closed circuit television
sam e enhancem ents as a CCTV w ith the display on
(CCTV) system s and computer-based system s (Table
a computer screen (Figure 14-6). In addition to CCTV
14-1). The CCTV system s m odify a video image. A
features, a screen m agnifier can m odify the fonts or
typical CCTV (Figures 14-1 and 14-2) allow s the user
font spacing and include a variety of features to allow
 Figure 14-1. Conventional C C T V iTelesensory
A lladin), w ith curtain feature turned on to reduce
glare from screen. O th e r advantages: excellent
controls such as lever controls tor magnification
on control of contrast features mot visible). The XY
table has margin stops, and controlled resistance to
movem ent. Disadvantages: The illum ination of the
Figure 14-2. A . Com ponent C C T V used for tak­
X Y table creates glare, the d evice requires manual
ing a blood sam ple. B. Com ponent C C T V used
focus, and the monitor cannot be moved.
for small appliance repair.

Figure 14-4. Notebook system w ith remote cam era. A .

Cam era positioned for telescopic view in g at distance (the
Figure 14-3. Portable C C T V systems. A . Head- monitor in the adjoining room) w ith near-cap up. Note lum i­
mounted C C T V . В. I landheld C C T V (courtesy of nance enhancem ent. B. Cam era positioned dow n for reading
Eschenbach O ptik of A m erica, Kidgefield, ( T). w ith near-cap in place.
 D ocu m «fitl - H k ro to ft Wocd
to № ln§*t Format look Table tfrdow ЫФ
-г#*. ia in i4 ia M 4 •

Figure 14-5. A workstation designed for good ergonom ics tor

som eone w ith severe vision im pairm ent. The display stand
is height and distance adjustable to allow a closer working
distance w ithout com prom ising posture. Th e seat should Ix-
fully adjustable as w e ll. Th e C C T V XV table and keyboard
have been positioned to m inim ize rotation of the trunk and
neck. The same monitor is used for C C T V and com puter dis­ i ^ D o c u m e n t l - M icrosoft Word
play by sw itching between C C T V and com puter o r splitting
the display. Most im portantly all of the com ponents can be View Insert Format Tools
repositioned to va ry lx>dy positioning. Earphones are for text-
to-speech (Steinm an).

Figure 14-6. A . Com puter screens w ith no enhancem ent.

A ctive accessibility features in M icrosoft W ind ow s enables
contrast enhancement and magnification up to about 2X w ith
full screen view — com ponents only are enlarged. B. A screen
magnifier program enlarges a portion of the display with
much greater m agnification (4X is illustrated) and also pro­
vides text-to-speech to read displayed text aloud.
 Table 14-2.

The Success-Oriented Clinical Reasonins Process for Electronic Devices

1. D efine goals and task perform ance requirements.
2. Evaluate context and ergonom ics.
3. Consider optical and nonoptical devices w ith eyecare provider.
4. D eterm ine the display enhancem ent.
5. Evaluate perform ance with all necessary assistance.
6. Consider cosm etic, social, financial, prognosis, and ergonom ics.
7. Provide or arrange for instruction.
8. Consider cost.

Table 14-3.

Ancillary Devices for CCTV and ComouLer Use................ .

• Privacy screen
• M onitor stand - variable height, distance and lateral positioning
• Adjustable office ch air on wheels
• Corner desk w ith swivel ch air if using more than one display
• G lare screen, Velcro (translucent yellow plastic with Velcro)

ents might benefit from electronic devices and pres­
ent these options concurrently with optical devices.
Startin g w ith optical devices, and m oving on to
the more expensive electronic devices if the optical
devices fail, may discourage a client from consider­
ing the CCTV. If the initial evaluation indicates that
an electronic device may be more effective than an
optical device in enabling the client to achieve his or
her goals, then the therapist should dem onstrate the
CCTV system first. The client will be encouraged at
first just by perform ing a desired task and develop­
ing som e basic skills and w ill be pleasantly surprised
if a less expensive optical device is later found to be
sufficient.
Sp ecial considerations associated with the low
vision evaluation for electronic devices include the
follow ing (Table 14-2).
G oals an d Perform ance
Requirem ents
W hat is the task the client w ishes to perform?
Exam ples include correspondence, view ing pictures or
graphs, reading short or long passages, and searching
for inform ation. What arc the perform ance require­
ments? Exam ples include norm al fluent reading (for a
student or som eone working) for >1 hour, skim m ing,
and scanning.
Context an d Ergonomics
This includes the range o f tolerable working d is­
tances for different goal tasks. Are tw o hands required
to perform the task or can the client perform the task
holding a device w ith one hand? W here will the client
sit to perform the task? W hat is the closest possible
working distance? A ncillary devices such as m onitor
stands and antiglare screens should be considered
(Table 14-3).
Optical Devices an d Prognosis
A prescription for a device from a physician will
support requests for external funding. Moreover, the
client should have proper eyeglasses for the expected
w orking distance from the monitor. In som e cases,
special prescription for a closer w orking distance
will enable the user to more easily
У use the electronic
device.
ten com m unication can generally be provided by
a therapist in the context of m edical rehabilitation.
Shopping on the Web, using em ail, spreadsheets,
database, or proprietary softw are requires consider­
able instruction that is generally beyond the scope of
"m edical necessity" and the skill of most therapists.
Vocational rehabilitation and college-level educational
program s are often available to provide such instruc­
tion, although these program s m ay be expensive
and require the client pay for the instruction. It is
the responsibility of the therapist to arrange for such
instruction before a device is recommended for such
vocational goals.
A ffordability
T h e client ultim ately selects a preferred device
if he is paying for it. If an agency, school system, or
insurance pays, the therapist must provide objective
perform ance evaluations and work w ithin the agency
requirem ents.
Electronic devices are expensive. Young adults
under 21 who have not yet graduated high school or
vocational program s are eligible for what rem ains
the best resource for instruction and equipm ent— the
public school system . If the client is enrolled in a pub­
lic school system , the school is required by Federal
Law I.D.E.I.A. (12/04) to provide devices necessary for
education, including electronic and optical devices. A
request for such a device m ust include clear perfor­
m ance data in support of the recom m endation, w ith
data relating the device to the educational objectives
as stated in the student's Individual Educational
Program (IEP). The parents should m ake such a
request w ith the help of the special education teacher
who provides low vision services. M any states have
Blind and Vocational Rehabilitation Services that pay
for assistive devices for adults w ith vocational goals,
including prim ary hom em akers and caregivers. These
agencies, however, have budget lim itations. Thus, let­
ters w ith objective perform ance data must provide
a convincing argum ent that a device is necessary to
perform an essential task for a particular job or to
live independently. There has been lim ited success
obtaining reim bursem ent from M edicare, Medicaid,
and other medical insurance for assistive devices for
low vision and blindness. However, a therapist should
at least try to help the patient obtain reim bursem ent.
W hen docum enting the need for devices, it is essential
to justify medical necessity. For the CCTV, for example,
the justification might be for m edication management,
diabetic m anagem ent, and self-care functions such as
skin checks or catheter management.
E l e c t r o n i c D isplay D evices:
EDD V ersus CCTV
CCTVs are com prised of three basic features: the
cam era that focuses on the m aterial being read, the
display of the enlarged im age o f the m aterial being
read, and the table on w hich the user rests the m ate­
rial being viewed. The more conventional term CCTV
has been used in this text. Evolving technology has
been replacing the "T V " or televidco com ponents with
digitally based com ponents, rendering the term CCTV
a technical misnomer. Figure 14-1 illustrates a classic
tabletop CCTV system . The display is a video m onitor
using a CRT tube, som etim es a conventional TV set.
Newer display system s use the lighter and more
portable LCD displays that could have critical visual
characteristics that are often inferior to the CRT-tvpc
monitors. Newer digital CCTVs also use digital cam ­
eras that may likew ise have inferior visual display
characteristics when compared to older videocam eras.
N ote that the material being viewed is on an XY table
that can be moved horizontally and vertically under a
fixed cam era. Figure 14-2 illustrates som e various uses
of a com ponent CCTV system, where the cam era can
be detached and positioned for a variety o f tasks and
the monitor moved as well. The tabletop CCTV has
been used for groom ing and sm all appliance repair as
well. The detachable cam era on a com ponent CCTV
can be set up like the tabletop system, but the com po­
nent system s are considerably m ore versatile. Figure
14-3 illustrates the head-mounted and handheld sys­
tem s that are the most portable and versatile but may
have sm aller and inferior display characteristics com ­
pared to tabletop CCTVs and may, therefore, be more
d ifficult to use.
Som e com ponent system s allow the cam era to be
moved m anually or electronically to scan as well and
use an XY table accessory (see Figure 14-4). The most
popular use of the CCTV is for reading and w riting
activities.2 These activities can easily be perform ed
w ith the less expensive tabletop CCTVs. CCTVs are
available that share the display m onitor with a com ­
puter (see Figure 14-4), allow ing the user to quickly
switch back and forth from the display o f some
printed m aterial or inform ation on a screen and the
display of a word-processor or som e other application.
These mav be used with tw o cam eras as well and can
¥
display inform ation from the tw o sources on the sam e
monitor (see Figure 14-5). Split-screen CCTVs are gen­
erally the products o f choice in vocational rehabilita­
tion with users in typical w hite-collar jobs w ho also
use computers, such as Dan in Case Study 1.
 ---------------------------------------------------------------------Table 14-4:----------------------------------------------------------------------
_____________________________________ Important Properties of a CCTV______________________________________
• Ease and use of controls
• Levers rather than knobs
• M agnification is easy to reach
• Easy focus or auto focus
• 1-step switch between natural and contrast enhanced display
• Magnification between IX to 3X
• High and stable contrast with moving text (low smear)
• Ergonomic flexibility
• Table characteristics, (adjustable horizontal and vertical resistance, m argin stops, locking capability).
• Low glare from table illuminator
• Portability
• Color
• Camera stability (component system)
• Product support and integrity of vendor
Consider how a person with low vision typically
uses a CCTV. To read, the user will take the page or
book and place in on the XV table, center the book, and
position it by feel up against a lip so that it is perfectly
horizontal on the XY table. When starting, the user
must setup and focus the unit. After the setup, the
user rarely touches any control except the magnifica­
tion and a switch between normal view and reading-
enhanced view.
The setup is as follows. For a reading-enhanced
view, the user first sets up the color of the display
and the contrast. The client might choose high-con-
trast light yellow text on a dark blue background, for
example. Sometimes horizontal or vertical guidelines
on the screen are displayed to help the user stay on a
line or column. To focus the unit, the person increases
the magnification to maximum, and then adjusts the
focus until the letters appear clearest. The CCTV will
then keep the focus throughout the range of m agnifi­
cation as long as the thickness of the reading material
docs not chnngo. Sometimes a clear plastic overlay
must be used to hold the reading material flat to stay
in focus. The user will then decrease magnification
and either adjust the margin stops or place a finger or
move the book so that the table stops at the beginning
and end of the lines or column displayed. Finally, the
user increases magnification until the text can be read.
The reader then can start reading by moving the book
from left to right under the camera of the CCTV. At the
end of the line, the user w ill quickly move the table
back over the line just read, and then up slightly until
the beginning of the next line is seen.
For viewing pictures, the client will adjust the
CCTV to use natural color and contrast. For writ­
ing, the user will lock the table or increase the drag
so it does not move as casilv and move the table to
where the user wishes to write. For three-dimensional
objects (trim m ing fingernails, taking a blood sample,
or fixing an appliance), the user must readjust the
focus to the correct depth plane. Focusing on lowcr-
contrast objects is difficult. It is often helpful to have
high-contrast focusing targets for the client to use.
Once the focus is set, it is often easier to move
the object being viewed closer or further from the
camera to maintain focus, than to readjust focus. For
an experienced user, CCTV' setup can be completed
in a few seconds, with focus being the hardest part.
A beginning user might find the setup tedious and
overwhelming.
Carrying electronic devices such as CCTVs and
monitors presents a problem for those doing home-
based or workplace-based low vision practice. For
CCTV evaluation, the therapist may schedule a dem­
onstration by a vendor who will provide the dev ice at
the same time a treatment session is scheduled. For
instruction, a rental may be arranged. The choice of
which devices to demonstrate to clients will depend
on the w illingness of vendors to provide such sup­
port.
monitor can be set up and positioned at any distance
or height with a monitor stand. Newer product lines
have display monitors that can be moved. This is an
im portant feature tor those requiring higher m agnifi­
cation, where relative distance m agnification is used
in combination with relative size m agnification on
the screen. With a closer working distance, one often
must bring the monitor closer and raise it to enable an
upright posture. With a separate monitor, the user can
put the m onitor on an adjustable stand and change the
elevation and working distance to achieve a comfort­
able posture (see Figure 14-5).
Table Characteristics
For som eone with motoric impairment, low frus­
tration tolerance, and/or incoordination, table char­
acteristics become the most important features of a
CCTV. A table should at least have a lip against which
the material can be rested to insure it is positioned
horizontally. The table should have greater resistance
to movement vertically than horizontally to help the
user stay on the sam e line. The table should have tab
stops to stop movement when the beginning and end
of a line is reached. The table should have a lock­
ing m echanism or m echanism for increasing drag
if som eone plans to use the CCTV for viewing and
working on objects or writing.
Glare From Table Illumination
Since the CCTV is often most useful for people
with impaired contrast sensitivity, glare from the
light illum inating the material being read becomes
a significant problem. Fabricating and positioning a
glare shield between the display monitor and the XY
table where the light is shining can solve this problem.
The shield often can be attached with Velcro without
invalidating a product warranty. Ideally, the shield
could be made from a clear, colored plastic so the cli­
ent can still see how the page or book is positioned
under the CCTV camera.
Portability
CCTV systems in general have becom e sm aller
and lighter. Currently, relatively inexpensive hand­
held cam eras can be purchased. Som e use any TV,
others can use a computer monitor, and most can
be purchased with a portable display monitor. The
handheld cameras are difficult to use and these svs-
tems afford limited control over magnification. When
considering a portable monitor or use of a laptop
display, one must consider the effect of the usually
sm aller display on relative size magnification and
ergonomics. Component systems are now available
that work through a computer and may be used with
a portable notebook computer (see Figure 14-4). An
important advantage o f head-mounted displays, the
proxim ity of the screen to the eye enables the same
range of m agnification possible w ith a conventional
CCTV. Head-mounted svstem s and handheld system s
package the camera and display together (see Figure
14-3) and are portable, but decrease the display area.
W hen compared with stand or handheld magnifiers,
handheld electronic devices afford enhanced con­
trast and m agnification adjustment and a somewhat
greater field of view at distance. One must recall that
a simple, relatively inexpensive, illuminated handheld
optical device affords comparable m agnification to a
handheld electronic device, good illum ination under
varied lighting m agnification conditions, and greater
potential field of view and magnification if the eve-to-
lens distance is decreased.
Color
Color features add cost and complexity. Color only
enhances reading if the user appreciates color contrast
features, such as vellovv letters on a dark blue back-
ground, to decrease glare. Otherw ise, color becom es
useful to those using the CCTV to enjoy pictures, read
tables, graphs, and maps, and color illustrations.
C am era Stability an d Rotational
Cam era Adjustment
With component CCTV system s (see Figure 14-2),
the camera often attaches to an arm that might easily
bounce and m agnify any movement of the table on
which it rests. Likewise, when a cam era is pointed
at a target from an oblique angle, the object will be
viewed as rotated on the screen. Som e units allow one
to rotate the camera to compensate. For those using
the CCTV for skin inspections, or to work in a shop,
one also should consider how the camera might be
mounted. A camera with a conventional camera screw
mount is an advantage, as one might be able to use the
assortm ent of relatively inexpensive camera m ounting
systems, including table and tube clam p mounts and
tripods, available in a photography store.
Product Support/Integrity o f
Vendor
Unlike optical devices that only can be prescribed
by an eyecare provider, CCTV devices can be sold
and dispensed without any special qualifications.
Moreover, most low vision services cannot afford to
stock and m aintain the plethora of expensive and
ever-changing product lines. A good relationship
between a vendor of such products and a therapist
becom es essential to effective delivery of low vision
rehabilitation services. The therapist can provide the
vendor with valuable advice as to what products will
 ____________________ Instructional Strategies for CCTV___________________
1. Setup
2. U se of XY Table
Begin w ith activity of interest to patient
H orizontal and vertical scanning
3. Reading and W riting
Successive horizontal lines of print
Sentences or sequenced words
Random words and num bers
4. Practice W riting
Learn to find the pen tip
Begin with thick felt-tip pen, thick-lined paper
Start w ith signature, proceed to w riting
Com pletion tasks
5. Localization training
Sp otting strategies
Locate sequential num bers in the corner of page
Practice finding and nam ing the first word in successive paragraphs
Locate byline or headline
R eading a picture caption
6. Skim m ing and Scanning
M agnify text perform system atic left-right and vertical scanning. Search text for particular words
or num bers
7. G room ing, skin inspections, and w orking w ith three-dim ensional objects

sell, and provide a vendor with an opportunity to sell m anufacturers and distributors of electronic devices
their products. If a vendor is frequently dem onstrat­ are keenly aw are of m aintaining a good reputation
ing and selling products at a site, the vendor is often am ong a group where word of mouth can m ake or
w illing to provide dem onstration units at no charge break a company.
for the therapist to dem onstrate and use for train­
ing. O utpatient therapists may depend on vendors Instructional Strategies
to correctly configu re a device in a client's home and
G enerally with a CCTV, one begins instruction
provide som e hom e-based instruction. Therapists
with use of the XY table, setup o f the device, read­
can educate therapists as to instructional strategies.
ing, w riting, and finally other special applications
Vendors can keep therapists abreast of new techno­
suited to an individual client's interest (Table 14-5). To
logical developm ents and train therapists in how to
m otivate an am bivalent or resistant client, or som e­
use new equipm ent. If a vendor is unw illing to sup­
one who is expected to find learning the CCTV d if­
port his or her product, oversells expensive features,
ficult, the therapist should begin with an activity that
and fails to respond to queries from consum ers, the
directly addresses a client's interest or individual goal,
therapist often must provide the additional support
teaching actual use o f the device before the therapist
a client requires. T h e therapist has a responsibil­
instructs the client on setup. We have presented an
ity to carefully docum ent com plaints by consum ers
order of instruction used for a client w ith recent
regarding vendors and report unethical behavior first
vision loss who is resistant to change and is expected
to the distributors and m anufacturers of the prod­
to find learning an electronic device difficult. If setup
uct, and possibly to regulatory agencies. Fortunately,
is taught later, however, the client cannot practice at
home or independently until demonstrating compe­
tency with setup and basic trial and error problem
solving. The therapist might try to instruct a helper on
setup it som eone is available. Indeed, for the reluctant
client, the therapist should not recommend purchase
of the device until competency with task performance
has been demonstrated or a helper can setup the
device and solve problems. For a client who is willing
and able, setup instruction should be first. Indeed,
with younger vocationally-aged clients and students,
instruction can often be completed in one session.
For the reluctant client, expect instruction to require
several sessions. Rolf Lund and Gale Watson have
described a detailed, excellent instructional program
for the CCTV, as well as a detailed account of CCTV
design and u se ’ as part of the Learи to t h e Your Vision
for Rending (LUV) series.
O ne challenge in providing CCTV' instruction is
gaining access to these expensive devices. A well-
equipped clinic will have at least one CCTV system,
preferably a color system with most extras that can
be set up to simulate a less expensive system. All of
the instructions described below, except for the setup,
will rather easily transfer to another CCTV as long as
the design of the XV table is similar. In the case of the
reluctant client, to avoid transfer of learning issues,
the therapist should recommend the device available
for instruction in the clinic.
Setup
If a client finds learning a CCTV challenging,
teaching a client how to setup a CCTV requires access
to the unit the client will be using after discharge. The
client must be taught to use the following features in
the recommended order:
1. On/off switch and initial setup. Turn it on,
turn all settings to natural view, and m inim ize
m agnification by feel.
2. After prefocusing the system, teach operation
of the m agnification setting.
3. Teach focus if auto focus is not available. Place
a high-contrast target like a letter so that it is
centered in the display screen. M axim ize mag­
nification. Adjust focus. M inim ize m agnifica­
tion again. If auto focus is used, demonstrate
how it might be confused and corrected.
4. leach contrast polarity and color contrast set­
tings to select ideal reading enhanced view as
determined by the evaluation.
5. Teach the user to switch quickly from natural
view to reading enhanced view.
6. Teach adjustment of contrast, screen brightness,
and aperture settings (these are not changed
very often and may even be taped in particular
position to avoid accidental change).
Use of the X Y Table
In the success-oriented approach, the first activity
a client performs with a difficult device should be of
interest, and part of a stated goal. Reading is the most
comm on goal, but if the client had hoped for the day
when she could perform cross-stitch again, then the
demonstration material should be a photograph of
cross-stitch, and the task might be "looking for missed
stitches". The well-equipped service will have life-size
photographs of a variety of nonreading activities for
such clients as a starting point. Photographs will be
much easier to m anipulate at first, then three-dim en­
sional objects. If a client has central field loss, the fol­
lowing instruction can be incorporated into eccentric
view ing training (see Chapter 9) as the "steady eye
technique" once development of eccentric fixation of
isolated fixation targets has been mastered.
The change in the visual motor dem ands of reading
or any task presents the greatest challenge with the
CCTV. Typically, people are accustomed to directly
looking at whatever they wish to see. For this reason,
optical devices are more natural to use. With a CCTV,
the user must look at a display positioned above or to
the side of the object being viewed. When someone
tries to locate som ething under a CCTV, the beginning
user will often first try to look directly at the book or
material on the XY table, rather than at the display.
Before this instruction begins, the therapist should
set up the CCTV with the appropriate focus and
natural color and the lowest m agnification setting.
The therapist positions the client's hand to point to
som ething on a paper and instructs the client to "find
the tip of your finger" by moving the XY table, using
hand-over-hand assistance. This step is used to dem ­
onstrate the difference between direct view ing and
CCTV viewing. Once the client finds the tip of his
finger, m agnification is increased. This exercise can be
continued, but as an advanced exercise later until the
client can find his finger by feel. Another demonstra­
tion that might help a user understand CCTV m agni­
fication is to place the cutout o f a square window on
an enlarged print version o f the initial worksheet. The
window can be moved along the paper to illustrate the
necessary ¥ limitations in field of view that occur with
magnification.
Before this instruction begins, the therapist should
setup the CCTV with the appropriate focus and natu­
ral color. The CCTV should now be setup in reading
mode, optim ized contrast and color for reading,
focused, and set to lowest m agnification. If available,
XY table friction settin g should allow greater vertical
than horizontal resistance. If this is done bv J a thera-
pist, the therapist should describe this setup process
to the clicnt.
T h e starting exercise teaches the client to devel­
op system atic horizontal and vertical scanning. An
exam ple o f a practice sheet might be rows of repeat­
ing, sequential single digit num bers, with five spaces
betw een num bers and double spaces betw een lines.
The num bers are connected by a horizontal line (see
CCTV instruction docum ents in the Appendices). The
therapist first show s the client how to position the
paper on the XY table, against the lip and centered.
The sheet is preview ed at the lowest m agnification at
which the client can see start and stop of lines, and
the m argin stops (if any) are set. The client is then
show n how to increase m agnification until the letters
or num bers can be easily recognized. The client is
then instructed to move the table horizontally, start­
ing at the first line. Sequential num bers and letters are
generally easy to recognize and provide im m ediate
feedback if a client loses his or her place. At the end
of the line, the client is instructed to retrace back over
the line to the b egin nin g and move up to the next line.
If available, a m argin stop should be set to stop tray
m ovement when the beginning of the line is reached.
If the XY table does not have m argin stops, the client
can position his finger or a heavy object to the left of
the tray on the table so that it stops the tray movement
when the beginning of a line is centered in the display.
T h e client should be reassured that once CCTV use is
m astered, this scan can be perform ed very quickly.
If the therapist anticipates the client may have dif­
ficulty reading sheets with standard 12-point print,
the size of the letters and num bers on the paper being
viewed can be increased to allow m agnification of the
CCTV' to be reduced. An en larging copier should not
be used, rather the overall size of the layout should
rem ain the sam e so that the num bers are larger but
the sam e distance apart.
With electronic devices and the resistant client, the
therapist should attem pt to m ake the task as easy as
possible. To upgrade the activity and teach problem
solving, position the paper incorrectly so that the lines
are on a diagonal and challenge the client to identify
and correct the problem. Move the table so that a few
w ords are skipped or a line is skipped, and have the
user find the b egin nin g of the line once again.
Reading an d Writing
R eading in stru ction contin u es from scan n in g
sequential num bers and letters, to simple sentences,
isolated short words, and more complicated sentences,
as described in C hapter 9. At first, the exercises should
only involve reading successive horizontal lines of
task across a full page. Wright and W atson's workbook
is an excellent source of graded engaging exercises for
reading rehabilitation.4 Initially, the material should
be selected that involves sentences or sequenced
words or num bers to provide im m ediate feedback if
the user skips a line or som e words. Activities involv­
ing random words and num bers can be presented
once skipping errors are m inim al. As this practice can
be somewhat tedious, the exercises should involve
gam es such as counting words that describe people
or finding num bers that add up to 10. Practice w riting
can be incorporated into the reading exercises in a
graded manner. First, the client m ight sim ply draw a
line through selected words or numbers, then draw a
line under the word, then a circle around, and finally V
a square around selected words or numbers.
If the client is having difficulty' w riting at the mag­
nification level used for reading, then w riting practice
should occu r separately at first. To begin, the client
must learn to find the pen under the CCTV camera
and becom e accustom ed to a different visual-m otor
orientation. The client points to a high-contrast target
on the XY table at a random location and then moves
his hand on the table until the target and tip of the
finger are displayed on the screen. T h is task is first
performed at m inim um m agnification and graded to
increased difficulty w ith higher m agnification, and
finally the use of a pen is added. Practice with this
task should enable the client to adapt visual motor
coordination w ith the CCTV so that positioning
objects for a better view feels more natural. With w rit­
ing, the table m ight be locked at first or the friction
increased if this setting is available. T h e setup for
w riting should involve a thick felt-tip pen w ith thick
lined paper, lower m agnification and natural color set­
tings. Start with a signature, sim ple shapes, and then
move on to writing. O nce the client feels com fortable
w riting enlarged print at a lower CCTV m agnification
setting, grade up the difficulty of the task by using
the contrast/color settings used for reading, then pro­
gressively increase CCTV m agnification with paper or
form s w ith sm aller, more typical lines.
Completion tasks, in which the user must fill in a
m issing word guessed from context, provide excellent
practice. This teaches writing, as well as close strate­
gics for reading as described in Chapter 9. O nce the
user is competent reading lines of text, the difficulty
of the task m ight be increased by presenting reading
m aterial in colum ns and then interspersed with fig­
ures, tables, and ads, as is typical of a new spaper or
m any books.
Localization
A more d ifficult but functionally im portant task
with a CCTV is localization. This involves spotting
strategics where first the material is viewed with
lower m agnification and the approximate location of
the critical information is estimated from the layout
of the material as seen with lower magnification.
The user centers the suspected location of the critical
inform ation on the screen, and increases m agnifica­
tion to read. If in the wrong place, the user uses the
material just read to better estim ate the location of the
critical information. The user decreases magnification
somewhat to enlarge the field of view and moves the
material and increases the magnification to read when
the target is expected.
Functional reading, such as reading m edicine
labels, finding the total on a bill, finding information
in a printed advertisement, reading a recipe or instruc­
tions, and finding and identifying faces in a photo­
graph all involve localization strategies. Localization
practice proceeds first with having the client locate
sequential numbers in the corner of a blank page, then
to the middle of a page. Then the client might practice
finding and nam ing the first word in successive para­
graphs, locating the byline or headline, and reading
a picture caption. This phase of instruction can be
completed using bills, m edicine labels, instructions,
and recipes. Note that the user is frequently changing
magnification. Users require convenient access to the
m agnification control for such advanced skills.
S kim m ing and Scanning
Skim m ing and scanning is the most advanced
reading task. In som e cases, the user cannot use
localization strategies because the lavout of the page
in an unm agnified view does not indicate where criti­
cal information is located on a page. The client must
now m agnify the text until it can be read and perform
system atic left-right-vertical scanning to look for some
text. This task might be to search text for particular
words or numbers. In most cases, a combination of
scanning and localization can be used. For example,
looking up a word in the dictionary or a name in the
phone directory might initially involve localization.
The client must check first letters and then decrease
m agnification, using the less magnified view to skip
pages and whole blocks of text until the expected
location of the expected starting letter is centered and
then magnified. Once the reader is close to the target,
scanning methods can be used to find the target.
G room ing/Diabet ic
M a nagem e tit/Read ing Labels
To begin this step in instruction, the client should
demonstrate competency with CCTV setup and prob­
lem solving, especially with focusing. Tabletop CCTVs
can be used to inspect hands and trim nails visually.
The client should be competent with visual-motor
coordination with a CCTV, such as w riting tasks.
To start, a target is applied to a finger or picked
up and viewed after focus is adjusted. The therapist
instructs the user to inspect his hand and find the
target. The goal is for the client to be able to move an
object and position it so that it is in focus. Subsequent
practice tasks might include fastening buttons, adjust­
ing zippers, simple sew ing activities like separat­
ing seams, cutting, and painting three-dim ensional
objects. These activities require that the CCTV' be fre­
quently refocused. Subsequent activities can be varied
according to the client's interests and needs.
To read a m edicine label, syringe, or to blot a bead
of blood onto a test strip, the hand or object being
viewed should rest in the center of the XY table so the
distance from the camera does not change. In most
cases, the table should be locked or friction increased
for stability. Л m edicine bottle or syringe m ight be
rotated while resting on a firm surface. To facilitate
this activity for som eone with im paired motoric con­
trol, the therapist might easily fabricate stands and
holders from scraps of splinting material or dispense
some firm putty to a client to stabilize objects.
Working With Crafts and
Three-D im ensional Objectsy
Grooming, Skin Inspections, and
Self- Ca theteriza tion
These activities are more easily performed with
component CCTV system s (see Figure 14-2). With
a detachable or adjustable camera, the objects are
often viewed at odd angles so the image <>n the dis­
play appears rotated. If the camera does not have a
rotational adjustment, the user should position the
camera with direct horizontal or vertical alignm ent
with the object rather than direct the camera at an
oblique angle. For example, if setting a cam era to
m agnify a screen at the end of a rectangular table, the
user should position the camera directly in front of
screen, at the other end of the table, rather than from
the side. It a component CCTV is used as a m irror
substitute for groom ing, the camera might be directed
at a m irror so the view is reversed like a real mirror.
Otherw ise, the user will need to readapt because the
view will appear reversed from working in front of a
mirror. Some component CCTVs have a setting that
will reverse the display on a screen horizontally just
like a m irror for just such an application. If the camera
can be handheld, component CCTVs can be used for
skin inspections. Component system s may also allow
the camera to be mounted for self-catheterization. The
challenge w ith all of these tasks is learning to approxi­
mate the correct camera positioning by feel or with the
use of visible markers or tactile cues.

