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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

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C ontents

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
P reface

The emergence of three separate factors over the postgraduate education. This textbook is designed to
past two decades has vaulted the profession of occu­ provide a practical and clinically oriented guide to
pational therapy into the m ainstream of low vision enable occupational therapists to begin this process of
rehabilitation. These three factors are the high preva­ independent study and reading in order to seize this
lence of vision impairment in the elderly, which is the opportunity and the responsibility of joining the team
fastest growing segment of our population; chronic of professionals that cares for this population.
underfunding and the lack of availability of treatment We have established three objectives for this book.
for the elderly through the current structure called the The first is to present our viewpoint of the role of
"blindness system "; and the inclusion of low vision as occupational therapy in the field of low vision rehabil­
a disability under Medicare Guidelines in the early itation. Low vision rehabilitation is a relatively young,
1990s. Because of these three factors, occupational developing discipline and occupational therapy is the
therapists now have a prim ary role to play in this newest professional addition to this field. A number
field. of other professions have been involved in this area of
In addition, there are four other very strong argu­ care for decades, and the challenge is for occupational
ments for occupational therapy to play a more promi­ therapy to define a role within the established system
nent role in vision rehabilitation. that will augment current service delivery rather than
1. W hile the elderly comprise the majority of factionalize service delivery into competing services.
the low vision population, they are the most In Chapter 1, we present our ideas about various cur­
underserved by existing state, charitable, and rent roles of the occupational therapist regarding low
private programs. Because of the lack of avail­ vision as well as a suggested "ideal" role. We consider
ability of services and treatment through the how these practice settings fit into current service
current system, rehabilitation may be delayed delivery systems as well as the cost-effectiveness of
and these individuals are likelv * to become these roles.
socially isolated, depressed, and dependent. Our second objective for this book is to create a
Involvement of occupational therapists through resource for occupational therapists to independently
the healthcare system provides significantly learn about low vision rehabilitation for the older adult
greater access to low vision rehabilitation for in preparation for providing these services in clinical
the elderlv. practice. W hile there arc several excellent books on
2. Two-thirds of older persons have at least one vision rehabilitation written for other professionals
other chronic condition, in addition to low involved in this field, to our knowledge there is cur­
vision, that lim its their independent func­ rently no stand-alone textbook w ritten specifically for
tioning. Occupational therapists are already occupational therapists on this topic.
prim ary providers for older clients with other O ur third objective is to create a resource that can
chronic conditions. be used by occupational therapists to prepare for
certification exam inations such as that offered by the
3. O ccupational therapists are trained in the
Academy for Certification of Vision Rehabilitation
physical, cognitive, sensory, and psychological
and Education Professionals (ACVREP) and the AOTA
aspects of disability and aging, and therefore,
Specialty Certification in Low Vision.
may be the natural choice to work with older
1'his book was not designed to cover vision reha­
persons whose limitations in daily living are a
bilitation in the pediatric population. We decided that
result of a combination of deficits.
trying to cover both populations in one book would
4. Occupational therapists are more evenly d is­ not do justice to either population. W hile the needs of
tributed throughout the United States than children with vision impairment are significant, occu­
other vision rehabilitation professionals, who pational therapists are much more likelv to be called
tend to be located in larger metropolitan areas. upon to help the elderly population because of the
Low vision services can be more widely dis­ current insurance reimbursement system. Thus, we
seminated through the healthcare delivery chose to devote this book entirelv j to the adult client
+ with vision impairment.
The challenge at this time is for occupational The book is divided into four sections with 17chap­
therapists to achieve competency in this field. This ters, Appendices, and a companion website.
will require a combination of independent study Section I contains six chapters that are designed to
and reading, clinical experience, and in some cases. provide background information about epidemiology.
Mi Preface

history, roles of various professionals, anatom y of the 6. Are low' vision rehabilitation services pro­
eye and visual system , eye d iseases that cause vision vided by occupational therapists covered by
im pairm ent, optics of lenses and m agnification, and M edicare and other insurance?
psychosocial issues related to vision im pairm ent. 7. How do I properly bill insurance for low vision
Section II is devoted to the evaluation of clients with rehabilitation services?
vision im pairm ent. In Chapter 7, Dr. Paul Freem an, a
8. Are optical aids and other devices covered by
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 9. W hat equipment do I need to get started in the
to provide enough inform ation so that occupational field of low vision rehabilitation?
therapists w ill be able to understand the exam ination
process and com m on term inology used in reports Chapter 16 is designed to provide answ ers to these
they are likely to see from eyecare providers. In im portant questions. We also included a short chapter
Chapter 8, we describe our recom m endations for the designed to provide som e guidance about wrriting
occupational therapy low vision evaluation. goals for low' vision rehabilitation.
T h e third and largest section of this book is The book is accom panied by a website that con­
devoted to low vision rehabilitation. In Chapter 9, tains evaluation form s and other docum ents referred
we begin w ith an overview of the entire process and to in the book, plus a list o f m any o f the key
suggest an organized, seven-step treatm ent process. resources about low vision and rehabilitation ser­
Individual chapters are devoted to the use of thera­ vices currently available, including general infor­
peutic activities, m odification of environm ent, the use mation, large-print and audio resources, computer
of nonoptical assistive devices, teaching clients how to technology, com m unity resources, and low vision
use optical devices, incorporating computer technol­ equipm ent vendors.
ogy in low vision rehabilitation, and an entire chapter This book is a collaboration of occupational thera­
on adaptive diabetes self-m anagem ent tools and tech­ pists and optom etrists. Just as collaboration was
niques w ritten by Debra Sokol-McKay, a well-known important for the com pletion o f this book, collabora­
occupational therapist and certified diabetes educator tion betw een these two professions, as well as oph­
w ho w rites and often lectures about this topic. thalm ologists, vision rehabilitation therapists, orien­
The book concludes w ith a section devoted to prac­ tation and m obility specialists, and social workers, is
tical issues and practice m anagem ent. All three of us vital for insuring quality care for clients w ith vision
have had extensive experience presenting workshops im pairm ent. It is our hope that this book w ill become
for occupational therapists about low vision rehabili­ an im portant resource for occupational therapists
tation. D uring these workshops, num erous practical entering this exciting field, w hich the A m erican
questions have been asked about howr to get started in O ccupational Therapy Association has identified as
the field of low vision rehabilitation. Som e of the ques­ one of the top ten em erging fields in occupational
tions that have often been asked include: therapy in the next m illennium .
1. W hat are the educational requirem ents for an We have built a model of practice on a foundation
occupational therapist to provide low vision of evidence, or theory derived from em pirical science.
rehabilitation services? This text will provide the professional w ith a start­
2. Is certification necessary to provide low vision ing point, an evaluation methodology, and tools and
rehabilitation services? procedures that have been shown to be effective. With
accum ulating experience, the professional will chal­
3. How does the occupational therapist interact
lenge our suggestions and assum ptions. Professionals
with other vision rehabilitation professionals?
will continue to search for published peer-reviewed
4. W hat practice opportunities arc available? research on low vision rehabilitation and perform
5. How do I m arket my services as a provider of careful clinical observation to build som ething better,
low vision rehabilitation services? and, finally, tell us about their discoveries.
Section I

Introduction and Background

Epidemiology, History, and Clinical
Model for Low Vision Rehabilitation

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

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 W hile m any studies have used less than 20/40
ates difficulty in com paring one study to another. visual acuity in the better-seeing eye as the criterion
for low vision, from a practical standpoint it is rea­
Prevalence o f Low Vision and sonable for occupational therapists to be interested
in the 20/70 or worse criterion that has been adopted
Blindness in the United States by M edicare carriers. M edicare is the m ain source of
In this section, we review the prevalence and reimbursem ent for low vision rehabilitation for occu­
incidence of low vision and blindness in the United pational therapists and the ICD-9-CM coding system
States. This research is im portant to someone plan­ definition of low vision is worse than 20/60 visual
ning to develop a new low vision service. The planner acuity in the better seeing eye.
com bines these statistics with published census data M assof3 analyzed the data from all five popula­
to estim ate the potential need for services in a given tion-based studies of vision im pairm ent in the United
area. Prevalence refers to the current num ber of people States. He used the 20/70 or worse criterion as the
suffering from an illness in a given year. This num ber definition of low vision along with the 2000 census
includes all those who may have been diagnosed in data. Based on these param eters, he estim ated that
prior years, as well as in the current year. For example, 1.275.000 whites and 230,000 blacks over age 45 have
if the prevalence of a disease is 80,000, it m eans that low vision. Looking only at the M edicare eligible
there are 80,000 people living in the United States with population (65 years and older), he estim ates that
this illness. 1.120.000 whites and 135,000 blacks have low vision.
Incidence refers to the frequency of development It is im portant to note that even these num bers are
of a new illness in a population in a certain period of an overestim ation because they include many poten­
time, norm ally 1 year. W hen we say that the incidence tially correctable cases of cataract (about 15% to 20%).
of a disease has increased in past years, we mean that Although these prevalence rates are certainly sign ifi­
more people have developed this condition year after cant, they are only about one-tenth the num ber cited
year, eg, the incidence of thyroid cancer has been ris­ by other authors.2'12
ing, w ith 13,000 new cases diagnosed this year.
The most up-to-date estim ates of the prevalence than 80 years made up only 7.7% o f the population but
of visual im pairm ent in the United States were pub­ accounted for 69% o f the severe visual im pairm ent.13
lished by the Eye D iseases Prevalence Research Group It is this group that is the fastest-grow ing segm ent of
in 2004.13 Because of the difficulty and expense of the US population. Prevalence and incidence clearly
im plem enting an appropriate sam pling schem e, few depend on ethnicity, age, and socioeconom ic vari­
population-based studies of a national scope have ables. Som eone planning to develop services should
been carried out in the United States to estim ate the look to the most recent published research and census
prevalence of visual im pairm ent.13 To m eet this need data to develop m ore precise estim ates o f need by
for prevalence data, principal investigators from eight considering age and ethnic and socioeconom ic com ­
population-based vision studies agreed to standard­ position of the region being studied.
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 L e a d in g C auses o f V isual
calculated based on eight different studies. These
estim ates were then applied to the population of the I m p a ir m e n t in the U nited
United States as reported in the 2000 census to esti­
mate the num ber of visually impaired persons nation­ States
ally. Projections of prevalence in 2020 were also made
based on census projections for the US population in The leading cause of severe visual im pairm ent
that year. The definition of blindness used was 20/200 am ong w hite A m ericans in 2000 was AMD, which
or worse in the better-seeing eye and for low vision accounted for 54% o f visual im pairm ent w ith cata­
20/40 or worse in the better-seeing eye. ract (9%). Diabetic retinopathy (6%) and glaucom a
Using this approach, the authors found that in (5%) were the next most com m on causes13 (Table 1-2).
2000 there were an estim ated 937,000 blind A m ericans These conditions are described in detail in C hapter 4.
older than age 40, a prevalence of 0.78%. The num ­ The leading causes o f severe visu al im pair­
ber of persons with low vision was estim ated to be ment in black persons were cataract (37%), diabetic
2.4 m illion (1.98% prevalence). This num ber is sig­ retinopathy (26%), glaucom a (7%), and A M D (4%).
nificantly higher than the estim ate from M assof of Among H ispanics, glaucoma w as the most comm on
about 1.5 m illion. The m ain reason for the difference cause (29%), followed by AM D (14%), cataract (14%),
is likely the definition of low vision used in each and diabetic retinopathy (14%).
study. M assof3 used 20/70 or worse in the better-see­ It is surprising that there is such a high prevalence
ing eye as the criterion, versus 20/40 or worse in the of low vision due to cataract, since it is generally a treat­
better-seeing eye used in this recent study. Because able condition. Surgical treatm ent of cataract has been
occupational therapists in the United States function show n to be a very effective procedure. A national
w ithin the healthcare system and depend prim arily study of cataract surgery investigators found that 96%
on M edicare funding for reim bursem ent of low vision of the clients were improved based on Snellen visual
rehabilitation, the lower estim ate is more representa­ acuity and 89% reported improvement and satisfaction
tive o f the need for occupational therapy services for based on a 14-item instrum ent designed to m easure
low vision rehabilitation in the United States. functional im pairm ent. Since cataract surgery is so
successful, it is questionable w hether it should even be
Incidence o f Low Vision an d included as a cause of low vision, because low vision
is defined as a loss of vision that cannot be treated
Blindness w ith lenses or any other m edical/surgical treatment.
The only published incidence data (new cases of There arc, of course, som e situations in which cata­
low vision each year) for the United States are from racts cannot be treated surgically because o f other
the Beaver Dam Eye Study.14 The num ber of new cases coexisting m edical or ocular conditions. In such cases,
of low vision and blindness is greatest for people over cataracts could indeed be a cause of low vision. Evans
the age of 65 years, and based on the Beaver Dam Eye and Rowlands15 reviewed the literature to determ ine
Study data, M assof3 estim ated the incidence to be the prevalence of correctable visual im pairm ent in the
about 250,000 cases per year in 2000 and 500,000 new United Kingdom. Many of their findings apply to the
cases per year in 2025. Lnited States. They reported that betw een 20% to 50%
The prevalence and incidence of low vision in the of older people have undetected reduced vision and
United States are high, and experts predict a large the m ajority of these had correctable vision problem s
increase over the next tw o decades because the preva­ such as refractive error and cataracts. The Baltim ore
lence of low vision increases sharply in persons older Eye Study found that alm ost 70% of people report­
than 65. In the study by Congdon et al, persons older ing low vision based on reduced visual acuity alone

Table 1-2

Causes of Blindness (Visual Acuity <20/2001 bv Race/Ethnicity

Macular Diabetic
Degeneration Cataract Glaucoma Retinopathy Other

W hite Persons 54.4% 8 .7 % 5.4% 6.4% 9.7%

Black Persons 4.4% 36.8% 7.3% 26% 25.6%
H ispanic Persons 14.3% 14.3% 28.6% 14.3% 28.6%

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
P ro fe s s io n s In v o lv e d W it h
C orrectable vision im pairm ent is associated with
poorer general health, living alone, and lower socio­
Low V is io n C a re
econom ic status.15 O ften the therapist becom es the Low vision rehabilitation is a relatively young,
first person to identify correctable im pairm ent and developing discipline and occupational therapy is the
initiate appropriate referral to an ophthalm ologist or newest professional addition to this field. The various
optom etrist. In the m eantim e, when correctable vision professions and their roles are listed in Table 1-3. At
loss is encountered, the therapist needs to have avail­ the end of this chapter, we present our ideas about the
able relatively inexpensive, short-term interventions roles and relationships for these various professions
that enable clients to m aintain their occupations and in the field of low vision rehabilitation.
routines until the underlying problem is corrected.
M ost studies have indicated that AM D is the lead­ O phthalm ologists
ing cause of low vision in developed countries.16'17
The prevalence of A M D in low vision clinics has been O phthalm ologists are physicians who, after gradu­
reported to be betw een 23% and 44% .18 W arren19 ating from medical school, specialize in the diagnosis
reported on her experience as an occupational thera­ and treatm ent of eye disease by com pleting a resi­
pist w orking in a low vision program in an oph­ dency in ophthalmology. M any ophthalm ologists also
thalm ology departm ent. Th irty-seven percent of com plete a fellowship program to further specialize
the clients referred for occupational therapy (low in an area of ophthalmology. A num ber of specialty
vision rehabilitation services) had AMD, 9% diabetic areas exist, including cataract, glaucom a, retina, cor­
retinopathy, 7% glaucom a, 3% neurological problems, nea, pediatric ophthalm ology, and neuro-ophthal­
and 44% had other m iscellaneous conditions. Thus, mology. Considering that the most com m on causes
low vision caused by AM D is the condition that of low vision are retinal and neurological pathology,
occupational therapists will be most likely to treat. the main sources of potential referrals for low vision
Note that because people w ith stroke and resulting rehabilitation are ophthalm ologists specializing in
hem ianopia or oculom otor problem s do not meet the retinal disease and neuro-ophthalm ologists. There is
criteria for low vision, the current estim ates of low no specific subspecialty o f low vision in the profes­
vision associated with neurological problem s likely sion of ophthalmology. Occasionally, ophthalm olo­
are underestim ated. In these cases, the underlying gists specialize in low vision rehabilitation. There are
condition can be still be treated by an occupational currently about 16,000 practicing ophthalm ologists in
therapist using the neurological diagnostic codes. 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