C o m p u t e r Systems
The increasing popularity of the personal computer
in the early 1980s w as a breakthrough for people who
were blind. The first operating system s, eg, MS DOS,
displayed text, one line at a time, in a form that could
be easily transm itted to text-to-speech conversion
hardw are. People who had difficulty reading visu­
ally, now could read and w rite as quickly and effi­
ciently as a typically sighted user. The advent of the
now-standard graphical user interface (eg, M icrosoft
W indows, Apple M acintosh) and dependence on the
m ouse has subsequently presented the blind user
w ith a m ajor obstacle to full access to the world of
computing. Since the advent of the graphic interface,
softw are developers and com puter engineers, many
of whom were blind, fought back with innovation and
advocacy that encouraged m anufacturers of operat­
ing system softw are to m ake their operator interface
system s accessible. This w as true not only for people
with visual im pairm ent, but also for those with a vari­
ety o f other im pairm ents as well. Currently, operating
svstem s have built-in features that enable relatively
easy access by people with mild im pairm ent. Those
w ith more severe im pairm ent can access software,
and other m anufacturers of hardw are and softw are
have developed screen readers and display m agnifiers
that enable access by people with any level of vision
loss. Full access to softw are and resources now is lim ­
ited by the design of more specialized softw are and
design of fully accessible Web pages. For example, few
available instruction.il typing program s or computer
gam es are fully accessible by people who are blind.
The personal computer stands as the potential­
ly most powerful assistive device to enable a user
w ith any level of vision loss to easily access print
and num erical inform ation and to recover inclusive
functional w ritten com m unication. As discussed in
C hapter 9, people who can read by listening as
quickly, comfortably, and efficiently as a typically
sighted person. Not only can a user with low vision
access em ail and much inform ation on the Web, but
with docum ent readers that are now reasonably inex­
pensive, the com puter user can scan and read printed
inform ation with m agnification and visual enhance­
ment w ith screen m agnifiers or w ith speech or Braille
using a screen reader.
Getting Started
To provide clients with access to these powerful
tools, the therapist must learn how to adapt computer
system s and operate com m on assistive equipm ent, but
he or she does not need to becom e a computer expert.
This chapter provides a "getting started guide" down
the road of com puter assistive systems. The inform a­
tion changes so rapidly, specific instructions and
product recom m endations would becom e quickly
outdated. We will direct the reader to resources where
this inform ation can be found and provide recom ­
m endations about w hat to look for when evaluating
equipm ent and softw are. This chapter will provide
the reader w ith an overall strategy on how to narrow
in on specific equipm ent, skills, and procedures for
using computer-based assistive technology. For the
service that cannot afford to stock and m aintain the
expertise to teach all com peting products, selection
of one or tw o preferred system s often is sufficient.
Therapists can obtain free dem onstration softw are
for evaluation and introductory ✓ instruction. Extended
instruction on use o f the equipm ent typically is
beyond the scope o f a low vision service and can be
provided by vendors or separate agencies.
Although the vendors o f such equipm ent and
instructors have special expertise w ith com puters
and the specialized program s and applications, these
individuals often do not have special training in
low vision rehabilitation and require a collaborating
therapist with such training. These instructional and
equipm ent providers require a therapist to setup the
equipm ent and workplace so that the client with low
vision can easily read the display. To share the equip­
ment, the collaborating therapist providing vocational
rehabilitation might consider working in the sam e
facility with com puter instructors and vendors.
Required Equipment and Skills
In typical outpatient, hom e-based, or workplace-
based low vision rehabilitation settings, the therapist
needs to be prepared to perform basic evaluation and
introductory instruction w ith affordable equipm ent
and basic skills. The hardware, softw are, skills, and
resources required are listed in Table 14-6. A therapist
can avoid the necessity o f ow ning and learning m any
devices by having just one or two available. Most cli­
ents w ill depend on the therapist for specific product
recom mendations. Using the guideline in this chapter,
the therapist should periodically evaluate the d iffer­
ent devices available and select one or tw o o f the best
products for dem onstration and instruction.
Carrying electronic devices such as com puter m oni­
tors presents a problem for those doing hom e-based or
workplace-based low vision practice. Those interested
in com puters usually already ow n a computer. It is rec­
om m ended that the therapist have all of the necessary
softw are on his or her ow n (portable) com puter and
use that computer for evaluation and dem onstration
rather than the client's computer. Com puter program s
for the visually im paired often conflict with other
program s and require special hardware. Loading the
softw are on a client's com puter often results in many
Foundation for the Blind and available online for no
cost (http://wwvv.afb.org/aw/main.asp). T h e publica­
tion provides product reviews and unbiased inform a­
tion on what's new in computer technology. T h e fol­
lowing websites arc also good sources of inform ation
for updated product inform ation:
http://www.abledata.com
http://www.closingthegap.com
http://www.resna.org/taproject
htt p ://w w w.a fb.org
http://www.csun.edu
http://www.disabilityresources.org/AT-BLIND.
html
M aintaining updated versions of the softw are can
be very costly unless one has dem onstration versions
that are free of cost. Dem onstration softw are usually *
is fully operational with tim e limits. There are two
basic strategies for lim iting tim e. First, the therapist
m ay lim it the tim e a person can access the softw are
to about 30 minutes each tim e the com puter is turned
on. This lim itation is usually sufficient for evaluation
and initial instruction. The second strategy is for the
softw are to run norm ally for a fixed num ber of days,
then stop functioning. This, of course, is not satisfac­
tory. Therapists are encouraged to contact vendors
and m anufactures to provide dem onstration versions
that can be used by practitioners for evaluation and
instruction for more than a lim ited num ber of days.
Prerequisite Client Skills and
Abilities
Unfortunately, computer assistive devices continue
to be difficult to use. Until m anufacturers sim plify use
o f this technology, clients m ust have intact problem
solving, sem antic and procedural memory, reason­
ing, and frustration tolerance. For a person who has
worked w ith com puters for most of his or her life,
m any operations that m ay be somewhat challenging
for the therapist, m ay for this client be as fam iliar
and easy as getting dressed in the morning. These
individuals often can use this equipm ent despite some
cognitive lim itations.
The m ajor prerequisite skill for com puter use is
touch typing. A potential user with even moderate
vision loss must learn to touch type before he or she
can use a computer with efficiency. Close working
distances in order to see the screen or the keys gener­
ally renders the "h u n t and p eck" method impossible.
Fortunately, program s like Talking Typing Teacher
(M arvelSoft E nterp rises Inc, A bbotsford, British
Colum bia) have been developed that teach people
who are blind to type on a computer, and the Hadley
School for the Blind has a correspondence typing
course for people who are blind. Sim plified, talking
word processors are also available. To locate typing
program s for the blind, search the Web using the key
term s "typing instruction b lin d " and "w ord proces­
sor blind." In general, if a person is physically able,
typing is preferred to speech recognition software.
D etecting and correcting errors that inevitably result
from speech recognition is slower than typing it cor­
rectly the first time.
The com plexity and instability of com puters pres­
ents a m ajor obstacle to use of com puter assistive
devices. Enabling som eone with cognitive lim itations
and/or low frustration tolerance to access com puter
assistive low vision devices is lim ited bv
*
the resource-
fulness and skill of the therapist. Sim plifying comput­
er access, however, requires special training on oper­
ating system s and softw are m odifications, and setup
of screen m agnification and screen reader program s.
Even sophisticated com puter users with functional
vision should have available optical devices, usually
a handheld m agnifier sufficient to enable a com puter
screen to be read if assistive softw are or the computer
fails to work properly or does som ething unexpected.
The available optical device allow s the user to see the
screen and solve the problem.
Screen Magnification Options
D isplay Enhancem ent: M ild/
M oderate Vision Loss
For those with approxim ately 20/80 to 20/100 acu­
ity or better, who can read 2M print or sm aller print
fluently at 40 cm (16 in) (required m agnification of
less than 10 diopters [D] equivalent power (EPJ), use
of optical devices w ith a standard operating system
is usually sufficient. The user requires an adjustable
m onitor stand and an ability to touch type. Icons,
text, and m ouse pointers can be easily enlarged 2X (5
D EP) using standard operating system s (see Figure
14-6). These m odifications do not change the essential
layout of the operating system and are thus easiest to
learn. The setup steps are as follows:
• The mouse setup features allow enlarged mouse
pointers to be used. An "inverted" feature should
be selected so that the pointer autom atically
changes color on a background to reverse con­
trast.
• By finding the "accessibility" options in the
setup softw are (in "Control Panel" in W indows)
the operating system can be set to double the
size of all text displayed. The accessibility set­
ting also allow s various reverse and color con­
trast settings as well. The setup features for the
display also can be adjusted to provide w hite on
black or any required color contrast. Icons can be
enlarged using the display control as well.
 ________________ Important Properties of Screen Magnifiers________________
• Stability (m ost im portant): the computer does not stop working properly w hile program is running.
• Ease of use for sim ple applications such as em ail and word processing and the program s used by
the client.
• M agnification 2X to 10X.
• Q uick and easy m agnification adjust.
• Use w ith screen reader.
• Q uick and easy change from contrast best for reading and norm al view.
• Script files can be w ritten so setups can be custom ized for applications.
• Targeting feature: the view can be preset to jum p to targets frequently accessed with a keystroke.
• Font m odifiability.
• Scroll features.

• O nce set in the operating system , the screen
enhancem ents should autom atically apply to
the m enus of com m on word processors, spread­
sheets, database program s, and Web browsers. If
one needs to enlarge the text displayed w ithin
the particular program (the text the user is typ­
ing in a word processor), the "norm al tem plate"
m ust be m odified so the "v iew " or "zoom set­
tin g " is set to an appropriate m agnification.
In the view menu, Web browsers can be set to
enlarge the print of pages and change contrast
o f Web pages as well.
• Despite all of these changes, som etim es m es­
sages will appear in an unm agnified view. For
this reason, the user should always have addi­
tional optical m agnification devices available
that allow seeing norm al displays in a pinch.
the screen), or optical m agnifiers that are positioned
in front of the screen. O ne can achieve the sam e
m agnification more easily and inexpensively w ith a
clearer im age of the screen w ith relative distance mag­
nification. For example, increasing the m onitor size
from about 19 to 25 inches m ight nearly double the
cost, w hile achieving an enlargem ent of only about
1.25%. The sam e m agnification can be achieved by
decreasing working distance from 40 cm (16 in) to 32
cm (12 in) at the cost of new reading glasses.
If a client must use a num ber of different comput­
ers, eg, a computer support person, he or she should
have optical devices available that are sufficient to
access computers on a regular basis. Exam ples of such
devices are full-field m icroscopes, with hand m agnifi­
ers for additional m agnification, and a telem icroscope
if the client is instructing som eone or needs to provide
hardw are repairs.

To m agnify the screen, up to 5 D EP or 2X enlarge­

ment, som etim es up to 10 D (4X) will be tolerated. The
use o f a full-field m icroscope prescribed by an eyecare
provider along with an adjustable m onitor stand will
enable the user to sit up straight and bring the m oni­
tor closer to the eyes (see Figure 14-5). Because the
hands are now obscured by the monitor, touch typing
is required. By com bining relative distance m agni­
fication and operating system enhancem ents, one
can achieve up to 4X to 6X enlargem ent (10 to 20 EP
m agnification). Additional screen reader features are
available that allow the user to highlight text and have
the com puter read the text aloud.
We do not recom mend use of large m onitors and
optical Fresnel m agnifiers (m agnifiers that adhere to
Display Enhancem ent: M oderate
to Severe Vision Loss
For those requiring more than 2X to 4X enlarge­
ment, separate screen m agnifier program s like
MAGic (w w w .freedom scientific.com ) or Zoom texz
(www .aisquared.com ) should be considered as an
option. For larger m agnification, or text-to-speech,
screen m agnifiers and screen readers packaged with
operating system s are generally unsatisfactory. The
screen m agnifier has more additional features than a
CCTV (Table 14-7). W hile a CCTV enlarges a portion
of the printed page, screen m agnifiers enlarge a por­
tion of the screen (see Figure 14-6). T h e user must now
learn scan n in g skills, often using the m ouse to scan
 the entire screen. As with a CCTV, scanning can be a
tim e-consum ing and difficult skill to master. Screen
m agnifier program s, u nlike CCTVs, have features that
allow one to autom atically jum p to areas of interest
on a screen. For example, with a word processor one
might use a m ouse to scan and read a docum ent being
typed, but as soon as a letter key is pressed, the screen
m agnifier w ill jum p to the place in the text where the
text is being typed. If a m essage box appears on the
screen, the screen m agnifier can be set to autom ati­
cally jum p to the text displayed in the box and then
back to where the user was previously reading once
the box is closed.
With softw are that a client uses often, such as
database program s, screen m agnifiers can be prepro­
gram m ed using script program s. W hen the softw are
is started, the script file w ill change m agnification
and display characteristics for that particular soft­
ware. For exam ple, the script program will assign spe­
cial control keys so that the user can, with a key press,
jum p to a particular area on the screen for data entry.
T h is is called a targeting feature. This feature allows
users to enter data in a program by quickly jum ping
to the data entry fields most com m only used with the
press of a key rather than searching the screen to find
it. These are used prim arily by clients with vocational
goals and require advanced instruction and support
beyond the scope of a general low vision service.
Screen m agnifier program s have features that can
m odify text characteristics, such as font type and
spacing, to allow the user to more easily read without
changing the font of the docum ent being read or w rit­
ten. For example, ZoomText (Ai Squared, M anchester
Center, VT) w ill display the text in a long docum ent in
a m arquee fashion, scrolling the text from left to right
at a preset speed. The reader no longer needs to hunt
for the beginning of lines, but can use the steady eye
technique to more easily read without m oving his or
her head or gaze position. T h is feature can be set up
and used for training steady eye technique for people
w ith central field loss (see Chapter 9). Most im por­
tantly, several screen m agnifiers can be combined
w ith screen readers, allow ing users to read and listen
to text at the sam e time. These combined svstem s are listed in text format at the top of the screen, start­
¥
are the softw are of choice for most people with low
vision— even moderate vision loss. Table 14-7 lists the
im portant properties of screen m agnifiers. The most
im portant property is stability. Stability indicates that
the program operates consistently and does not stop
w orking unexpectedly. For som eone w ith norm al
vision, softw are m alfunctions are frustrating but gen­
erally obvious. For som eone with low vision, it is often
d ifficult to distinguish a softw are m alfunction from a
routine operational problem.
Text-to-Speech/Bm ille Softw are
O nce used only by people w ith profound vision
loss, the screen reader allows a blind individual to
navigate a computer screen. The screen reader reads
text and num bers displayed on a screen at the cur­
sor to the reader using com puter speech or Braille
displays. Screen readers m ight also read entire docu­
ments, lines, sentences, or paragraphs at a tim e at a
preset speed so that a user can read a docum ent of
several pages at a time. Braille displays are pads that
are about tw ice the length o f a spacebar or more with
moveable pins that are usually positioned just under
the spacebar. The device in Figure 14-7 can be used as
a Braille display. The pins, representing Braille char­
acters, are raised and correspond to the text displayed
on a line in the screen. Special translation softw are
converts text to Braille.
Som e screen readers work w ith a mouse, reading
whatever text or num bers are displayed where the
mouse pointer stops. Indeed, a special mouse w ill pro­
vide the user w ith tactile feedback as the user scan s a
page. For example, the m ouse m ight bum p w hen the
user leaves a window. In general, som eone w ith low
vision will use a com puter much more efficiently with
only keyboard controls, avoiding the m ouse as much
as possible. Using the keyboard, the user must, there­
fore, m em orize dozens of key com binations that direct
the cursor to scan a page horizontally or vertically, to
jum p through text a word, sentence, or paragraph at
a tim e, start reading, read faster or slower, or jum p to
preset locations in a particular application.
Using only the keyboard, a user can control all of
the features as w ell as position the cursor on all major
operating system s, word processors, spreadsheets,
database program s, and Web browsers. The screen
reader still reads what is being displayed at the loca­
tion of the cursor. Since most people use a mouse,
the instructions and help features on these program s
som etim es neglect to sum m arize keyboard controls.
O ne needs to search the website for the softw are m an­
ufacturer, and search for this inform ation. In general,
a convention has developed w here the control features
ing w ith "File/Edit." O ne can press the ALT key and
the underlined or first letter on this menu for kev-
board access. For exam ple, holding the ALT key down
and pressing F followed by a P will open the File
menu to the print screen. The script file feature and
targeting feature described above for screen m agni­
fiers actually were first developed for screen readers
and are thus available from major com m ercially avail­
able screen readers to allow one to jum p the cursor to
preset locations with key com binations.
Graphics, graphical icons, and unusual format in
Web pages, docum ents, and softw are present a con-
 _________________Important Properties of Screen Readers_____________
• Stability.
• Ease of use for simple, com m on applications and the applications used by the user.
• U se w ith m agnification softw are using the sam e controls as m agnification softw are.
• The screen reader used with m agnifier uses the sam e controls as a screen reader used alone.
• Q uick speed adjust, repeat reading a line or sentence w ith a single keystroke.
• Script files and targeting features.
• Web compatibility.
• Com patibility w ith softw are applications required by the client, including DOS.
• Full com patibility with comm on applications such as Outlook, M icrosoft Word, Excel, Internet
Explorer, and Access.
• Adobe PDF file compatibility.
• Visual dependence to use is not required to set up or use.

tinual challenge to the operation of screen readers. At
the very least, screen readers norm ally announce to
the user that it has encountered a graphic, or a graphic
control. All m ajor program m ing languages, operating
system s, and Web designs now have a feature where
the program m er or designer can provide text that
describes a graphic or a control. Many, unfortunately,
have not used these features. O ne useful service a
therapist m ight provide is to identify softw are and
websites that are fully accessible by a blind user using
a screen reader. Softw are is available that checks sites
for accessibility. These program s can be found by
searching "accessible web sites b lin d " on the Internet.
O f the many features that are m ost im portant for the
beginning user (Tabic 14-8), stability rem ains the most
im portant. Screen readers tend to have the most prob­
lem s with stability, especially with the Web.
P rin t Reading Systems
T h is author recalls the first docum ent or print
reader (the Kurzweil m achine), which cost $40,000
and was very slow and developed for people who
w ere blind. Scanners and softw are are now available
for a few hundred dollars and have features that con­
vert printed text into speech and are relatively fast.
Although the sophisticated, visually im paired client
can use the inexpensive system s, com m ercial systems
were not developed with blind users in mind and
thus arc often d ifficult to access with screen readers.
Several m anufacturers currently sell program s that
work on the standard PCs. D ocum ent readers are also
sold as stand-alone docum ent readers that are specifi­
cally designed for users with low or no vision and are
easier to use than computer-based system s. Inevitably,
docum ent readers m ake m istakes and som etim es do
not read print in the correct sequence when textbooks
or docum ents have m ultiple colum ns. The system s
designed for the blind user allow errors to be avoided
or more easily corrected. Stand-alone system s are
more expensive but easier to use and more stable
than system s designed to work w ith conventional
computers. The features that are m ost im portant for
successful use by the beginner are sum m arized in
Table 14-9.
Recordings for the Blind an d
Sighted Readers
T h e National Library for the Blind and Physically
Handicapped (NLBPH) is a federally-funded agency
that provides recordings or Braille transcriptions of
current novels and m agazines to users who cannot
read because of visual, p h ysical or cognitive disabil­
ity. Recordings for the Blind (RFB) is a private agency
that provides a sim ilar service for little or no fee. RFB
m ore often provides textbooks and teaching m ateri­
als.
T h e technology involved in presenting recordings
of books and m agazines is rapidly changing. In 2005,
recordings were generally available on audiotape
cassettes that were specially form atted to work more
slowly and store tw ice as much as conventional cas-
settes. Special players arc required; these arc gener­
ally available for free from NLBPH. As the audio
quality of these players is often poor, earphones
are recom m ended, especially for elderly clients who
likely have at least mild hearing loss. The major d is­
advantage of audiotapes is that the tone of the speaker
 Table 14-9.