O ptom etrists Low vision exam ination

Treatm ent of refractive error
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 United States. D uring this 4-year program , optom etry
ally involve the use of m edication and surgery. Thus, students learn to diagnose and treat vision and eye
clients often see the ophthalm ologist first because of health problems. Treatment m odalities include the
a perceived significant change in vision. T h e ophthal­ use of eyeglasses, contact lenses, eye drops and other
m ologist attem pts to restore norm al visual function m edication, vision therapy, and low vision rehabilita­
by treating the eye disease. In som e cases this fails, tion. After graduating from optom etry school, som e
or in other cases the vision can never be restored to optom etrists com plete residency program s in special­
norm al and the client is now faced with perm anent ty areas such as low vision, vision therapy, pediatrics,
low vision. It is at this point that the ophthalm ologist contact lenses, and prim ary care optometry.
should refer the client with low vision to other profes­ Trying to locate a qualified low vision optom etrist
sionals for further evaluation and rehabilitation. for a client can be challenging because the profes­
sion of optom etry does not recognize specialties.
O ptom etrists Therefore, any optom etrist can provide low vision
services, regardless of his or her experience in this
A fter graduating from a 4-year college program ,
area. However, the Am erican Academy of O ptom etry
optom etrists com plete 4 years of additional educa­
Low Vision Section has a Diplomate program for
tion at one of the 17 colleges of optom etry in the
interested optom etrists. To becom e a Diplomate in
Low Vision, an optom etrist m ust pass a w ritten lead more productive, active, and independent lives
test, an oral exam ination, and a practical low vision through a variety o f m ethods, including the use of
exam ination. A s of 2006, there were only about 45 adaptive equipment.
practicing Low Vision Diplomats worldwide. A cur­ O ccupational therapists in m ental-health settings
rent list of optom etrists that have successfully com ­ treat individuals who are m entally ill, developmen­
pleted this process can be found at the website for the tally disabled, or em otionally disturbed. To treat these
A m erican Academy of O ptom etry (www.aaopt.org).20 problems, therapists choose activities that help people
The Am erican O ptom etric A ssociation also has a Low learn to engage in and cope w ith daily life. Activities
Vision Section. Although there is no testing program include tim e m anagem ent skills, budgeting, shop­
required to becom e a m em ber of this section, optom ­ ping, hom cm aking, and the use of public transpor­
etrists who have joined are likely to have a strong tation. O ccupational therapists also may work with
interest in the area of low vision. Som e low vision individuals who are dealing with alcoholism , drug
optom etrists have completed a residency program abuse, depression, eating disorders, or stress-related
and/or a m asters degree in low vision rehabilitation disorders.
while others have chosen to specialize in this area Currently, a bachelor's degree in occupational ther­
and have acquired additional knowledge and clinical apy is the m inim um requirem ent for entry into this
skills through continuing education and independent field. Beginning in 2007, however, a m aster's degree
learning. Currently there are about 36,000 optom ­ or higher will be the m inim um educational require­
etrists in the United States and there are about 1000 ment. All states and the D istrict of Colum bia regu­
m em bers in the Low Vision Section of the American late the practice of occupational therapy. To obtain a
O ptom etric Association. license, applicants must graduate from an accredited
O ptom etrists who specialize in low vision help educational program and pass a national certification
those with vision problems sec better, even if surgery, exam ination. The National Board for Certification in
m edications, and conventional glasses can no longer O ccupational Therapy, Inc. (NBCOT®) is a not-for-
im prove sight. They design and prescribe low vision profit credentialing agency that provides certification
devices (eg, optical, nonoptical, electronic) and make for the occupational therapy profession. Those who
recom m endations about lighting, contrast, and other pass the exam are awarded the title, Occupational
environm ental factors that influ ence vision. Low Therapist Registered (OTR).
vision optom etrists often work along with low vision As of 2006, entrv-level education was offered in
therapists such as occupational therapists, vision about 40 bachelor's degree program s, three postbac­
rehabilitation therapists, and orientation and m obility calaureate certificate program s for students w ith a
specialists who teach clients how to use these assis­ degree other than occupational therapy, and about 85
tive devices in A D L and assist with orientation and entry-level m aster's degree programs.
m obility issues. O ccupational therapists have been peripherally
involved in the rehabilitation of clients w ith low
O ccupational Therapists vision since the early days o f the profession in 1917.19
Their involvement, however, was never as the main
According to the AOTA's Practice Framework, occu­
caregiver for low vision clients. Rather, if a client w ith
pational therapists focus on assisting people to engage
other disabilities also happened to have low vision,
in daily life activities or occupations that they find
the occupational therapist would attempt to take care
m eaningful and purposeful. O ccupational therapists'
of these needs as well. Until recently, low vision reha­
expertise lies in their knowledge of occupation and
bilitation was rarely the prim ary focus of occupational
how engaging in occupations can be used to affect
therapists. This all changed in 1990, when the Health
hum an perform ance and the effects of disease and
Care Finance A dm inistration (HCFA) expanded the
disability.1 O ccupational therapists work with individ­
definition of physical im pairm ent to include low
uals w ho have conditions that are mentally, physically,
vision as a condition that can benefit from rehabilita­
developmentally, or em otionally disabling, including
tion. With this change, physicians could specifically
low vision.
refer clients w ith only low vision to occupational
O ccupational therapists may work exclusively with
therapists for low vision rehabilitation services.19
individuals in a particular age group or with particu­
O ccupational therapists are currently the only
lar disabilities. In schools, for exam ple, they evaluate
therapists among the group described in this chapter
children's abilities, recom mend and provide therapy,
that are licensed and can function independently in
m odify classroom equipment, and help children par­
the M edicare reim bursem ent program . Thus, occupa­
ticipate as fully as possible in school program s and
tional therapists have a unique opportunity to make
activities. O ccupational therapy also is beneficial to
an impact as providers for the older client with low
the elderly population. Therapists help the elderly
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
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 additional continuing education, by passing a certifi­
in addition to the specialized body of knowledge cation exam , and also com pleting supervised clinical
required for teachers of students w ith visual im pair­ training.
m ents.22 TV Is work with blind and visually impaired
infants, children and youth of all ages, including those Social W orkers
with multiple disabilities. They apply low vision and
Social workers help people function optim ally in
blindness adaptive equipment and strategies, and, like
their environm ent, deal w ith their relationships, and
vision rehabilitation therapists, are qualified to teach
solve personal and fam ily problems. Social workers
Braille. TV Is often operate as itinerant teachers, trav­
often see clients who face a life-threatening disease or
eling from school to school to serve children where
a social problem, such as inadequate housing, unem ­
they are located. They serve as the child's prim ary
ployment, a serious illness, a disability, or substance
case m anager in school, and m ay solicit the expertise
abuse. Social workers also assist fam ilies that have
o f additional therapists to develop specific goals and
serious domestic conflicts, som etim es involving child
objectives that com prise the child's Individualized
or spousal abuse. Social workers often provide social
Education Plan (IEP).
services in health-related settings that now a rc gov­
TV Is are prepared in accredited higher education
erned by managed care organizations.
program s recognized by the AER in the United States
In regard to low vision rehabilitation, social work­
and Canada. At present, there are approximately 40
ers provide individual and group counseling and
institutions of higher learning offering special educa­
facilitate consum er access to appropriate com m unity-
tion program s for teacher preparation in the area of
based services, including public assistance program s,
blindness and low vision.22 TV1 program s often rec­
rehabilitation program s, senior centers, hospitals,
ommend or require prior degrees or certification in
and clinics.24 They use self-help techniques to assist
elementary, secondary, or special education. TV Is are
blind and visually impaired adults who m ay be eco ­
certified through their appropriate state’s Departm ent
nomically, physically, mentally, or socially in need of
of Education.
vision-related rehabilitation services.24 Because o f the
significant psychosocial problem s related to vision
Low Vision Therapists im pairm ent, social workers play a key role in the field
In recent years, a more generic term has developed o f vision rehabilitation.
to describe therapists who engage in low vision reha­ Although a bachelor's degree is sufficient for entry
bilitation and have been certified by the ACVREP as into the field, an advanced degree has becom e the
Certified Low Vision Therapists: CLVT. T h is term standard for many positions. A m aster's degree in
is actually trademarked and can only be used by social work (MSVV) is typically required for positions
som eone who has been certified by the ACVREP. An in health settings and is required for clinical work as
individual w ho has been certified as a low vision well. As of 2004, the Council on Social Work Education
therapist by the ACVREP w ill have the initials CLVT (CSW E) accredited 442 BSYV program s and 168 MSVV
after his or her nam e and degree. There are currently program s. All states and the D istrict o f Colum bia have
two university program s that offer a degree in low licensing, certification, or registration requirem ents
vision therapy (Pennsylvania College of O ptom etry regarding social work practice and the use of profes­
and University of Alabam a, Birm ingham ). However, sional titles. Most states require 2 years (3,000 hours) of
the term is also being used in the low vision field to supervised clinical experience for licensure o f clinical
describe any therapist engaged in low vision reha­ social workers. In addition, the National Association
bilitation. To becom e a low vision therapist, one must of Social W orkers (NASW ) offers voluntary creden­
pass a national certification exam ination adm inistered tials. Social workers w ith an MSVV m ay be eligible
by the ACVREP. To be eligible for this exam ination, for the Academy o f Certified Social W orkers (ACSIV),
one m ust possess a bachelor's degree. Thus, a vision the Q ualified Clinical Social Worker (QCSW ), or the
rehabilitation therapist, an O & M , a teacher of the Diplom ate in Clinical Social Work (DCSW ) credential,
visually im paired, an occupational therapist, a physi­ based on their professional experience.
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 H istory of L o w V is io n
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 General H istory
eligible because they are already part of the healthcare
and M edicare system s. Many occupational therapists Eyecare professionals have been treating correct­
also have becom e certified low vision therapists with 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
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
• 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 disciplines.26 As life expectancy continued to increase,
first video m agnification units, were developed. the prevalence of low vision in the elderly popula­
tion grew and fueled the expansion of low vision
1970s to 1990s program s. This era also saw a significant increase in
From the 1970s to the 1990s, the team approach to the quantity and quality of research on low vision.
low vision care gained m om entum as professionals This started with a National Eye Institute initiative in
from various disciplines becam e m ore fam iliar with the mid-1980s and the grow th in low vision research
the philosophies, skills, and techniques of associated 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 for the Blind's National Task Force on General and
the world. Starting with maybe a dozen publications Specialized Services, Working Group on Allied Health
before 1950, the number of publications has doubled Professional Relationships:
every decade to approximately 3700 between 1990 and
2000> Professionals in the vision field are demonstrating
a heightened awareness o f a concern about the
1990s to Present increasing number o f allied health professionals
"The last decade of the twentieth century produced (ie, occupational therapists) who are providing
what is perhaps the greatest change in vision rehabili­ vision-related services that have been traditional­
tation since the 1950s."25 Beginning in the late 1980s, ly administered by trained and certified rehabili­
the federal government dramatically reduced funds tation teachers, teachers of students with visual
for programs that provided services to individuals impairments, O&M specialists, and low vision
who were blind or visually impaired. Subsequently, therapists.37
in 1991 the HCFA, which administered Medicare,
amended its definition of physical impairment to O rr and Huebner go on to state that "the concern
include visual impairment. T h is change allowed of professionals in the vision field is that allied health
M edicare coverage for the first tim e by licensed professionals may not have the specialized knowledge
healthcare providers for low vision rehabilitation with base and skills needed to work with this population
vision loss as the primary diagnosis when prescribed because they have not received university training in
by a physician. This amendment also set the stage for rehabilitation teaching and/or O&M ."37
the involvement of occupational therapy in the field of There have been several failed attempts in which
low vision rehabilitation. legislation has been introduced into the US Congress
This delivery system of low vision rehabilitation to provide Medicare coverage for vision rehabilita­
service is sometimes referred to as the "health care tion professionals other than occupational therapists.
system " in contrast to the blindness system described These efforts are ongoing and at this tim e it is dif­
above. Because M edicare does not recognize vision ficult to predict the results o f these efforts. The topic
rehabilitation therapists or O&M specialists as of Medicare coverage for low vision rehabilitation will
licensed healthcare providers, these professionals are be covered in detail in Chapter 16.
not reimbursed for their services through Medicare.
W hile these changes were certainly welcomed by
occupational therapists, other professionals such as H istory of O ccupational Therapy
rehabilitation therapists, O&M specialists, and low Involvement in Low Vision
vision therapists were concerned about being left out
of this alternative system for providing low vision Rehabilitation
rehabilitation. In addition, some vision rehabilitation The impetus for occupational therapy's involve­
therapists even expressed concern about the abil­ ment in the area of low vision rehabilitation was the
ity o f occupational therapists to provide low vision 1991 amendment by the HCFA that allowed M edicare
rehabilitation care as indicated in the following state­ coverage for the first time for licensed healthcare pro­
ment from a report of the American Foundation viders for low vision rehabilitation. Since that time,
efforts have been made at the national, state, and local O thers have argued that there are a num ber of
levels to enable occupational therapy to play a pri­ im portant reasons why the occupational therapist
mary role in low vision rehabilitation. should play a prim ary role in low vision rehabilita­
M ary Warren has been a strong advocate of occu­ tion.38-43 These reasons arc listed below:
pational therapy involvement in low vision rehabilita­ 1. Although the elderly com prise the m ajority of
tion. She has lead the way w ith significant publica- the low vision population, they are the most
tions,12'19'34'38*40 national leadership,40 presentation underserved by existing state, charitable, and
o f m any continuing education courses, clinical work private program s. Because of the lack o f avail­
as an occupational therapist treating clients w ith low ability of services through the blindness sys­
vision,19 and helping to establish a university-based tem, rehabilitation m ay be delayed and these
training program in low vision rehabilitation for individuals are likelv
•f to becom e socially
occupational therapists at the U niversity of Alabama, ed, depressed, and dependent. Involvement of
Birm ingham . In 1995, she stated "Although occupa­ occupational therapists through the healthcare
tional therapists have been involved in the rehabilita­ system provides significantly greater access to
tion of persons with vision loss since the inception low vision rehabilitation for the elderly.43
of the profession in 1917, we never played an exten­ 2. Two-thirds of older persons have at least one
sive role in low vision rehabilitation."38 Occupational other chronic condition, in addition to low
therapists have indeed always played a role in low vision, that lim its their independent func­
vision rehabilitation because nearly tw o-thirds of tioning. O ccupational therapists are already
older adults w ith low vision have at least one other prim ary providers for older clients w ith other
chronic medical condition that mav у interfere with chronic conditions.38'43 O ccupational thera­
ADL and require occupational therapy.41 Thus, in pists are trained in the physical, cognitive, sen ­
the context of providing care for other chronic condi­ sory, and psychological aspects o f disability
tions, occupational therapists routinely m anage issues and aging, and therefore, m ay be the natural
related to low vision in their elderly clients. choice of professionals to work with older per­
However, with the inclusion of low vision as a d is­ sons w hose lim itations in ADL are a result of a
ability under M edicare guidelines in the early 1990s, com bination of deficits.31*
occupational therapists now have a prim ary role to
3. O ccupational therapists are more evenly d is­
play in this field. This sudden involvement by occupa­
tributed throughout the United States than
tional therapists in low vision rehabilitation has lead
O & M s and vision rehabilitation therapists,
to som e controversy. The prim ary basis for this con­
who tend to be located in larger metropolitan
troversy was a perception that the im petus for occupa­
areas. Low vision services can be m ore widely
tional therapy's entrance into the low vision arena was
dissem inated through the healthcare delivery
not a change in education and preparation of its practi­
system .38
tioners. Rather, it w as purely based on reim bursem ent
issues. Thus, other vision rehabilitation therapists
have raised questions about occupational therapists' O ccupational therapy as a profession, as well as
qualifications, education, and clinical experience in individual therapists, have reacted in a positive way
the area of low vision. For example, Lam bert42 raised to this debate. In the past 15 years, many occupational
the following concerns about occupational therapists: therapists have gained the knowledge base and clin i­
• They m ay be u nfam iliar w ith the various disci­ cal skills necessary to provide excellent care to clients
plines in the field, and thereby fail to appropri­ requiring low vision rehabilitation. This h as been
ately refer clients for other needed services. accomplished through a variety of learning formats,
including independent study, continuing education
• They have inadequate knowledge or specialized
courses, clin ical internships, and university-based
training in low vision.
training. In addition, m any occupational therapists
• C linics may favor occupational therapy in the have completed the sam e national certification pro­
delivery of low vision services even though more gram that other low vision rehabilitation therapists
disability-specific professionals may be the most must complete. T h is certification process is run by
appropriate provider. the ACVREP, which was established in January 2000.
It is an independent and autonom ous legal certifica­
As discussed earlier, sim ilar concerns were raised tion body governed by a volunteer Board of Directors.
by O rr and 1 luebner in 200137 when they expressed ACVRHP's mission is to offer professional certification
their unease about occupational therapists' lack of for vision rehabilitation and education professionals
specialized knowledge base and skills needed to work in order to improve service delivery to persons with
w ith the low vision population. vision im pairm ents. As o f January 2006, there were
approximately 2,100 certified O &M specialists, 600 rehabilitation could not be served within this
certified vision rehabilitation therapists, and 300 cer­ model.
tified low vision therapists. Although ACVREP does 3. Decrease in funding for the blindness system:
not release data on how many occupational therapists There have been significant budget cuts, creat­
arc certified, it is likelv
that many
J of the 300 who are ing funding problems and limited availability
certified low vision therapists arc occupational thera­ of services for the older population.
4. Changes in M edicare: Changes over the past
In 1995, the AOTA devoted its entire October issue
decade in M edicare policy now allow occupa­
to the topic of low vision and in 1998 developed the
tional therapists to provide low vision reha­
Occupational Therapy Practice Guidelines fo r Adults with
bilitation in medical settings such as hospi­
Low Vision. In recent years, the ЛОТА has listed low
tals, outpatient clinics, nursing homes, and in
vision rehabilitation as one of the "10 em erging areas"
client's homes.
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 M assof45 proposed a practice model for standard­
pists and occupational therapy assistants can achieve izing low vision rehabilitation as a healthcare service
specialty certification from the AOTA, indicating that (Table 1-6). He and others have emphasized the sim i­
they have acquired the knowledge and skills to be larities between physical medicine and rehabilitation
specialists in low vision intervention.44 (PM&R) and low vision rehabilitation.45'47
Fifteen years in the history of a profession is a According to Fishburn,47 the aim s o f PM&R are
relatively short time. Yet within this timeframe, occu­ to prevent injury or frailty, m inim ize pathology, pre­
pational therapy has made dramatic strides toward vent secondary complications, enhance function of
becom ing a prim ary care provider in the area of vision involved systems, and develop compensatory strate­
rehabilitation. With the need for these services grow­ gies. She argues that these are essentially the same
ing significantly as the US population grows older, aim s of low vision rehabilitation. In addition, many
there is a need for many more occupational therapists clients now being served w ithin the PM&R system
to become involved in this exciting area of practice. As have low vision as a secondary disability. The primary
occupational therapists become involved, it is critical reason for their rehabilitation might be physical, neu­
to be aware of the history of low vision rehabilitation rologic, or cognitive impairments caused by stroke,
in the United States, the various professions involved, diabetes, brain injury, or demyelinating disease.47
and some of the sensitivities and important political Thus, low vision rehabilitation should be part of
issues described above. 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,
C lin ic a l M o d el
it is also important to review the WHO vocabulary
defining impairment and disability. In 1980, the WHO
Although the blindness system or educational
proposed four term s that should be used when defin­
model ot low vision rehabilitation has been the domi­
ing impairment and disability.5 This terminology is
nant system since the 1950s, the four factors listed
illustrated in Figure 1-1.
below challenge the continued viability of this model
• A disorder is an anatomical deviation from nor­
o f care.
mal and can be congenital or acquired. Examples
1. Growing demand for low vision services: The
of visual disorders causing low vision are AMD,
demand for low vision services is expcctcd to
diabetic retinopathy, glaucoma, and cataract.
grow rapidly in the next decade. The popu­
lation of the United States is aging and the • Impairment is a loss or abnorm ality in function.
prevalence of eye disease that causes low The impnirment can be cither physiological
vision is greatest in people 65 years of age and or psychological. Visual im pairm ents include
older. More therapists are needed to meet this decreased visual acuitv, m reduced contrast sensi*
demand. tivity, central scotom as (blind spots in the center
of the visual field), and constricted visual fields.
2. Poor distribution of vision rehabilitation pro­
viders: Vision rehabilitation therapists and • Disability refers to a restriction or an inability to
O&M specialists are not well distributed perform a task in the normal way. Examples are
throughout the country. They tend to be locat­ difficulty reading newspaper print, recognizing
ed in larger metropolitan areas. As a result, faces, and driving a car.
large num bers of people requiring low vision
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

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

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
Eye Health Evaluation
Magnification Evaluation

• Handicap is a disadvantage that prevents or Although the scenario described above represents
lim its the fulfillm ent of a role that is normal for current thinking about the interaction between the
the client. Examples are the inability to work or optometrist and occupational therapist, we suggest
engage in hobbies, and restricted social interac­ that to provide optimal care for clients, the ideal work­
tions. ing relationship could be modified as detailed in the
section below.
In the model presented below, the ophthalmologist
and optom etrist are prim arily interested in the disor­ Role of the Occupational Therapist
der and impairment, while the occupational therapist The role of the occupational therapist is to deter­
m anages the disability and handicap, although there mine the cognitive, psychosocial, and physical needs
may be overlap in some areas. of the client to resum e m eaningful roles, routines, and
occupation. The occupational therapist perform s a
Role of the Ophthalmologist comprehensive evaluation o f the client's performance
The role of the ophthalmologist is to diagnose and areas such as ADL and instrum ental activities of
treat the eye disease. This might involve the use of daily living (IADL), education, work, play, leisure, and
medication or surgery. W hen it is clear that vision has social participation.1 According to the AOTA Practice
been permanently impaired due to the eye disease, Framework, ADL refers to activities that are oriented
the ophthalmologist refers the patient to a low vision toward taking care of one's own body, such as: bath­
optom etrist for evaluation and treatment. ing, bowel and bladder management, dressing, eating,
feeding, functional mobility, personal device care,
Role of the Low Vision Optometrist and personal hygiene.1 IADL refers to activities that
are oriented toward interacting with the environment
The optometric low vision exam ination is described and are generally optional in nature, such as: care
in detail in Chapter 7. The evaluation includes the of others, child rearing, comm unication device use,
components listed in Table 1-7. com m unity mobility, financial management, health
The role of the optometrist is to evaluate the patient management, and meal preparation.1 The occupation­
and determ ine whether a change in the traditional al therapy low vision evaluation includes review of
eyeglass proscription might be of benefit. The o p t o m ­ the reports from the ophthalm ologist and low vision
etrist also perform s a detailed evaluation of distance optometrist, and further evaluation of the im pairm ent
and near visual acuity, contrast sensitivity, assessment as needed to identify what client and environmental
of central scotomas, and peripheral visual field. Based factors might limit performance. This evaluation is
on the results of this evaluation and the case historv, described in detail in Chapter 8.
the optometrist begins the process of determ ining the Based on the results of the optometric low vision
m agnification needs of the client for various ADL and evaluation and the occupational therapy evaluation,
selects and prescribes appropriate low vision opti­ the therapist designs a vision rehabilitation treatment
cal aids. The optometrist then refers the client to the program to enable the client to achieve the established
occupational therapist for training in the use of the performance goals. The rehabilitation program should
prescribed devices for various ADL.
include education about the functional implications would convey this inform ation to the optom etrist,
o f visual im pairm ent, m anagem ent of psychosocial who would then determ ine and w rite the final pre­
issues, referral to com m unity resources, teaching scription. O f course, to be effective this would have
the client visual scan n in g skills that optim ize the to be an ongoing and interactive process in w hich the
use o f rem aining vision, the use of both optical and optom etrist and occupational therapist work together
nonoptical assistive devices in ADI., and environm en­ to determ ine the appropriate optical devices for a cli­
tal m odifications including m anagem ent of lighting, ent. Under either model, ultimately, the optom etrist
contrast, and glare. In most states, a physician must would prescribe all recom m ended optical devices.
approve and periodically review the occupational The prim ary support for this model is that occu­
therapy treatm ent plan. The physician approving the pational therapists routinely observe their clients
plan should be a low vision optom etrist even in states engaged in various occupations and ADL. T h is creates
in which approval is not required. Effective low vision an ideal situation to help determ ine the type o f device
rehabilitation requires the specialized expertise of a and m agnification that will work best for the client in
low vision optom etrist because rehabilitation requires the ADL most im portant to the client. In every other
integrated m anagem ent of the visual effects of the area of practice, occupational therapists routinely
disease, refractive error, and the optical dem ands of a include m easurem ent of physical function as part of
task. The occupational therapist will need to refer the the evaluation. W hen an occupational therapist with
clicnt back to the low vision optom etrist if it becom es advanced training in low vision rehabilitation works
apparent that the prescribed optical devices are not as with a low vision optom etrist, an occasion may present
effective as desired. O ther potential referrals include in which the occupational therapist m ay be asked to
orientation and m obility and social work. m easure acuity, visual fields, and contrast sensitivity.
An im portant issue is how the occupational thera­ O ptom etrists, w ith their specialized understanding
pist interacts w ith eyecare providers. In the sections of optics, refractive error, and the functional effects
above, we described a typical model where the oph­ of disease and progression of disease, must insure
thalm ologist will generally refer the client to a low that all optical device options are considered and that
vision optom etrist for further evaluation and treat­ the optical devices and prescribed eyeglasses work
ment. Then the optom etrist refers to the occupational together. This model highlights the strengths o f each
therapist. There are exceptions to this standard of profession and allow s both the occupational therapist
practice. W hen an ophthalm ologist has advanced and low vision optom etrist to provide com plem en­
training in low vision, a direct referral might be made tary and essential com ponents of the rehabilitation
to the occupational therapist, along w ith collabora­ process. T h is model would also be a cost-effective col­
tion with the occupational therapist in evaluation and laboration, with the occupational therapist perform ­
treatm ent of the visual im pairm ent. Many occupa­ ing many of the tim e-consum ing procedures typically
tional therapists practice in educational, home care, required in a low vision evaluation, thereby decreas­
or other settings in w hich a low vision optom etrist ing the tim e required by the eyecare provider.
is not physically present. In these settings, eyecare
providers not specializing in low vision rehabilitation
or other physicians may refer clients directly to the Su m m a r y
occupational therapist. In such cases, we propose that
follow ing the initial occupational therapy evaluation, This chapter w as designed to establish the im por­
the occupational therapist refers the patient to a low tance of low vision rehabilitation for the practice of
vision optom etrist before implementation of the treat­ occupational therapy and to review the definitions,
ment plan. epidemiology and history o f low vision and low
However, it is our belief that an alternative model vision rehabilitation in the United States. W e also pre­
should be considered. We believe that the ideal prac­ sented a model of clinical care w ith suggested roles
tice situation would be for an occupational therapist for the various professions involved w ith low vision
to play a role in the final determ ination of the appro­ rehabilitation.
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
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by age-related macular degeneration: results of treatments in a 37. Orr AL, Huebner K. Toward a collaborative working relationship
phase 1 and 2 study. Arch Ophthalmol. 1999;117:1177-M87. among vision rehabilitation and allied health professionals. / Vis
17. Schwartz SD. Age-related imculopathy and age-related macular Imp Blind. 2001;95(8):468-482.
degeneration. In: Silverstone B, Lang MA. Rosenthal B. Faye EE, 38. Warren M. Including occupational therapy in low vision reha­
eds. The Lighthouse I landbook on Vision Impairment and Vision bilitation. Am / Occup Ther. 1995;49(9):857-860.
Rehabilitation. New Yurk: Oxford University Press; 2000, 39. Warren M. Low Vision: Occupational Therapy Intervention
18. Lovle-Kitchin J, Bowman KJ. Senile Macular Degeneration: with the Older Adult. Bethesda, MD: American Occupational
Management and Rehabilitation. Boston, MA: Butterworth; Therapy Association; 2000.
1985. 40. Warren M. Occupational therapy practice guidelines for adults
19. Warren M. Providing low vision rehabilitation services with with low vision. In: Lioberman D. Ed. The AOTA Practice
occupational therapy and ophthalmology: a program descrip­ Guidelines Series. Bethesda, M D: American Occupational
tion. Am J O ccup Ther. 1995:49(91:877 88.3. Therapy A s s o c ia tio n ; 2 0 0 1 :1 -2 5 .
20. American Academy of Optometry. American Academy o f 41. Elliott DB. Trukolo-llic M. Strong JG, Pace R. Plotkin A, Severs
Optometry Low Vision Section List o f Low Vision Diplomates. P. Demographic characteristics of the vision-disabled elderly.
2005. Invest Ophthalmol Vis Sci. 1997;38:2566-2575.
21. Crews IE, Luxton L. Rehabilitation teaching for older adults. In: 42. Lambert J. Occupational therapists, orientation and mobil­
Orr AA. Ed, Vision and Aging. New York: American Foundation ity specialists and rehabilitation teachers. J Vis Imp Blind.
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22. Duffy MA, Huebner K, Wormsley DP. Activities of daily liv­ 43. McGinty Bachelder J, Harkins D. Do occupational therapists
ing and individuals with low vision. In: Scheiman M, Ed. have a primary role in low vision rehabilitation? Am / Occup
Understanding and Managing Vision Deficits: A Guide for Ther. 1995;49(9):927-930.
Occupational Therapists. Thorofare, NJ: SLACK Incorporated;
2002: 289-304.
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2005;l0(9>:10-15. New York: AFB Press; 2001:61-70.
45. Massof RW, et al. Low vision rehabilitation in (he U.S. health
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4<>. Wainapel SF. Low vision rehabilitation and rehabilitation medi­
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in Low Vision Rehabilitation. New York: AFB Press: 2001:55-

Review of Basic Anatomy,

Physiology, and Development of the
Visual System

junctivitis, com m only called pink eye. Conjunctivitis

B asic A n a t o m y and can be secondary to bacterial, viral, or allergic etiol­
P h y s io l o g y ogy. Infection of the conjunctiva is generally self-lim it-
ing, but occasionally conjunctivitis can lead to inflam ­
T h is chapter is designed to provide a review of the mation of the cornea as well.
basic anatomy and physiology of the visual system. The bulbar conjunctiva covers the w hite portion of
Space lim itations prevent a com prehensive d iscu s­ the eye called the sclera. The sclera is the external coat
sion of this topic. Readers requiring more in-depth of the eye and is a w hite tissue covering the posterior
inform ation about these topics should review the texts five-sixths of the eye. The anterior one-sixth of the
listed in the Bibliography of this chapter. outer coat of the eye is the transparent structure called
the cornea (Figure 2-2). The cornea is an extrem ely
O rbit, Eyelids, and Eyeball im portant structure of the eye because it is the key
optical component responsible for refraction of light
A traditional method of describing the anatomy of that enters the eye. It is an unusual tissue because
the eye is to begin with the outerm ost structures and it is clear and has no blood vessels. T h e cornea is
move inward. The orbit of the eye, which is a bony susceptible to infection from bacterial, viral, fungal,
recess in the skull, contains a num ber of major struc­ or allergic causes, and inflam m ation of the cornea is
tures, including the eyeball, the optic nerve, the m us­ referred to as keratitis. Severe inflam m ation, a corneal
cles o f the eye, and their nerves and blood vessels. The burn due to exposure to toxic substances, or traum a to
eyeball, w hich is about 2.5 cm long, is suspended in the cornea can all lead to scarring and loss o f trans­
the orbital cavity in such a way that the six extraocular parency of the cornea. T h is can then lead to a loss of
m uscles can move it in all directions. vision if the scarring is located in the central portion
The eyelids protect the eyes from injury and exces­ of the cornea. Reduced visual acuitv secondary
у * to
sive light and keep the cornea moist. As illustrated in central corneal scarring is a condition that may be
Figure 2-1, the upper eyelid partially covers the iris, encountered by occupational therapists in clients who
whereas the entire inferior half of the eve is normally have experienced head trauma. O ther com m on age-
uncovered. The eyelids are covered internally by the related problem s of the anterior part of the eye that
highly vascular palpebral conjunctiva. The palpebral affect vision and cause discom fort include blepharitis
conjunctiva continues onto the eyeball and is called (chronic inflam m ation of the lids) and dry eye. These
the bulbar conjunctiva. Inflam m ation of either the can be m anaged m edically but with varying success.
bulbar or palpebral conjunctiva is referred to as con­
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
outer coat of the eye is the trans­
parent structure called the cornea
(Steinman). Retina


O ptic Nerve

D irectly behind the cornea is a clear, watery fluid

V itreous
called the aqueous humor, w hich is produced in the
posterior cham ber and fills the anterior cham ber of The vitreous body is located behind the lens (see
the eye (Figure 2-3). The aqueous is continuously pro­ Figure 2-3). It consists of a jelly-like substance called
duced by the ciliary body and provides nutrients for vitreous humor, in w hich there is a m eshwork o f col­
the avascular cornea and lens. A fter passing through lagen fibrils. Vitreous humor is a colorless, transpar­
the pupil from the posterior cham ber into the anterior ent gel. It consists of 99% w ater and form s four-fifths
cham ber, the aqueous is drained off through canal of of the eyeball. In addition to transm itting light, it
Schlem m (Figure 2-3). holds the retina in place and provides support for the
lens. Unlike the aqueous humor, it is not continuously
Lens replaced.

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 T h e eyeball has three concentric coats. The first or
humor. Like the cornea, the lens is both transparent outerm ost coat, the sclera, was described above. The
and avascular and is another key part of the refractive middle coat is a heavily pigmented, vascular layer
system o f the eye. To accom m odate or focus on objects, consisting of the iris, ciliary body, and the choroid.
the lens m ust change shape. The ciliary m uscle con­ The iris, w hich is the colored portion of the eye (Figure
tracts, and this allow s the lens to thicken, enabling 2-4), is located between the cornea and the lens. The
the individual to focus. As an object moves away, the eye color depends on the am ount and distribution of
ciliary m uscle relaxes, the lens becom es thinner, and pigment in the iris. The iris is a contractile diaphragm
the focusing system relaxes. The lens of the eye is the that has a central, circular aperture for transm itting
structure that gradually loses its transparency as a light called the pupil. The size o f the iris continually
person ages. T h is loss of transparency and develop­ varies to regulate the am ount of light entering the eye
ment of opacities is referred to as cataracts. through the pupil. The ciliary body lies betw een the
Ciliary Muscle

Z o n u le s


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 ments, called saccades, arc both designed to allow the
secretes aqueous humor. The ciliary body also con­ individual to use the fovea.
tains the ciliary muscle, which can contract or relax T h e retina is com posed of 10 layers, including the
to perm it accom m odation or focusing of the eye. The pigmented epithelium , which is closest to the choroid
choroid is a dark brown m em brane and is also part and the photoreceptors (cones and rods).
of this m iddle coat of the eye. It continues from the Beneath the pigmented epithelium of the retina
ciliary body and covers the entire posterior portion of are these four layers (Figure 2-6) from the outside
the eye. The choroid attaches firm ly to the retina and (furthest from the retina) to the inside (closest to the
contains the venous plexus and layers of capillaries retina):
that are responsible for nutrition of the retina. 1. Sclera (white part of the eye)
2. Large choroidal blood vessels
Retina 3. Choriocapillaris
The most internal coat of the eye is the retina, 4. Bruch's mem brane (separates the pigmented
which is a thin, delicate membrane. T h e retina is the epithelium of the retina from the choroid).
posterior portion of the eye and there is a circular
depressed area called the optic disc (Figure 2-5). This
Note that light must pass through all layers of the
is where the optic nerve enters the eye and its fibers
retina to reach the photoreceptors, where the visual
spread out in the neural layer of the retina. Because it
process begins. D iseases such as m acular degenera­
contains nerve fibers and no photoreceptor cells, the
tion or diabetic retinopathy that affect the clarity of
optic disc is insensitive to light. For this reason, it is
retina, or sw elling that affects the shape of the retina,
som etim es referred to as the blind spot. A nother very
w ill have a profound effect on vision.
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
Photoreceptors (Cones and Rods)
we look at an object, we m ust aim the eye so that the Light causes a chem ical reaction in cones and in
im age of the object is focused on the fovea. Smooth rods, beginning the visual process. Activated photore­
eye movements, called pursuits, and jum p eye m ove­ ceptors stim ulate bipolar cells, w hich in turn stim ulate
Blood Vessels
Nerve Fiber Layer
Ganglion Cen Layer

Innef Plexiform Layer

Inner Nuclear Layer

[ Outer Ploxilorm Layer

Outer Nuclear Layer

Fovea Photoreceptor Outer Segments

M acula Retinal Pigment Epitnetium

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 Figure 2-6. Ten layers of the retina (Steinm an).
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 involved would be the right inferior rectus and the left
o f the ganglion cells, through the optic nerve, and to superior oblique. The left superior oblique moves the
the visual cortex at the occipital lobe of the brain. left eye down and to the right and the right inferior
There are about 6.5 to 7 m illion cones in each eye, rectus moves the right eye down and to the right. To
and they are sensitive to bright light and to color. The determ ine which of the two rem aining m uscles is at
highest concentration of cones is in the macular. The fault requires additional clinical testing.
center of the m acular contains onlv* cones and no rods. Three cranial nerves supply innervation to the six
The highest concentration of rods is in the peripheral extraocular muscles. The third cranial nerve inner­
retina, decreasing in density up to the macular. Kods vates the superior, inferior, m edial recti, and the infe­
are used for night vision and do not detect color, rior oblique muscle. The fourth cranial nerve supplies
which is the m ain reason it is difficult to tell the color innervation to the superior oblique, and the sixth
o f an object at night or in the dark. Defective or d am ­ cranial nerve innervates the lateral rectus.
aged cones results in color deficiency. Defective or Diplopia, or double vision, is a very com m on
dam aged rods result in problem s seeing in the dark symptom of clients treated by occupational therapists,
and at night. particularly after cerebrovascular accident or head
trauma. Diplopia occurs when the object at which
Muscles of the O rbit and Their the individual is looking stim ulates the fovea of one
eye and a nonfoveal part of the retina of the other
Innervation eye. Thus, diplopia suggests m isalignm ent of the
Six extraocular m uscles attach to each eve and eyes. There are a num ber of disorders that can lead
allow m ovem ent in all directions of gaze. There are to diplopia. Brain injury from stroke or traum a that
four rectus m uscles— the superior, inferior, lateral, affect the midbrain or cerebellum area often affect
and medial recti m uscles— and two oblique muscles both balance and eye movements. Among the more
called the inferior and superior oblique muscles. com m on problem s are cranial nerve palsies. The most
Each of the six m uscles has one position of gaze com m on nerve palsies seen by occupational therapists
in which it exerts the main influence on eye position. are sixth and fourth nerve palsies.
Figure 2-7 illustrates the various positions of gaze that The m ost com m on causes of fourth nerve palsy
are evaluated clinically. The diagram also displays are head traum a and vascular problems. Fourth cra­
the m uscle that is prim arily responsible for movement nial nerve palsy can be unilateral or bilateral and can
into each position of gaze. T h is diagram is the basis affect the superior oblique muscle. Bilateral fourth
for the clinical evaluation of eye m uscle problems. nerve palsy is often seen follow ing vertex blow s to the
For exam ple, if a client has difficulty moving his head, such as those that occu r in m otorcycle accidents.
eyes down and to the right, the two possible muscles The presence of a fourth nerve palsy causes the eye
Figure 2-7. Positions
o f gaze that are evalu­
ated by clinicians when
testing the extraocular


with the affected muscle to drift upward. The client temporal half of the retina of the left eye. Similarly,
has difficulty looking down and to the right if it is a visual information from the left field strikes the nasal
left superior oblique problem, and down and to the half of the retina of the left eve and the temporal half
left if it is a right superior oblique problem. of the retina of the right eye (Figure 2-8). When the
Sixth cranial nerve palsies are the most frequently fibers from each optic nerve reach the optic chiasm , a
reported ocular motor nerve palsies. The nerve has semi-decussation or partial crossing takes place. The
the longest intracranial course of any nerve and is fibers from the temporal part of the retina rem ain on
often subject to damage with raised intracranial pres­ the temporal or outside aspect of the chiasm and are
sure. The causes include vascular disease, trauma, called uncrossed fibers. The nasal fibers of the retina
elevated intracranial pressure, and neoplasm. The cross over in the chiasm and arc called crossed fibers.
sixth nerve innervates the lateral rectus. A sixth nerve After leaving the chiasm , the fibers form the optic
palsy will interfere with the client's ability to abduct tract. Thus, all visual information originating from
the eye (move the eye away from the nose). the right field travels in the left optic tract, and all
visual inform ation originating from the left field trav­
Visual Pathways els in the right optic tract. The fibers in the upper half
of the tract originate from the upper half of the two
One of the most common vision problems occu­
retinas, and the fibers from the lower half of the tract
pational therapists encounter after acquired brain
com e from the lower half of the two retinas. The fibers
injury is visual field deficits. A right or left field loss
from the optic tract synapse in the lateral geniculate
is referred to as an homonymous hemianopsia. To
body. The cells of the lateral geniculate body give rise
understand why a client would lose vision on just
to new fibers, which form the optic radiation. These
one side, it is necessary to understand how visual
fibers then proceed to the cells of the visual cortex
information travels from the retina to the visual cor­
(Figure 2-9). Any lesion that affects the visual pathway
tex. Vision begins with the capture of images focused
on only the right or left side after this decussation
by the optical media on photoreceptors of the retina.
takes place will affect either the left visual field or
The fibers from the upper half of each retina enter the
right visual field.
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
Vision Areas of the Brain
erally in the optic nerve, and fibers from the fovea lie The brain is divided into several different lobes.
centrally. This arrangement persists throughout the Starting anteriorly are the frontal lobes, which are
entire course of the visual pathways from the optic responsible for decision m aking, planning ahead,
nerve through the chiasm, the optic tracts, and optic emotional tone, abstract thinking and carrying out
radiations. intentions. Immediately behind them and in front
Visual information from the right field strikes of the motor area is the prefrontal cortex, which
the nasal half of the retina of the right eye and the is involved in organizing and sequencing complex
Figure 2-8. The right visual cortex
receives information from the left Optic Radiations
visual field and the left visual cor­ LGN
tex receives information from the
right visual field.