_______________ Important Properties of Document Readers_________________

• Stability.
• Ease of use for the reluctant client.
• Low error frequency even with poor quality print and unpredictable formats (evaluation with a
newspaper is recommended).
• Low error frequency if original is not aligned properly.
• Fast scan rates, automatic feed with multiple pages.
• For low vision users, documents can be read aloud w hile document, charts, and figures are sim ultane­
ously viewed with screen magnification.

changes (the "M ickey Mouse effect") if the speaking

rate is increased or decreased. It becom es difficult to
Evaluation
skim a book. As is often the case with visual reading,
Computer system s should be considered as assis­
users fall asleep when listening. Unlike visual read­
tive devices as well as adaptations for those who
ing, the tape keeps playing. The reader must now try
aspire to use computers as a perform ance goal. As a
to rewind to where he or she fell asleep. Audiotapes
general rule, clients for whom a CCTV7 would be seri­
are "tone indexed." Chapters and sections are marked
ously considered for a reading or w riting goal might
so that during the fast rewind, a tone or tones can be
benefit from adapted computer system s as well. For
heard m arking the beginning of a chapter, for exam ­
those with reading and w riting goals that do not nec­
ple. The user can rewind until the tone is heard, then
essarily involve computers, evaluation of clients for
stop the recorder near the beginning of the chapter.
use of assistive computer system s is virtually identical
Note that special switches are now available that shut
to the evaluation performed for the CCTV, except the
off the player if the listener falls asleep and releases
criteria for frustration tolerance and problem-solving
the switch.
ability is more stringent for computer systems.
Digital talking books, available from RFB and other
Computers should be considered for clients who
private suppliers, uses CDs to store both a recording
must engage in w riting more than required for activi­
by a reader (as opposed to computer speech) and a
ties of daily living (ADL). Word processing is often
digital transaction of the material. With digital talk­
easier than handwriting for those with moderate
ing books, the user can much more easily scan the
vision loss, especially if they already can touch type
recording. The user must acquire special CD players
or have incoordination impairment or arthritis. People
or softw are that can be installed on any PC to use this
with vocational goals involving extensive reading and
technology- Ipods (Apple Computer) and other MP3
writing, data processing, searching for inform ation,
players are able to store music, audio books, and radio
and virtually anyone working at a desk will benefit
broadcasts that can be downloaded from the Web to
from consideration of assistive computer systems. In
play ori demand.
addition, therapists should perform an evaluation of
Personal Organizers an d Other people with mild vision loss who have included com ­
puter use in their perform ance goals.
Devices Computer system s are sim ilar to CCTV, except:
Blind users used personal organizers before they • Evaluate reading perform ance with text-to-
becam e widely used by those with typical vision. speech versus reading versus both.
These devices essentially are keyboards. Instead of a • Evaluation of other physical requirem ents rel­
display, the device uses text-to-speech played through evant to ergonomics.
standard earphones. Som e models have special key­ • Evaluation o f cognitive capability. The client
boards and displays for Braille users as well. Talking
requires good frustration tolerance, ability to
cell phones, talking global positioning devices, and
learn and recall multistep operations, and trial
echolocation devices that use sound to indicate obsta­ and error problem solving. Computer systems
cles are available as well. are routinely used successfully tor many with
 developmental disabilities and can be adapted
tor cognitive impairment.
Instructional Strategies
In general, instruction w ith com puter system s
depends on the specific configuration provided and is
beyond the scope of this text. Som e general strategies
for the more reluctant user are as follows:
• C hoose system s prim arily on the basis of sta­
bility. Nothing is more frustrating to a begin­
ning user than when a computer stops working
and the user cannot tell if it was a user error or
a program error.
• The first skills to learn are how to start and
restart a computer. The user should be taught
"escape strategies"—how to return to a com ­
fortable, fam iliar place in the computer such as
the start menu if the computer starts doing the
unexpected.
• Do not begin w ith instru ctions on setup.
Often setup can be automated, so that when
the client signs onto the computer as a user,
the assistive program s start and configure
automatically, and the desktop will appear in a
fam iliar format. O nce the therapist determ ines
the optim um setup, this inform ation can be
stored onto a CD or other storage m edia and
transferred to another computer with the help
o f a com puter-savvy assistant.^
• Begin w ith typing instruction program if nec­
essary. then a sim plified word processor and
then to email.
• Use optical devices and m odifications in oper­
ating system softw are if possible, rather than
special screen m agnifiers or screen readers.
• Remove all icons from the desktop. Place appli­
cations frequently used on the top of the start­
up menu. See the help menu for the operating
system for instructions on how to do this.
• 1 lave available a sim plified computer for dem ­
onstration using a different nam e (Mr. Easy)
for evaluation and initial instruction.
A ccessories and Er g o n o m ic s
A visually im paired student, worker, or leisure
participant using a com puter system or CCTV will
be m oving a lot more than a typically-sighted user
and is thus at risk for repetitive strain injury. W hen
recom m ending electronic system s, the therapist must
use a variety of m ethods to enable good ergonom ics
(see Table 14-9). The use of a m onitor stand is the most
im portant. The w orkspace should be set up so that
the user can switch quickly am ong all of the devices
that must be used. For example, a user providing cus­
tomer service by telephone needs to easily access the
telephone, so a headset is essential. Som eone using an
optical device to read docum ents requires a task light
and work space for visual reading. Som eone typing
from print might require the m agnified view of the
original positioned to be read with good posture with
a reading stand or CCTV. The corner of a corner desk
with a swivel chair allow s one to avoid lateral back
movement. Split-screen CCTVs also have a feature
where the user can sw itch betw een the CCTV and
computer display with a foot sw itch, allow ing one to
copy without m oving the head (see Figure 14-5).
Another configuration involves having the com ­
puter read the typed m aterial aloud while the client is
reading visually. This is an excellent strategy for the
beginning typist. G lare is often a problem in a large
office area. A privacy screen positioned in front o f the
m onitor allow s only the person directly in front of the
m onitor to see what is displayed without decreasing
the light from the display. T h is is the best method to
elim inate glare and allow s for privacy for som eone
who is displaying a m agnified im age on the screen.
Su m m a r y and V iew of
the Future
CCTV technology and computer technology con­
tinue to converge. Many types of devices (see Table
14-1) will soon be available in one portable system.
In 2006, CCTVs with digital cam eras store an im age
that a user can view just like the im age on a standard
CCTV. System s such as the Mvreader (Eschenbach
O ptik of America, Ridgefield, CTT) provide most of
the visual enhancem ents described above for screen
m agnifiers, the ability to change fonts, letter spacing,
and scroll text for easier visual reading. CCTVs that
read text aloud are on the horizon. As com puter sys­
tems continue to becom e m iniaturized, handheld, and
m ore cosm etically acceptable, head-mounted system s
will allow som eone to look at a book and im m ediately у
have the book displayed in a visual format optim ized
by his or her therapist and eyecare provider, as well
as read aloud.
O ne area that still requires considerable attention
is development of system s that are easier for clients to
use. For example, we need an accessible word proces­
sor or em ail system that is as easy to use as a typew rit­
er. Most of the additional features available are simply
unim portant to m any consum ers with low vision.
O ne m ust not forget that most clients w ith recent
vision loss simply w ish to recover the fam iliar. They
often approach new ground with fear and trepida­
tion. For exam ple, replacing a dial or lever that adjusts
m agnification w ith a push button control neglects to
consider what is fam iliar to most older consumers.
Finally, one unfortunate consequence of em erging
technology has been an apparent decline in human
to hum an contact that for all of us is m ost important.
For the older, often lonely, client who has recently lost
vision, a friend reading the newspaper or helping read
mail provides so much more than the achievem ent of
efficient reading perform ance.
R eferences
1. Hensil J, Whittaker SG. Comparing visual reading versus audi­
tory reading by sighted persons and persons with low vision. I
Vis Impair Blind. 2000;94<12>:762-770.
2. De I'Aune W, Watson GR. Stelmack |, Maino J, long S. Л
national survey of veterans' use of low vision devices. Optom
Vis Sci. 1997;74:249-259.
3. Lund R. Watson C R . The CCTV Book: Habilitation and
Rehabilitation With Closed Circuit Television Systems. Frolond,
Norway: Synsforum AN'S; 1997.
A. Wright V, Watson GR. Learn to Use Your Vision for Heading (LUV
Reading Series). Lilburn, G A : Bear Consultants; 1996.
5. Whittaker SG. Young T. Toth-Cohen S. Universal tailored access:
automating setup of public and classroom computers. / Vis
Impair Blind. 2002;96(6):448-451.
Prospective Diabetes Study (UKPDS) have dem on­
strated the benefit of tight blood glucose control on
the reduction in the development and progression of
chronic complications. The results of the DCCT (1983
to 1993) showed a reduction in risk of com plications
(eye disease: 76%; kidney disease: 50% ; nerve disease:
60% ; cardiovascular disease: 35%) when persons with
type 1 diabetes w ere treated w ith an intensive m an­
agem ent regim e consisting of four injections per day
or use o f an insulin pump and blood glucose m onitor­
ing four or more tim es per day. The UKPDS (1977 to
1991) showed the im portance of intensive blood glu­
cose control to persons with type 2 diabetes. It report­
ed that better blood glucose control through intensive
antidiabetic therapy resulted in a 25% reduction in
m icrovascular com plications, including retinopathy,
and a 35% reduction in early kidney damage. In
addition, improved blood pressure control through
medication in persons with high blood pressure and
diabetes resulted in reductions in: stroke (33%), death
from the long-term com plications of diabetes (33%),
and serious deterioration of vision (33%).
I n t r o d u c t io n t o D iabetes
a n d Its I m p a c t o n V is io n
Diabetes m ellitus is a group of metabolic diseases
characterized by hyperglycemia or high blood glu­
cose. Diabetes occu rs when the bodv J cannot use the
glucose in the blood because the pancreas is not able
to m ake or release enough insulin, the insulin that is
m ade is not effective because of resistance of the cells
receiving it, or both. The sym ptom s of acute hyper­
glycem ia include frequent urination, excessive thirst,
extrem e hunger, blurred vision, fatigue, headache,
poor wound healing, and m uscle cramps.
The tw o m ajor types of diabetes are type 1 (for­
merly juvenile-onset, type I, or insulin dependent)
and type 2 diabetes (formerly adult-onset, type II, or
noninsulin dependent). The other two form s of diabe­
tes include gestational and secondary. Type 1 diabetes
affects 5% to 10% of persons with diabetes and most
often develops before age 30.1 Persons with type 1
diabetes require an external source of insulin to su s­
tain life, due to autoim m une destruction of the insulin
producing cells of the pancreas. A genetic predisposi­
tion underlies the cause of type 1 diabetes.
Type 2 diabetes affects about 90% to 95% of per­
sons w ith diabetes. It is usually diagnosed after 30
years of age; however, it is becom ing increasingly
more prevalent in young children and adolescents.
Both insulin deficiency (although variable) and insu­
lin resistance are present in persons with type 2 dia­
betes. M ajor risk factors for type 2 diabetes include
age (high prevalence in older adults), ethnic back­
ground, positive fam ily history of type 2 diabetes, and
obesity. Type 2 diabetes may initially be treated with
weight loss, diet, and exercise. O ral m edications and
then ultim ately r
insulin may /
be needed as the disease
progresses.
Diabetes can contribute to a multitude o f conditions
affecting the eyes, including diabetic retinopathy,
m acular edema, cataracts, glaucoma, ocular palsies,
and fluctuating vision. In addition, the incidence of
m acular degeneration, although unrelated to d iabe­
tes, is also strongly related to increased age and thus
another prevalent eye condition in persons with type
2 diabetes. EveJ disease is 25 tim es more com m on in
persons with diabetes than in the general population.
The CDC estim ates that 3 m illion people in the United
States report both vision loss and diabetes, out of an
estim ated total of 20.8 m illion people with diabetes.
Diabetic retinopathy, the most com m on eye condi­
tion, is often detectable w ithin 5 years of diagnosis.
Nonproliferative retinopathy is present in 90% of
persons with type 1 diabetes after 20 years; 50% will
progress to the proliferative stage. A fter 20 years, 80%
of persons with type 2 diabetes treated with insulin
w ill have nonproliferative retinopathy; 40% will prog­
ress to the proliferative stage. Twenty percent o f per­
sons with type 2 diabetes but not treated w ith insu­
lin w ill have nonproliferative retinopathy, with 5%
advancing to the proliferative stage. M acular edema
affects 10% to 15% of persons in all groups/
Diabetic retinopathy can occur in a m ild to very-
advanced form, from nonproliferative (formerly back­
ground or preproliterative) to the proliferative stage.
The nonproliferative stage is further broken down
into mild, moderate, severe, and very severe. Mild
nonproliferative diabetic retinopathy (NPDR) occurs
when the m icrovasculature o f the retina becomes
weakened and begins to leak fluids. Sm all depos­
its are formed on the retina and tiny hemorrhages
appear. O ften no vision loss is noted at this stage.
D uring moderate to very severe NPDR, further vascu­
lar dam age occurs, resulting in capillary closure and
retinal ischem ia; however, persons at this stage may
not detect changes in vision.
In the final stage, proliferative diabetic retinopathy
(PDR), new blood vessels begin to grow along the
retina in response to the hypoxia. However, these
vessels are very fragile and w ill rupture, causing
preretinal and vitreous hem orrhages. At this stage,
vision im pairm ent may range from mild blurring
to severe vision loss. Persons experiencing bleeding
may report a veil, cloud, or streaks of red material
w ithin their field of vision. In addition, the fibrous
scar tissue that develops betw een the vessels, retina,
and vitreous can contract and pull on the retina, caus­
ing retinal tears and detachm ent. A retinal detach­
m ent can causc total blindness in the affected eye. If
neovascularization occurs in the optic disc, the risk
for m ajor vision loss is high.
M acular edema can be present in NPDR or PDR and
it may im pair central vision. The im pact on vision may
vary from mild blurring to severe loss. Fluctuating
vision may arise from sw elling in the lens of the eve
as a result of high and low blood glucose levels, or it
may be in response to postural changes, environm en­
tal conditions such as lighting, eve fatigue, or general
fatigue.
A major treatm ent for severe to very severe NPDR
and PDR is panretina! photocoagulation or laser
surgery, which is applied in a scatter pattern to the
peripheral retina. This treatm ent does not target the
new abnorm al blood vessels them selves, but is thought
to halt their proliferation by destroying enough tissue
that the demand for oxygen is decreased.9 A vitrec­
tomy may be performed when hem orrhages do not
resolve or when retinal detachm ent has or m ay occur.
D uring vitrectomy, the vitreous contents are removed
and replaced with a clear solution. C linically signifi­
cant m acular edema is treated w ith focal photocoagu­
lation to seal leaking blood vessels. The goal of these
treatm ents is to reduce vision loss.
T h e functional vision in persons w ith diabetic eye
disease is quite variable, ranging from mild blur­
ring, irregular patches of vision loss in the central
or peripheral field of vision, to severe vision loss or
total blindness. Vision loss may vary betw een both
eyes. It is not uncom m on for a person with diabetes
and vision loss to have a preferred, better-seeing eye.
An eye report m ay be helpful to provide visual acuity
and visual field m easurem ents w ithin a clinical set­
ting; however, it is also im portant to obtain a sense
of what a client can see during functional activities
in a natural environm ent. An individual's subjective
acuity or personal experience of his or her vision loss
is just as im portant as objective acuity or results from
an eye chart, especially w ith respect to low vision. The
client's perform ance of activities requiring vision may
be better than acuity suggests, or in some cases worse.
Two clients with diabetic eve *
disease and sim ilar
vision changes may use their residual vision d iffer­
ently. A client may well have, through experience, d is­
covered areas of usable vision, w hich may not appear
consistent w ith actual acuity measurem ents.
C hronic Complications
of D iabetes and G eneral
Precautions
Prolonged hyperglycem ia is the cause of the many
chronic and system ic com plications of diabetes. These
com plications affect both the large and sm all blood
vessels in the body and therefore are divided into two
m ajor categories: m icrovascular and m acrovascular.
The m icrovascular conditions include retinopathy,
neuropathy, and nephropathy. Tw enty percent of
persons with type 2 diabetes w ill have m icrovascular
com plications upon diagnosis. M acrovascular com ­
plications include: coronary artery disease, cerebral
vascular disease, and peripheral vascular disease.
These com plications contribute significantly to the
morbidity j
and m ortalityJ
associated with diabetes,
particularly in persons with long-standing diabetes.
Retinopathy that has advanced to the prolifera­
tive stage carries with it a num ber o f precautions to
prevent retinal bleeding. These include avoiding the
following behaviors: lifting objects heavier than 5
pounds (or lim it as determ ined by physician), bend­
ing so the head is lower than the waist, engaging in
activities that raise blood pressure in the eyes, moving
suddenly, and straining. A prim ary care provider and
ophthalm ologist should be consulted before engaging
in strenuous activities.
Diabetic neuropathy, another m icrovascular com ­
plication, can be diffuse, affecting the peripheral and
autonom ic nervous system s, or it can be focal, affect­
ing a single nerve or group o f nerves. It is chronic and
progressive in nature. Peripheral neuropathy is the
most prevalent form. Sym ptom s include a “pins and
needles" sensation, pain, num bness, the inability to
detect tem perature or position, and inability to feel
feet when walking. Precautionary m easures include
care in use and disposal o f sharp objects, exposure to
and handling of hot items, and im plem enting proper
foot care.
Autonomic neuropathy involves nerves that control
autom atic bodv✓ functions and affect mostly internal ✓
organs. This form o f neuropathy tends to occu r later
in the course of diabetes. Fifty percent o f persons with
diabetes w ho have peripheral neuropathy also have
autonomic neuropathy. Autonomic neuropathy may
affect m any system s, including the genitourinary, the
gastrointestinal, the cardiovascular, and the sudom o-
tor (responsible for the body's tem perature regula­
tion).
Cardiovascular effects of autonom ic neuropathy
are noteworthy. They include postural hypotension,
w hich can cau se lightheadedness, d izzin ess, and
w eakness. Precautions include slow positional chang­
es and transitional movements. Cardiac denervation
syndrom e, a fixed heart rate that does not change
in response to stress, exercise, breathing patterns,
or sleep, m ay be present. In later stages of cardiac
denervation, a silent or painless myocardial infarction
(M I) can occur. O ther typical sym ptom s o f a MI, such
as nausea, shortness o f breath, sw eating, and vomit­
ing, may be present. T hese sym ptom s require im m e-
 With respect to the health m aintenance devices
suggested above, the following guidelines should be
considered. Large, LCD (liquid crystal display) devic­
es should be evaluated by the individual w ith diabetes
and vision loss to insure that they can consistently be
read; getting close to the display may not be an option.
W hen suggesting any talking device, many voice-
related features need to be considered before recom ­
m ending a specific model. These include voice clarity,
volume, speed, pitch, and accent. In m any cases where
a hearing im pairm ent is present, a m ale voice may be
preferable due to the lower pitch (Figure 15-1).