Figure 2-9. V isual pathw ay from

the optic nerve to the visual cor­
O ptic Radiations

O ptic Chiasm

O ptic Nerve

motor behavior. The temporal lobes are associated to be the prim ary visuosensory area in man. Outside
with hearing and also provide som e contribution to of area 17 and closely follow ing its contours are two
vision. The parietal lobes are responsible for tactile other areas that are concerned with visual reactions
recognition. Parietal lobe injury com m only results as well. These are called areas 18 and 19. M ost physi­
in perceptual deficits that disrupt am bulation and ologists agree that vision is a function of higher parts
self-care activities. H em i-sensory neglect is a com ­ of the brain than just the visual cortex. The message
mon problem in clients with a lesion in the posterior relayed to area 17 enables a person to see. It docs not
parietal cortex. enable a person to recognize what he or she sees or to
The occipital lobe contains the visual cortex, with recall things that have been seen. These functions are
nerve pathw ays leading to higher centers in the dependent on other parts o f the brain. In order for a
parietal and temporal lobes, w here visual sensations person to be able to interpret the sensory inform ation
acquire m eaning. Lesions in the visual cortex and in reaching area 17, the m essage must be sent on to the
associated areas can produce visual and perceptual two secondary'«/ visual areas and areas 18 and 19. Area
problem s. 18 is concerned exclusively w ith the recognition of
A ll of the visual fibers end in the striate area of the objects, anim ate or inanim ate, but is not concerned
cortex, w hich is called area 17. Area 17 is considered 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
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

seen at 20 feet. The client in our exam ple could only

V is u al A c u it y 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
Definition the United States and the units in feet are referred to
Visual acuity is a m easure of the sm allest high-con- as "im perial units". In other countries, in the research
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 m eters rather than feet are used to express distance
the size of the letter or about the stroke width or the visual acuity using the M system described below. For
gap in a C. Most people are fam iliar with the concept example, 6/6 is equivalent to 20/20 acuity (6 m eters is
of 20/20 visual acuity. An individual with "20/20" about 19 feet), 6/60 is equivalent to 20/200 acuity, and
acuitv is considered to have norm al ability to see small 6/30 is equivalent to 20/100 acuity.
detail at the distance tested. The num erator refers to In traditional vision screen ings, visual acuity
the testing distance at w hich the subject recognizes below the level of 20/30 to 20/40 is considered cause
the stim ulus. The denom inator refers to the letter size. for referral. However, clinically, any deviation from
Letter size is described as the distance at w hich the 20/20 is considered a problem, and in the course of
letter being viewed could be identified by a client with the vision evaluation the clinician must determ ine the
norm al visual acuity. Since larger letters can be seen basis for the loss of visual acuity.
further away, a larger num ber in the denom inator The m eaning of 20/20 visual acuity can also be
indicates a larger size letter on the eye chart. For an expressed based on a m athem atical concept. Som eone
exam ple, we will use a client w ith 20/100 acuity. This with 20/20 visual acuity is able to recognize a letter
indicates that he or she was tested at 20 feet and the that subtends a visual angle of 5 m inutes of arc at the
sm allest letter the client could see was large enough so eye (Figure 3-1); the critical detail is 1 m inute o f arc.
that som eone w ith norm al visual acuity could identify As illustrated in Figure 3-1, this m eans that if you
the letter presented at a distance of 100 feet. A letter draw a line from the top of a 20/20 letter to the eye
that could be seen at 100 feet is 5X larger than a letter 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
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
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

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).


F P ■
T О Z з
L P E D *4
«С P E С F D
ас гт
E D F С Z P :4V

• >bV

!» L E F O D P C T
* T D P b T C E O
P X 2 Z O L C T T D IO *V
Figure 3-3. Feinbloom Chart

6 1 5 4 8 2

much higher acuity levels, such as 20/700, 20/800, and the low vision client. In this chapter we w ill review
20/1000. In addition, the chart should have an equal three visual acuity charts that are effective and widely
num ber of letters at each acuity level. W hen only one used.
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 Low V is io n D is ta n c e V is u a l
obtained was accurate and reliable. Current standards
for near and distance acuity charts standardize the A c u it y C h a r ts
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 O riginal D istance Test C h art for
enables more precise and repeatable m easurem ents
and also enables the experienced practitioner to more
the Partially Sighted
easily perform calculations at nonstandard test d is­ T h is chart (Figure 3-3) is often called the Feinbloom
tances and estim ate m agnification. C harts adhering to Distance Test C hart and is widely used and consid­
this standard are referred to as Log charts. ered the gold standard by som e authorities.1 The
A ny therapist who has been involved with low advantage is that the chart has num eric optotypes
vision rehabilitation w ill relate to the follow ing sce­ at the follow ing visual acuity levels: 20/700, 20/600,
nario. A client is referred for low vision rehabilitation 20/400, 20/350, 20/300, 20/225, 20/200, 20/180, 20/160,
with a m edical diagnosis of m acular degeneration. The 20,140, 20/120, 20/100, 20/80, 20/60, 20/40, 20/30,
referral also indicates the best-corrected visual acuity 20/25, 20/20, 20/10.
as: right eye 20/200, left eye: counting fingers. W hat The chart w as calibrated for 20 feet, but is typically
does counting fin gers m ean and how does the therapist used at a 10-foot distance, which m eans the acuity val­
use this inform ation to properly code for Medicare ues listed above would be doubled. T h is m eans that
docum entation and reim bursem ent? Generally, the at a 10-foot distance, the acuity range extends from
term counting fingers m eans that the eye doctor used 20/1400 to 20/20.
the standard projected Snellen chart for the visual Freem an and Jo se1 discuss the advantages o f per­
acuitv exam ination. The client was unable to see even form ing this test at 10 feet and include the following:
the large letter " E " at the top of the chart. The eye doc­ • Doubles the num ber of lines the client can
tor, therefore, held up his hand and waved it, show ing attempt com pared to a standard visual acuity
anyw here from 1 to 5 fingers, and asked the client chart.
"H ow m any fingers do you se e ?" This is obviously • D ecreases the background confusion because
not an appropriate assessm ent of visual acuity and the num bers are not spaced as close together as
indicates that the eye doctor sim ply did not have the w ith a standard visual acuity chart.
proper equipm ent to com plete the exam ination and
• Allows for better lighting and less glare.
did not use an acceptable method for the visual acu­
ity assessm ent. In such cases, the therapist will need • Elicits a m ore positive response than a standard
to repeat visual acuity testing using an appropriate visual acuitv chart.
target and technique described below.
Because of these issues special visual acuity eye If a client cannot even see the large " 7 " at 10 feet,
charts have been developed. T here are a num ber of the chart can be moved to 5 feet. At this distance, the
excellent visual acuitv ¥ ch arts that are available for acuity range is extended from 20/1400 to 2800 because

ial co rr
each tim e you decrease the distance by half, you The standard test distance is 4 m eters, but for low
double the denominator. vision evaluations the test distance is usually halved
A nother m ajor advantage of this visual acuity chart to 2 m eters to insure that a client can read the largest
is that because of the large visual acuity range that can letters. This also m akes conversion to Snellen equiva­
be assessed, alm ost all clients with low vision will be lent easy. O ne ju st adds a zero to the num erator and
able to read at least som e letters on the visual acuity denom inator. For exam ple, a 2/10 acuity m easurem ent
chart. This is im portant from a psychological stand­ in M units becom es 20/100 in im perial notation.
point. M any clients w ith low vision have had negative
experiences during visual acuity testing (being unable C hronister Pocket A cuity C h art
to even see the large "E "). This can be depressing.
The C hronister Pocket A cuity C hart (CPAC) is
The client feels that there is no hope if he or she could
very sim ilar to the Feinbloom chart (Figure 3-5). It
not sec the eye chart at all. With the Feinbloom chart,
has m any acuity gradations, from 20/220 to 20/10
however, most clients are able to read quite a few lines
when used at 20 feet, from 20/449 to 20/20 at 10 feet,
on the chart, leading to a much more positive experi­
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
A m ajor advantage of the Feinbloom chart is porta­
one's pocket. Therefore, it is easy for an occupational
bility. For this reason, the Feinbloom chart is recom­
therapist to carry this chart when providing care in a
mended for home-based evaluation. The Feinbloom
client s home, hospital room, or nursing hom e room.
chart is also valuable because it can be used to assess
It does share the sam e shortcom ing as the Feinbloom
eccentric viewing. T h is technique is often required
chart, having only two letters per visual acuity level
when an occupational therapist is assessing eccentric
from 20/220 to 20/40, and then four letters per visual
view ing, and is reviewed in detail in Chapter 8.
acuity level from 20/30 to 20/10.
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 Low V is io n N e a r V is u a l
levels, and only three per line from 20/200 to 20/60.
Another problem is the letters arc not standard, so
A c u it y C h a r ts
acuity measured w ith the Feinbloom ch art m ay not
A com m on goal of clients with low vision is to be
match acuitv measured with another chart. Because
able to read again. Therefore, the evaluation of near
o f these shortcom ings, the Feinbloom C hart should be
visual acuity is essential because this visual acuity
supplemented w ith one of the two described below, if
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
Early Treatm ent Diabetic the visual requirem ents for reading than letter acu­
R etinopathy Study C h art ity.4-5 Near visual acuity testing differs from distance
visual acuity testing in tw o ways.
Using a design developed by Lovie-Kitchen and
1. In addition to testing the client's ability to read
Bailey,3 this Log chart provides five letters per line
single letters or num bers, charts w ith phrases
and also standardizes the separation betw een let­
and sentences are also used to evaluate read­
ters. A unique aspect of the Early Treatm ent Diabetic
ing ability.
Retinopathy Study C hart (ETDRS) is its geom etric
progression of size differences betw een lines, referred 2. The meter system of notation is often used for
to as logM A R progression (Figure 3-4). O ptotypes near visual acuity testing as mentioned earlier
on each line are 0.1 log unit or 25% larger than the in this chapter (see Table 3-1).
previous line. T h is format results in every three lines Three com m only used near visual acuity charts are
representing a halving or doubling of visual acuity described below.
at any given view ing distance, eg, if one starts at 100
and goes down three steps (step 1 = 80, step 2 = 80 Lighthouse N ear A cuityTest (M eter
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 Lighthouse N ear A cuity Test (LHNV-1) letter
the gold standard for accurate, repeatable m easure­ chart is illustrated in Figure 3-6 and shows that the
ment. However, the FTD RS chart is large and cannot card has both Snellen equivalent and m eter system
be easily carried for home healthcare. Thus, it may not notation. N ear visual acuity testing is typically per­
be practical for home health practice. formed at 40 cm with clients with norm al vision. If
К D N R О во

= z к C S V = 60

D v о н с 50

03 о H v с к 40

02 Н Z С К О 32

01 N С К Н D 25
иnи on
-.1 S Z R D N 16
•2 ИС ОЯ 0 »Z 5
-3 »оо«и 10

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.
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tv •*Н« -•'Св Ж
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av -2L
W • » « * * ! *т ггвЖг *»*£аж*в№*<
Occ»r» c < i ) f w r а д » 4 * л « м * » 1 1« rv-pcctf t/личкь*
im 1к.н 1ж к -« iow m * * r w m c n n t i д о г * * м i w t a t io o n

Figure 3-6. Lighthouse Near Visual Acuity Chart (Steinm an).

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

Lighthouse Near Visual Acv ty Test <sec o m >eomo#

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6 U— -------------------------- •-?;# --- ---- -------------- чГ-- * »w «*» ю
5 м \ *>?t jtflO Jao
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Figure 3-9. M N Read N ear Visual A cuity Test

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

Mur* Ъил*- Уг,ила

«из 2 0 .4 0 0 1.3

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 w ere not able

to finish playing the 2bW
> 1 .1

gam e before dinner

The MN Read acuity chart has been validated
and can be used to provide a sensitive and reliable
C o n tr a s t Sensitivity
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
D e fin itio n
acters (including a space). The reading levels of the An important topic that is related to visual acuity
passages are approximately the same, about a 3rd to is contrast sensitivity. W hile visual acuity tests enable
4th grade difficulty. An estim ate of reading acuity is the therapist to estim ate how well som eone can see
given by the smallest print size at which the client can small high-contrast objects, contrast sensitivity testing
read the entire sentence without making significant enables the therapist to estim ate how well someone
errors. (Usually reading perform ance deteriorates can see larger low-contrast objects. Contrast sensitiv­
rapidly as the acuity limit is approached, and it is easy ity is related to visual acuity, but provides information
to determ ine the level where reading becomes impos­ that is not as well captured by visual acuity m easure­
sible.) The exam iner uses a stopwatch to record the ment.7 Contrast sensitivity is strongly associated with
tim e required to read each paragraph and this allows reading performance,8 mobility,9'10 driving,11'12 face
a determination of reading speed. 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
S ig n ific a n c e o f V is u a l A c u ity sible for a client to have reasonably good visual acu­
ity, but still complain of problems such as dim, foggy,
in Low V is io n R e h a b ilita tio n or unclear vision or sensitivity to bright light. Visual
acuity only allows us to evaluate one limited aspect
As we reviewed in Chapter 1, the definition of low of the person's ability to see. Contrast sensitivity is a
vision is based on either distance visual acuitv or measure of how faded or washed out an image can be
visual field. Thus, visual acuity is a critical assessment before it becom es indistinguishable from a uniform
in low vision care. The definition used to determine field. A person with impaired contrast sensitivity
M edicare eligibility is 20/70 or worse in the better- might describe the problem by saying "it is like look­
seeing eye with best correction. In the United States, ing through a dirty windshield when 1 drive". People
visual acuity is used to categorize a person as legally with reduced contrast sensitivity often are very par­
blind (20/200 or worse in better-seeing eye with best ticular about lighting. They usually are glare sensitive
correction). This entitles the individual to a number or can see best over only a very narrow range of light
of entitlements and benefits, such as property tax intensity.
exemptions, an extra income tax exemption, reduced Contrast sensitivity determ ines the lowest contrast
fares on public transportation, access to social security level that can be detected by a client for a given size
disability, and books on tape. Visual acuity is also target. Contrast can vary from no contrast (0%) to
used by the low vision optometrist to estim ate the highest contrast (100%). For example, high-quality
m agnification needs of a client. The optometrist deter­ print has 85% to 95% contrast, while paper currency
mines the actual visual acuity and divides that value lias only 55% to 60% contrast. Another term that
bv the desired acuitv level. Let's say a client's visual is used is contrast threshold. Contrast threshold is
acuity is 20/200 and the client needs to see 20/50 defined as an object with the lowest contrast that a
print for the desired ADL. O ne would divide 200 by client can recognize. A client with normal vision can
50, yielding an estimate of 4X enlargement needed to usually see objects with as little as 2% to 3% contrast.
achieve this task. If the contrast of an object is less than the contrast
T h e difference betw een target size and acuity threshold of the client, the object cannot be seen. Table
threshold is acuity reserve, estimated by dividing 3-2 shows the contrast of some common everyday
the target size being viewed by target size al acuity objects. This table indicates that the contrast of most
threshold. If a person with normal vision wishes to objects is considerably higher than the normal contrast
read 1M print (typical of newspaper) at 40 cm, he or threshold of 2% to 3%. The difference between the
she requires better than 0.5 M acuity threshold at the contrast of objects and a client's contrast threshold is
same distance. Print size must be twice acuity thresh­ contrast reserve, expressed as a ratio of object contrast
old for fluent, comfortable reading (see Chapters 7 divided by contrast threshold. For fluent reading and
and 9). 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 (%) Object

5 M aroon chair on m aroon carpet
74 Maroon chair on gray carpet
80 Illum inated Red Exit sign
82 Black automobile on sunny street
32 Gray automobile on shady street
55-60 US currency
71-75 Daily newspaper
76-80 Paperback books
88-93 Glossy periodicals

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 estim ated. People with im paired contrast sensitivity
at threshold, ie, one divided by the lowest contrast at often are sensitive to lighting. They are more sensitive
which forms or lines can be recognized. If a person to glare, and often see best over a narrow range of
can see details at very low contrast, his or her contrast light— som etim es bright, som etim es dim light. There
sensitivity is high, and vice versa. A client with a con­ is m ounting evidence in the literature that suggests
trast threshold of 2% has higher contrast sensitivity that contrast sensitivity may be a sensitive indicator of
(1/2 = 30) than a client with a contrast threshold of disease and disease progressions.15’18 Contrast sensi­
10% ( 1/10 = 10). tivity should be assessed when a client's perform ance
does not match the expected results,19 eg, if a client
Exam ples of Low C on trast in reports difficulty seeing on a cloudy day or a very
bright day and visual acuity testing shows no change
Activities of Daily Living from previous visits. A nother exam ple: if a client can
• 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 rend enlarged print well but cannot re a d with e q u iv a ­
faces carrv¥ the visual inform ation related to lent m agnification w ith an optical device (assum ing
facial expressions. all other factors such as visual acuity and working
• Orientation and m obility: We need to see low- distance arc the sam e), the therapist should consider
contrast form s such as the curb, faint shadows, contrast sensitivity testing. O ptical devices degrade
and the last step of carpeted stairs when walk­ print contrast and create lighting problems. In our
ing. W hen driving, seeing in dusk, rain, fog, clinical experience, people with impaired contrast
snow fall, and at night are challenging tasks sensitivity (higher than 5%) often are very sensitive to
requiring good contrast sensitivity. glare from reflections from optics, degraded contrast
from optics, and problems with lighting.
• Reading and w riting: Poor quality copies, news­
print, an old Bible.
Clinical Assessment o f C ontrast
• Kitchen tasks: Cutting chicken, onion or other
light colored objects on a white or light colored Sensitivity
cutting board, pouring a glass of water. Contrast sensitivity has traditionally been m ea­
sured with gradings (Figure 3-10) that m easure the
W h y Is C on trast Sensitivity ability to see low contrast over a full range of object
sizes. In recent years, however, letter contrast sensitiv­
Im p ortan t to Measure? ity testing has becom e the preferred m ethod in clin i­
In all conditions w here visual acuity is reduced, cal settings because it is easy to adm inister and clients
contrast sensitivity is reduced as well. However, in are fam iliar w ith the use of letters to test vision.20 The
som e conditions that reduce acuity, contrast sensitiv­ Pelli-R obson Contrast Sensitivity ✓ C hart has been a
ity is reduced more than expected based upon the popular method o f testing letter contrast sensitivity.21
visual acuity alone. This m eans that if visual acuity The Pelli-Kobson Contrast Sensitivity C hart (Figure
only is tested, the visual disability of the person with 3-11) is a large wall-m ounted chart, 59 cm wide and
relatively reduced contrast sensitivity will be under­ 84 cm high, that consists of 16 triplets of letters, each
Figure 3-10. VisTech Contrast Sensitivity Testing.
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
f ■

|\V/* b m m .u


«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
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.
Significance o f Disorders
The three letters w ithin each triplet have constant of C on trast Sensitivity for
contrast, w hereas the contrast across triplets, read­
O ccupational Therapy
ing from left to right, and continuing on successive
lines, decreases in contrast. The client reads the letters As indicated above, contrast sensitivity testing
across and down the chart, as in standard letter acuitv provides us with inform ation about the clients' visual
m easurem ent. Instead of the letters decreasing in size, function that is not available from standard visual
however, they decrease in contrast. T h e final triplet acuity testing. Because contrast sensitivity is closely
in which the client reads two of three letters correctlv associated w ith reading, m obility, driving, and other
determ ines the Log contrast sensitivity. ADL, it is particularly im portant for occupational
Although widely used by researchers, it has not therapists.
been widely used by clin ician s for a variety of rea­ In vision rehabilitation, occupational therapists
sons.20 First, it is inconvenient for testing in small can help clients with contrast sensitivity problems
clin ical spaces, as it requires a large amount of wall by increasing the contrast o f objects being viewed.
space. Second, it is difficult to arrange lighting that M ethods of m odifying contrast include the environ­
will uniform ly illum inate such a large area. Third, a mental m odifications that enhance contrast or add
wall-m ounted chart is difficult to keep clean and free color contrast, lighting m odifications that elim inate
o f defects.20 glare, m obility instruction, and the use of closed cir­
Recently, A rditi20 reported on a new letter con­ cuit televisions.19 These interventions are described in
trast sensitivityу test called the Mars Letter Contrast detail in Chapters 10 and 14.
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 R efractive D isorders
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. Definition
Either test involves instructions to test at a set d is­
tance based on near normal vision. For low vision, Refraction is the term used to describe the evalua­
one must be careful that testing was performed at a tion of the optical system o f the eye. We use the term
d istance w here the letters w ere larger than letter size refractive error to describe any disorder of refraction.
at acuity threshold. This can be easily done by first W hen the optom etrist perform s the refraction, he or
finding the distance where the high contrast letters on she determ ines w hether the individual is em m etropic
the chart are barely visible, and then decreasing the (absence of refractive error), myopic (nearsighted),
test distance by one-half and then one-half again. hyperopic (farsighted), or astigm atic. The refraction
Figure 3-13. Light rays entering
the eye are perfectly focused
on the retina in emmetropia

is the exam ination procedure used to determ ine if a an individual views an object through a sm all open­
client w ill benefit from glasses and the exact prescrip­ ing in front of the eye. This setup will bring an object
tion that is appropriate. into focus on the retina regardless of refractive error.
Any attempted focusing adjustment by the lens of the
Classification o f Refractive eye (accommodation) will simply m ake the blurred
vision worse. Thus, a client with myopia will have to
Conditions move closer to the object he/she is trying to view. A
person who has myopia ("nearsightedness") will have
Em metropia better visual acuity at near than at distance if he or she
This term is used to describe the condition in which is not wearing correction.
there is an absence of refractive error. In emmetropia,
the light rays entering the eyes focus right on the Hyperopia (Farsightedness)
retina. Figure 3-13 illustrates how the light rays enter­ Hyperopia is a condition in which light rays enter­
ing the eve are perfectly focused on the retina in ing the eve focus behind the retina and the indi­
emmetropia. In such a case, the client is neither near­ vidual must accommodate to see clearly. * This need to
sighted nor farsighted and does not have astigmatism. accommodate requires the use of m uscular effort. The
Emmetropia is not necessarily considered normal, amount of effort necessary is greater when the indi­
expected, or desirable. In fact, the average person is vidual looks at near. Figure 3-15 illustrates that to see
slightly hyperopic. clearly, a person with hyperopia must contract the cili­
ary muscle to change the shape of the lens in the eye
Myopia (Nearsightedness) and regain clarity. Contraction of the ciliary muscle
M yopia is a condition in which the light rays enter­ leads to a change in focus and is referred to as accom ­
ing the eye focus in front of the retina. In myopia, the modation. The effort that is necessary to accommodate
vision is blurred at distance but clear at near. Figure 3- is directly related to the degree of hyperopia. A very
14 shows why a client with myopia experiences blurred high degree of hyperopia requires so much m uscu­
vision. The light rays entering the eye are focused in lar effort that it cannot be overcome and results in
front of the retina because the optics of the eye are too blurred vision. Moderate degrees of hyperopia can be
strong relative to the length of the eye. The myopic overcome using accommodation. The constant need
eye has a longer axial length than the emmetropic or for accommodation, however, requires the use of m us­
hyperopic eye. The hum an eye can make no internal cular effort and leads to signs and symptoms, such as
adjustment to overcome the optical problem associ­ blurred vision, eyestrain, tearing, burning, inability to
ated with myopia. An individual with myopia can concentrate and attend, avoidance of visual tasks, and
squint, which actually does allow improved vision, the need to move the object of interest closer or farther
but this is generally considered an unacceptable way away. In younger people, sm all degrees of hyperopia
to regain clarity because it can cause discom fort and are generally successfully overcome without sym p­
is cosm etically unacceptable. Squinting helps com­ toms. Remember that a low degree of hyperopia is
pensate for the blur associated with myopia because it considered normal, expected, and desirable. An older
creates a pinhole effect. A pinhole effect occurs when 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

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

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
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

Normal Vision Astigmatic Vision uncorrectod astigmatism (Steinman).

Spherical Cornea Astigmatic Cornea

effect that astigm atism has on the light rays focusing environm ent. Moderate degrees o f astigm atism can
on the retina. In order to see clearly, a person with som etim es be overcome using accom m odation. The
astigm atism will attem pt to accom m odatc. W hile constant need for accom m odation, however, requires
accom m odation may improve clarity in one direction the use of m uscular effort and leads to signs and
(eg, vertical lines), accom m odation never completely sym ptom s, such as blurred vision, eyestrain, tearing,
clears an im age w ith astigm atism , and the effort that burning, inability to concentrate and attend, avoid­
is necessary to accom m odate may lead to discom ­ ance of visual tasks, and the need to m ove the object
fort. As discussed above for hyperopia, the degree of of interest closer or farther away. Sm all degrees of
accom m odation necessary is related to the degree and astigm atism are com m on and are generally success­
type of astigm atism . In som e cases of astigm atism , fully overcom e w ithout sym ptom s. A person with
accom m odation has no beneficial effect on clarity. astigm atism w ill have reduced acuity at both distance
A very high degree of astigm atism generally cannot and near, and may see stripes in one direction more
be overcom e and results in blurred vision. If not cor­ clearly than stripes in another, so som e letters may be
rected carlv, such problems can lead to amblyopia easier to see than others.
(loss o f vision) and difficulty interacting w ith the
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
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 rally (toward the ear) about 90 degrees, and nasally
am ount of refractive error might not significantly (towards the nose) about 60 degrees (Figure 3-19b).
affect functional vision in som eone who has severe Thus, with only one eye open, a client has a horizontal
vision loss. However, a good refraction should always visual field of about 150 degrees and vertically about
be the very first step in the treatm ent of any low 120 degrees. T h is is true for each eye. Note that with
vision client, even w ith severe vision loss. Researchers both eyes open, the horizontal field only increases by
have been surprised at the high prevalence of uncor­ about 30 degrees. W hile only the object being viewed
rected refractive errors in the elderly population. directly is seen clearly, the client is able to see this
The Baltimore Eye Study found that alm ost 70% of entire area peripherally and can perceive movement
people reporting low vision based on reduced visual and the presence of objects in the entire visual field.
acuity alone actually only needed new eyeglasses.22 As indicated in Chapter 1, the definition o f low vision
C orrectable vision im pairm ent is associated with includes not only visual acuity, but visual field as well.
poorer general health, living alone, and lower socio­ A person is said to be legally blind if the visual field is
econom ic status.23 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
V is u a l F ie l d D is o r d e r s 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
D e fin itio n requirem ent for driving is 120 degrees horizontally.

The term visual fie ld describes how much of the Causes of Visual Field Loss
visual world an individual can see while looking
straight ahead at a point of fixation. W hen a client has Visual field loss is usually classified as central ver­
a normal visual field, he or she can see everything sus peripheral visual field loss. As described above
from the fixation point superiorly about 50 degrees, and in Figure 3-19, the visual field is 150 degrees hori­
interiorly about 70 degrees (Figure 3-19a), tem po­ 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. Visual inform ation from the right field strikes the
Outside this central 20 degrees is referred to as periph­ nasal half of the retina of the right eye and the tem ­
eral visual field . We use these term s to classify visual poral h alf of the retina o f the left eye. Sim ilarly, visual
field loss as central or peripheral visual field loss. The inform ation from the left field strikes the nasal half of
"rule of thum b" is that the thum b at arm's length is the retina of the left eye and the temporal h alf o f the
about 2 degrees; a fist is about 10 degrees wide. retina of the right eye (see Figure 3-20a). W hen the
fibers from each optic nerve reach the optic chiasm , a
Peripheral Visual Field Loss decussation takes place. T h e fibers from the temporal
Peripheral visual field problem s are associated with part of the retina rem ain on the tem poral or outside
many eye d iseases and diseases that affect the brain, aspect of the chiasm and are called uncrossed fib ers (see
such as acquired brain injury, glaucoma, and retinitis Figure 3-20a). The nasal fibers of the retina cross over
pigm entosa (described in detail in Chapter 4). O ne of in the chiasm and are called crossed fibers. A fter leav­
the most com m on peripheral visual field disorders is ing the chiasm , the fibers form the optic tract. Thus,
a right or left field loss, referred to as an homonymous all visual inform ation originating from the right field
hem ianopsia. To understand why a client would lose travels in the left optic tract, and all visual inform ation
vision to just one side, it is necessary to understand originating from the left field travels in the right optic
how visual inform ation travels from the retina to tract. The fibers in the upper half of the tract originate
the visual cortex (Figure 3-20a). Vision begins with from the upper half of the tw o retinas, and the fibers
the capture of im ages focused by the optical media from the lower h alf of the tract com e from the lower
on photoreceptors of the retina. The fibers from the h alf of the two retinas. The fibers from the optic tract
upper h alf of each retina enter the optic nerve above synapse in the lateral geniculate body. The cells o f the
the horizontal m eridian, and those from the lower lateral geniculate body give rise to new fibers, which
h alf enter below the horizontal m eridian. Fibers from form the optic radiation. These fibers then proceed to
the periphery of the retina lie peripherally in the optic the cells of the visual cortex (see Figure 3-20a). Any
nerve, and fibers from the fovea lie centrally. This lesion that affects the visual pathway on only the right
arrangem ent persists throughout the entire course of or left side after this decussation takes place in the
the visual pathways from the optic nerve through the optic chiasm will affect either the left visual field or
chiasm , the optic tracts, and optic radiations. right visual field in both eyes. For exam ple, Figure 3-
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).

20b illustrates what a client with normal visual fields Glaucoma is a disease that causes progressive
would see. Figure 3-20c illustrates a lesion on the right peripheral field loss that could eventually lead to total
side o f the brain and in this case the individual would loss of vision. A person with peripheral visual field
only see the dog. Any damage to the eye or optic nerve loss due to glaucoma loses field in all directions, not
will affect one eye. Any damage to the optic chiasm just the left or right side. Thus, as the field loss pro­
itself often affects both eyes, with a different effect on gresses, it is like looking through a tube (Figure 3-21).
each eye. For example, the left field of the right eye Retinitis pigmentosa causes peripheral field loss that
and right field of the left eye may be affected. Brain is sim ilar to the loss caused by glaucoma.
injury associated with trauma or stroke often leads to
this type of visual field loss and may require vision
rehabilitation by occupational therapists.
Figure 3-21. Illustration ot peripheral visual field loss char­
acteristic of glaucoma (Steinm an).

dard A m sler Grid consists of a square grid of white

Central Visual Field Loss
horizontal and vertical lines on a black background
The most com m on visual field loss that an occupa­ (Figure 3-23). The client view s this target with one
tional therapist is likely to encounter is central visual eye open at a distance of about 13 inches. T h e clicnt
field loss associated with diseases of the m acula, such is asked to fixate the central dot and report if all the
as m acular degeneration. This type of visual field loss corners arc visible, if the grid is uniform , and if any
is referred to as a central scotoma. A scotom a is defined areas of the grid are distorted or missing.
as an island of absent or reduced vision in the visual
Central field testing becom es more d ifficult to
field, surrounded by an area of normal vision. adm inister and interpret if people have central field
loss because when they attempt to look directly the
Clinical Assessment o f Visual Field fixation target in the center of the field test, the target
Disorders disappears from view. As a result, people may look to
the side of a target to sec it, or som e with recent vision
Peripheral visual field testing is generally per­ loss just keep generating random searching eye move­
formed in the office of the optom etrist or ophthal­ ment trying to look at a fixation target. By adapting
m ologist w ho refers the client for low vision reha­ the standardized procedure, the eyecare practitioner
bilitation. Standard field testing requires that a client or low vision therapist can not only describe a client's
m aintain a steady fixation eye position. With people central fields, but also his or her fixation eye move­
who have gaze instability, or severe attention deficits, ments (see C hapter 10).
visual field testing becom es m ore o f an art. As a thera­
pist teaches a client to function with gaze instability, Significance of Visual Field
he/she often com bines field testing with instruction
on controlling gaze position and m ay provide criti­ Disorders for Occupational
cal data on a client's visual fields. Central field test­ Therapy
ing is best perform ed using a simple screen set at 1
M (Tangent Screen) (Figure 3-22a,b), or using more The status of the visual field is an im portant m ea­
expensive com puterized visual field testing (Figure sure of visual function that m ust be considered by the
3-22c). Unless one has a bowl perimeter, testing can occupational therapist when developing a low vision
be done using confrontation field testing m ethods rehabilitation treatm ent plan. In som e cases, the visual
described in Chapter 7. This requires no special equip­ field disorder is a secondary issue and in others it is
ment and can easily be perform ed by an occupational the prim ary reason for the client's disability. Central
therapist. field loss is the most com m on cause of low vision, and
Central visual field testing can be performed using m anaging unstable fixation that results from central
a device called the A m sler G rid lest. The stan­ 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 3-23. Am sler G rid (Steinman).