Figure 15-1. l arge display or talking blood pressure

monitors and weight scales. A cute Complications of

D iabetes
diate m edical attention. Stress testing should precede
any type of exercise program .
Focal neuropathy is generally acute and tim e-lim ­ Hypoglycemia
ited, w ith pain often being the prim ary symptom.
The m ajor acute com plication of diabetes is hypo­
The most com m on form of focal neuropathy is carpal
glycemia or low blood glucose, w hich is defined
tunnel syndrom e, w hich is three tim es more comm on
as a blood glucose level o f less than 70 mg/dL.
in persons w ith diabetes than am ong the rest of the
Hypoglycemia is not a result of diabetes itself but is
population.^
a consequence of its treatment. Typical causes relate
Nephropathy is the final m icrovascular com plica­
to the am ount and tim ing of: 1) insulin or certain
tion. End-stage renal disease may result in sym ptom s
anti-diabetes m edications (but not all), 2) physical
of nausea, vom iting, dyspnea, lethargy, hypertension,
activity, and 3) food or carbohydrates eaten. Common
and fluctuating blood glucose levels. Ninety-five per­
sym ptom s can include: sw eating, shakiness, difficulty
cent of persons with diabetic nephropathy have some
concentrating, blurred vision, dizziness, w eakness, or
retinopathy, w ith 50% being blind or having lost sig­
trouble perform ing a routine task. Severe hypogly­
nificant vision. T h is syndrom e is entitled renal-retinal
cem ia can result in pronounced confusion, seizures,
syndrom e. M onitoring blood pressure by use of a
com a, and death.
large display or talking blood pressure cuff m ay be
H ypoglycem ia is treated with carbohydrate con­
required.
taining foods or beverages such as juice/soda, honey,
M acrovascu lar com p lication s are responsible
or com m ercially made products such as glucose tablets
for 80% of the m ortality of adults w ith diabetes.
or gel. If possible, the person should check his or her
M acrovascular com plications are characterized by
blood glucose level to determ ine the am ount o f carbo­
both arteriosclerosis and atherosclerosis. Coronary J hydrates required to raise his or her blood glucose to
artery disease can lead to congestive heart failure
a safe level. Regardless of w hether or not the person
(CHF) or a heart attack. M onitoring CH F-related fluid
is able to test, the sym ptom s should be treated as soon
retention by use of a large display or talking scale
as possible. It is recommended that clients consum e 15
becom es critical.
gram s of carbohydrate (4 ounces juice or regular soda,
Cerebral vascular disease can lead to a stroke.
1 tablespoon honey, or 3 to 4 glucose tablets) and then
Sym ptom s such as dizziness, slurred speech, num b­
retest their blood glucose in 15 m inutes to determ ine if
ness or w eakness in an arm or leg, or sudden loss of
additional treatm ent is required. T h is is know n as the
sight may occur. A bility to access em ergency medical
15/15 rule. If a meal is not planned w ithin 1 to 2 hours
services is im portant. Peripheral vascular disease
of treating a hypoglycem ic reaction, then a snack con­
can lead to lower leg and foot ulcers and the need
taining 15 to 30 gram s of carbohydrate should be con­
for am putation. Sym ptom s can include pain with
sum ed to prevent another episode o f hypoglycemia.
standing, w alking, or at rest. G uidelines may include
Several safety m easures and adaptations can be
rem ain in g seated during tasks, incorporating rest
implemented to assist the client w ith vision im pair­
periods into standing/w alking activities if pain is
ment to avoid or m anage hypoglycemia. Persons with
relieved by rest, and seeking m edical attention if pain
diabetes should always w ear diabetes identification
interferes w ith program or is reported at rest.
and carry a blood glucose monitor and a readily avail­
able carbohydrate source at all tim es. Physical activity
that m ight lower blood glucose should be scheduled
1 to 3 hours after mealtime. The individual with
diabetes should be referred to a physician or diabetes
educator if: 1) sym ptom s of low blood glucose are
no longer recognized, 2) a significant episode of low
blood glucose occurs, or 3) if blood glucose levels are
low for 2 days at the sam e tim e of day.
Low vision, talking, or Braille tim epieces will
enable clients w ith vision loss to insure tim eliness of
m eals and m edications. Large-print or taped blood
glucose records w ill allow the person with diabetes
and his or her physician to determ ine events that may
have contributed to low blood glucose. Noncaloric/
low sugar products like diet soft d rin ks can be
marked with a rubber band to distinguish them from
those that are nondiet. Im m ediate access to em ergency
phone num bers is critical and several possible adapta­
tions include: large print, preprogram m ing telephone,
and speed or voice dialing. Low vision and nonvisual
m ethods for blood glucose monitoring, m easuring
insulin and obtaining desired portions of carbohy­
drate foods will be addressed later in this chapter.
Very high blood glucose levels can lead to tw o d if­
ferent acute and life-threatening conditions: diabetic
ketoacidosis (DKA) and hyperosm olar hyperglycem ic
state (HHS). DKA occurs most frequently in persons
with type 1 diabetes, w hile HHS is more common
in elderly persons w ith type 2 diabetes. Both condi­
tions are characterized by pronounced hyperglyce­
mia, dehydration, and altered mental state and if left
untreated, m ay result in coma and death. Both require
im m ediate medical attention.
D efinition of D iabetes Self-
M anagement and the Role of
the Low V ision T herapist
Diabetes self-m anagem ent consists of a variety
o f tasks: 1) blood glucose m onitoring, 2) medication
m anagem ent (including insulin), 3) meal planning,
4) exercise or physical activity, and 5) foot and skin
care. Each of the above tasks is interrelated, and taken
together, the client can achieve improved blood glu­
cose control by im plem enting an integrated diabetes
self-m anagem ent program . By this means, the client
can live a healthy lifestyle and avoid, delay, reduce,
and/or m anage the long-term com plications of d iabe­
tes. Each of the above task areas poses unique chal­
lenges to a person with vision impairment.
The basic role of the low vision therapist is to pro­
vide support, reinforcem ent, and referral. This role
requires knowledge of diabetes, its com plications,
functional im plications, and precautions, in addition
to knowledge of professionals in the field of diabetes.
In an advanced role, the low vision therapist provides:
1) general training in low vision and nonvisual skills
and environm ental m odification related to organiza­
tion, contrast, lighting, and m agnification; and 2)
specific training in the tools and techniques o f adap­
tive diabetes self-m anagem ent. This advanced role
requires in-depth, current knowledge of all facets
of diabetes and diabetes self-m anagem ent, as well
as practical knowledge o f low vision tools and tech­
niques relative to diabetes management.
In 1994, the Visually Impaired Persons Specialty
Practice Group (VIP-SPG) of the A m erican Association
of D iabetes Educators (AADE) and D ivision II
(R ehabilitation Teaching) o f the A ssociation for
Education and Rehabilitation of the Blind and Visually
Impaired (AFR) jointly developed G uidelines for the
Practice of Adaptive Diabetes Education for Visually
Im paired Persons (ADEVIP). Specific guidelines are
included in ADEVIP for professional educational back­
ground, the respective role o f the low vision therapist
and the certified diabetes educator, and the expected
process and content o f adaptive diabetes education.
The ADEVIP offered the following guidelines:
• Continuing education in diabetes treatm ent must
be updated every 2 years.
• Contact client's prim ary healthcare professional
to assure that client has had basic diabetes self-
care instruction.
• O nly teach adaptations and not basic diabetes
self-care (should reinforce proper self-care).
• Never give specific advice on medication, nutri­
tion, or exercise.
• No direct care, such as prefilling of syringes.
• A fter client has learned adaptive techniques, but
before relying on it for self-care, refer client back
to client's prim ary healthcare professional for
confirm ation o f skill.
Although the ADEVIP practice guidelines were
designed for AFR vision rehabilitation professionals,
they are equally applicable to low vision therapists in
the field of occupational therapy.
M embers of the D iabetes
Self- M anagement T eam and
T heir Roles
It is im portant to be aw are of m em bers o f the
diabetes m anagem ent team, each m em ber's role, rea­
sons to refer to these other healthcare providers, and
resources for reim bursem ent for their services. The
core diabetes team should consist of the client, a phy­
sician, a nurse diabetes educator, a dietician, an oph­
thalm ologist, and a low vision optometrist. Persons
w ith diabetes should be educated as to the availability
and roles of these team members.
In general, everyone w ith type 1 diabetes should be
seen by an endocrinologist, w hich is a physician who
specializes in endocrine disorders, including diabetes.
M any persons w ith diabetes, particularly uncom plicat­
ed type 2, can have a prim ary care provider such as an
internist or fam ily physician effectively m anage their
diabetes. An endocrinologist may be recommended
for an individual with type 2 diabetes if he or she is
follow ing an intensive diabetes self-m anagem ent pro­
gram requiring three or more insulin injections a day
or is using an insulin pump. O ther circum stances that
may w arrant follow-up by an endocrinologist include:
blood glucose levels consistently higher than desired,
one or more diabetes complications, other medical
conditions that m ake diabetes m anagem ent more dif­
ficult, or an individual's desire for a change in his or
her diabetes care plan. Routine follow-up visits should
be scheduled every 3 to 6 m onths, or more frequently
if the client has difficult keeping blood glucose lev­
els under control, is experiencing com plications, or
becom es ill.14
The nurse diabetes educator provides com prehen­
sive training in diabetes as well as basic and more
advanced diabetes self-m anagem ent tasks. Referral
for initial or follow-up training by a nurse diabetes
educator is recom m ended when an individual: lacks
inform ation or has m isperceptions about what diabe­
tes is and its effects on the body, has not received basic
diabetes self-m anagem ent training, or has difficulty
with at least one diabetes-related task. A diabetes
nurse educator should also be consulted when a cli­
ent would like to incorporate physical activity into his
or her diabetes self-m anagem ent program or needs a
plan for m anaging stress o r illness.
A d ietician provides train in g in healthy meal
planning and develops individualized m eal plans,
taking into account many variables, including caloric
requirem ents, food preferences, and cultural back­
ground. Referral to a dietician is recomm ended when
an individual does not know what to eat or how much
to eat, feels restricted by his or her m eal plan or m akes
unhealthy food choices, lacks or has an outdated
food/meal plan, or has not seen a dietician in several
years.
An ophthalm ologist is necessary to diagnosis eye
disease(s), m onitor disease progression, and provide
medical treatm ent inclusive of prescription eyewear,
m edications, and eye surgery. This team m em ber is
especially im portant when diabetic retinopathy, mac­
ular edema, glaucoma, or even m acular degeneration
are already present, in order to m aintain optimum
eye health and visual functioning. All persons with
diabetes should receive routine dilated eve exam s at
least every year, or more frequently depending on
the presence and degree of eye disease. It is recom ­
mended that persons with proliferative retinopathy
receive an ophthalm ologic exam every 2 to 4 m onths
or more often.7
The role of the optometrist is to determine whether
a change in the traditional eyeglass prescription might
be of benefit and to perform a detailed evaluation of
distance and near visual acuity, contrast sensitivity,
assessment of central scotomas, and peripheral visual
field. Based on the results of this evaluation and the case
history, the optometrist begins the process of determ in­
ing the magnification needs of the patient for various
activities of daily living (A DI,) and selects and prescribes
appropriate low vision optical aids. To be most effective,
the optometrist and occupational therapist should work
together to determine the appropriate optical devices
for a patient. Optometrists will often make suggestions
about lighting, contrast, and glare and how these issues
affect the patient's ability to effectively use the optical
device. The optometrist then refers the patient to the
occupational therapist for training in the use of the pre­
scribed device in various ADL.
O ther potential m em bers o f the diabetes self-m an­
agement team may include, but are not lim ited to, a
dentist, psychologist, podiatrist, and nephrologist.
M ost insurances pay for diabetes self-care training
provided by a nurse or a dietician wrho is a diabetes
educator and who is affiliated with a healthcare set­
ting or medical office. Outpatient diabetes self-m an­
agement education is reim bursable under M edicare
and includes up to 10 hours of one-tim e initial train­
ing w ithin a continuous 12-month period, and 2 hours
of follow-up training each year thereafter. A physician
must order these services. T h e approved providers
include physician-run clinics and hospital-based out­
patient program s that include a registered dietician
and a certified diabetes educator and are accredited
by the Health Care Finance A dm inistration (HCFA),
now called the Centers for M edicare and M edicaid
Services (CMS). In January 2002, M edicare added
a new Part В benefit for Medical Nutrition Therapy
(M NT). Eligible persons w ith diabetes can receive
3 hours of initial M N T and up to 2 hours annually
thereafter in addition to the hours for basic diabetic
self-m anagem ent education (DSM E).
M edicare Part В reim bursem ent has been available
for blood glucose m onitoring equipm ent since October
1998. M edicare covers 80% o f the cost o f a blood glu­
cose monitor and ancillary supplies, including test
______________________ Sample Assessment Questions______________________

Blood Glucose Monitoring

Do you m onitor your blood glucose? If so, how often?
Have you received form al training in using a blood glucose monitor and from who?
W hat blood glucose m onitor do you use?
Can you consistently read the display?
Do you have difficulty or require assistance in any aspect of using your blood glucose m onitor? Inserting
the strip, locating the blood sample on the finger, placing the blood drop on the test site of the test strip?
Can you and do you record your blood glucose results? W ho uses these results and how?
How do you discard lancets?
W hat pharm acy do you use for your supplies?

Medication Management and/or Insulin Measurement

A re you able to accurately and consistently identify your m edications or see the lines on your syringe? If so,
describe your method?
Do you use insulin? If so, what type(s) of insulin, their dosage (s), and tim e(s) o f day taken?
W hat brand/size of syringe do you use?
I low do you know when your insulin vial is empty?

Nutrition Management
Have you ever received instruction in how and what to eat with diabetes? How long ago did you receive this
instruction and from where?
Do you have special guidelines or a meal plan to follow? If so, describe.
Are you able to read your meal plan, food labels and other nutritional inform ation?
How do you determ ine portions and m easure food quantities?
Do you prepare your ow n m eals? If you have difficulty or receive assistance, identify in what tasks? Setting
stove and oven dials, determ ining when food is done, cutting food?
Have you ever burned yourself? If so, describe how?
Ф Ф

Foot and Skin Care

Are you able to bath your feet and don socks and shoes?
Do you inspect your feet? If so, how often and by what method?
Do you have your physician inspect your feet every visit or do you regularly see a podiatrist?
Do you have num bness or tingling in your hands and feet?
Do you cut your nails? If so, how?
W hat do you do if you have an injury to your foot or a foot infection?

Physical Activity/Exercise
Do you have an exercise program or are you interested in beginning one?
Do you have any difficulty getting around indoors or outside?
Does your vision prevent you from engaging in physical activity? D escribe what activities.
Have you ever been instructed in exercise related precautions?
Do you wear a diabetes identification tag?

Healthcare/Sick Day
Can you readily access em ergency phone num bers or em ergency assistance?
Do you have a sick day plan? If so, are you able to read it?
Do you have a sick day kit that you can readily access?
Does your physician want you to m onitor your weight or blood pressure?
Can you take your tem perature when you are not feeling well?
and coordination deficits related to the com plications
o f diabetes, such as peripheral neuropathy, carpal
tunnel syndrom e, and stroke. Additional diagnoses
that may require further adaptations include arthritis,
trem ors, and hearing loss. O ften, vision loss neces­
sitates the use of other senses for task completion,
including sense of touch and hearing. The ability to
localize touch; detect position, movement, pressure
and pain; and discrim inate tem perature are all neces­
sary-
Cognitive functioning needs to be assessed in the
areas o f concentration, ability to follow multiple-step
directions, problem -solving skills, ability to form
m ental images, capacity to learn new inform ation, and
memory. Learning adaptive diabetes self-m anage­
ment often requires that the individual interpret and
integrate inform ation, perform m athem atical com ­
putations, and implement algorithm s. Psychosocial
functioning is im portant to assess due to the high
rates o f depression and anxiety in persons with d iabe­
tes. Social, em otional, and physical support system s;
insurance coverage and/or financial resources; and
level of independence the client desires should all be
noted.
A reas of Intervention in
A daptive D iabetes
Self- M anagement
General Intervention Strategies
M any persons with diabetes and vision im pair­
ment will want to utilize their residual vision to com ­
plete diabetes self-m anagem ent tasks. The low vision
therapist's role is to insure the client achieves accurate,
safe, consistent results when incorporating rem ain­
ing vision. M ethods to m axim ize use of residual
vision include: modification of the task environm ent
through lighting, organization, and contrast; use of
optical devices; and labeling and m arking techniques.
Both general and specific applications of the above
principles will be provided. Depending on the extent
and type o f vision loss, the client m ay achieve varying
degrees o f independence in a diabetes self-care task
and may need to also supplem ent perform ance with
nonvisual techniques or devices as well.
Lighting
Lighting is the most essential environm ental con­
sideration to enable a person w ith low vision to use
his or her rem aining vision (see Chapter 10). If addi­
tional lighting is beneficial, then it is im portant to
incorporate a flexible arm task lamp that perm its the
level of wattage preferred by the client. The task lamp
needs to be positioned nearest the better-seeing eye or
opposite the person's working hand in order to avoid
casting shadows on the im m ediate work surface. Glare
from the work surface, such as the table, or from the
equipment, such as the blood glucose m onitor display,
needs to be m inim ized by a covering in the former
exam ple and repositioning the lam p in the latter.
O rganization can include reduction in clutter,
advanced preparation, and consistency in placement
of task materials. Keep like equipm ent together. Using
a tray with a lip is helpful for organizing task equip­
ment. A tray can help the user m aintain orientation to
supplies, can assist to define the workspace, and can
prevent m aterials from "getting aw ay" from the user.
The latter is especially im portant w here "sharps,"
such as lancets or syringes, and liquids from m easur­
ing beverage portions, can drop or be spilled onto the
floor. Advanced preparation is helpful so that a diabe­
tes task can be completed in a sequential, tim ely fash­
ion w ith a m inim um of stress. A ssem bling a lancing
device before turning on a blood glucose m onitor or
having beverages labeled to enable the user to discern
noncaloric from caloric are both exam ples where prior
preparation is very beneficial.
Enhancing contrast can be achieved by placing
light-colored supplies on a dark surface and vice
versa. The background should be solid in color to
avoid having items "lo s t" in busy patterns. Placing a
syringe against a w hite background perm its the black
plunger tip and syringe m arkings to stand out, w hile
a dark blood glucose m onitor and dark test strips will
be more visible on a light tray.
O ptical Devices
O ptical devices can be incorporated into many d ia­
betes self-m anagem ent tasks, although each type of
device has it benefits and lim itations and must be tai­
lored to the individual and the task (see Chapter 13).
The low vision optom etrist and the low vision thera­
pist work together as a team to educate the individual
w ith diabetes and vision loss regarding devices that
are available, their features, and their applications.
Portable optical devices allow the user to perform a
task such as blood glucose m onitoring or nutrition
label reading away from the home. Spectacle format
m agnification and stationary closed circuit televi­
sions (CCTVs) allow both hands to be used during
a task such as insulin m easurem ent. M agnification,
however, w ill not resolve the decreased contrast pres­
ent in blood glucose m onitor and insulin pum p liquid
crystal displays. Relative distance m agnification can
also be used by bringing the eye closer to the task or
the task closer to the eye (see Chapter 10).
Figure 15-2. Blood glucose monitoring setup with
environm ental adaptations and marked large display
monitor and lancing device.
M arking an d Labeling
Techniques
M arking can also be incorporated to bring attention
to features of objects that are less visible to a person
with diabetes and vision im pairm ent. M arkings can
be visual, focusing on high-contrast, bright colors;
they can be tactile, em phasizing textural proper­
ties such as raised or rough m arkings; or they can
com bine elem ents of both. The features that can be
m arked include indiscernible features such as a test
strip port on a blood glucose monitor or weight mark­
ings on a food scale. Due to potential contact with
blood, m arking m aterials should be durable, perm a­
nent and washable, such as tactile m arking liquid or
fabric paint, bum p or touch dots, or even rubber bands
(Figure 15-2).
General Teaching Strategies
Provide choices and alternatives to clients, outline
the benefits and lim itations o f a piece of equipm ent
or a technique, and provide guidance to elicit safe
choices. Rem em ber alw ays that retinopathy and other
form s o f eye disease as well as diabetes are all pro­
gressive, and the client needs to be aw are of other
equipm ent that may be available to satisfy his or her
future needs. Adaptive d iabetes self-m anagem ent
techniques and devices are rarely ideal, and it is up
to the client to determ ine what is most suitable and
workable for his or her own needs. The follow ing is
a list of general teaching strategies that will enhance
the learning experience for the person w ith diabetes
and vision loss:
• Allow for visual and tactile exploration of equip­
ment and its setup.
• Be very descriptive and specific in the explana­
tion, relying on low vision, tactile, and auditory
cues.
• If beneficial, provide inform ation on what might
be seen so that the person with vision loss can
sense what a sighted person might experience.
• Establish agreem ent on spatial positioning and
directional concepts, such as front and back,
right and left.
• Have client decide where to place or how to
position an object, or explain positioning in
established fram es of reference, such as clock or
cardinal positions.
• Always establish a point o f reference to guide
orientation to other objects around it.
• Establish a comm on term inology, introducing
new term s as desired or needed by the client.
• Allow the client to direct his ow n learning expe­
rience by working through a process as inde­
pendently as possible, providing feedback as
needed. Build on client's knowledge and experi­
ence.
• Encourage client to m ake suggestions regarding
problem -solving approaches.
• Let client know what is being done at all tim es
and why, in order to provide a com plete and
integrated experience.
Process and Outcomes
A high degree o f accuracy in perform ing the tasks
of diabetes self-m anagem ent is necessary. Therefore,
the follow ing is strongly recom m ended:
F igure 15-3. Talking blood glucose m oni­
tors.
device to highlight the location of buttons, settings, or
openings. Producing a larger, more visible blood drop
or using a w hite towel for contrast will help to discern
and obtain a sufficient blood sam ple. For som e blood
glucose m onitors, placement of high-contrast mark­
ings on the monitor or creation of a high-contrast test
strip guide may assist the user in locating and placing
the blood drop on the test site.
Blood glucose m onitors w ith speech capability
are available for persons who are unable to use large
display m onitors; however, legal blindness is required
before insurance coverage can be obtained w ith the
exception of one model. Currently there are four
options on the US m arket for blood glucose m oni­
tors with speech capability, with a fifth model seek­
ing FDA approval. T h e A ccu-chek Voicemate is a
two piece unit, designed to fit together, wherein the
standard blood glucose m onitor inserts into and is
sold w ith the voice unit. Two older m onitors, the
O ne Touch Basic and the O ne Touch Surestep, can be
coupled w ith a separate voice attachm ent by a data
cable. These two m onitors can be purchased sepa­
rately from their respective voice attachm ent or as a
package. The fourth and fifth m onitors, the Prodigy
and the SensoC ard, are newer, fully integrated talking
m odels, as the speech com ponent is incorporated into
the m onitor itself. The SensoCard is aw aiting FDA
approval, which is expected to be received in the near
future (Figure 15-3).
The Voicemate can be coded nonvisually by inser­
tion of a code key. It has a bar code reader to iden-
tify different types of Lilly insulin. It has a relatively
large strip, called the Com fort Curve strip. This strip
has a sm all curved cutout on the right side of the
strip, w hich is where the blood is applied. A mod­
erate am ount of blood is needed. The m onitor will
beep when it detects blood at the test site. A second
drop of blood can be applied within 15 seconds. The
Voicemate com es w ith instructions in large print and
on cassette tape.
The O ne Touch Basic has a relatively large strip,
with the test site located on top of the strip. This
monitor requires visual calibration and cleaning. The
test site on the Basic test strip should not be touched
during blood drop application and requires a m oder­
ate to large drop o f blood. A blood drop guide, called
the Suredrop, can be used to facilitate successful blood
placement, but it must be purchased separately. "N ot
enough blood retest" appears on the display and is
verbalized when the blood drop is too sm all or was
smeared.
The O ne Touch Surestep also requires visual cali­
bration and cleaning. It has a relatively large strip,
with the test site on the top. It requires a relatively
large blood drop. Blood can be dabbed on the test site.
This monitor requires blood placement on the strip
before insertion into the monitor. A blood drop guide,
called the Sureguide, can be purchased separately to
aid in blood sam ple placem ent on the test strip.
The SensoCard is a slim , com pact unit, which can
be coded nonvisually by a code strip. It has a rela­
tively sm all test strip. The blood is applied to the end
or tip of the strip, and a very sm all am ount o f blood
is required. The m onitor autom atically turns on with
strip insertion and beeps when blood is applied. It
only requires battery replacem ent in a single unit.
D irections will b e m ade available in large print and
audio format. T h e SensoC ard can be switched from
English to G erm an w ithin the sam e unit. The m anu­
facturer is anticipating PDA approval in Septem ber,
2006. Cost is moderate.
The Prodigy is a sm all, com pact unit that currently
requires visual coding. The m anufacturer indicates
(as of Septem ber 2006) that a "no cod e" feature will
be included. The strip is sm all in size. The blood is
applied to the end or the tip of the strip and a very
sm all am ount of blood is required. The m onitor auto­
m atically turns on w ith strip insertion and beeps
when blood is applied. The Prodigy only requires
battery replacement in a single unit. D irections will
be m ade available in large print and cassette upon
request. The Prodigy can be switched from English
to Spanish w ithin the sam e unit. T h e current Prodigy
announces blood glucose readings and room tem­
perature. The m anufacturer is currently m odifying
its m onitor to give it greater speech capability. The
Prodigy Duo com bines a Prodigy m eter w ith a w rist
style blood pressure cuff, which announces both
blood pressure and heart rate data. The combination
unit is compact, lightweight and simple to use. Both
units are low cost..
W hen vision is insufficient, additional nonvisual
techniques may be required. Tactile features on m oni­
tors, strips, or lancing equipm ent can aid in locating
and identifying key parts, or equipm ent can be adapt­
ed w ith raised m arkings. Features such as notches
or cutouts and sm ooth or textured surfaces can aid
in properly orienting and inserting the test strip, or
locating the test site. The monitor's m anual w ill aid
in determ ining how a strip can be explored. Sighted
assistance may be used to determ ine the num ber of
tim es a finger needs to be milked before an adequate
blood sam ple is achieved. Feeling for w etness on the
finger or m aking a mental map may help the user to
locate the blood drop on the finger after lancing.
Blood glucose m onitors and their supplies are pro­
vided and billed for by pharm acies (these m ay include
hospital-based, local, mail order, or chain drugstores;
regional/national general m erchandise stores; and
grocery stores). Talking blood glucose m onitors are
also available through many of the above suppliers.
M any pharm acies, however, are unaw are of the avail­
ability of talking models and require education as to
their features and the reim bursem ent criteria and pro­
cess. Each therapist needs to develop resources in his
or her local area. Many individuals with diabetes have
developed a relationship with a particular pharm acy
and it is preferable to u tilize this pharm acy if possible.
It is im portant to determ ine if the pharm acy will bill
insurance directly or will bill the individual, who then
must seek reim bursem ent from his or her insurance.
A mail order medical supplier or a pharm acy that
delivers m ay be an added benefit for the person w ith
diabetes and vision loss.
M any physicians and endocrinologists are also
unaw are of the availability of talking blood glucose
m onitors and would benefit from sim ilar education. A
prescription must be w ritten by the physician treating
the individual's diabetes in order for a blood glucose
m onitor to be covered by insurance. The prescription
should include the following inform ation: the nam e
of the blood glucose monitor, the diagnosis code, the
testing frequency, and the quantity o f test strips and
lancets desired beyond that provided by the starter
kit. If a talking model is being sought, a statem ent
of legal blindness should also be included on the
prescription. A corroborating eye report from the
eyecare physician may be required by the pharmacy,
the insurance company, or the medical physician to
support the diagnosis o f legal blindness.
O ral M edication
M anagement
Being able to identify, track, and adm inister m edi­
cations, both in oral and injectable form, is a critical
com ponent of diabetes self-m anagem ent. Most adults
diagnosed w ith diabetes take oral m edication, insulin
or both. According to the CDC, betw een the years
2001 and 2003,16% of the adults diagnosed with d ia­
betes took insulin only, 12% took both insulin and
oral m edications, 57% took oral m edications only, and
15% did not take either insulin or oral m edication.1 It
is im portant to have som e fundam ental knowledge
about the different kinds of oral m edications and
insulin, as well as som e of their key properties/char­
acteristics.
There are five categories of oral agents used to nor­
m alize blood glucose levels. Several classes, including
the sulfonylurcas and m eglitinidcs, work on the pan­
creas to increase the release o f insulin. These tw o cat­
egories of m edications are capable of reducing blood
glucose levels below norm al and therefore can result
in hypoglycemia.
C om m only used m edications in th is category
include: Glucotrol, A m aryl, Prandin, and Starlix. The
rem aining three categories, because of the site of their
action, only reduce high blood glucose, but do not pro­
duce hypoglycem ia. Two of these categories of m edi­
cation, the biguanides, which includes Glucophage,
and the thiazolidinediones (TZDs), w hich includes
Actos and Avandia, all function as insulin sensitizers,
enhancing glucose transport into fat and skeletal tis­
sue. The final category, the alpha-glucosidase inhibi­
tors, such as Precose, work on the sm all intestine,
reducing the rate of starch digestion and glucose
absorption.
Clients m ay initially be treated with a single m edi­
cation, progressing to com bination therapy w herein
tw o or more oral agents, or an oral agent and insu­
lin, may be used. Several of the m edications above
have now been com bined, form ing such drugs as
Glucovance (Glvburide and Glucophage), M etaglip
(Glucophage and Glucotrol) and Avandamet (Avandia
and Glucophage) enhancing medication compliance.
The dosing frequency, the tim e(s) o f day, and whether
 Alarm system, to remind the client to take his or her
medication.