Figure 3-22c. Com puterized visual field testing (Steinman).

is im portant to rem ember that a client could have per­ 5. Bailey IL, Lovie IE. The- design and use of a new near-vision
chart. Am I Optom Physio! Opt. 19B0;57:378-:»87.
fect visual acuity in both eyes and yet still have low
6. Legge CE, Russ |A, Luebker A, La May )M. Psychophysics of
vision based on a deficit in visual field that does not reading. VIII. The Minnesota Low-Vision Reading Lest. Optom
involve central vision. Vis Sci. 1989;66( 121:843-853.
7. Haegerstrom-Portnoy G. Schneck ME, Lott LA, Brabyn |A. The
relation between visual acuity and other spatial vision measures.
Optom Vis Sci. 2000:77:653-662.
Su m m a r y 8. Whittaker SC, Lovie-Kitt hin ). Visual requirements for reading.
Optom Vis Sci. 1993:70(1 ):54-65.
It is im portant for occupational therapists to under­ 9. Marron |A, Bailey IL. Visual factors and orientation: Mobility
stand visual acuity, contrast sensitivity, visual refrac­ performance. Am / Opiom Physiol Opt. 1982;59:413-426.
10. Kuyk T. Elliott IL. Visual correlates of mobility in real world
tion, and visual field disorders. T h is chapter reviewed
settings in older adults with low vision. Optom Vis Sci.
definitions, test procedures, and the significance of 1998;75:538-547.
these problem s in low vision clients. II Wood |M, Elderly drivers and simulated visual impairment.
Optom Vis Sci. 1995;72:115-124
12. Owsley C, Sloane ME. Contrast sensitivity, acuity, and the per­
ception of "real-world" targets. Brit I Ophthalmol. 1987;71:791-
R eferences 796.
13. West SK, Rubin GS. Broman AT. Munoz B, Bandeen Roche K,
1 Freeman PB, lose RT. the Art and Practice o f Low Vision. 2nd e<l. Turano K. How does visual impairment affect performance on
Boston: Butterworlh-Heinemann; 1997. tasks of everyday life? The SEE Project. Salisbury Eye Evaluation.
2. Brilliant Rl Essentials o f lo w Vision Practice. Boston: Buttmvorth- Arch Ophthalmol. 2002;120(6):774-780.
Heinemann; 1999. 14. Rubin GS. Roche KB, Prasada-Rao P. Fried I P. Visual impairment
3. Bailey II, Lovie It. New design principles for visual acuity letter and disability in older adults. Optom Vis Sci I994;71i12):750-
( harts. Am I Optom Physiol Opt. 1976;53:740-745. 760.
4. Sloan LL. New test charts for the measurement of visual acuity
at far and near distances. Am I Ophthalmol. 1959;48:807-813.
15. Alexander kR, Derlacki DJ, Fishman C A. Visual acuity vs. 20. Arditi A. Improving the design of the letter contrast sensitivity
letter contrast sensitivity in retinitis pigmentosa. Vision Res. test. Invest Ophthalmol Vis Sci. 2005:46:2225*2229.
1995;35:1495-1499. 21. Pclli ПС, Robson JG. Wilkins AJ. The design of a new letter
16. Elliott D8, Hurst MA. Simple clinical techniques to evaluate contrast chart for measuring contrast sensitivity. Clin Vis Sci.
visual function in patients with early cataract. Optom Vis Sci. 1988;2:187-199.
1990;67:822-825. 22. Tielsch JM, Sommer A. Witt K. Katz J, Royall RM. Blindness
17. Hawkins AS. Szlyk JK Ardickas Z, Alexander KR. Wilensky |T. and visual impairment in an American urban population. The
Comparison of contrast sensitivity, visual acuity, and Humphrey Baltimore Eve Survey. Arch Ophthalmol. 1990;l0fi(2):286-290.
visual field testing in patients with glaucoma. / Glaucoma. 23. Evans BJ, Rowlands G. Correctable visual impairment in
2003;12:134-138. older people: a major unmet nned. Ophthalmic Physiol Opt.
18. Rubin GS, Adamson IA, Stark VVJ. Comparison of acuity, contrast 2004 ;24i 3): 161 -180.
sensitivity, and disability glare before and after cataract surgery.
Arch Ophthalmol. 1993;111:56-61.
19. Cummings RW. Muchnick BG, Whittaker SG. Specialized test­
ing in low vision. In: Brilliant R L Ed. Essentials o f Low Vision
Practice. Boston, MA: Butterworth-Heinemann; 1999:47-69.
Eye Diseases Associated
With Low Vision

I n t r o d u c t io n A ge - R elated M a c u la r
T h is chapter reviews only the eye d iseases that are D egeneratio n
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 Description
leading causes of severe visual im pairm ent among A M D is a degenerative, acquired disorder of the
white A m ericans in 2000 were age-related m acular central retina called the m acula, which usually occurs
degeneration (AMD), accounting for 54% of visual in patients over age 55, and results in progressive,
im pairm ent, w ith cataract (9%), diabetic retinopathy som etim es significant, irreversible loss o f central visu­
(6%), and glaucoma (5%) the next most com m on al function from either fibrous scarring or atrophy of
causes.1 The leading causes of severe visual im pair­ the m acula. It is the leading cause of vision loss in the
m ent in black persons w ere cataract (37%), diabetic adult population.
retinopathy (26%), glaucoma (7%), and AM D (4%). The macula is located roughly in the center of
Am ong H ispanics, glaucom a was the most comm on the retina and is a sm all and highly sensitive part
cause (29%), followed by A M D (14%), cataract (14%), of the retina responsible for detailed central vision.
and diabetic retinopathy (14%).1 Therefore, w hile the The fovea is the very center of the m acula. T h e nor­
relative prevalence m ay differ depending on race and mal macula has a characteristic appearance and is
ethnicity, the prim ary eye diseases that the occupa­ more heavily pigmented than the surrounding retina
tional therapist w ill encounter when dealing w ith (Figure 4-1). The macula allow s us to appreciate detail
adult patients w ith low vision are AMD, diabetic and perform tasks that require central vision, such as
retinopathy, glaucoma, and cataract. 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 Blood Vessels
surrounding retina (Steinman).



adjacent structures of the eye, w hich w as reviewed in AVID is classified as either d ry (nonexudative) or
Chapter 2. As a brief review, the retina is com posed of wet (exudative).
10 layers. Two of the im portant layers that becom e an
issue in A M D are the retinal pigm ent epithelium that D ry AMD
is closest to the choroid, and the photoreceptors (cones
Dry (nonexudative or atrophic) A M D accounts for
and rods) (Figure 4-2). Beneath the retinal pigment
90% of all patients w ith AM D in the United States.3
epithelium of the retina are four additional layers (see
The disorder results from a gradual breakdown o f the
Figure 4-2) ranging from the outside (furthest from
retinal pigm ent epithelium (RPE), the accum ulation of
the retina) to the inside (closest to the retina):
drusen deposits, and loss o f function of the overlying
1. Sclera (w hite part of the eye)
photoreceptors (Figure 4-3). Most patients w ith dry
2. Large choroidal blood vessels AM D experience gradual, progressive loss o f central
3. Choriocapillaris visual function. This loss o f vision is more noticeable
4. Bruch's m em brane (separates the pigmented during near tasks, especially in the early stages of
epithelium of the retina from the choroid) 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
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
W et AM D
50 and is characterized by any o f the follow ing prob­
lem s: Although wet (exudative) A M D accounts for only
1. D rusen: Drusen are discrete, round, slightly 10% of patients with AMD, 90% o f the AM D patients
elevated whitish-yellow spots in the m acular w ith significant vision loss have this form of the
area and elsew here in the retina. Drusen are disease.4 6 Wet AM D is characterized by the develop­
one of the earliest signs of AM D and are typi­ ment of neovascularization in the choroid, leading to
cally clustered in the m acular area. They may leakage of blood and subsequent elevation o f the RPE
change in size, shape, color, and distribution (Figure 4-4). Patients with wet AM D tend to notice a
over time. more profound and rapid decrease in central visual
2. Hyperpigmentation: Hyperpigmentation refers function. T h e leakage of blood from the new choroidal
to areas of increased pigmentation and may vessels causes distorted vision, central scotom a, and
not be associated with drusen. blurred vision. As the blood in the vitreous dissi­
pates, vision might improve somewhat.
3. H ypopigm entation: H ypopigm entation refers
to depigm entation and is typically associated
with drusen.
Figure 4-2. Layers of the retina
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


Figure 4-3. Photoreceptors (Steinman).

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

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

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

betw een increased cum ulative exposure to sunlight
Most studies have indicated that AM D is the lead­ and ultraviolet radiation and wet A M D .,(> However,
ing cause of low vision in developed countries.8'9 The strong epidem iologic evidence is lacking. W eaker
prevalence of A M D increases with age, and about 30% associations have been found w ith obesity, hyperten­
o f patients 75 years of age and older are affected.3'10 sion, m acrovascular disease, raised cholesterol, and
W hile A M D is the leading cause of visual impairm ent cataract surgery.
am ong w hite A m ericans (54%), it is less prevalent in D ietary associations have also been found both
black persons (4%) and H ispanics (14%).1 W arren11 w ith the signs of AM D and with progression to
reported on her experience as an occupational thera­ vision loss.17' 19 In a w ell-conducted prospective study,
pist w orking in a low vision program in an oph­ dietary fat intake was system atically analyzed after
thalm ology departm ent. Thirty-seven percent of the correcting for other risk factors.1* Vegetable fat intake
patients referred for occupational therapy (low vision had the strongest relationship w ith A M D progression,
rehabilitation services) had AMD. Thus, low vision with a relative risk of 3.82 for the highest fat-intake
caused by A M D is the condition that occupational quartile com pared with the lowest quartile. Higher
therapists w ill be most likely to treat. intakes of total fat and o f saturated, monounsaturated,
polyunsaturated, and transunsaturated fats all raised
Risk Factors the relative risk of AM D progression about twofold.
W eekly fish intake and eating nuts two to three tim es
Table 4-1 lists the risk factors associated w ith AMD.
a week were m ildly protective. The im plication is that
Age is the most significant risk factor and clearly
a large sh ift away from vegetable oils, m argarine, and
increases the risk of both developing AM D and of pro­
fat-containing processed foods might reduce this epi­
gressing to the late stages of the disorder.12 Although
dem ic of blindness in the elderlv.
age is a strong risk factor, AM D and vision loss do
There is also evidence from a random ized con­
not inevitably o ccu r w ith advancing age. People w ith
trolled trial that high-dose dietary supplem ents of
an A M D-affected first-degree relative have a 50%
the antioxidants vitam in C, vitam in E, beta-carotene,
lifetim e risk of experiencing advanced AM D and
and zinc can reduce the risk of progression from large
vision loss, and tend to develop it earlier than those
or soft drusen to advanced AM D and visual loss bv ¥
without a fam ily history.13 Sm oking is associated with
about 20% com pared w ith controls over 6 years.20
a fourfold increase in the risk of AM D and visual loss
However, high-dose zinc can cause gastric irritation or
and, again, tends to promote earlier occurrence.14
anem ia, and beta-carotene may possibly be associated
Studies have consistently implicated fem ale gender as
w ith an increased risk o f lung cancer am ong smok­
a risk factor. In the Fram ingham Eye Study, fem ales
ers. Uncontrolled studies suggest the antioxidants
with A M D outnum bered m ales by 50% , but this may
selenium , lutein, and zeaxanthin, w hich localize in
have reflected the increased proportion of women
the norm al macula, may also help. There are as yet
in the older age groups. In the Beaver Dam Study,
no studies to show w hether dietary supplem ents are
results controlling for age showed a twofold higher
protective in patients in the early stages o f dry AMD
incidence of A M D in women than in men in the 75-
or in the 20% of patients who are at genetic risk.
Figure 4-5. The effect of m acular scotoma in age
ж : related m acular degeneration (Steinman).


It is not yet known w hether m ajor d ietary adjust­ expressions usually becom e severely im paired. The
ment and/or introduction of dietary supplements for consequences of AM D lead to loss of independence,
large num bers of elderly people will be justified in lowered self-esteem , decreased mobility, increased
term s of preventing blindness. O n present evidence, risk of injury due to falls,21'22 and depression.23
we should identify people at increased risk of AMD, Figures 4-5 and 4-6 illustrate what a patient m ight see
encourage them to stop sm oking, and promote a diet w ith A M D and a m acular scotoma.
that includes vegetables, fish, and nuts and reduces Som e patients w ith A M D have a phenomenon
fatty foods laced w ith vegetable oils. Antioxidant called Charles-Bonnet Syndrom e or visual hallucina­
supplem ents m ay be recommended if a fresh diet tions.24 This is an occasional com plaint of patients
is im practical and if retinal signs of progression are with bilateral A M D and may occur spontaneously
present. C lients should not attem pt to treat them selves with no known external cause.
w ith vitam in therapy and should be encouraged to
ask the eyecare practitioner w ho is treating the retinal Treatment
Treatment of AM D includes various medical pro­
cedures to slow the progression of the disease, low
Effect on Vision vision rehabilitation including optical and nonoptical
Visual acuity varies with the extent of the degen­ devices, environm ental changes, education, support
eration and includes distortion, blurred vision (espe­ groups, and training in eccentric view ing, scanning,
cially at near), and central scotoma. With dry AMD, and reading.
visual acuity can range from 20/20 to 20/400. Visual
acuity with wet A M D is generally worse than 20/400. Dry AM D
All patients with only AM D have central visual field There is no medical treatm ent for drv J A M D that
defects w ith normal peripheral vision. Patients with can restore vision loss. Patients w ho have earlv retinal
A M D alm ost never go totally blind. However, if AMD changes such as sm all drusen or mild pigmentation
occurs in both eyes, the visual acuity loss along with changes may experience no sym ptom s or may notice
the central scotom a significantly im pair a person's slowly progressive changes in visual function. These
ability to engage in activities of daily living and patients are generally seen by an eye doctor every 6
quality of life. H igh-resolution tasks such as reading, months. T h e eye doctor should educate the patient
w riting, sew ing, telling tim e, taking care of financial to look for signs of decreased vision, scotom a, and
issues, driving, and distinguishing colors and facial 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.
Figure 4-7. Amsler G rid. Distortion reported by patient

function monocularly. Some eye doctors give the Laser Surgery

patient an Amsler Grid (Figure 4-7) for self-assess­
ment at home. The patient is able to see changes in In the 1990s, m ost A M D treatm ent research
the pattern of blur, distortion, and scotoma using the focused on laser photocoagulation. The M acular
Am sler grid. Patients are instructed to return for fur­ Photocoagulation Study Group showed that laser
ther examination w ithin 24 hours of the onset of new photocoagulation was effective in the treatment of
sym ptom s because 10% of patients with dry AMD neovascularization if the vessels were not too close to
progress to wet AMD. Studies have shown that early the fovea.23'26 This procedure uses a laser to destroy
treatment of wet AM D may limit the extent of damage the fragile, leaky blood vessels. A high-energy laser
and v ision loss. beam is aimed directlv J onto the new blood vessels
and destroys them, preventing further loss o f vision.
Wet AMD However, laser treatment also may destroy som e sur-
The principal aim of treatment of wet AMD is to rounding healthy tissue and some vision. Therefore,
preserve visual acuity and reduce the risk of addi­ laser surgery is more effective if the leaky blood
tional severe vision loss for as long as possible. This vessels have developed away from the fovea. Only
goal can be accomplished by destroying the choroidal a small percentage o f people with wet AMD can be
neovascularization without causing serious damage to treated with laser surgery, because in most patients
the retina. There are several treatm ents for wet AMD the disease is near the center o f the macula 27 The risk
that have proved effective in large-scale randomized of new blood vessels developing after laser treatment
clinical trials. These include laser photocoagulation, is high. Repeated treatments may be necessary. In
photodynamic therapy with verteporfin, and injec­ som e cases, vision loss may progress despite repeated
tion o f drugs called angiogenesis inhibitors. None treatments.
of these treatments is a cure for wet AMD and they
do not improve vision. Each treatment may slow the Photodynamic Therapy
rate of vision decline or stop further vision loss, but A light-activated drug called verteporfin (Visudyne,
the disease and loss of vision may progress despite Novartis Pharm aceuticals Corporation, Hast Hanover,
treatment. Som etim es treatments may result in an NJ) is injected intravenously and travels throughout
im m ediate decline in vision, in order to m axim ize the body, including the new blood vessels in the eye.
vision in the long run. Treatments may also create The drug tends to "stick'' to the surface of new blood
blind spots around the central most part of vision, so vessels. Low power, nonthermal laser light is shined
that, for example, one or two letters in a word might into the patient's eye for about 90 seconds and activates
be missing. the drug. The activated drug destroys the new blood
vessels and leads to a slower rate of vision decline. apy represents a m ajor advance against AMD. It will
U nlike laser surgery, this drug does not destroy su r­ prevent severe vision loss in the m ajority o f appropri­
rounding healthy tissue. Because the drug is activated ately selected patients w ith new -onset wet AM D and
by light, the patient must avoid exposing his or her has opened the door to further investigation in the
skin or eyes to direct sunlight or bright indoor light m anagem ent of this potentially devastating disease.
for 5 days after treatment.
Photodynam ic therapy has been shown to be effec­ Antioxidants
tive in selected patients with certain types of wet
In a clinical trial called the Age-Related Eye Disease
AM D and slows the rate of vision loss.28-29 It is
Study (AREDS), researchers found that high levels of
im portant to understand how "success" or "effective­
antioxidants and zinc significantly reduce the risk of
ness” is defined in these studies. In photodynamic
advanced AM D and its associated vision loss.3' In this
therapy investigations, the researchers com pare the
study, patients at high risk of developing advanced
risk o f losing 15 or more letters (3 lines) of vision w ith
stages of AM D lowered their risk by about 25% when
the treatm ent versus placebo treatment. The studies
treated w ith a high-dose com bination o f vitam in C,
dem onstrating "success" reduced the risk of losing
vitam in E, beta-carotene, and zinc. In the sam e high-
15 letters from 61% in the placebo group to 33% in
risk group, the nutrients reduced the risk of vision
the vcrteporfin-treated group.29 Thus, this treatment
loss caused bv / advanced A M D bv j about 19%. For
does not totally stop vision loss or restore vision in
those study participants who had either no A M D or
eyes already damaged by AMD. Rather, the treatment
early AMD, the nutrients did not provide an appar­
slow s the progression of vision loss. Treatm ent results
ent b e n e fit33 It is im portant to understand that these
often are tem porary and may need to be repeated as
nutrients are not a cure for AMD, nor w ill they restore
often as everv •*
3 months.
vision already lost from the disease. However, they
A nother im portant finding from these studies is
may delay the onset of advanced AMD.
that the greatest benefits of photodynam ic therapy
The specific daily am ounts of antioxidants and zinc
can be achieved if the diagnosis is made early and
used by the study researchers were 500 m illigram s
patients receive therapy before the disease causes too
of vitam in C, 400 international units of vitam in E, 15
much destruction of the m acula.30
m illigram s of beta-carotene (often labeled as equiva­
lent to 25,000 international units of vitam in A), 80
Injections m illigram s of zinc as zinc oxide, and 2 m illigram s
I n D ecem ber2004, the Food and D rug A dm inistration of copper as cupric oxide. Copper was added to the
(FDA) approved the latest treatm ent available for wet AREDS form ulation containing zinc to prevent cop ­
AMD, called M acugen (Eyetech Pharm aceuticals Inc. per deficiency anem ia, a condition associated with
and Pfizer Inc., New York, NY). M acugen (pegap- high levels of zinc intake. People w ho are at high risk
tanib) is a vascu lar endothelial grow th factor (VEGF) for developing advanced AM D should consider tak­
inhibitor. W hen Macugen is injected into the vitreous ing the formulation under the supervision of a retinal
hum or of the eye, it has the capability of neutralizing specialist.
a specific grow th factor that prom otes the grow th of It is also im portant to understand that there is no
abnorm al new blood vessels in eyes with wet AMD. evidence that this AREDS form ulation is effective for
The result is a decrease of the vascular grow th and those diagnosed w ith early-stage AMD. T h e study
leakage that are together responsible for the visual did not find that the formulation provided a benefit to
loss in wet AMD. M acugen has demonstrated preven­ those with early-stage AMD.
tion o f visual loss as com pared w ith previous "stan­
dard of care" treatm ents that include photodynam ic Low Vision Rehabilitation
therapy.31 M acugen has broad im plications for treat­
Although vision loss cannot be restored w ith m edi­
ment because it is effective in m anagem ent of all types
cal treatm ent, low vision rehabilitation is an effective
o f new -onset wet AMD. In fact, M acugen has show n
treatment that enables patients w ith dry AM D to
that it can prevent severe visual loss (defined as loss
function more effectively in activities of daily living
o f three lines of visual acuity on the Snellen eye chart)
(ADL) and regain independence in spite o f the visual
in as m any as 70% of the treated patients during the
deficit. The occupational therapist's role in low vision
period of follow-up.32 Unfortunately, M acugen only
rehabilitation includes instruction in the use of opti­
has a tem porary effect and must be readm inistered
cal and nonoptical assistive devices; m odification of
approxim ately every 6 weeks. Furtherm ore, only 6%
lighting, contrast, and other environm ental factors;
of patients experienced gain s in visual acuity and the
treatment to learn adaptive eye movement patterns,
average patient in the study still lost visual acuity over
scanning, and reading skills; education; and involve­
the 2 years of treatm ent. N evertheless, M acugen ther­
ment in support groups.
M any patients w ith AMD may not have had a symptoms. People with NIDDM are frequently obese
recent exam ination and may benefit from a change and sedentary.
in eyeglass prescription. If prescribed in conjunction Diabetes can affect the retinal blood vessels and
with low vision rehabilitation, most patients with cause hemorrhaging and abnormal growth of new
AMD respond well to m agnification at both distance blood vessels into the vitreous (Figure 4-8).
and near (see Chapter 9). This is especially true with Diabetic retinopathy has four stages:
people who have the dry type of AMD. Because the 1. Mild Nonproliferative Retinopathy. At this
loss of vision is gradual, these individuals may d is­ earliest stage, m icroaneurysm s occur. They
engage from occupations such as reading for pleasure arc sm all areas of balloon-like swelling in the
or sew ing because the tasks become difficult, and are retina's tiny blood vessels.
often not referred because the condition has not stabi­ 2. Moderate Nonproliferative Retinopathy. As the
lized. These clients may develop depression, yet inter­ disease progresses, some blood vessels that
vention may be as simple as instruction about lighting nourish the retina arc blocked.
and a new set of reading glasses. These treatments are
3. Severe Nonproliferative Retinopathy. Many
discussed in detail in Chapters 10 through 12.
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
D iabetic R etinopathy body to grow new blood vessels for nourish­
4. Proliferative Retinopathy. At this advanced
Description stage, the signals sent by the retina for nour­
Diabetic retinopathy is the most serious vision- ishment trigger the growth of new blood ves­
threatening complication of chronic diabetes mellitus. sels. These new blood vessels are abnormal
Although there has been extensive research over sev­ and fragile. They grow along the retina and
eral decades, knowledge about the etiology of diabetic along the surface of the clear, vitreous gel that
retinopathy is still incomplete. Diabetes mellitus is fills the inside of the eye. By themselves, these
a chronic, incurable disease with major medical and blood vessels do not cause symptoms or vision
social implications. Diabetes occurs when the pan­ loss. However, they have thin, fragile walls. If
creas does not produce enough insulin or when the thev*
leak blood, severe vision loss and even
body cannot effectively use the insulin it produces. blindness can result. Proliferative diabetic
The vascular complications of diabetes involve all retinopathy is the more advanced form of the
organ systems, including the eye. Diabetes is a het­ disease, and in this condition the new blood
erogeneous group of diseases with different etiolo­ vessels hemorrhage and grow into the vitre­
gies and clinical features. The two major categories of ous. The vitreous may then pull away from
diabetes are insulin-dependent diabetes m ellitus and the retina, causing additional hemorrhage into
noninsulin-dependent diabetes mellitus. the vitreous. This blocks transmission of the
light through the normally transparent vitre­
Insulin-Dependent Diabetes Mellitus ous, causing significant vision loss. Floaters
Insulin-dependent diabetes mellitus (1DDM), or or debris in the vitreous may follow along
type 1, or juvenile onset diabetes mellitus, occurs at with retinal detachm ent and additional loss
any age but most often before the age of 30 years. It of vision. Fluid can also leak into the center of
has an abrupt onset that requires medical treatment. the macula, the part of the eye where sharp,
Only approximately 10% of the patients with diabetes straight-ahead vision occurs. The fluid makes
m ellitus have type 1 diabetes and the rem aining 90% the macula swell, blurring vision. This condi­
have type 2 diabetes mellitus. tion is called macular edema. It can occur at
any stage of diabetic retinopathy, although
Noninsulin-Dependent Diabetes it is more likely to occur as the disease pro­
gresses. About half of the people with prolif­
Mellitus erative retinopathy also have m acular edema.
Noninsulin-dependent diabetes m ellitus (NIDDM), M acular edema can cause significant loss of
or type 2, occurs at any age but most often in adults. vision along with distortion of vision.
It has an insidious onset and a subtle progression of
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
Figure 4 -8 . Diabetes can affect the retinal blood vessels and frequently have im paired contrast sensitivity (because
cause hemorrhaging and abnormal growth of new blood ves­
of cataracts), cloudy vitreous and retinal edem a, are
sels into the vitreous (Steinm an).
very glare sensitive, and are particular about lighting.
Thev may also have a central scotoma due to effects
Prevalence of Diabetes and of the diabetes on the m acular area (maculopathy),
loss of peripheral vision, and difficulty in dim light.
Diabetic Retinopathy Treatm ents (described below') often leave clients with
D iabetes m ellitus affects 18 m illion people (about a sm all island of good vision. They m ay see individual
6.3% of the population) in the United States.34 An num bers or letters but not words. The treatm ents also
estim ated 5.2 m illion people in the United States have produce scotom as in the periphery, or "sw iss ch eese"
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 vision. Figure 4-10 illustrates the visual problem s o f a
leading cause of death in the United States after heart patient with diabetic retinopathy.
disease and cancer.34 The prevalence of diabetes var­
ies by age as indicated in Figure 4-9. M en and women Treatment
are equally affected. About 1.3 m illion people aged 20 D uring the first three stages of diabetic retinopathy,
years or older are diagnosed per year w ith new cases no treatm ent is needed, unless m acular edema is pres­
o f diabetes m ellitus.34 ent. The current approach in these early stages em pha­
Diabetic retinopathy is the leading cause of new sizes the early recognition of retinopathy, vigorous
blindness in the 20- to 64-year-old population in the control of blood glucose, and direct therapy with laser
United States. It accounts for about 12% of all new photocoagulation and vitreous surgery 41
cases o f blindness each уyear. In a recent study
у of US Proliferative retinopathy is treated w ith laser sur­
adults 40 years and older known to have diabetes, gery. This procedure is called laser photocoagulation
the estim ated prevalence rates for retinopathy and treatment. Laser photocoagulation treatm ent helps to
vision-threatening retinopathy w ere 40.3% and 8.2%, shrink the abnorm al blood vessels. The ophthalm olo­
respectively.1 The estim ated US general population gist places 1,000 to 2,000 laser burns in the areas of the
prevalence rates for retinopathy and vision-threaten­ retina away from the m acula, causing the abnorm al
ing retinopathy w ere 3.4% (4.1 m illion persons) and blood vessels to shrink. Because a high num ber of
0.75% (899,000 persons).1 Future projections suggest laser burns are necessary, two or more sessions usu­
that diabetic retinopathy will increase as a public ally are required to com plete treatment. Although the
health problem, both with aging of the US population patient may lose som e peripheral vision, scatter laser
and increasing age-specific prevalence of diabetes treatm ent can save central vision.
over tim e.1 T h e prevalence of diabetic retinopathy Laser photocoagulation treatm ent works better
am ong patients w ith diabetes is m ore dependent on before the fragile new blood vessels have started to
the duration of the disease than the patient's age.1516 hemorrhage. Thus, patients with diabetic retinopathy
Figure 4-9. Prevalence of
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 diabetes by age (Steinman).
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)

□ P e rc e n t

2 0 -3 9 4 0 -5 9 60 +

Figure 4-10. Illustration of visual problems of a client

with diabetic retinopathy (Steinman).

should bo seen frequently for follow-up appointments.

Even if hemorrhaging has begun, laser treatment may
Effectiveness of Treatment
still be possible, depending on the amount of bleed- Both laser surgery and vitrectomy are effective in
ing. reducing vision loss.4243 People with proliferative
If the hemorrhaging is severe, the patient may retinopathy have less than a 5% chance of becoming
need a surgical procedure called a vitrectomy. During blind within 5 years when they get timely and appro­
a vitrectomy, blood is removed from the vitreous of priate treatment. Although both treatments have high
the eye. During this procedure, the ophthalmologist success rates, they do not cure diabetic retinopathy.
inserts a sm all instrum ent into the vitreous of the eye Once a patients has proliferative retinopathy, he or she
and removes the vitreous that is clouded with blood. will always be at risk for new hemorrhages.
The vitreous is replaced with a salt solution.

Figure 4-11 b. Aqueous fluid flowing into anterior cham ber

anterior cham ber (Steinman). (Steinm an).

fication, where contrast can be enhanced and m agni­

Low Vision Rehabilitation
fication varied. The occupational therapist must often
The first step in low vision rehabilitation is an accu­ work w ith the patient to improve eccentric view ing
rate refraction by the low vision optom etrist and mod­ if the m acula is involved in the disease. Nonoptical
ification of the patient's eyeglasses, if required. O ne devices such as a glucose m onitor and insulin-syringe
o f the unique problem s that occurs w ith diabetes is aids are helpful to the patient.40 Chapter 15 covers the
fluctuation of vision due to changes in refractive error rehabilitation of the diabetic patient in detail.
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 G lauco m a
diabetes is often associated w ith other conditions
treated by occupational therapists, the occupational
therapist should routinely screen for vision loss, the Description
onset o f retinal edema with A m sler grid, and insure
the patient has a thorough retinal exam ination by a Glaucoma is not a single clinical entity, but a group
eyecare practitioner every 6 months. In m anaging any of ocular diseases w ith various etiologies that cause
client w ith diabetes, even those w ithout diagnosis of an elevation of pressure in the eye (intraocular pres­
low vision, the occupational therapist should always sure (IOP]), ultim ately leading to progressive optic
be vigilant for visual changes and frequent eye exam i­ nerve dam age and loss of peripheral visual function.
nations. Figure 4 -lla is an illustration of the front o f the
A hallm ark of diabetic vision changes is impaired eye, called the anterior chamber. T h e ciliary body is
contrast sensitivity. The low vision optom etrist may the structure that produces aqueous flu id . T h is fluid is
prescribe special tinted lenses that block blue wave­ produced on a daily basis and flows to the front o f the
lengths in an attempt to improve contrast, elim inate eye as illustrated in Figure 4-1 lb. Because the eye is a
glare, and reduce sensitivity to light (photophobia).40 closed structure, if new fluid is produced on a daily
Patients often require multiple optical devices for vari­ basis, an equal am ount o f fluid must drain out of the
ous ADL. Because of their fluctuating vision, these eye to m aintain the proper IOP. Under normal condi­
individuals usually respond well to electronic m agni­ tions, the amount of aqueous fluid that is produced
is equivalent to the am ount that drains out on a daily for m easuring eye pressure. The Schiotz and
basis, m aintaining equilibrium and normal IOP. In applanation tonom eter m easure eye pressure
glaucom a, this equilibrium is disrupted. There are a by directly applying pressure on the cornea.
num ber of reasons why a person m ay develop glau­ The tonom eter is gently placed against the
com a; however, regardless of the cause, the ultimate eyeball and a pressure reading is then taken
problem is loss of th is equilibrium , which causes a rise from the instrum ent. These m ethods require
in IOP. W hen the IOP rises, the nerve fibers exiting anesthetic drops in both eyes. Eye pressure
the eye through the optic nerve are compressed and can also be m easured by sending a puff o f air
dam aged. The fibers that are generally affected in the onto the eyeball. No anesthetic eyedrops are
beginning of the disease are those that carry inform a­ required for this method.
tion about our side vision (peripheral vision). Thus, 2. Pupil d ilation: Special eyedrops are used
in the initial stages of the disease, glaucoma leads to to tem porarily enlarge the pupil so that the
a gradual loss o f peripheral vision. In most cases of eyecare specialist can obtain a better view of
glaucoma, the disease is painless because the rise in the inside o f the eve.
pressure is very gradual. As a result, a person with
3. Visual field: T h is m easures the entire area that
glaucoma may be unaw are of the problem until the
can be seen when the eye is looking forward to
loss o f vision is advanced. Thus, routine eye exam ina­
docum ent straight-ahead (central) and/or side
tions are im portant to rule out this disease, and are
(peripheral) vision. The test m easures the dim ­
the best way to avoid the consequences of glaucoma.
mest light that can be seen at each spot tested.
Glaucoma is classified as prim ary opcn-angle glau­
The test consists of responding by pressing a
coma when it is not related to another underlying con­
button every tim e a flash of light is perceived.
dition, and secondary when the cause of the glaucoma
is another ocular or system ic disease, trauma, or the 4. Visual acuity:
¥ This m easures how well the
use o f certain drugs. Prim ary open-angle glaucoma person sees at various distances. W h ile seated
represents about 70% of all glaucom a and is a chronic, 20 feet away from an eye chart, the person is
progressive disease causing optic nerve dam age and asked to read standardized visual charts with
subsequent visual field loss. It occurs prim arily in each eye. The test is perform ed w ith and w ith­
adults and generally affects both eyes, although one out corrective lenses.
eye can have more advanced disease than the other. 5. Pachym etry: This procedure u ses ultrasonic
The m ajority of persons with prim ary open-angle waves to help determ ine corneal thickness.
glaucom a have elevated IOP. As described above, the
elevated IOP observed in prim ary open-angle glauco­ Prevalence
ma usually results from decreased outflow of aqueous
fluid from the eye. T h e cause of this decreased outflow Glaucoma is an incipient disease, and can prog­
is not well understood, but may be due to acceleration ress to significant loss in peripheral visual function
and exaggeration of norm al aging changes in the area before the patient is aw are that there is a problem.
o f the eye responsible for drainage of aqueous fluid An estim ated 2.5 m illion A m ericans have open-angle
(anterior cham ber angle).44,4? glaucom a,46 although at least half of all cases may be
undiagnosed.47 Prim ary open-angle glaucom a rep­
How Is Glaucoma Diagnosed? resents about 70% o f all adult glaucom a cases.48 The
Baltim ore Eye Survey estim ated the prevalence of
Several tests can help the eyecare professional glaucom atous blindness to be 1.7 per 1,000 in the
detect glaucoma. Individuals at high risk for glaucoma general population, o f which more than 75% was due
should have a dilated pupil eye exam ination at least to prim ary open-angle glaucom a.49 O ver 11% o f all
every 2 years. High risk factors for glaucoma include blindness and 8% of all visual im pairm ent may be due
being an A frican A m erican over 40, having a fam ily to glaucom a.48 Prim ary open-angle glaucom a is 6.6 to
history o f the disease, or for the general population, 6.8 tim es more prevalent and accounts for about 19%
being over 60. Those who are very nearsighted, have of all blindness am ong A frican Am ericans, compared
a history of diabetes, have experienced eye injury or w ith 6% of blindness in Caucasians.49
eye surgery, or take prescription steroids also have
an increased risk of developing glaucom a. Japanese Risk Factors
ancestry is a risk factor for norm al-tension glaucoma.
Tests involved in the diagnosis of glaucoma include: Risk factors for glaucoma include general and ocu­
1. Tonom etry: M easures the fluid pressure lar factors (Table 4-2). Age is a m ajor risk factor for
inside the eye. There are several m ethods 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

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
Treatment of glaucom a usually begins with m edi­
A m ericans develop the disease earlier, do not respond
cations (pills, ointm ents, or eyedrops) that help the
as well to treatm en t arc more likely to require su r­
eye cither drain fluid more effectively or produce less
gery, and have a higher prevalence of blindness from
fluid. Several form s of laser surgery can also help
glaucoma than Caucasians.51 Finally, a fam ily history
fluid drain from the eve.
of glaucoma is also a significant risk factor. O cular
factors include high IOP, thinness of the cornea, and Laser Trabeculoplasty
abnorm al optic nerve anatomy.
In this procedure, a high-intensity beam of light is
aim ed at the area o f the anterior cham ber of the eye
Effect on Vision
responsible for drainage of the aqueous fluid. Several
Left uncorrected, glaucom a causes a reduction in evenly spaced burns are used to stretch the drain­
visual field (Figure 4-12), which may progress to total age holes and allow the fluid to drain better. Laser
blindness. Central vision is generally unaffected until trabeculoplasty is a com m on treatm ent if topical med­
the end stage of the disease.40 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 69

Figure 4-1 3a,h. Illustrations of ,i cataract iSteinman).

tion. Visual scan n in g strategies to com pensate for an

Conventional Surgery
overall field loss, sim ilar to techniques used w ith field
Conventional surgery m akes a new opening for cuts associated with stroke, are used as well. Severe
the fluid to leave the eye. T h is often is done after visual field loss associated w ith end-stage glaucoma
m edicines and laser surgery have failed to control can create problem s w ith orientation and mobility
pressure. and referral to an orientation and m obility (O&M )
Conventional surgery is about 60% to 80% effec­ specialist is often required.40 Electronic m agnification
tive at low ering eye pressure. If the new drainage m ay be useful because it allow s for increased contrast
opening narrows, a second operation m ay be needed. and brightness.40 The occupational therapist's role in
Conventional surgery works best if the patient has not low vision rehabilitation includes m edication m an­
had previous eye surgery, such as a cataract opera­ agement, especially if eyedrops are used; instruction
in the use of optical and nonoptical assistive devices;
Surgical intervention, the third level of treatment m odification of lighting, contrast, and other envi­
for prim ary open-angle glaucom a, is required in many ronmental factors; referral for orientation and m obil­
m oderate or advanced glaucoma patients to lower the ity; education; and involvement in support groups.
pressure if other treatm ents have not been successful. Chronic glaucoma usually responds well to treatm ent
T h is surgery is also designed to im prove the drainage if the patient consistently adm inisters eyedrops. For
o f aqueous from the eye. Filtration surgery usually this reason, the occupational therapist should care­
results in a dram atic and stable reduction in ЮР. ^ fully evaluate medication m anagem ent if a patient
Although long-term control of IOP is often achieved, experiences vision loss w ith chronic glaucoma.
many patients must rem ain on m edications and may
require additional surgery.