Insulin M a n a g e m e n t
Insulin is the medication most often associated with
diabetes. It is currently used in an injectable form.
Several inhaled insulins are on the horizon (Exubera
recently obtained FDA approval), and oral insulin is
being tested outside of the United States. Currently,
three com panies m anufacture injectable insulin in
the United States: Lilly (brand nam es H um ulin and
I lumalog), Novo Nordisk (Novolin, Novolog, and
Figure 1 5 -4 . Selected lo w visio n m e d ic a tio n m anage­
Levemir), and Aventis (Lantus and Apidra). Insulins
ment systems.
are classified according to their on set of action, peak
effect, and duration of action. T h e four classifica­
tions of insulin include fast-acting or rapid-acting
it is taken before or with food varies with each m edi­
(I lumalog, Novolog, Apidra), short-acting (R or regu­
cation.
lar), interm ediate-acting (N or NPH), and long-acting
A w ide array of adaptive techniques and equip­
(Lantus and Levemir). Lantus, one o f the new er insu ­
ment are available that incorporate low vision and/or
lins, is a "peakless" insulin. Several prem ixed insulins
nonvisual features to enable independent identifica­
are also available (70/30, 50/50, 75/25). Som e insulins
tion and tracking of oral m edications. Task lighting,
are clear, colorless solutions, w hile other insulins are
a contrasting background, optical m agnification, and
suspensions, which should be evenly cloudy.
pill vial m agnifiers all can assist a person to use
Insulin dosing frequency is dependent on the type
rem aining available vision to identify medication. Pill
of diabetes, level of insulin deficiency or resistance,
containers can be labeled in large print or a color-cod­
tim ing and carbohydrate content of m eals, physical
ing system can be implemented. W hen vision is insuf­
activity, and w aking and sleeping patterns. Com m on
ficient, w ooden or plastic letters can be used as tactile
dosing frequencies include a single daily injection
labels or sm all adhesive-backed dots can be applied to
adm inistered in the m orning or at bedtim e or a two-
the container representing the num ber of pills to be
injcction regim e with insulin adm inistered in the
taken (Figure 15-4).
m orning before breakfast and before the evening
M any of the visual and tactile labels convey only a
meal or at bedtim e. Intensive insulin therapy ranges
lim ited am ount of inform ation, such as a medication's
from three to four tim es per day, w ith a four-injection
nam e or how m any pills are to be taken; however,
regim e requiring one injection in the m orning and one
auditory m edication labels are capable of recording
at each mealtime. Som e persons take a "fixed " dose of
additional label inform ation. Som e of the auditorv у insulin that is set by their physician. O thers take a
labels, such as the Tel Rx, consist of a sm all recording
"variable" dose, which is a dose that can be altered by
device that attaches to the medication bottle, while
the individual, taking into account his or her current
other system s, such as the Aloud Audio Labeling
blood glucose level and carbohydrate am ounts eaten
System, have a recording/playback m echanism and
or to be eaten, am ong other factors.
separate labels.
Many steps are required for safe insulin use. They
Several m ethods are also available to enable a
include: insulin storage, identification (if more than
person to track his or her medication usage. O ne
one is taken), insulin/vial preparation, m easurem ent,
technique is to apply elastic bands to the bottle equal
m ixing (if more than one is taken), air bubble m an­
to the num ber of daily doses, remove one band after
agement, adm inistration, injection site m anagem ent,
taking each dose, and then reapply all bands after tak­
determ ination of quality and quantity o f vial contents,
ing the last dose. Large-print and Braille pillboxes are
and sharps disposal. Specific inform ation regarding
also popular alternatives. Such pillboxes are available
insulin itself can be obtained from the m anufactur­
in different shapes and sizes, ranging from lx/day
er's guidelines. Low vision therapists should adhere
to 4x/day. M any pillboxes come in different colors so
to standard procedures for preparing, m ixing, and
that one color can be used for the m orning, another
draw ing up insulin and can begin to fam iliarize
for the night. Som e pillboxes come equipped with
them selves w ith these basic procedures through edu­
tim ers and auditory alarm s, such as the e-pill Multi
cational m aterials available through syringe m anufac-

Figure 15-5. Various syringe magnifiers and accessory devic­
es.
turers such as Becton-Dickinson (B-D). Following are
some very basic principles:
• Suspension insulins should be rolled between
the palm s to resuspend the insulin contents in
the vial.
• Pressurize insulin vial by filling vial with
amount of air corresponding to desired insulin
dose, prior to draw ing out insulin.
• W hen preparing a mixed dose, the clear insulin
should be drawn into the syringe before the
cloudy/suspension insulin.
• Always insure syringe and vial are vertical, with
the vial inverted, when drawing out insulin.
• Sharps (needles and lancets) should be disposed
of in a hard plastic, opaque container with a
screw cap.
Many low vision and nonvisual techniques and
devices are now available to assist in insulin m anage­
ment. All insulin bottles are the sam e size and shape
except for those m anufactured by Aventis, such as
Lantus and Apidra, which are taller and thinner. To
distinguish two sim ilar vials, a rubber band can be
placed around one of the insulins, or a commercially
made color-coded, large-print sleeve, such as the
Insuleeve, can be incorporated. One of the talking
blood glucose monitors has a bar code reader, how­
ever it will onlv read one of the insulin manufacturer's
bar codes (the Lilly brand).
A wide range of visual and nonvisual devices
can be used for insulin measurement. The primary
method of insulin delivery is the vial and syringe. It
is important to be aware of the features of a syringe,
which include: syringe/barrel size, needle gauge
(width), and needle length. For visual accuracy in dos­
ing, the syringe size is matched to the insulin dose to
be injected, as follows:
• 0.25 cc (for doses < 25 units)
• 0.30 cc or 3/10 cc (for doses -< 30 units)
• 0.5 cc or Vi cc (for doses < 50 units)
• 1 cc (for doses 50 to 100 units)
In addition to the environmental m odifications and
optical devices identified earlier in this chapter, several
m agnifiers are made specifically to fit on the syringe
and they may enable a person with mild vision loss to
read the dose m arkings on the barrel. These include
the clip-on syringe magnifier, the B-D Magni-Guide,
and the Tru-Hand. The syringe m agnifiers currently
available provide up to 2X m agnification and will fit
any syringe. They vary in their features, which may
include a holder for the insulin vial, the plunger, or
the syringe barrel, all of which will assist the user to
align the syringe needle with the rubber stopper on
the vial. Two separate devices, the Center-aid and the
Insul-cap, will guide the syringe needle into the rub­
ber stopper of the vial; the latter device also holds the
syringe firm ly to the vial (Figure 15-5).
When choosing a nonvisual insulin measurem ent
device, several factors need to be considered. These
include: amount of insulin taken (large or sm all dose),
whether the dose is fixed or variable, single or mixed,
the current type o f syringe used, and the person's
desire to be fully independent. The fixed dose devices
require setting by a sighted person, while the variable
dose devices do not require any sighted assistance
(Figure 15-6).
T hree fixed dose devices are currently Ф avail-
able: the Safe Shot, the Unit Calibration Aid, and
the InjectAssist. These measuring devices hold the
syringe and can be preset for either one or two doses.
The plunger is pulled back to the preset stop, which
measures a specific insulin dose. The Unit Calibration
Aid requires a 1 cc syringe. The tw o devices available
for variable insulin doses are the Vi cc Count-a-Dose
and the Syringe Support. Both can be used for single
or mixed doses. The Count-a-Dose requires a B-D cc
syringe with a 'Л-inch needle. Each unit o f insulin is
measured by a single click that can be felt and heard.
The second device, the Syringe Support, uses a B-D
1 cc syringe. The device is set by a calibrated screw,
with a single turn of the screw m easuring 2 units of
insulin.
Although the procedure for using each insulin
measurement device differs, the nonvisual technique
Figure 15-6. Lett to right: fixed dose (3 1
and variable dose (2) insulin measurement
d evices; insulin pens and dosers.
for rem oving air bubbles in the syringe and knowing
when the insulin vial is em pty is universal. Removing
air bubbles is critical because air bubbles take up
space that in su lin should be occupying and therefore
the insulin dose will be less. Expelling air bubbles is
perform ed by draw ing insulin into the syringe, push­
ing it back into the vial at least three tim es, then filling
the syringe w ith the desired dose on the fourth time.
Tapping the syringe w ill help release air bubbles.
It is im portant to avoid using an alm ost em pty
insulin vial, as air can be draw n in instead of insulin.
Using no more than ЧлО units out of 1000 unit vial
will insure that there is sufficient in su lin in the vial
at all tim es. A lways determ ine how many doses an
insulin vial contains without using the last 50 units.
For exam ple, if a person took 50 units each day from a
1000 unit vial of NPH, one vial would last 19 days (950
50 = 19). T h e person should set aside 19 syringes
and start a new vial when these are used. A second
technique is to mark off each successive day on a cal­
endar that a dose is taken (in this case 19 days), using
different m arking sym bols for each 19-day period.29
Insulin pens and insulin dosers, another method
of insulin delivery, can be operated nonvisually,
although most are not endorsed by the m anufacturer
for this use. Pens com e in a w ide range of insulin
form ulations. Som e pens are reusable and require
refilling with insulin cartridges; other pens are pre­
filled and disposable. Depending on the model, pens
can deliver insulin in Уг unit, 1 unit, or 2 unit incre­
ments. A n audible and tactile click is noted for each
increm ent when d ialing a dose. The three insulin
m anufacturers listed earlier all m anufacture at least
one insulin pen.
The insulin pump, a continuous method of insu­
lin delivery, can be used w ith som e success by som e
persons w ith vision loss. An insulin pum p is a m in­
iaturized, com puterized device the size o f a pager
that delivers insulin through flexible plastic tubing
to a sm all needle inserted just under the skin. It is
program m ed to closely m im ic the body's normal
release of insulin. The pum p releases a steady trickle
of insulin 24 hours a day (preprogram m ed basal rate/
dose) and at the press of a button it can deliver a spe­
cific am ount of insulin (bolus dose) calculated by the
pum p user to handle the rise in blood glucose caused
bvW meals. Som e m odels com e with tactile buttons and
audio features for program m ing bolus insulin doses.
Candidates for the insulin pum p must m eet specific
requirem ents including, but not lim ited to, type of
diabetes and residual insulin levels, in order to obtain
insurance coverage.
Insulin adm inistration itself mav
j focus on m ethods
to achieve increased control during the injection pro­
cess. By pinching the skin, gently placing the needle
on the skin, and then inserting the needle, the person
with vision loss can avoid the usual dart-like motion
and can control where the needle is inserted.' A prod­
uct called the NeedleAid can also help to stabilize an
insulin syringe or pen against the skin and insures
injection at proper angle and to proper depth.
Insulin m easurem ent devices that arc used in
conjunction with syringes are available through the
several specialty low vision catalogs listed at the end
of this chapter under Resources. Many can also be
purchased directly from the m anufacturer and some
from select pharm acies. These devices are paid for
out of pocket. Insu lin pens and dosers, as well as pen

F igure 15-7. Tactile, large display, talking food scales;
food measurement tools; food templates/models.
bowl m ay be used to estim ate a single carbohydrate
choice of puffed cereal. A food template or model
can also be utilized to tactilely estim ate a portion of
cake or baked potato. More specific m easurem ent of
solid foods and beverages can be obtained by using
nested, large-print, color-coded, or tactilely marked
m easuring cups. Portion-controlled serving utensils
for hot foods can be purchased from restaurant supply
stores. A large display, or talking or tactilely marked
scale can be used to m easure foods by weight (Figure
15-7).
Meal plans and nutrition inform ation m ay be
enlarged on a copier, but m aintaining contrast and
clarity is critical. Reform atting material into large
print or in audio by m eans of a cassette tape or digital
recorder may be required. A meal plan can be refor­
matted and custom ized in print size for each indi­
vidual. Som e general guidelines when reform atting
a meal plan into large print include the following:
use black print on w hite or yellow paper that has a
dull finish, choose a plain versus fancy font, increase
spacing betw een lines of print, left ju stify print, use
headings that are larger and bolder than regular large
print, and avoid colum ns and charts. It is beneficial to
becom e very fam iliar with any material to be audio
recorded so that recording proceeds at a natural but
even pace; scripting may be helpful.
F o o t C are
Regular and thorough toot care is essential for
avoiding or m inim izing low er-extrem ity com plica­
tions in persons w ith diabetes. Foot and skin care
becom es an extrem ely im portant task in light of
peripheral neuropathy and vascular com plications. In
the United States, about 86,000 lower lim bs are am pu­
tated every year due to diabetes; this is about 50% of
all lower limb am putations. About 60% of people with
diabetic retinopathy have had foot problems. Foot
care includes basic hygiene, proper foot inspection,
appropriate footw ear, and special precautions. Many
techniques and devices are available to assist the per­
son with vision loss to perform these tasks safely.
Basic hygiene includes: w ashing the feet daily with
mild soap and warm water, drying betw een the toes,
and avoiding foot soaks. Low ering the water tem pera­
ture on the water heater, using a scald-free adapter,
or a low vision or talking bath therm om eter may be
helpful to insure bathwater tem perature is w ithin a
safe range (98° to 100° Fahrenheit). Applying alcohol-
free m oisturizing lotion to the feet (but not betw een
toes) prevents dry, cracked skin. Cutting or using
chem ical corn or callus removers should be avoided;
however, if at low risk/approved by the physician, a
pum ice stone may be used for sm oothing purposes.
Sighted assistance for cutting nails should be obtained
from a reliable friend or fam ily member. A podiatrist
should be seen when thick, hard nails or foot prob­
lems are noted. An em erv board mav be used to file
and sm ooth rough edges of toenails. Toenails can be
periodically checked with fingertips to insure they are
filed straight across and not too short.
A foot inspection should be done daily at a con­
sistent tim e and place, such as after bathing or before
bed. Visual techniques are to be used only if rem ain­
ing vision is adequate and reliable. Visual m ethods
may include incorporating appropriate lighting, a
handheld m agnifier, contrast (dark towel behind foot),
and m agnifying/lighted m irrors. However, sighted
assistance should be obtained w eekly * or if a new
problem is detected. In addition, a physician should
perform a foot inspection every visit, and a podiatrist
should be seen at least annually.
Nonvisual m ethods can be utilized when vision is
insufficient. A tactile foot inspection requires intact
sensation in the hand and fingertips. The fingertips
are used to explore the entire foot in a careful, orga­
nized fashion. The skin is inspected for cuts, blisters,
sw elling, new calluses, and other irregularities, with
particular attention to any previous or existing foot
problems. Changes in foot shape are noted and the
back of the hand can be used to feel for excessively
cool areas (decreased circulation) or warm areas (pos­
sible inflam m ation), in com parison to other areas of
the foot or the opposite foot.
In addition, changes in foot odor should be noted,
especially when rem oving socks and shoes. A bad or
unusual foot odor can be sign of a fungal infection;
often a suddenly offensive or foul odor will be the
first indication of an infection. Socks should be felt for
wet or cru sty areas that might be indicative o f blood
or discharge. If discharge has adhered to the sock,
a sticking or pulling sensation may be noted during
sock removal. Following inspection, if a cut, blister, or
sore has not begun to heal w ithin a day, the physician
should be contacted. A foot that is painful or swollen
requires im m ediate medical attention.
Socks and shoes should be worn at all tim es and
socks should be changed daily. Socks should not be
lumpy or mended, and they should be m ade of m ateri­
als that "b reath e" and keep feet dry (such as wool and
synthetic blends). Shoes should be of a closed style and
should fit well upon purchase. Similarly, they should
be made of m aterials that allow air to circulate, such
as canvas or leather. Persons w ith diabetes should feel
inside their shoes before putting them on each tim e to
m ake sure the lining is sm ooth and that there are no
hidden objects, nail points, or rough areas.
Additional precautions include avoiding artificial
heat, such as heating pads and electric blankets; cross­
ing the legs for extended periods; and w earing tight
socks and garters, which hinders blood circulation.
P hysical A ctivity / E xercise
and P r ec a u t io n s
The role of exercise and physical activity in m aintain­
ing and improving health is well known. Additional
benefits to the person w ith diabetes include: improv­
ing blood glucose control, allow ing m uscles to use
insulin more effectively, assisting in controlling blood
pressure, decreasing LDL cholesterol w hile increasing
the beneficial HDL cholesterol and reducing stress
(stress can increase blood glucose levels). Several
risks are also associated w ith exercise in persons with
diabetes; however, these risks can be avoided with
proper exercise program design and adherence to pre­
cautions. These risks include: hypoglycem ia during
or after physical activity/exercise (even several hours
after), hyperglycemia (usually in type 1), exacerba­
tion of heart disease, and w orsening of complications,
including retinopathy.
A physician should always be consulted before
starting an exercise program , particularly if the indi­
vidual is over 35 years of age, has not exercised in a
long time, or has m edical conditions such as heart d is­
ease or breathing difficulties. General exercise gu id e­
lines include: m aintaining hydration; incorporating
stretching, w arm -up and cool-dow n; avoiding vigor­
ous exercise in extrem e environm ental conditions;
and beginning an exercise program slowly. Exercise
should be stopped if pain, light headed ness, or short­
ness of breath occurs.
A dditional gu id elines should be implemented
when an individual has diabetes. Diabetes of greater
than 5 years' duration or the presence of complica­
tions requires a physician to be consulted. Exercise
precautions such as w earing diabetes identification,
exercising with som eone w ho is fam iliar with diabe­
tes, w earing proper shoes, and inspecting feet after
exercise are all im portant. A range o f safety m easures
should be implemented during exercise to avoid or
m anage hypoglycem ia. The safest tim e to exercise is 1
to 3 hours after a meal. Bodv*
areas that are likelv
</
to be
involved in the exercise should be avoided as injection
sites, when planning to exercise im m ediately after
insulin adm inistration.
Blood glucose levels should be m onitored before
and after exercise, as well as during if sym ptom s
of low blood glucose are experienced. Persons w ith
diabetes should always carry a fast-acting source of
carbohydrates at all tim es. Exercise should be avoided
when blood glucose levels are greater than 250 mg/
dL and urine testing reveals ketones are present.
Although not a typical occurrence, it would be more
likely to occur in a person w ith type 1 diabetes.
An ophthalm ologist should be consulted when a
person wants to engage in exercise and has diabetes
and vision loss, especially more advanced retinopathy.
Proliferative retinopathy requires avoidance o f the fol­
lowing activities:7
• Activities that raise the blood pressure in the
body or head (doing resistance exercises with
weight m achines, lifting free weights, or using
rubber exercise bands).
• Bending the head forw ard below the level of
the heart/waist (toe touches, sit-ups, som e yoga
exercises).
• I lolding breath or straining (as when tightening
abdom inal m uscles and lifting legs).
• Activities that jar or involve bouncing of the
head (jogging, contact sports).
• Strenuous, high impact activities (high impact
aerobic dance, racquet sports, intense com peti­
tive sports).
• Strenuous arm exercises (row ing or arm bike
exercise).
• Activities involving severe atm ospheric pressure
changes (diving, mountain clim bing).
Various adaptations are available to enable persons
w ith diabetes and vision loss to participate in physical
activity and exercise. A w alking program is an easy
and readily accessible form o f exercise. W alking can
be done by m eans of a treadm ill or in fam iliar areas
using points of reference such as w alls and furniture.
W alking with a friend (using sighted guide technique),
a guide dog, or using a m obility cane is also an option.
A guide wire, rope, or railing can be used to mark
off an area such as a Jvard or indoor track. Persons
with vision im pairm ent can use* a tandem or station­
ary bike for cycling. Sw im m ing can be a year round
activity requiring m inim al adaptation. Alternatives
include: sw im m ing near a w all of the pool, using lane
markers, or participating in water aerobics.
Safety m easures should be implemented when par­
ticipating in aerobic exercise. The floor area should be
checked for hazards and obstacles. Positioning near a
wall or chair helps to m aintain orientation. Exercise
can be perform ed in a seated position. Several exercise
videos are now available that are designed specifically
for persons with vision loss. Talking pedom eters and
large-print exercise records can be used to track and
record exercise progress.
R eso u r c e s
Educational Offerings
• A m erican A ssociate of D isease Educators
(AADF.) "ABC Course," a 1-day introductory
course for beginning diabetes educators. This
program is not offered according to a fixed
schedule. Interested parties should contact
AADE at 1-800-338-3633 or visit w w w .aadenet.
org
• AADE's "C ore Concepts: The A rt and Science of
Diabetes Education/' a 3-day intensive course.
For dates and locations, contact AADE as above.
Organizations
• A m erican A ssociation of D iabetes Educators
(A AD E) - D isabilities/ V isu al Im pairm ent
Specialty Practice Group; www.aadenet.org or
1-800-338-3633
• A m erican D iabetes A ssociation (ADA); www.
diabetes.org or 1-800-342-2383
• A m erican D ietetic A ssociation; w w w .eatright.
org or 1-800-877-1600
• N ational Library Service for the Blind and
Physically H andicapped (N LS), Library of
C ongress, w w w .loc.gov/nls publications in
accessible formats.
• National D iabetes Inform ation Clearinghouse
o f National Institute of D iabetes & Digestive &
Kidney D iseases (NIDDK); www.niddk.nih.gov
or 1-800-860-8747
• National Federation of the Blind (N FB); www.
nfb.org, M aterials C enter (410) 659-9314
Publications
Professional Publications
• Am erican Association of Diabetes Fducators.
Diabetes Education: A Core Curriculum for Health
Professionals. 5th ed. AADE; 2003.
• Chous A P. D iabetic Eye Disease. Auburn, VVA:
Fairwood Press; 2003.
• National Federation of the Blind (NFB). Diabetes
Resources: Equipment. Services, and Information
(2004-2005 Edition). Available in accessible for­
mat.
• Sokol-M cK ay D, Buskirk P, W h ittaker P.
Adaptive Low-Visionand Blindness lechniques
for Blood Glucose M onitoring. Diabetes Educator.
2003;29:614-630.
• W illiam s A. Using participatory action research
to m ake diabetes education accessible for peo­
ple with visual im pairm ent. (Doctoral d isserta­
tion, Saybrook Graduate School, San Francisco,
CA.). UMI Proquest Digital D issertations.
Publication #AAT 3174539. 2005.
C onsum er Publications
• D iabetes A ction N etw ork A rticles, NFB.
Accessible format.
• D iabetes Burnout - W hat To Do W hen You
Can't Take It Anym ore, A m erican Diabetes
A ssociation (ADA). Accessible format.
• D iabetes: Ihe Basics. D iabetes Association of
Greater Cleveland. Accessible format, www.
dagc.org or (216) 591-0800.
• Diabetes Forecast, a m onthly publication avail­
able through m em bership of ADA. Publishes
a yearly Resource Guide. A ccessible form at
through NLS.
• The D iabetes Home Video G uide - Skills
for Self-Care, M ilner-Fenw ick, Inc., produced
in affiliation with AADE, accessible format,
ww w .m ilner-fenw ick.com or 1-800-432-8433
• D ia b e te s S e lf-M a n a g e m e n t; www.
D iabetesSelfM anagem ent.com o r 1-800-234-
0923
• Exchange Lists for Meal Planning 2003 Edition,
A m erican Dietetic A ssociation and Am erican
Diabetes Association, available through NFB
in accessible format.
 • Liv ing with Diabetes and Visual Impairment,
D iabetes Association of Greater Cleveland,
Accessible format, www.dagc.org or 1-216-591-
0800
• Resource Guide to Aids and Appliances, NFB.
Accessible format.
• You, Your Eves
Ф
and Diabetes, distance educa-
tion course in accessible format, Hadley School
for the Blind, www.hadley-school.org or 1-800-
323-4238
• Voice of the Diabetic, NFB. Accessible format.
Products
Adaptive Equipment an d Blood
Glucose Monitors
• The Eye-Dea Shop: 1-216-791-8118 ext. 278/279
or www.clevelandsightcenter.org
• e-pill, LLC, Medication Reminders: 1-781-239-
8255 or www.e-pill.com
• Independent Living Aids, Inc: 1-800-537-2118
or www.independentliving.com
• Insuleeve: 1-201-791-9024 or www.insuleeve.
com
• LS&S Group, Inc.: 1-800-468-4789 or www.lss-
group.com
• MaxiAids: 1-800-522-6294 or www.Maxi-Aids.
com
• Pharma Supply, Inc.: 1-866-373-2824 or www.
pharmasupply.com
• Science Products: 1-800-888-7400 or www.sci-
enceproduc ts.org
Insulin Pens and O ther Forms o f
Insulin Dosers
• Eli Lilly and Com pany: 1-800-545-5979 or
w w w.l i11ydiabetes.com
• Novo Nordisk: 1-800-727-6500 or www.novo-
nordisk-us.com
• Owen Mumford, Inc: 1-800-421-6936, or www.
о wen mumford .com
• Sanofi-Aventis: 1-800-981-2491 or www.sano-
fiaventis.com/us
Blood Glucose Monitors
• Abbott Laboratories, Abbott Diabetes Care:
1-888-522-5226 or w w w .abbottdiabetescare.
com
• Bayer Health Care, I.I.C., D iabetes Care
Division: 1-800-348-8100 or w w w .ascensia.
com
• BB1 Healthcare, BB1 Holdings Pic: Sensocard. It
is expected that this product w ill be marketed
through catalog distribution and YValMart.
• BD: 1-888-232-2737 or www.bddiabetes.com
• D iagnostic D evices Inc: P rodigy and
Prodigy Duo. w w w .p rod igym eter.com .
Vlarketed through catalog distribution and
PharmaSupply.
• I lome Diagnostics, Inc: 1-800-342-7226 or www.
homed iagnostics.com
• H yp ogu ard : 1-800-818-8877 or w w w .hypo-
guard.com
• LifeScan, Inc.: 1-800-227-8862 or w ww.lifescan.
com
• Roche D iagnostics: 1-800-858-8072 or w w w.
roche.com or w w w .accu-chek.com
• U.S. Diagnostics, Inc.: 1-866-216-5308 or www.
usdiagnostics.net
R eferences
1. American Diabetes Association, National Fact Sheet, 2005, p. 3,
Available at http://www.dial>eies.org/uedocumenlSL/nationaldia-
beiesFactSheetRev.pdf, accessed .November 25. 2005.
2. American Diabetes Association, Projection of Diabetes Burden
Through 2050, 2001. Available at http://carc.diabetcsjoumals.
orj*'<:gi/content/full/24/n/1936eSEC2. Accessed January 25,
2005.
3. American Diabetes Assoc iation, Economic Costs ot Diabetes in
tin- U.S. in 2002, 2002, Available at httpi/Zcare.diabetesjournals.
org/cgi/content/fuil/26/3/917. Viewed November 25, 2005.
4. Andrus M, Leggett-Frazier N, Pfeifer M. Chronic complications
of diabetes: an overview. In: Franz M, Fd. A Core Curriculum
for Diabetes Educators. 5th ed. Diabetes and Complications.
Chicago, IL: American Association of Diabetes Educators;
2003:56.
5. National Institute of Diabetes and Digestive and Kidney Diseases,
Diabetes Control and Complications Trial, Nil I Publication No.
94-3874, September, 1994. 1-2.
b. Diabetes Trials Unit, University of Oxford, UK Prospective
Diabetes Study, 2002. Available at http://www.dtu.ox.ac.uk/
index.html'maindoc»/ukpds/. Accessed January 28, 2006.
7. Bernbaum M, Stich T. Eye disease and adaptive diabetes
education for visually impaired persons. In: Franz M, Ed. A
Core Curriculum h r Diabetes Educators. 5th Ed. Diabetes and
Complications. Chicago, IL: American Association of Diabetes
Educators: 2003:125-
8. Centers for Disease Control and Prevention. Diabetes surveil­
lance system: visual impairment. Available at: http://www.cdc.
gOv/diabetes/$tatistic$A'isual/fig1.htm. Accessed |ul\ 21. 2005
9. Chous AP. Diabetic Eye Disease. Auburn, WA: Fairwood Press;
2003:106.
10. Sokol-McKay D, Buskirk K, Whittaker P. Adaptive Low-Vision and
Blindness Techniques for Blood Glucose Monitoring. Diabetes
Educator. 2003;29:614-630.
11. Ratner R. Pathophysiology of the diabetes disease state. In:
Fran/ M, Ed. A Coro Curriculum for Diabetes Educators. Sth ed.
Diabetes and Complications. Chicago, II: American Association
of Diabetes Educators; 2003:10.
12. Koenig P. The eye, retinopathy and other pathologies. In: Cleary
M, Ed. Diabetes and Visual Impairment: An Educator's Resource
Guide. Chicago, IL: The American Association of Diabetes
Educators Education and Research Foundation; 1994:34.
13. Funnell M, Feldman E. Diabetic Neuropathy. In: Fran/ M, Ed. A
Core Curriculum for Diabetes Educators. Sth Ed. Diabetes and
Complications. Chicago, IL: American Association of Diabetes
Educators: 2003:200.
14. Coonrod 8. Ernst K. Nephropathy. In: Franz M, Ed. A Con*
Curriculum for Diabetes Educators. 5th Fd. Diabetes and
Complications. Chicago. IL: American Association of Diabetes
Educators: 2003:156.
15. A.D.A.M . Inc., 15/15 Rule. |Medline Plus Website, Medical
Encyclopedia, published by the National Institutes of Health)
Aug. 1,2004, Available at: http://www.nlm.nih.gov/medlineplus/
ency/imagepages/19815.htm. Accessed January 21, 2006.
16. Mullooly C. Chalmers K. Physical activity/exercise. In: Fran/ M,
Ed. A Core Curriculum for Diabetes Educators. Sth Ed. Chicago,
IL: American Association of Diabetes Educators; 2003:69.
17. Hinnen D. Guthrie D, Childs D, et al. Pattern management of
blood glucose. In: Franz M, Ed. A Core Curriculum for Diabetes
Educators Sth Ed. Diabetes Management Therapies. Chicago. IL:
American Association of Diabetes Educators; 2003:218.
18. ADEVIP Task Force. Guidelines for the practice of adaptive
diabetes self-care equipment for visually impaired persons
(ADEVIP). Diabetes Educator. 1994;20<2>:111-118.
19. Williams A. Working with your diabetes team. Voice o f Ibe
Diabetic. 2005;20<3):12-13. '
20. American Association of Diabetes Educators and Roche
Diagnostics Corporation. Reimbursement Primer. Chicago, IL;
2000:38.
21. Am erican Diabetes Association, Part II M edicare Benefits for
Medical Nutrition Therapy. 2002. Available at: http://www.
diabetes.org/for-health-professionals-and-sdentists/recognition/
dsmt-mntfaqs.jsp. Accessed lanuary 21, 2006.
22. American Association of Diabetes Educators. Guide to Medicare
Reimbursement Diabetes Education and Supplies. Available at:
http://members.aadenet.org/scriptcontent/MNTMedicareGuide.
cfm. Accessed January 21, 2006.
23. Centers for Medicare & Medicaid Services, Medicare and You
- 2006 Handbook, 2006, Available at: http:/Avww,medicare.
gov/Publications/Pubs/pdf/10050.pdf. Accessed January 28,
2006.
24. Lrdke R. How to choose footwear. Diabetes Self-Management.
2005;July/August: 37.
25. Sokol-McKay D, Buskirk K. Whittaker P. Adaptive low-vision and
blindness techniques for blood glucose monitoring. Diabetes
Educator. 2003;29:614-630.
26. Task Force on ADEVIP. Guidelines for Practice of Adaptive
Diabetes Education lor Visually Impaired Persons. In: Cleary M,
Ed. Diabetes and Visual Impairment: An Educator's Resource
Guide. Chicago, IL: The American Association of Diabetes
Educators Education and Research Foundation; 1994: xxxiii.
27. American Diabetes Association. Clinical Practice Guidelines
2005. Diabetes Care. 2005;28(1):SI0.
28. White J, Campbell R. Pharmacologic therapies for glucose
management. In: Franz M. Ed. A Core Curriculum for Diabetes
Educators. Sth Ed. Diabetes Management Therapies. Chicago, IL:
American Association of Diabetes Educators: 2003:104.
29. Petzin^er R Adaptive medication measurement and admin­
istration. In: Cleary M, Ed. Diabetes and Visual Impairment:
An Educator's Resource Guide. Chicago, IL: The American
Association of Diabetes Educators Education and Research
Foundation; 1994:129-130.
30. Kitchel JF. Large Print: Guidelines for Optimal Readability and
APHontTM a font for low vision. American Printing House for
the Blind; 2004. Available at: www.aph.org/edresearch/lpguide.
him. Accessed lanuary 22, 2006.
31. Vinicor F. Macrovascular disease. In: Franz M, Ed. A Core
Curriculum for Diabetes Educators. Sth Ed. Diabetes and
Complications. Chicago, IL: American Association of Diabetes
Educators; 2003:101.
32. Williams A. Foot care. Diabetes Self-Management. 1999:32-34.
 Establishing a Low Vision
Rehabilitation Specialty Practice
In t r o d u c t io n
Throughout this text, we have tried to establish the
research and clinical basis for providing low vision
rehabilitation as part of occupational therapy prac­
tice. We have emphasized that the ability to evaluate
and treat low vision is necessarvw to meet the needs of
many clients. Occupational therapists working with
the adult population will encounter many clients with
low vision, even if this is not the prim ary reason the
client has been referred for occupational therapy.
The prevalence and incidence of low vision in
the United States are high and experts predict a
large increase over the next tw o decades because the
prevalence of low vision increases sharply in persons
older than 65 years. In the study bv Congdon et al,1
persons older than Я0 years made up only 7.7% of the
population but accounted for 69% of the severe visual
impairment. It is this group that is the fastest-growing
segm ent of the US population. Based on this inform a­
tion, the American Occupational Therapy Association
(AOTA) has called low vision rehabilitation one of the
top 10 em erging fields in occupational therapy.
It is our hope that if you have reached this section
of the book, you have a strong interest in becoming
more involved in this new and exciting practice area
of occupational therapy. If so, you are likely to be left
with a number of im portant questions about educa­
tional requirements, certification, practice opportuni­
ties, billing, and reimbursement.
Some of the im portant questions that need to be
addressed include:
1. W hat are the educational requirem ents for an
occupational therapist to provide low vision
rehabilitation services?
2. Is certification necessary to provide low vision
rehabilitation services?
3. How does the occupational therapist interact
with other vision rehabilitation professionals?
4. What practice opportunities are available?
5. How do I market my services as a provider of
low vision rehabilitation services?
6. Are low vision rehabilitation services pro­
vided by occupational therapists covered by
M edicare and other insurance?
7. How do I properly bill insurance for low vision
rehabilitation services?
8. Are optical aids and other devices covered by
insurance?
9. W hat equipment do I need to get started in the
field of low vision rehabilitation?
 T h is chaptcr is designed to provide answ ers to
these critical questions.
D idactic E d u c a t i o n / C linical
T raining
Although inform ation about the visual system is
certainly part of every occupational therapy curricu ­
lum, the inform ation provided is generally basic and
introductory. Few program s are designed to prepare
the entry-level occupational therapist for the practice
of low vision rehabilitation, either from a didactic or
clinical training perspective. M ary W arren states that
"Although occupational therapists have been involved
in the rehabilitation of persons with vision loss since
the inception of the profession in 1917, we never
played an extensive role in low vision rehabilitation."2
O ccupational therapists have indeed always played a
role in low vision rehabilitation because nearly •f
two-
thirds of older adults with low vision have at least
one other chronic m edical condition that m ay inter-
fere with activities of daily living (ADL) and require
occupational therapy.3 Thus, in the context of provid­
ing care for other chronic conditions, occupational
therapists must routinely m anage issues related to low
vision in their elderly clients.
Perhaps the entry-level occupational therapy pro­
gram curricu la need to be reconsidered, given the
prevalence of low vision in the adult population.
However, at the present time, most occupational ther­
apy graduates, as well as experienced occupational
therapists need to gain additional inform ation and
clin ical experience to feel com fortable practicing low
vision rehabilitation at a sophisticated level, much as
hand therapists seek specialized training. A useful
guide to the core knowledge base required to practice
low vision therapy is provided by the Academy for
Certification in Vision Rehabilitation Professionals
(ACVRP) (w ww.acvrep.org).
A w ide range of educational opportunities are now-
available for occupational therapists to receive this
additional educational experience. These opportuni­
ties include graduate degree level program s, multiple-
day continuing education workshops (both on-site
and online), presentations from com panies that sell
and produce optical aids, home study courses, and of
course, textbooks like this one.
W hile all registered/licensed occupational thera­
pists are legally qualified and currently able to pro­
vide and bill for low vision rehabilitation services
w ithout any additional education or certification, most
will need additional education and clin ical experience
to com petently function as low vision therapists. The
decision about how much additional educational expe­
rience and the nature of the educational experience is
a personal one that each occupational therapist must
make. Individuals vary in their preferred learning
style. For an assertive, self-assured individual with
strong independent learning skills, reading a book,
taking a home-study course, and gaining som e expe­
rience w ith optical aids from a m anufacturer's work­
shop m ay be sufficient to develop the core knowledge
base. Additional clinical practice supervised by an
experienced low vision therapist is also recom m ended
and is required for certification. Som e may prefer to
enroll in a formal graduate program in low vision
rehabilitation that includes clinical training. The vari­
ous opportunities are listed w ith contact inform ation
in Table 16-1. We have tried to m ake this listing as
com plete as possible. O f course, organizations com e
and go and new program s are being developed. Thus,
it is important to use this table as a starting point and
be aw are that new program s and educational oppor­
tunities will certainly be available after publication of
this book.
C o n t in u in g E d u c a t io n
C ourses
It is comm on for occupational therapists to gain
knowledge about new areas of practice through post­
graduate, continuing education sem inars and work­
shops. O ne- and tw o-day w orkshops are offered
periodically for low vision rehabilitation. Som e of
the com panies offering such workshops are listed in
Table 16-1. These workshops generally cover infor­
mation about epidem iology o f low vision, diseases
causing low vision, basic optics, the occupational
therapy evaluation and low vision rehabilitation, bill­
ing for services, and hands-on experience w ith optical
aids. After com pleting one or tw o of these courses
m ost occupational therapists would feel com fortable
providing basic low vision rehabilitation services to
clients presenting with low vision as a secondary
diagnosis. Som e self-assured occupational therapists
m ight feel com fortable enough to initiate a low vision
service in a hospital setting, or provide home-based
low vision rehabilitation services with clients present­
ing w ith a prim ary diagnosis o f low vision.
Com panies that produce and sell optical devices
som etim es provide inexpensive continuing education
for occupational therapists and these sem inars offer
an excellent opportunity to gain hands-on experi­
ence with m icroscopes, m agnifiers, telescopes, closed
circuit televisions (CCTVs), and other video d is­
play technology. For exam ple, Fschenbach O ptik of
America (http://eschenbach.com /sem inars.php) has
been providing this service for many years and this
 Table 16-1.

Postgraduate Educational Opportunities for Education in Low Vision Rehabilitation

Name of Organization Type of Education Contact Information
Pennsylvania College of Graduate level www.pco.edu/acad_progs/
O ptom etry All distance learning g rad / g sjv r.h tm
Certificate or M asters in Low Vision
Rehabilitation
Certificate or M asters in Rehab
Teaching
Certificate or M asters in Orientation
and Mobility

University of Alabam a, Graduate level education www.uab.edu/ot/lvrcert/pro

Birm ingham M asters or C ertificate in Low Vision gram _description.htm
Rehabilitation

Vision Education Sem inars 2-Day W orkshops on Low Vision www.v isionedsem i na rs.com
presented across the United States

Lighthouse courses W orkshops on Low Vision presented www.lighthouse.org

across the United States

Eschenbach courses 2-Day W orkshops on Low Vision ww w.Eschenbach.com

presented across the United States

visA bilties 2-Day W orkshops on Low Vision www.visabilities.com

presented across the United States

AOTA home study course Home study course www.aota.org

AOTA/Jewish Guild for the

Blind O nlin e Study Course O nline course www.aota.org

The Hadley School for the Blind O nline course w w w. had ley-sc hool .org/

Lions Vision Research and O nline course http://lowvisionproject.org/

Rehabilitation Center at the Johns
H opkins W ilm er Eye Institute

O cusource O nline course w w w.ocusou rce.com /

com pany offers sem inars in m any cities around the
country on an annual basis. The Eschenbach course is
entitled "L ow Vision Care...What s it All A bout?" This
low vision care presentation for eyecare and rehabili­
tation professionals is designed as an introduction to
low vision care and optical devices.
The prim ary m issing ingredient from short continu­
ing education courses is clin ical experience w ith clients.
G aining m eaningful clinical experience is the greatest
challenge facing the therapist who would like to be
involved in low vision rehabilitation. O pportunities
may exist in some com m unities for an interested occu-
pational therapist to volunteer or find em ploym ent in a
situation in w hich low vision rehabilitation is already
being provided by another experienced therapist. In
any case, finding a setting to acquire supervised clin i­
cal instruction is a challenge. Recognizing this chal­
lenge, ACVREP w ill arrange supervision o f applicants
for certification from a distance using technological
m ethods.
H o m e St u d y an d D istance
E d u c a t io n
In 1995, the AOTA devoted its entire O ctober issue
to the topic of low vision and in 1998 developed the
AOTA O ccupational Therapy Practice G uidelines for
Adults with Low Vision. In 2000, M ary Warren edited
a home study course entitled Low Vision: Occupational
Therapy Intervention with the Older Adult, published
by AOTA.4 These three docum ents provide a wonder­
ful starting point for independent learning. In 2006,
the AOTA published revised practice guidelines for a
specialty certification in low vision (www.aota.org).
A recent trend in education is online or distance
learning and many opportunities now exist for this
type o f education in the area of low vision rehabilita­
tion. T h e Hadley School for the Blind (http://www.
hadley-school.org) currently offers a num ber of online
courses for professionals, including coursew ork in
Braille, low vision technology, introduction to low-
vision, self-esteem and adjusting with blindness, and
m acular degeneration. These courses are provided
without any tuition charge.
The Lions Vision Research and Rehabilitation
Center at the Johns H opkins W ilm er Eye Institute
offers som e exceptional distance learning opportuni­
ties and outstanding up-to-date inform ation about
low vision rehabilitation at their website (http://
lowvisionproject.org). T h is site is also the gateway to
the Low Vision Rehabilitation Network (LVRN). This
is a network of low vision providers and researchers,
and m em bership allow s individuals to participate in a
num ber of collaborative projects, including:
• Free online continuing professional
education courses.
• Exchange ideas and views w ith colleagues in
online forums.
• Participate in live online low vision case
conferences.
• Participate in live online low vision research
sym posia.
• Participate in an online "W hat's New in Low
V ision" website.
• Help plan the Low Vision Rehabilitation
O utcom es Project.
M em bership in LVRN is free and open to low
vision rehabilitation practitioners, researchers, stu ­
dents, educators, adm inistrators, policy-makers, busi­
ness people, and anyone else who is interested in
advances in the field of low vision rehabilitation.
A course currently offered on this website is entitled
"U nderstanding Visual Im pairm ents and Functional
Rehabilitation of Visually Im paired Patients." The
course consists of 22 lectures and supplemental mate­
rial that cover the follow ing topics: anatom y and
physiology of vision, diseases o f the visual system,
optics and optical devices, functional and ADL assess­
ments, visual skills training, rehabilitation services
and resources, and vision enhancem ent and adaptive
technology.
An organization called O cusource (http://www.
ocusource.com ) uses a different approach to distance
learning and provides extensive inform ation and
resources about low vision, including continuing
education. T h is organization, founded by Dr. Lou
Lipschultz, a low vision practitioner, offers a web-
based voice-conferencing system , all in an accessible
format. Participants are able to view presentations,
and m eet live w ith speakers and vendors.
An online course entitled "Low Vision in Older
Adults: Foundations for Rehabilitation" is the result
of collaboration between the AOTA and SightCare, a
program of The Jew ish Guild for the Blind. The course
w as w ritten by a low vision optom etrist, a certified
environm ental design specialist, and an occupational
therapist. It is made up o f three lessons:
• Lesson 1: An orientation to vision loss: its
causes, effects, and interventions
• Lesson 2: Vision enhancem ent with
m agnification: theory and practice.
• Lesson 3: Environm ental considerations.
O f course, the professional journals listed in Table
16-1 and textbooks like this one are available to assist
occupational therapists in gaining inform ation about
low vision rehabilitation as independent learners.
U niversity - B ased G raduate
E d u c a tio n
Some occupational therapists may prefer more for­
mal, university-based graduate education. Two excel­
lent program s designed for occupational therapists
are now available to m eet this need and are listed in
Table 16-1. Both program s offer a certificate or master's
degree in low vision rehabilitation.
The Departm ent o f Graduate Studies in Vision
Im pairm entof the Pennsylvania C ollegesof O ptom etry
(http://pco.edu/acad_progs/grad/grad prgs.h tm )
prepares a variety o f professionals to work with
people w ho are visually im paired. These program s
include the:
• M aster of Science and Certificate in Low
Vision Rehabilitation
 • M aster of Education and Certificate in
Education of Children and Youth w ith Visual
and Multiple Impairments
• M aster of Science and Certificate in
Orientation and M obility
• Master of Science and Certificate in
Vision Rehabilitation Therapy (formerly
Rehabi Iitation Teach ing)
The program most likely to be of interest to occupa­
tional therapists is the M aster of Science and Certificate
in Low Vision Rehabilitation. A ll of these programs,
w ith the exception of the full-tim e Master's degree in
Orientation and Mobility, are now available through
distance education.
T h e U niversity o f A labam a, B irm in gh am
Departm ent of Occupational Therapy offers a gradu­
ate certificate program in low vision rehabilitation
(http://main.uab.edu/Shrp/default.aspx7pid =76987).
T h is program is designed for occupational thera­
pists with bachelors, m asters, or doctorate degrees.
It consists of 17 credit hours of specialized courses
in low vision rehabilitation. Students take 11 credits
o f core courses designed to provide a foundation in
providing low vision rehabilitation services, 4 cred­
its o f elective courses to address specific aspects of
intervention in greater depth, and a 2-credit course in
advanced application. All of the courses arc offered
online through a web-based curriculum . The cu r­
riculum is designed with the working occupational
therapist in mind. Coursework em phasizes practical
application of the inform ation taught. Students can
enroll in the certificate program or com bine comple­
tion of the certificate program with a postprofessional
m aster's degree in occupational therapy. Students
com pleting the certificate program need to complete
an additional 10 credits of coursework and 6 credits
of research to receive the post professional m aster's
degree. Coursew ork for the postprofessional degree
is also online.
Thus, many educational opportunities are avail­
able for an occupational therapist who would like to
becom e involved in low vision education. It is sim ­
ply a m atter of deciding on one's learning style and
researching som e of the available options.
C ertification
Certification in low vision therapy is not required at
this tim e for occupational therapists. Any registered/
licensed occupational therapist is able to provide low
vision rehabilitation and bill for these services. In
Chapter 1, we discussed the various professionals
involved in low vision rehabilitation of adult clients.
These include occupational therapists, low vision
therapists, vision rehabilitation therapists (formerly
rehabilitation teachers), and orientation and mobil­
ity (O&M ) specialists. O f these three groups, only
occupational therapists are licensed and function as
independent service providers in the M edicare system
and in some regions for other com m ercial insurance
program s. Vision rehabilitation therapists, low vision
therapists, and O&M specialists often work for state
agencies, private organizations, and school systems.
In 2006, the services of these professionals were not
reimbursed by M edicare, M edicaid, or most private
insurance.
Although occupational therapists do not require
certification to practice low vision rehabilitation, it is
a desirable goal for the following reasons:
• Certification dem onstrates that the therapist
has advanced skills low vision rehabilitation.
• Certification may be required in the future
bv¥
insurers for reimbursem ent, even for
occupational therapists.
A c a d e m y f o r C ertification
of V ision R ehabilitation and
E d u c a t io n P rofessio n als
Currently there are two active certification pro­
gram s for low vision therapy. The first is a certifica­
tion process run by ACVREP, which was established
in January 2000. It is an independent and autonomous
legal certification body governed by a volunteer Board
of Directors. ACVREP's m ission is to offer profession­
al certification for vision rehabilitation and education
professionals in order to improve service delivery to
persons with vision im pairm ents. As of January 2006,
there were approxim ately 2,100 certified O&M spe­
cialists, 600 certified vision rehabilitation therapists,
and 300 certified low vision therapists. Although
ACVREP does not release data on how manv J occu-
pational therapists are certified, it is likely that many
of the 300 who are certified low vision therapists are
occupational therapists.
The ACVREP certification program that is appropri­
ate for occupational therapists is called the Certified
Low Vision Therapist (CI.VT). To be eligible to take
the w ritten certification test, candidates m ust meet
the eligibility criteria listed in Table 16-2. Candidates
passing a 100-item w ritten exam ination receive certi­
fication that is valid for a 5-year period (Table 16-3).
Certified low vision therapists must go through a
recertification process every 5 years. To be recerti­
fied, an individual must dem onstrate that he or she
has m aintained continuing professional com petence
bill M edicare. The essentials of this billing and neces­
sary docum entation process required for Medicare
will be reviewed later in this chapter. In this mode of
practice the occupational therapist is a private prac­
titioner and must have an office address for billing
w hile providing care in the client's home. The thera­
pist m ust m arket him- or herself to other professionals
who are likely to encounter elderly clients with low
vision. Such professionals include ophthalm ologists
(prim arily retinal, glaucoma, and cataract special­
ists), low vision optom etrists, geriatricians, large eye
hospitals, and other rehabilitation therapists such
as physical therapists, speech-language pathologists,
other occupational therapists, recreational therapists,
and social workers.
W e have provided a sample brochure and intro­
ductory letter in the Appendices. These documents
can be used to develop these relationships with other
professionals.
N ursing H o m e s
Research has shown that a high percentage of nurs­
ing hom e residents are visually impaired. For exam ­
ple, Horowitz9 conducted a study of a 250 bed, long­
term facility and found that 23% of the residents were
visually impaired. Vision loss among nursing home
residents complicates many of the care-related tasks
for providers of nursing home services, and interferes
with the clients' ability to engage in ADL.10
Thus, there is a significant need for occupational
therapists who currently work in nursing homes to
become involved in low vision rehabilitation in order
to care for a large percentage of their clients.
A cute C are / R ehabilitation
H ospital
We know that the two most comm on causes of
low vision are m acular degeneration and diabetic
retinopathy. Older people with cardiovascular d is­
ease and diabetes m ake up a significant percent­
age o f the patients in acute care and rehabilitation
hospitals. These are the same people who are likely
to have m acular degeneration and low vision. In
addition, many patients admitted to rehabilitation
hospitals with cerebral vascular accident or traumatic
brain injury may experience significant visual field
loss, which also falls into the category of low vision
impairment. Thus, occupational therapists working
in this setting have an opportunity to establish a low
vision service w ithin such rehabilitation departments.
Development of such a service helps to insure that
there are therapists with appropriate clinical abil­
ity and that clients receive appropriate and timely
treatment. Occupational therapists may practice in
outpatient and home health services associated with
rehabilitation hospitals, enabling reim bursem ent from
private insurers as well as M edicare and M edicaid.
R etirement / A ssisted L iving
C o m m u n it ie s
O pportunities also exist in assisted living com m u­
nities because of the aging population that live in such
facilities. The basic underlying theme when looking
for the population that is likely to need low vision care
is to find older adults. An occupational therapist can
arrange to m ake educational presentations about low
vision and low vision rehabilitation in assisted living
com m unities. Providing such education and helping
people better understand what can be accomplished
in spite of perm anent vision loss can be quite impor­
tant for people. M any individuals do not even seek
care because they have simply been told by previous
professionals that there is not much that can be done.
The occupational therapist can develop a working
relationship with an ophthalm ologist and/or a low
vision optometrist. People seeking more inform ation
or additional care for their visual im pairm ent can be
referred to an eyecare professional for an evaluation.
If low vision rehabilitation is required, the eyecare
professional can then refer the client to the occupa­
tional therapist for such care. This care would be pro­
vided by the occupational therapist as an independent
provider.
C o m m u n i t y - B ased A gencies
Until the late 1990s, most o f the low vision reha­
bilitation in the United States was provided within
the service delivery system that has been called the
"blindness system " (see Chapter 1). This system is
also som etim es referred to as the educational rehabili­
tation model, or the nonm edical vision rehabilitation
system .11 This system is a com prehensive nationwide
network of services consisting of state, federal, and
private agencies serving children and adults with
blindness and low vision.12 Because of limited pub­
lic funds to support these services, however, only a
lim ited percentage of people requiring low vision
rehabilitation are able to receive these services in
com m unity-based, state, or federally-funded agencies.
This scarcity of resources has led som e vision reha­
bilitation agencies to hire occupational therapists to
provide services.7 T h e advantage is that occupational
therapists can be reim bursed by Medicare, while
vision rehabilitation therapists and O&M specialists
cannot. Thus, there may be opportunities for occu ­
pational therapists in these agencies. O ccupational
therapists working in these agencies would generally
be salaried employees.
Low V isio n O p t o m e t r i s t
A nonconventional op p ortu n ity w ould be to
becom e affiliated w ith a low vision optom etrist. They
design and prescribe low vision devices (eg, optical,
nonoptical, electronic) and m ake recom m endations
about lighting, contrast, and other environm ental fac­
tors that influence vision. Although low vision optom ­
etrists should ideally work closely w ith low vision
therapists, this may not alw ays be the case. Som e low
vision optom etrists are not fully aware of the capabili­
ties of occupational therapists. Thus, once an occupa­
tional therapist identifies a low vision optom etrist in
the area, one challenge may be to educate this eyecare
professional about the role of occupational therapy in
low vision rehabilitation.
A second challenge is trying to locate a qualified
low vision optom etrist. The profession of optom ­
etry does not recognize "specialties". Therefore, any
optom etrist can provide low vision services, regard­
less of his or her experience in this area. However, the
A m erican Academy of O ptom etry Low Vision Section
has a Diplomate program for interested optometrists.
To becom e a Diplomate in Low Vision, an optom etrist
m ust pass a w ritten test, an oral exam ination, and a
practical low vision exam ination. Currently, there are
only about 45 practicing Low Vision Diplomats world­
wide. A current list of optom etrists that have suc­
cessfully completed this process can be found at the
website for the A m erican Academy of O ptom etry.13
The A m erican O ptom etric A ssociation also has a Low
Vision Section. Although there is no testing program
required to becom e a m em ber of this section, optom ­
etrists that have joined are likely to have a strong
interest in the area of low vision. Som e low vision
optom etrists have completed a residency program,
w hile others have chosen to specialize in this area
and have acquired additional knowledge and clinical
skills through continuing education and independent
learning. Currently, there are about 36,000 optom ­
etrists in the United States, and there are about 1,000
m em bers in the low vision section of the Am erican
O ptom etric Association.
There are two potential ways of working with the
low vision optom etrist. The first m ethod would be as
an employee. T h e low vision optom etrist would refer
patients to the occupational therapist w orking in his
or her practice. The therapist would evaluate and pro­
vide treatment in the doctor's office. The office would
bill and be reim bursed for the therapist's services and
provide an hourly salary to the occupational therapist.
A nother scenario would be for the low vision optom e­
trist to refer patients to an occupational therapist func­
tioning as an independent provider. In this case, the
therapist would not provide services in the doctor's
office. Rather, he or she would need an office and also
could provide services in the client's home. In either
case, the occupational therapist would require regis­
tration as an independent provider. In som e states, not
all private insurers recognize occupational therapists
as independent providers. In these situations, occupa­
tional therapists may work for and bill through agen­
cies or outpatient rehabilitation services.
O p h t h a l m o l o g is t
Perhaps the most effective way o f finding clients
w ho require low vision rehabilitation is to work w ith
an ophthalm ologist. O phthalm ologists are physicians
who specialize in the diagnosis and treatm ent of eye
disease by com pleting a residency in ophthalmology.
Many ophthalm ologists also com plete a fellowship
program to further specialize in an area of ophthal­
mology. A num ber of specialty areas e x is t includ­
ing specialists in cataract, glaucoma, retina, cornea,
pediatric ophthalmology, and neuro-ophthalm ology.
O phthalm ologists most likely to treat clients with low
vision are the retinal, glaucom a, and cataract special­
ists. Since most patients who have low vision have
retinal problems or loss of vision due to glaucoma,
these are the types of specialists with whom the
occupational therapist should develop relationships.
Doctors in these offices exam ine a high percentage of
patients with various retinopathies on a daily basis.
A very high percentage o f their patients require fur­
ther care. Unfortunately, many ophthalm ologists do
not refer for low vision rehabilitation.14 O ccupational
therapists can identify these ophthalm ologists and
arrange a visit, at w hich the therapist can educate the
physician about his or her capabilities, and the poten­
tial advantages for the patients in the practice. There is
no specific subspecialty of low vision in the profession
o f ophthalmology. There arc currently about 16,000
practicing ophthalm ologists in the United States.
The prim ary areas of interest and responsibility of
the ophthalm ologist are the diagnosis and treatment
o f eye disease. Treatment m odalities generally involve
the use of medication and surgery. Thus, clients often
see the ophthalmologist first because of a perceived
significant change in vision. The ophthalmologist
attem pts to restore normal visual function by treating
the eye disease. In some cases this fails, or in other
cases the vision can never be restored to normal and
the client is now faced with permanent low vision. It
is at this point that the ophthalmologist should refer
the client with low vision to other professionals for
further evaluation and rehabilitation.
A sim ilar working relationship described above
for the low vision optom etrist also applies to working
with the ophthalmologist, although few ophthalm olo­
gists specialize in low vision rehabilitation. Thus, the
occupational therapist would need advanced skills in
vision evaluation and optics.
Eye H ospital
Som e large metropolitan areas in the United States
have free-standing eye hospitals. A high percentage of
adult patients seen at these hospitals have low vision.
Many of these institutions have a low vision optom ­
etrist on staff and some may
/ already
* have established
low vision rehabilitation programs. If not, eye hospi­
tals represent a potential opportunity for occupational
therapists. O ur recommended approach would be to
use some of the ev idence for the effectiveness of low
vision rehabilitation reviewed in Chapter 9 in a presen­
tation to key personnel at the hospital. The article writ­
ten by M arv Warren entitled "Providing Low Vision
Rehabilitation Services with Occupational Therapy
and Ophthalm ology: A Program s D escription" is
an excellent article to include in such a discussion.
Occupational therapists working in such a setting
would generally be employees.
C olleges o f O p t o m e t r y -
Patient C are C linics
There are 17 Colleges of O ptom etry in the United
States and Puerto Rico. All of these colleges have
large patient care clinics with a low vision service.
These low vision services arc used to train optometry
students in all aspects of low vision care, including
rehabilitation. The low vision departm ents are staffed
by optom etrists who have completed residencies in
low vision and/or have many years o f experience as
low vision specialists. They are generally well-versed
in the current trends in low vision care and research
and should have an understanding of the important
role that occupational therapy has begun to plav in
low vision rehabilitation. Som e o f these clinics mav*
already employ rehabilitation therapists. Others, how­
ever, may not offer full-scope low vision care. Thus,
this is a potential opportunity for an occupational
therapist. The key contact person would be the C hief
of the Low Vision Service at the College of Optometry.
The occupational therapist would not have to convince
this individual of the im portance o f low vision reha­
bilitation. Rather, the presentation would em phasize
the unique contributions that occupational therapists
could make in the low vision service.
M arketing an d P ublic
R elations
W hether an occupational therapist establishes a low
vision rehabilitation service in a nursing home, reha­
bilitation hospital, the office of an eyecare provider, or
starts a private practice, there will be a need for mar­
keting and public relations to m ake the service grow.
In the following section, we present a scries of internal
and external m arketing and public relations ideas that
could be used in a variety of practice settings.
Internal Marketing
Within each practice setting, there w ill already be
a client base that mav be unaware of low vision and
low vision rehabilitation. The first and least expensive
method of m arketing is to m ake current clients aware
of the new low vision service.
Handouts an d Brochures in
Waiting Area
Most professionals utilize handouts and brochures
in their waiting room s to market various aspects of
their practices. It is a m atter of selecting appropri­
ate m aterials to m arket the low vision rehabilitation
aspect of your practice.
1. Handouts: M any materials arc available that
could be used as handouts in a waiting area.
For exam ple Lighthouse International offers a
series of brochures for consum ers that explain
 Table 16-4.

Samnle Resources for Consumer Education

Company/Vendor Topic Contact Information

Glaucom a Research Understanding and Living with Glaucoma http://www.glaucoma.org/learn/lit-
Foundation Glaucom a: W hat You Need To Know erature.php
Cataracts and Glaucoma

N ational Eye Institute Don't Lose Sight of Diabetic Eye Disease http: //w w w.nei .n i h .gov/ low v i sion /
Age Related Eve D isease Studv Information default.asp
Packet
Age-Related M acular Degeneration: What
You Should Know
Don't Lose Sight of Age Related M acular
Degeneration
Glaucom a: W hat You Should Know

Lighthouse Low Vision Defined: A Guide to the M ajor http://lighthouse.org/

International C auses of Vision Loss and W hat Can Be
Done to Improve Functional Vision
Vision Loss Is Not a N orm al Part of
Aging— Open Your Eyes to the Facts!
New sletters for consum ers

various aspects of low vision. They also offer

a m onthly new sletter designed for consum ­
ers called "C onsum er Tim es: Living Better
with V ision Loss". Table 16-4 lists som e o th er
resources for consum er education.
2. Brochures: T h in k about developing your own
brochure that explains low vision and the
im portance of low vision rehabilitation. An
exam ple of such a brochure is included in the
Appendices.
Internal Mailings
If your office/hospital is com puterized, you have
the ability to m ake a selective m ailing to clients by age
and by diagnostic condition, such as m acular degen­
eration, diabetic retinopathy, and diabetes. You can
periodically send out inform ation about low vision
and low vision rehabilitation. Sam ple handouts are
included in the Appendices.
External Marketing
In addition to m arketing directly to current clients,
it is im portant to m ake potential clients and other
professionals aw are of your service. W e refer to this
as external m arketing.
Speaking Engagements
O ne of the best m arketing tools available is to pres­
ent educational inform ation in a sem inar/workshop
format. Few people take advantage of this oppor­
tunity, however, because o f discom fort w ith public
speaking. Suggested audiences include groups of
older adults, consum ers with low vision, fam ilies
of consum ers with low vision, civic organizations,
churches, and synagogues. We suggest that instead of
w aiting for an invitation from an organization, that
the occupational therapist take the initiative and con­
tact potential organizations.

G rand Rounds/Sem inar Establish a Working Relationship

Presentations
In m ost institutional settings, case conferences,
grand rounds, and sem inars are periodically sched­
uled. T h is is an outstanding opportunity to m ake the
rest of the staff aw are of your service, the clients you
can help, and the expected outcomes.
W ith Other Professionals
In addition to ophthalm ologists and optom etrists,
there are many other professionals who work with
older adult clients with low vision. T hese include other
occupational therapists, physical therapists, speech-
language pathologists, recreation therapists, nurses,
soci.il workers, psychologists, fam ily physicians, neu­
rologists, neuro-ophthalm ologists, and geriatricians.
O ne way to cultivate a working relationship with
an optom etrist or general ophthalmologist with an
interest or specialization in low vision is to refer cli­
ents. If other physicians or professionals refer to an
occupational therapist, the occupational therapist,
who must work under the prescription of a physician,
may then refer the client to the optom etrist or oph­
thalmologist.
There is no simple way to get the nam es and
addresses of these people. You can som etim es get
nam es and addresses from telephone directories,
and from professional organization websites on the
Internet. M ailing lists can be purchased from organi­
zations such as the AOTA and sim ilar organizations
from other fields. We have included a letter of intro­
duction for professionals in the Appendices that could
be used to initiate contact. The goal is to develop true
inter-referral relationships with a group of profession­
als that share an interest in the care of clients with low
vision.
B illing , In s u r a n c e , and
M edicare Issues
Reimbursement Sources
T h e im petus for occupational therapy's involve­
ment in the area of low vision rehabilitation was
the 1991 am endm ent by the Health Care Financing
A dm inistration (HCFA) that allowed Medicare cover­
age for the first tim e for licensed healthcare providers
for low vision rehabilitation. Medicare is currently the
m ain source of reimbursement for low vision reha­
bilitation for occupational therapists. O ther potential
reim bursem ent sources are HMOs, private insurance
com panies, state agencies for the blind and visually
im paired, and private paying clients.
M ed icare an d Low V ision
R e h a b ilita tio n ( O u t p a t i e n t
S ettin gs)
The inform ation we provide in this section was
current when this book was published. 1 lowever, it is
im portant to understand that the CM S occasionally
m akes policy changes and the reader should carefully
review the CM S website and seek current information
about billing for low vision rehabilitation services
(www.cms.gov).
The current CM S policy on low vision rehabilita­
tion in an outpatient setting (M edicare B) states that
occupational therapy is a covered service if it meets
the following criteria:
1. Services must be prescribed by a physician and
furnished under physician-approved plan of
care.
2. Services must be perform ed by an occupation­
al therapist or occupational therapy assistant
under supervision of occupational therapist.
3. Services must be reasonable and medicallvj
necessary for treatm ent o f an individual's ill­
ness (must result in significant improvement
in level of function within reasonable period
ot time). M edically necessary is defined by the
diagnostic code and rehabilitation potential.
According to CMS, the purpose of vision rehabilita­
tion therapy is to m axim ize the use of residual vision
and provide patients with many practical adaptations
for A D L In doing so, it builds the confidence that
is necessary for ongoing creative problem solving.
Rehabilitation appears to be more effective if it is
started as soon as functional visual difficulties are
identified.
There can be coverage variations am ong M edicare
contractors, called fiscal interm ediaries, w hich are
allowed to establish local policies. Thus, it is im por­
tant to check with your local M edicare fiscal interm e-
diary before initiating any low vision rehabilitation
w ith clients.
According to CM S, coverage of low vision rehabili­
tation services is considered reasonable and necessary
only for patients with a clear m edical need. To meet
the criteria established by CM S you must dem onstrate
that:
1. The patient has a moderate to severe visual
im pairm ent not correctable by conventional
refractive m eans or certain types of visual field
loss.
2. The patient has a clear potential for significant
improvement in function following rehabilita­
tion over a reasonable period of time.
Before providing services, the occupational thera­
pist must develop a w ritten evaluation and treatment
plan. The treatm ent plan should include:
1. An initial assessm ent that docum ents the level
of visual impairment.
2. A plan of care identifying specific goals to be
fulfilled during rehabilitation.
 3. A definition of specific rehabilitation services
to be provided during the course of rehabilita­
tion.
4. A reasonable estim ate of when the goals will
be reached and the frequency at w hich the
services w ill be provided.
Periodic follow-up evaluations must be performed
by the referring physician during the course of the
rehabilitation.
Currently, C M S bases the m axim um num ber of
treatm ent sessions on the severity of the visual im pair­
ment, and the level of visual im pairm ent is based on
visual acuity w ith best correction and som e form s of
field loss. As of M arch 2006, individuals w ith central
field loss, generalized field constriction, hom onym ous
and heteronym ous bilateral field deficits, or acuity
loss of w orse than 20/60 in the better eye are eligible
for services.
Sessions are generally conducted over a 3-month
period o f tim e with intervals appropriate to the
patient's rehabilitation needs. If additional sessions
are necessary, medical record docum entation must
indicate the need for additional sessions.
Coding Guidelines
Vision rehabilitation therapy should be provided
by an occupational therapist or a physician or "in ci­
dent to a physician's professional services, when
perform ed by non-physician personnel under direct
supervision". T h e incident to a physician rules apply
to vision rehabilitation therapists and O &M special­
ists who are not licensed and are unable to perform
these services independently. O ccupational therapists
can perform these services independently and do not
require direct supervision by the physician.
Proper coding requires determ ination of the pri­
m ary and secondary diagnoses and the use of ICD-
9-CM codes. T h e 369 codes reflect the level of visual
im pairm ent and this must always be the prim ary
diagnosis. The secondary codes are the 362-377 codes
and these reflect the actual eye disease causing the
visual im pairm ent. The eye disease must always be
listed as the secondary diagnosis.
Table 16-3 is a convenient chart that can be used to
determ ine the appropriate code to be used for a client
based on the distance visual acuitv measurem ent. In
most cases, the visual acuity will be provided by the
referring eyecare professional. If for som e reason the
visual acuity is not provided, the occupational thera­
pist can use the acuity charts suggested in Chapter 8
to determ ine the visual acuity. An exam ple would be
a client for which the ophthalm ologist or optom etrist
refers the patient with the following inform ation. The
right eye visual acuity is 20/120 and the left eve visual
acuity is "counting fingers". T h e term "counting fin ­
gers" is used by som e eye doctors inappropriately.
Generally, it m eans that he or she had a traditional
eye chart that has no sym bols greater than 20/400.
As a result, if the patient is unable to see the 20/400
letter, some doctors will sim ply stand som e distance
in front of the patient, ask if the patient can see his or
her fingers, and count how many he or she is holding
up. T h is is not proper testing protocol. T h e doctor
should have an appropriate chart, and if not, reducing
the distance of the patient from the chart will allow
more accurate determ ination of acuity. Nevertheless,
in the real world, it is not uncom m on for an occupa­
tional therapist to receive a referral with the acuity as
"counting fingers". In such a case, the occupational
therapist would have to retest visual acuity.
To demonstrate the use of the chart in Table 16-5,
let us assum e we have a client who has been referred
to us for low vision rehabilitation. The referring eye
doctor reports that the visual acuity in the right eye is
20/120 and the visual acuity in the left eye is 20/1500.
The first step is to determ ine the level of im pairm ent
that each visual acuity represents. Looking at Table
16-5, one can determ ine that 20/120 falls into the cat­
egory of "m oderate im pairm ent" (refer to left column
of table), and 20/1500 falls into the category of "near
total im pairm ent" (left colum n of table). The next step
is to locate the category o f "m oderate im pairm ent" on
the left colum n of the chart and move across that row
until it intersects with the colum n w ith the heading of
"near total im pairm ent". The code found at the inter­
section of the row and colum n is the prim ary diag­
nosis used for M edicare billing. In this case, the code
would be 369.17. A second exam ple is a client w ith a
visual acuity of 20/200 in the right eye and 20/300
in the left eye. Use the approach suggested above. In
this case, both acuities fall in the category o f "severe
im pairm ent". Locate "severe im pairm ent" in the left
colum n and move across this row until it intersects
with "severe im pairm ent" on the top colum n. The
diagnostic code is 369.22.
The secondary diagnosis must be determ ined by
the referring eve doctor. Table 16-6 lists som e o f the
more comm on diagnoses o f low vision clients.
The treatment codes for low vision rehabilitation
are the traditional PM&R codes used by occupational
therapists and are listed in Table 16-7.
R eferrals f o r Lo w V ision
R ehabilitation
M edicare requires that an occupational therapist
receive a referral from a physician before initiating
an evaluation or low vision rehabilitation. Initially,
this referral could only be issued bv an ophthalm olo-
 Table 16-5.

ICD-9CM Codes for Visual Iirmairment - Primary Diagnosis15

Normal Near Normal Moderate Severe Profound Near Total Total

Establishing a Low Vision Rehabilitation Specially Practice

Vision Vision Impairment Impairment Impairment Impairment Impairment
Normal vision
20/20- 20/25 369.76 369.73 369.69 369.66 369.63

Near norm al vision

20/30-20/60 369.75 369.72 369.68 369.65 369.62

Moderate im pairment
20/80-20/160 369.76 369.75 369.25 369.24 369.18 369.17 369.16

Severe im pairment
20/200- 20/400
or VF =<20 degrees 369.73 369.72 369.24 369.22 369.14 369.13 369.12

Profound impairment
20/500- 20/1000
or VF <=10 degrees 369.69 369.68 369.18 369.14 369.08 369.07 369.06

Near total im pairm ent

20/1250-20/2500
or VF<=5 degrees 369.68 369.65 369.17 369.13 369.07 369.04 369.03

Total im pairment
no light perception (NLP)
369.63 369.62 369.16 369.12 369.06 369.03 369.01

Visual field defects 368.41 368.45 368.46 368.47

M aterial com

Scotom a involving central Visual field defects, generalized H om onym ous bilateral Heterony- *
area contraction or constriction field defects m ous bilat­
eral field
defects
direitos a u tora is

О
 Common ICD-9-CM Rilling Codes for Secondary Diagnosis
362.01 - Diabetic retinopathy, background
362.02 - D iabetic retinopathy, proliferate
362.35 - Central retinal vein occlusion
362.51 - M acular degeneration, dry
362.52 - M acular degeneration, wet
362.74 - Retinitis Pigmentosa
365.10 - Glaucom a, open angle, unspecified
365.20 - Glaucom a, primary, angle-closure, unspecified
366.10 - Cataract, senile, unspecified
368.46 - Field deficit homonymous, bilateral
377.10 - O ptic nerve atrophy
377.41 - O ptic neuritis

Table 16-7.

PM&R Codes Used for I.ow Vision Rehabilitation

Evaluations
97003 O ccupational therapy evaluation

97004 O ccupational therapy reevaluation

Therapeutic Procedures
97110 Therapeutic procedure, one or more areas, each 15 m inutes; therapeutic exercise» to
develop strength and endurance range of motion, and flexibility.

97112 N eurom uscular reeducation of movement, balance, coordination, kinesthetic sense,

posture, and proprioception

97530 Therapeutic activities, direct (one on one) patient contact by the provider (use o f dynam ic
activities to improve functional perform ance) 1 on 1 treatment each 15 minutes.

97533 Sensory integrative techniques to ehnance sensory processing and promote adaptive
responses to environm ental dem ands, direct (1 to 1) patient contact by provider, each
15 minutes.

97535 Self-care/hom e m anagem ent training (eg, ADL and com pensatory training, meal
preparation, safety procedures, and instructions in use o f adaptive equipm ent), direct
one-on-one contact by provider, each 15 minutes.

97537 Com m unity/reintegration training (eg, shopping, transportation, money m anagem ent,
avocational activities, and/or w ork environment/m odification analysis, work task
analysis), d irect one-on-one contact by provider, each 15 m inutes
 Table 16-8.
Recertification - Tim e Requirements
Type of Facility/Care
Skilled Nursing Facility
Home Health A
Home Health В
Com prehensive Outpatient Rehab Facility
gist or other medical doctor. However, the Balanced
Budget Refinem ents Act (PL. 106-113) signed into law
November 29, 1999, includes a technical am endm ent
that recognizes optom etrists as "physicians" for pur­
poses o f certifying a M edicare beneficiary's need for
occupational therapy services under M edicare Part B.
This new federal law does not, however, supersede
state law. Therapists in states with broad or no refer­
ral requirem ents will be able to accept referrals from
optom etrists in 36 states, the D istrict of Columbia, and
Puerto Rico have no referral requirem ents in either
their OT statute or regulations. However, it is possible
for the state occupational laws to specifically require
an MD or podiatrist as a referral source, for example.
In such cases, the state law would have precedence
and in such a state an occupational therapist could
not accept a referral from an optometrist. Currently,
optom etrists can provide a referral to an occupational
therapist in 37 of the 50 states. To determ ine the regu­
lation in your state, it is im portant to check w ith your
state occupational therapy association. You can check
your state law on the AOTA website (www.aota.org)
by searching for the State O T Law Database.
O ther M edicare
R eq uirem en ts
Individual Rehabilitation Plan
M edicare requires an Individual Rehabilitation
Plan for each client being treated by the occupational
therapist. T h e Individual Rehabilitation Plan prospec-
tively docum ents the treatm ent to m eet reasonable,
# o f Days
After 14 days and then ever}' 30 days
Every 62 days
Every 60 days
Every 60 days
well-defined goals. The Individual Rehabilitation Plan
m ust be signed by physician and must be reviewed by
a physician every 60 days.
Recertification/Reevaluations
M edicare also requires periodic recertification for
all clients receiving low vision rehabilitation. To be
recertified, the client must be exam ined by the refer­
ring physician and the Individual Rehabilitation Plan
must be signed. The required tim e period varies
depending on the environm ent, as listed in Table 16-
8.
Documentation
The docum entation requirem ents for vision reha­
bilitation therapy are identical to those required for
any other condition. Therapists must docum ent that
the treatment is reasonable and necessary, provide a
plan of care and regular progress notes, m ust dem on­
strate progress over time, and at the end o f treatm ent
provide a discharge sum m ary.
C urrent R e im b u r s e m e n t R ates
for V ision R ehabilitation
S ervices
Inform ation about M edicare reim bursem ent rates
can easily be accessed for any location in the United
States at the C M S website (www.cms.gov/phvsicians/
mpfsapp/stepO.asp).
 Establishing a tow Vision Rehabilitation Specialty Practice 307

Table 16-10.

Suggested Theraov Eauioment

Equipment Cost Source Phone

LS&S Equipm ent S2033.07 LS& S 800-468-4789
LUV Reading W orkbook $25 Lighthouse 800-829-0500

Low V ision Su pplies (From L S & S C atalog)

Kitchen Catalog Number Price

Long Oven M itts OM15 3.50
Low Vision Tim er 8402 12.95
Boil Alert 5739 2.95
Liquid Level Indicators EZ-1 12.95
M easuring Cups 4839 6.95
M easuring Spoons 6138 3.95
Talking Kitchen Scale 851059 114.95
Cutting Boards 826024 7.95
Jar Openers 75358-1002 8.95
Iron Safety Guard 75464-1000 53.95
Bright Dish Brush 3143 3.59
Bright Colored Dish Brush 3137 2.49
Talking Indoor/Outdoor Therm om eter 888S 13.95
Total $253.03

Make-up Catalog Number Price

H andsom e 5X Stand M irror M C lll S21.95
7X G ooseneck Stand M irror Z6V7 22.95
Z'Zoom 5X Compact ZZ30 11.95
5X Fluorescent ZLP05 59.95
Double Sided Lighted Makeup BE4 25.95
Total $142.75

Personal Care Catalog Number Price

5X M agnifying Clippers MCI 5.25
6X Tweezer M agnifyer 424 2.49
Superb Q uality Talking Scale LH S-3 79.95
Talking C linical Therm om eter 8842 12.95
32" Metal Rehab Reacher 571000 12.95
Jum bo Plastic Pill Box 67199 1.75
M agnifying Pill Cutter 67168 5.95
Total $128.54

Leisure Catalog Number Price

Visual Mate LM747 49.95
Needle Threader THREADER 2.75
Low Vision Pinochle Cards CC1A 1.25
M arinoff Large Symbol Playing Cards GPM 4.45
Jum bo Face Playing Cards pack 1223 2.45
Playing Card Holder 71252-0010 4.95
Continued
 Table 16-10, Continued

Suggested Theranv Eauinment

New York Times Large Print 9.95
40 Crossw ord Puzzles 0-812-91044-3 4.95
G iant Print Bible 883C 17.95
Low Vision Bingo Cards CC1A 1.25
Super Large Lam inated Bingo Cards LBC 1.25
10 Digit Talking Calculator A larm Clock 99025 14.95
Total $116.10

Reading/Writing Catalog Number Price

Able Table AT-l 46.95
Easy Reader ER1 21.95
20/20 Pen 13101 0.94
Flair/Gel Pens Staples 3.95
Large Print Appointm ent Book BP3 14.45
Big Print Address Book BP! 13.95
Large Print Calendar LPC 6.49
Bold Line Paper BLP100 2.95
Superior Letter W riting Guide LTG 3.95
O riginal Easy Writer Guide EWG 19.95
O riginal M arks Script Guide MS-1 23.95
Large Print C heck Register BP2 6.49
Signature Guide STSG 1.85

Reading/Writing Catalog Number Price

Large Envelope W riting Guide ENG 1.95
Deluxe C h eck W riting Guide KJV-1611 4.95
Leather Coin Purse MOW-3 7.95
Total $182.67

Talking Watches/Clocks Catalog Number Price

Black Face Silver Band LHS-127 MENS
LHSL LADIES 32.95
W hite Face Silver Band LHS-131 MENS
LHS-131L LADIES 32.95
Jum bo Low Vision Watch (leather) LHS-107 22.95
Q uartz Low Vision M ens 4211 69.95
Q uarts Low Vision (leather)Men/W omen 4211 GM EN S
4211 LADIES 74.95
Talking A tom ic Clock AT1000 49.95
Curved Talking A larm Clock 6695 9.95
Silver Beauty Talking Metal Watch SW5 11.75
Casual Talking W 3220163 9.95
Total $315.35
Continued
 Table 16-10, Continued.

Suggested Therapy Equipment

Labels/Identifiers Catalog Number Price

Bump O n Tactile M arkers BP-BL 2.75
BP-W
BP-CLEAR
Loc Dots LD-2 1.09 per pack
O riginal Touch Dots TDB 2.09
TDW
TDY
Wide Label M aker LM300 119.95
AC Adapter 40077 18.95
Tape Cartridges 53713
53721 15.95
Note-lt 91420 4.99
Key Pager 822028 12.95
Touch To See Braille/Tactile TTS 11.95
Sock Sorters 825029 3.45
Total $190.28

Telephone/Computers/TV Catalog Number Price

Big Button 900 MHz 614030 39.95
Big Button Plus 905 HI-905 29.95
Big Size Com puter M agnifier CTC-21H 49.95
Big Button Remote BW 0120 17.95
Jum bo Button Phone HI-JB20 69.95
Total $302.70

Lighting/Lamps Catalog Number Price

Econom ical Illum inated 3D M agnifying Lam p 3700 52.95
Chrom a lux Full Spectrum Bulbs A21FR/75
A21FR/100 7.45 ea
All Purpose Economy Lamp 2225-Z 54.95
G ooseneck Lamp 2030BLK 14.95
Economical Sw ing Lamp 2000BLK 14.95
O tt Lite Desk Lamp OTL-13 54.95
Deluxe Lamp 30302 74.95
Big Eye Lamp 01042.95
Total $401.65
 It is our hope that many readers will use the infor­
mation in this book to help meet the grow ing demand
for low vision rehabilitation services in the adult cli­
ent.
R eferences
1. Congdon N, O'Colmain B. Klaver CC, et al. Causes and preva­
lence of visual impairment among adults in the United States.
Arch Ophthalmol. 2004;122<4>:477-485.
2. Warren M. Including occupational therapy in low vision reha­
bilitation. A m /O c cu p Ther. 1995;49(9>:857-860.
3. Elliott DB, et al. Demographic characteristics of the vision-dis­
abled elderly. Invest Ophthalmol Vis S d . 1997;38:2566-2S75.
4. Warren M. Low Vision: Occupational Therapy Intervention
with the Older Adult. Bethesda, M D: American Occupational
Therapy Association; 2000.
5. American Occupational Therapy Association website <www.
aota.org).
6. Lambert I. Occupational therapists, orientation and mobil­
ity specialists and rehabilitation teachers. / Vis Imp Mind.
1994;88:297-298.
7. Orr AL. Huebner K. Toward a collaborative working relationship
among vision rehabilitation and allied health professionals. / Vis
Imp Blind. 200l;95i8):468-482.
8. McGinly Bachelder f, Harkins D. Do occupational therapists
have a primary role in low vision rehabilitation? Am I Occup
7her. !995;49(9):927-930.
9. Horowitz A. Vision impairment and functional disability among
nursing home residents. The Gerontologist. 1994;34:316-323.
10. Horowitz A, et al. Visual impairment and rehabilitation needs of
nursing home residents. / Vis Impair Blind. 1995;88:7-15.
11. Mogk L, Goodrich G . The history and future of low vision ser­
vices in the United States. I Vis Impair Blind. 2004;(Ocl):585-
600.
12. Ponchillia PE, Ponchillia SV. Foundations o f Rehabilitation
Teaching With Persons Who Are Blind or Visually Impaired. New
York: American Foundation for the Blind; 1996:3-21.
13. American Academy of Optometry. Low Vision Section List of
Low Vision Diplomates. 2005.
14. Pankow L, Luchins D. Geriatric low vision referrals by oph­
thalmologists in a senior health center. I Vis Impair Blind.
1998:92(11):748-753.
15. Hart AC. The Professional ICD-9-CM Code Book. Reston, VA: St.
Anthony Publishing; 2000.
R esource
• Academy forC ertification of Vision Rehabilitation
and Education Professionals (ACVREP) http://
w w w.ac v rep.org /
 Goal Writing
The Occupational Therapy Practice Framework divides
the intervention process into three substeps: the inter­
vention plan, intervention implementation, and inter­
vention review.1 According to the Framework, the inter­
vention plan includes objective and m easurable goals
w ith a tim efram e, an occupational therapy interven­
tion approach, and m echanism s for service delivery.1
In Chapters 9 through 15, we described an organized
approach for this intervention process w ith specific
vision rehabilitation techniques that fall into four of
the five categories of intervention approaches sug­
gested in the Occupational Therapy Practice Framework,
including: establishing or restoring perform ance
skills, m aintainin g perform ance skills, m odifying
context or activity demands, and preventing problems
in perform ance skills. O ur goal in this chapter is to
help therapists structure the development and w riting
of intervention goals. To do so, we have identified four
com ponents that should be incorporated into each
goal. These com ponents include: the areas of occupa­
tion and perform ance skills to be addressed, the type
of assistance required, criteria for success, and the
m ethod of assessment. W hen developing intervention
goals, it is im portant to develop goals that are realistic
and achievable,2 have a positive effect on the quality
of the patient's life, are measurable and quantifiable,
are related to function, and appropriately reflect the
patient's needs.
A com m on problem when trying to establish client-
centered goals is that clients with low vision m ay lose
interest in activities because visual difficulties may
reduce the ability to concentrate and sustain visual
attention.3 In such cases, the clicnt m ay actually deny
that the vision loss causes any ✓ lim itation in function.4
W arren states that this could result in problem s with
client safety and well-being.4 Such clients may sur­
vive by expending a great deal of effort and by taking
greater risks. It is, therefore, vital that therapists make
goal development an essential part o f the low vision
rehabilitation evaluation. We describe our recom ­
mended approach for goal development in Chapter 8.
This approach includes an assessm ent of the client's
functional ability before the loss of vision as well as a
detailed discussion to system atically develop a list of
realistic client-based goals for vision rehabilitation.
Clients typically want things to be the way they
were before the eye disease caused the vision loss.
In most cases, the client will need to realize that
som e significant changes will be required in life­
style. It is not unusual to hear some very unrealistic
expectations from clients. Remember that the prior
experience of this clicnt was that new glasses always
restored clear vision. Patients often expect the sam e
result even when the vision loss is caused bv disease.
They either fail to understand that the vision loss is
perm anent, or refuse to accept this prognosis. By the
tim e the client is being exam ined by the occupational
therapist, he or she has had num erous exam inations
with the ophthalm ologist and perhaps a low vision
optom etrist. T h e client should certainly be well aware
that there are no m iracle glasses, devices, or drugs
that w ill restore norm al vision. Yet, it is not unusual
for the client, when asked what he w ants to be able to
do, to say "1 w ant to be able to see well again", or "I
am hoping you can prescribe glasses that w ill help me
see well again".5
T h e therapist's role is to help clients w ith low
vision fulfill realistic vision-related goals.- It is useful
to review Table 7-4, w hich lists a series of questions
m odified from a "personal eyesight evaluation" devel­
oped by Paul Freem an, OD. These questions allow the
therapist to help the client system atically develop a list
of realistic goals for vision rehabilitation.
Table 17-1 represents an exam ple of the approach
we suggest for goal w riting. In this table, there are
four colum ns and the therapist can select an item
from each of the categories in order to w rite a goal. For
example, from Table 17-1, the therapist might select
one item from each colum n to construct the following
goal:
G oal: The client w ill be able to apply lipstick using
a m agnifying m irror and spot lighting, with m inim al
assistance. The client's perform ance w ill be assessed
bv
✓ direct observation.
Tables 17-2 through 17-11 provide sim ilar sugges­
tions for som e of the more com m on areas of occu ­
pational perform ance and perform ance skills, such
as m anaging medication, personal hygiene, clothing
m anagem ent, eating, home m anagem ent, food prepa­
ration, com m unication, and financial m anagem ent.
These tables are not designed to be comprehensive.
Rather, they represent one possible method that the
therapist may use to organize the essential skill of
goal writing. The therapist can use these tables to mix
and match items from each o f the four colum ns to
assist in goal writing. We suggest therapists use these
tables as a starting point and add to them as they
w rite new goals.

Area o f Occupation/
Performance Skill
W ill be able to identify
medication
W ill be able to use an
electric razor
W ill be able to apply lip­
stick
Will be able to measure
sham poo and conditioner
Will be able to identify
clothing and accessories
Will be able to locate
items on the table or on
the plate
Will be able to set the
stove or oven controls
W ill be able to slice a
piece of bread and butter
W ill be able to w rite a
letter, address an enve­
lope, or sign name
W ill be able to read
newspaper print, head­
lines/articles
Table 17-1.
Sample—Low Vision Goal Writing
Type of Assistance Criterion for Success Method of Assessment
O p tical A ids Independently Direct observation
handheld m agnifier With m inim al assistance Stop watch
Moderate assistance
stand m agnifier
m icroscopic spectacles
telem icroscope
portable video m agnifier
stand video m agnifier
telescope
m agnifying m irror
Lighting/Contrast
gooseneck lamp
lighted m irror
spot lighting
contrasting towels
contrasting bath mat
N onoptical D evices
Rx talking machine
identifying buttons
identifying labels
liquid level indicator
“bum p" dots
hi-m arks
Continued
 Tabic 17-1, Continued.

Sample— Low Vision Goal Writing

Area of Occupation/

Performance Skill Type of Assistance Criterion for Success Method of Assessment

O th er A ids

auditorv
Wsense

tactile sense

pill organizers

transfer equipment

grab bars

CCTV

Computer assisted device

Tabic 17-2.

Low Vision Goal Writing—Medication

Activity o f Daily Living Type o f Assistance Criterion M ethod o f Assessment

W ill be able to identify Using handheld Independently, or Direct observation

medication m agnifier, gooseneck w ith m inim al or
lamp, CCTV, Rx talking moderate assist
m achine

W ill be able to self- Using a predeterm ined Independently, with Direct observation
ad m inister medication system to insure a specific m inim al or m oderate
pill is m easured, pill assist, and without
organizers any errors

W ill be able to inject Using adaptive techniques Independently Direct observation

medication and aids
 Table 17-3.

Low Vision Goal Writing— Personal Care/Hvgiene

Activity of Daily Living Type o f Assistance Criterion Method o f Assessment

Will be able to put tooth­
paste on a toothbrush
Will be able to take a bath
or shower
Will be able to identify
simulated skin lesion
Will be able to use an elec­
tric razor
Scoop toothpaste from a
jar, squeeze toothpaste in
the hand or in the mouth
Transfer equipm ent, grab
bars, contrasting towels,
bath mat
Using mirror, telescope,
handheld m agnifier, CCTV
M agnifying m irror, light­
ed m irror spot lighting,
tactile sense
Independently, with m in- D irect observation
imal or moderate assist
Independently, with m in- Direct observation
imal or moderate assist
Independently (100% Direct observation
accuracy) or w ith assis­
tance (<100% accuracy)
Independently, set up Direct observation
assistance, m inim al,
moderate assistance

Table 17-4.

Low Vision Goal Writing—AppIying^iakc-U.pMaiL.Cm:e-

Activity of Daily Living Type of Assistance Criterion Method of Assessment

Will be able to apply Using m agnifying m ir-
lipstick ror, lighted m irror spot
lighting
Will be able to care Using m agnifying nail
for nails clippers, CCTV, spot
lighting
Will be able to apply Using m agnifying m ir­
skin products ror, lighted mirror, spot
lighting, adaptive tech­
niques
Independently, w ith no more Direct observation
than 1 deviation from the lips
Independently w ith no errors, Direct observation
with m inim al or moderate
assist
Independently, w ith set up Direct observation
assistance, m inim al assist
 Table 17-5.

Low Vision Goal Writing— Hair Care

Activity o f Daily Living Type o f Assistance Criterion Method of Assessment

Will be able to part Using m agnifying m ir­ Independently, with m ini­ Direct observation
and com b hair ror, lighted mirror, spot mal assist to part hair
lighting
W ill be able to m ea­ Using tactile sense Independently, with m ini­ Direct observation
sure sham poo and mal or moderate assist
conditioner
Will be able to m ain­ Using tactile sense Independently Direct observation
tain a hairpiece

ТЖГТт^Г
Low Vision Goal Writing— Clothing Management
Activity o f Daily Living Type o f Assistance Criterion Method o f Assessment

W ill be able to identify Using tactile sense and Independently Direct observation
clothing and accessories identifying beads, but­
tons, labels, clothing ID,
etc
W ill be able to clean Using tactile sense Independently, w ith m ini­ D irect observation
and/or polish shoes mal or moderate assist
W ill be able to sort Using tactile sense and Independently/ set up Direct observation
clothing for the laundry adaptive identifiers assistance

Table 17-7.

Low Vision Goal W riting— Eating

Activity o f Daily Living Type of Assistance Criterion Method of Assessment

Will be able to locate
item s on the table or on
the plate
Will be able to use salt,
spices, sugar during eat­
ing
W ill be able to cut, and
scoop foods
Using the locating tech­
nique
Using adaptive tech­
niques
Using the "clock" model,
scoop plates, plate guards
Independently or with Direct observation
m inim al or moderate
cueing
Independently, m inim al Direct observation
cueing
Independently, w ith set Direct observation
up assistance

Low Vision Goal Writing—Home Management
Activity o f Daily Living
Will be able to set the stove
or oven controls
W ill be able to m ake a bed
W ill be able to use the tele­
vision
itM-Vision Goal Writing—Food Preparation
Activity o f Daily Living
Will be able to pour cold
liquids into a cup
W ill be able to slice a
piece of bread and but­
ter it
W ill be able to m easure
liquids
Table 17-8.
Type of Assistance
Using "bu m p " dots, hi-
marks
Using tactile sense, safety
pin technique
Using telescope, reducing
the distance, voice descrip­
tion, "bu m p " dots
Table 17-9.
Type o f Assistance
Using a liquid level indi­
cator, ping pong ball, fin­
ger technique
Using an adapted knife,
low vision cutting board,
"spreading" technique
Using low vision m ea­
suring utensils, adaptive
techniques
Criterion Method of Assessment
Independently, with D irect observation
m inim al, moderate
assist
Independently, m inim al D irect observation
or moderate assist
Independently, m inim al, D irect observation
moderate assistance
Criterion Method of Assessment
Independently, set up assis­ D irect observation
tance
Independently, set up assis­ Direct observation
tance
Independently, set up assis­ Direct observation
tance, m inim al, moderate
assistance
 Appendices

• Activities of Daily Living Assessm ent and Treatm ent Plan

• O ptim izing Lighting for Low Vision
• Sighted Guide Techniques
• Teaching Com pensatory Scanning for Field Cuts or Unilateral Visual Inattention
• Low Vision Rehab Brochure
• Occupational Therapists and Low Vision Rehabilitation
• P r a c tic e S e n te n c e s
 A ctivities o f D aily L iving A ssessm ent a n d T reatment P lan

C licnt:___________________________________________________________ D O B :___ /___ /___ Date: _ / ______/ _

A d d ress_________________________________________________________ C ity _____________ State_____ Zip_____
T elep h one:________________________ Referring P h y sician :______________________________________________
Visual Acuity: Right Eye_____________Visual Acuity: Left Eve_____________
Eye D isease D ia g n o sis:_________________________________________________________________________

OT Evaluation of Visual Status if Not Available from Physician

VA (D istance) OD: VA (Distance) OS: VA (Distance) OU:

Feinbloom Chart Feinbloom Chart Feinbloom Chart

VA (Near) O D :______ VA (Near) OS: VA (Near) OU:

Reading S p e e d ____ Reading Speed Reading Speed
M NRead C hart MNRead Chart MNRead Chart

M A RS Contrast Sensitivity
Test (OU)
Eccentric V iew ing Evaluation: Eccentric Viewing Evaluation: Right
Right Eye Eve
Evaluation of Scotom a Evaluation of Scotom a (Clockface or
(C lockface or Tangent Screen) Tangent Screen) O S
OD

Veterans Affairs Lovv-Vision Visual Functioning Q uestionnaire

(VA LV V F Q - 4 8 ) : ____________

Background Information
How long have you experienced trouble s e e in g ? ____________
W hat is most difficult to s e e ? _______________________________
Have you ever had a low vision evaluation? Y / N
W h e n :_______________________________________ W h e re :______
Do you use any m agnifiers or special glasses? Y / N
W ho gave them to y o u ? __________________________________
Any previous vision rehabilitation services? Y / N Describe.

Any previous Home H ealth Therapy?_________________________________________________________

Other Health Issues

__H earing l o s s ___H earing Aid __ Diabetes __Dialysis __ Stroke __Hypertension __ Angina
__Cardiac problems „ A r t h r i t i s __Respiratory
M ed ication s:_________________________________________________________________________________
Sensorimotor/Cognitive Function
А КОМ UK: AROM LE Sensation: Problem Solving:
PROM UE: PROM LE Initiation: Awareness:
Strength UE: Strength LE O rganization: O rientation:
Further Cognitive Evaluation Indicated?

Living Situation
M em bers of household and relationship to y o u :_________________________
How do you currently spend your tim e ? _________________________________
How did you spend it before your vision lo s s ? ___________________________
W hat activities are the most difficult for you since your vision decreased?

Do vou receive assistance from anvone?

Food Preparation and Shopping

W hat food preparation do you do n o w ?________________________________
W hat foods did you prepare before your vision lo s s ? ___________________
Do you do your ow n grocery shopping? Y/N Sm all trips Full list
D escribe assistance received w ith sh o p p in g ____________________________
D o you have any difficulty com pleting the following tasks?
D escribe any food preparation d ifficu ltie s:_____________________________

Cooking and Appliance Use

A ppliances used in cooking: Stove Oven M icrowave Toaster oven Broiler
O th e r:_______________________________________________________________________________
Do you have any problem s cooking? Y/N
V isu a l_______________________________________________________________________
P h y sical_____________________________________________________________________

Table Techniques
O nce food is prepared, do you have any difficulty finding food on the plate?
Do you have any difficulty when eating o u t? _______________________________

Would you lik e to review any of th e follow in g table tech n iqu es?
Locating technique Y/N
Identifying the contents of a plate of food Y/N
Cutting food with a knife and fork Y/N
Scooping food with a fork Y/N
Seasoning food Y/N
C arrying containers of food and liquids Y/N
Buffer technique Y/N
O th e r:______________________________________________

Communications
Do you have any problem:
Signing your name? Y/N M eth o d :______
Reading any form of print? Y/N Large Standard
W riting letters? Y/N/NA