Low Vision Rehabilitation C atar ac t

M any patients with AM D may not have had a
recent exam ination and may benefit from a change in Description
eyeglass prescription. For patients with intact central
A cataract is an opacification or clouding of the lens
visual acuity and peripheral visual field loss, optical
in the eye that affects vision. Cataracts are very com ­
devices that m inify the visual field can be used. This
mon in older people and can occu r in either or both
is the opposite approach used for m acular degenera­
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
Risk Factors
reaching the retina. The lens consists mostly of The m ain risk for developing cataracts is aging. By
water and protein. W hen the protein clumps age 65, about h alf of all A m ericans have developed
up, it clouds the lens and reduces the light som e degree of lens clouding, although it may not
that reaches the retina. The clouding may im pair vision. O ther significant factors are diabetes,
becom e severe enough to cause blurred vision. a fam ily history of cataracts, previous eye injury or
Most age-related cataracts develop from pro­ inflam m ation, previous eye surgery, prolonged use
tein dum pings. W hen a cataract is sm all, the of corticosteroids, excessive exposure to sunlight, and
cloudiness affects only a sm all part of the lens. smoking.
Over time, the cloudy area in the lens m ay get
larger, and the cataract may increase in size. Effect on Vision
2. The clear lens slow ly changes to a yellow ish/brow n­ A cataract usually develops slowly and causes
ish color. The clear lens slowly changes color no pain. As a result, most people are unaw are of its
w ith age. At first, the am ount of tinting may development until it begins to interfere w ith everyday
be sm all and m ay not cause a vision problem. activities. Sym ptom s of a cataract include:
Over tim e, increased tinting may m ake it more • Blurry vision
d ifficult to read and perform other routine
• Increasing difficulty with vision at night
activities. This gradual change in the amount
o f tinting does not affect the sharpness of • Sensitivity to light and glare
the im age transm itted to the retina. With • Poor contrast sensitivity
advanced lens discoloration, a person may • Halos around lights
have difficulty identifying colors.
• The need for brighter light for reading and other
• Frequent changes in eyeglass or contact lens pre­
How Is a C ataract Diagnosed? scription
A cataract is easily detected in the course of any • Fading or yellow ing of colors
routine eye exam ination. The eyecare provider finds • Double vision in a single eye
reduced visual acuity that cannot be improved by
m odifying the patient's prescription. After dilating
Figure 4-14 illustrates the effect of cataract on
the pupil, the eye doctor uses instrum ents that pro­ v isio n .
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. The only effective treatm ent for a cataract is sur­
gery to remove the clouded lens and replace it w ith a
Prevalence clear lens implant. The lens im plant can correct refrac­
tive error as well. In some cases, one eye is corrected
Hye D iseases Prevalence Research Group com ­
to focus at near and the other to focus at distance.
pleted a research study in 2004 designed to determ ine
Cataracts cannot be cured with m edications, dietarv
the prevalence of cataract in the United States and to
supplements, exercise, or optical devices. However,
project the expected change in these prevalence fig­
in the early stages of cataract development, the sym p­
ures by 2020.54 They collected data from major popu­
toms may be improved w ith new eyeglasses, brighter
lation-based studies in the United States. They found
lighting, antiglare sunglasses, or m agnifying lenses.
that an estim ated 20.5 m illion (17.2%) A m ericans older
W hen these m easures are no longer effective, surgery
than 40 years have cataract in either eye. Women have
is necessary. O phthalm ologists treat cataract surgi­
a significantly higher age-adjusted prevalence of cata­
cally when vision loss interferes w ith a person's activi­
ract than men in the United States. The total number
ties, such as w orking, driving, reading, or w atching
of persons who have cataract is estim ated to rise to
TV. Typically, if a person requires surgery on both
30.1 m illion by 2020. They concluded that the num ber
eyes, the surgery is perform ed on each eye at separate
o f A m ericans affected by cataract and undergoing
times, usually about 4 to 8 weeks apart.
cataract surgery will dram atically increase over the
Cataract rem oval is one of the most com m on, saf­
next 20 years as the US population ages.54
est, and most effective types of eye surgery. More
than 1.5 m illion cataract operations are performed
Figure 4-14. Illustration of visual problems of a c li­
cnt with a cataract (Steinman).

each year. In a study of about 18,000 patients, Desai lens (IOL). An lOL is a clear, plastic lens that requires
et al reported that 92% of patients without other eye no care and becom es a permanent part o f the person's
disease achieved 20/40 or better visual acuity.-5 The eye. If a person cannot have an IOL because of some
main risk indicators associated with visual outcomes other eye disease or problems during surgery, a soft
and complications related to surgery were age, other contact lens, or glasses that provide high m agnifica­
eye diseases, diabetes, and stroke. Other studies have tion, would be required to obtain clear vision.
reported sim ilar results.'’6'57 Although cataract surgery is one o f the most effec­
There are two types of cataract surgery. The most tive surgical procedures, there are potential risks,
com m on procedure is called phacoem ulsification. including inflam m ation, infection, bleeding, swelling,
During this procedure, the surgeon removes the cata­ retinal detachment, and glaucoma. Occasionally, cata­
ract but leaves most of the outer layer (lens capsule) ract surgery fails to improve vision because of condi­
in place. The capsule helps support the lens implant tions such as glaucoma or m acular degeneration.
when it is inserted. During phacoemulsification, the Another potential complication of cataract surgery
ophthalmologist makes a sm all incision where the is a condition called posterior capsule opacification.
cornea meets the conjunctiva and inserts a needle- Common terms for this condition are second cata­
thin probe. The surgeon then uses the probe, which ract or after cataract. This condition occurs when
vibrates with ultrasound waves, to break up (emul­ th e back of the lens capsule (the part of the lens that
sify) the cataract and suction out the fragments. The isn't removed during surgery) eventually becomes
lens capsule is left in place to provide support for the cloudy and blurs the client's vision. Posterior capsule
lens implant. This procedure is som etim es referred to opacification can develop months or even years after
as small incision cataract surgery. The other procedure is cataract surgery and occurs about 25% of the time.
called extracapsular surgery. This technique is generally Treatment for posterior capsule opacification involves
used if the cataract has advanced beyond the point a technique called YAC. laser capsulotomy, in which
where phacoemulsification can effectively break up a laser beam is used to make a small opening in the
the clouded lens. This procedure requires a larger inci­ clouded capsule to let light pass through. This is a
sion where the cornea and sclera meet. Through this quick and painless outpatient procedure that usually
incision, the ophthalmologist opens the lens capsule, takes less than 5 minutes.
removes the nucleus in one piece and vacuums out the
softer lens cortex, leaving the capsule in place. With Low Vision Rehabilitation
either procedure, after the lens has been removed, it is
Because visual impairment from cataracts can be
replaced with an artificial lens, called an intraocular
corrected, cataracts rarely are the prim ary diagnosis
of moderate or severe vision loss. A s normal lens 3. Klein R, Klein BEK, Linton K. Prevalence of age-relat-
changes in the eyes of clients over 80 years old involve ed maculopathy. The Beaver Dam Study. Ophthalmology.
mild cataracts, in most cases of cataracts, low vision 4. Hyman LG, Lilienfeld AM, Ferris FL 3rd, fine S i. Senile
rehabilitation involves m anaging the m ild im pair­ macular degeneration: a case controi study. Am I Epidemiol.
ment in contrast sensitivity, light sensitivity, and visu­ 1983;118:213-227.
al acuity in older patients w ith a nonvisual prim ary 5. Murphy RP. Age-related macular degeneration. Ophthalmology.
diagnosis. In some cases, especially when other visual 1986;93:969-971.
6. Ferris FLI. Fine SL. Hyman LA. Age-related macular degen­
pathologies are present, if a client is medically frag­
eration and blindness due to neovascular maculopathy. Arch
ile or refuses the surgery, more severe cataracts are Ophthalmol. 1984;102:1640-1642.
not removed. W hen moderate cataracts are involved, 7. Fine AM, Elman MJ, Ebert IE, Prestia PA, Starr JS, Fine SL. Earliest
treatm ent focus is on m anagem ent o f glare, careful symptoms caused by neovascular membranes in the macula.
control o f lighting, and environm ental interventions Arch Ophthalmol. 1986;104:513-514.
8. Schmidt-Erfurth U, Miller |W. Sickenberg M, et al. Photodynamic
and electronic devices to m axim ize contrast of read­ therapy with verteporfin for choroidal neovascularization caused
ing material and objects with good results. Severe by age-related macular degeneration: results of treatments in a
cataracts left untreated w ill result in profound vision phase 1 and 2 study. Arch Ophthalmol. 1999;l 17:1177-1187.
loss. 9. Schwartz SD. Age-related maculopathy and age-related macu­
lar degeneration. In: Silverstone B. et al, Eds. The Lighthouse
Handbook on Vision Impairment and Vision Rehabilitation. New
York: Oxford University Press: 2000.
Su m m a r y 10. Leibowit/ HM, Krueger DE, Maunder I R, et al. The Framingham
Eye Study monograph: An ophthalmologic al and epidemiologi­
cal study of cataract, glaucoma, diabetic retinopathy, mac ular
It is im portant for the occupational therapist spe­
degeneration, and visual acuity in a general population of 2631
cializin g in low vision rehabilitation to keep updated adults. 1973-1975. Surv Ophthalmol. 1980;24<Suppl>:335-610.
about the latest research regarding eye pathology and 11. Warren M. Providing low vision rehabilitation services with
treatment. In a m ultidisciplinary low vision reha­ occupational therapy and ophthalmology: a program descrip­
bilitation setting, the occupational therapist often tion. Л т / Occup Гher. 1995; 49(9):877-883.
12. Hirvela H. Luukinen H, Laara E, Sc L, Laatikainen L. Risk factors
is involved in helping clients with medication m an­
of age-related maculopathy in a population 70 years of age or
agement. With clients who have active pathology, a older. Ophthalmology. 1996;103<6j:87l-877.
treatm ent plan usually includes instructing the client 13. Klaver CC, Wolfs RC, Assink )), van Duijn CM, Hof man A,
about how to self-m onitor for vision changes and de long PT. Genetic risk of age-related maculopathy. Arch
educating the client regarding the cause, treatment, Ophthalmol. 1998;116:1646-1651.
1-4. Klein R, Klein BE, Franke T. The relationship of cardiovascular
and prognosis associated with eye diseases. In a home
disease and its risk factors to age-related maculopathy. The
care, general ou tp atien t or inpatient setting where the Beaver Dam Eye Study. O phthalm ology. 1993;100(3):406-4I4.
occupational therapist does not practice w ith eyecare 15. Klein R. et al. The five-year incidence and progression of age-
providers, the occupational therapist w ho special­ related maculopathy: The Beaver Dam Study. Ophthalmology.
izes in low vision plays an active role in insuring 1997;104:7-21.
1(>. Newsome D. MedicaI treatment of macular diseases. Ophthalmol
that patients are receiving appropriate eyecare and
Clin North Am. 1993;6:307-314.
insuring appropriate referrals. In inpatient settings 17. Cho E, Hung S. Willett WC, et al. Prospective studv of dietary fat
with older persons who typically also have nonvisual and the risk of age-related macular degeneration. Am I Clin i\utr.
prim ary diagnoses, the occupational therapist often 2001 ;73(2):209-218.
is the first to identify the need for a referral to a low IB. Seddon |M . Cote), Rosner B. Progression of age-related macular
degeneration: association with dietary fat. transunsaturated fat,
vision optom etrist. In these settings, the occupational
nuts, and fish intake. Arch Ophthalmol. 2003; 121(121:1728-
therapist may provide stop-gap, nonoptica 1, low vision 1737.
interventions necessary to m aintain a rehabilitation 19. Seddnn JM, Rosner B, Sperduto RD, et al. Dietary fat and risk for
program w hile the patient is w aiting for an eye exam i­ advanced age-related macular degeneration. Arch Ophthalmol.
nation. 2001 ;119(81:1191-1199.
20. Age-Related Eye Disease Study Research Group. A randomized,
placebo-controlled, clinical trial of high-dose supplementation
with vitamins С and E. beta carotene, and zinc for age-related
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22. de Boer MR, Pluijm SM, Lips P, et al. Different aspects of visual
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2. Bird ЛС, Brcssler NM, Bressler SB, et al. An international classifi­
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1900; discussion 1900-1. nosis is less than 30 years. Arch Ophthalmol. 1984;102<4>:520-
24. Siatkowski RM, Zimmer B, Rosenberg PR. The Charles-Bonnet 526.
syndrome. ) Clin Neuroophthalmol. 1‘>90: 10:215 -21 tt. 39. Klein R, Klein BE, Moss SE, Davis MD. DeMets DL. The
25. Argon laser photocoagulation tor neovascular maculopathy. Wisconsin epidemiologic study of diabetic retinopathy. III.
Five-year results from randomized clinical trials. Macular Prevalence and risk of diabetic retinopathy when age at diag­
Photocoagulation Study Group. Arch Ophthalmol. nosis is 30 or more years. Arch Ophthalmol. 1984;102(4):527-
1991:109(8):! 109-1114, 532.
26. Krypton laser photocoagulation for idiopathic neovascular lesions. 40. Brilliant RL. Essentials o f Low Vision Practice. Boston: Butterworth-
Results ot a randomized clinical trial. Macular Photocoagulation Heinemann; 1999.
Study Group. Arch Ophthalmol. 1990;! 08(6) :832-837. 41. Horowitz A, Leonard F, Reinhardt |. Measuring psychosocial
27. Ciulla ТА. Danis RP, Harris A. Age-related macular degen­ and functional outcomes of a group model of vision reha­
eration: a review ot experimental treatments. .Sun Ophthalmol. bilitation services for older adults. I Vis Impairment & Blind.
I998;43(2):134-I46. 2000;94(5):328-338.
28. TAP Study Group. Photodvnamic therapy of subfoveal c horoidal 42. Early Treatment Diabetic Retinopathy Study Research Group.
neovascularization in age-related macular degeneration with Photocoagulation for diabetic macular edema. Early Treatment
verteporfin: one-year results of 2 randomized clinical trials— Diabetic Retinopathy Study report number 1. Arch Ophthalmol.
TAP л-port. Treatment of age-related macular degeneration with 1985;103(12):1796-1806.
photodynamic therapy. Arch Ophthalmol. 1999; 117(101:1329- 43. Smiddy WE, Feuer W. Irvine WD. Flynn IIVV Jr, Blankenship GW.
1345. Vitrectomy for complications of proliferative diabetic retinopathy.
29. Verteporfin therapy of subfoveal choroidal neovascularization in Functional outcomes. Ophthalmology. 1995:102(11):1688-
age-related macular degeneration: two-year results of a random­ lf>95-
ized clinical trial including lesions with occult with no classic 44. Alvarado J, Murphy C, luster R. Trabecular meshwork cellularity
choroidal neovascularization—verteporfin in photodynamic in primary open-angle glaucoma and nonglaucomatous nor­
therapy report 2. Arch Ophthalmol. 200l;13l(5):541-560. mals. Ophthalmology. 1984;91:564-579.
30. Bressler NM. Early detection and treatment of neovascular ■15. Grierson I. What is open angle glaucoma? Eye. 19в7;1:15-28.
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2002;15:142-152. incidence in the United States. Invest Ophthalmol Vis Sci.
31. Gragoudas ES, Adamis AP, Cunningham ET |r, Feinsod M, 1997;38:83-91.
Guyer DR; VF.GF Inhibition Study in Ocular Neovascularization 47. Prevent Blindness America. Vision Problems in the U.S.
Clinical Trial Group. Pegaptanib for neovascular age-related Schaumburg, IL: Prevent Blindness America; 1994.
macular degeneration. .V Engl I Med. 2004;351(27H2H05-28I6. 48. Leske MC, Rosenthal J. The epidemiologic aspects of open-angle
32. Azab \t, Benchaboune M, Blinder KJ, et al. Verteporfin therapy glaucoma. Am I Epidemiol. 1979;109:250-272.
of subfoveal choroidal neovascularization in age-related macu­ 49. Sommer A, Tielsch JM. Katz J, et al. Racial differences in the
lar degeneration: meta-analysis of 2-year safety results in three cause-specific prevalence of blindness in East Baltimore. N Engl
randomized clinical trials: Treatment of Age-Related Macular I Med. 1991;325:1412-1417.
Degeneration With Photodynamic Therapy and Verteporfin in 50. Hollows FC, Graham PA. Intraocular pressure, glaucoma, and
Photodynamic Therapy Study Report no. 4. Retina. 2004:24(11:1- glaucoma suspects in a defined population. Hi I Ophthalmol.
12 . 1966;50:570-586.
33. AREDS. A randomized, placebo-controlled, clinical trial of high- 51. Tielsch JM, Sommer A, Katz J. Royall RM. Quigley HA, Javitt J.
dose supplementation with vitamins С and F., beta carotene, Racial variations in the prevalence of primary open-angle glau­
and zinc for age-related macular degeneration and vision loss: coma. The Baltimore Eye Survey. /АМА. 1991;266:369-374.
AREDS report no. 8. Arch Ophthalmol. 2001:119(10):1417- 52. Baez K. Spaeth GL. Argon laser trabeculoplasty controls one-
1436. third of patients with progressive, uncontrolled open-angle glau­
34. National Institute of Diabetes and Digestive anil Kidney Diseases. coma for five years. Trans Am Ophthalmol Soc. 1991;84:47-58.
National Diabetes Statistics Fact Sheet: General Information and 53. Werner EB. D ranсe SM, Schulzer M. Trabeculectomy and the
National Estimates on Diabetes in the United States, 2003. progression of glaucomatous visual field loss. Arch Ophthalmol.
Bethesda, M D: US Department of Health and Human Services, 1977;95:1374-1377.
National Institutes of Health: 2003. 54. Congdon N, Vingerling |R. Klein BF. et al. Prevalence of cataract
35. Klein R. Klein BF, Moss SE, Davis MD, DeMets DL. The and pseudophakia/aphakia among adults in the United States.
Wisconsin Epidemiologic Study of Diabetic Retinopathy. X. Arch Ophthalmol. 2004;122:487-494.
Four-year incidence and progression of diabetic retinopathy 55. Desai P. The National Cataract Surgery Survey: II. Clinical out­
when age ot diagnosis is 30 years or more. Arch Ophthalmol. comes. Eye. 1993;7<Pi 4):489-494.
1989: l07(2):244-249. 56. McGwin G Jr, Scilley K. Brown J, Owsley C. Impact of cataract
36. Klein R, Klein BE, Moss SE. Davis MD. DeMets DL. The surgery on self-reported visual difficulties: comparison with a
Wisconsin Epidemiologic Study of Diabetic Retinopathy. IX. no-surgery reference group. / Cataract Refract Stirg. 2003:29'5):
Four-year incidence and progression of diabetic retinopathy 941-948.
when age at diagnosis is less than 30 years. Arch Ophthalmol. 57. Desai P, Reidy A, Minassian DC, Vafidis G, Bolger J. Gains
1989;107(2):237-243. from cataract surgery: visual function and quality of life, fit I
37. Klein R. The epidemiology of diabetic retinopathy: findings from Ophthalmol. 1996;80(10):868-873.
the Wisconsin Epidemiologic Study of Diabetic Retinopathy. Int
Ophthalmol Clin. 1987;27<4>:230-238.
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 1 Thin in
the Middle the Middle

Thin at Thick at
^ the edge ► the edge
Figure 5-1. A convex lens is thicker in the middle and thinner Figure 5-2. A concave lens is thicker at the edges and thinner
at the edges (Steinman). in the m iddle (Steinman).

you will see the acronvm OU used. T h is is used to are clear, it is a concave lens, opposite to the effect of
refer to both eyes, or oculus uturque. myopia.
Convex lenses are also used in most low vision opti­
cal devices such as handheld m agnifiers, stand mag­ Cylindrical Lens (Astigmatic
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 W hile a convex or concave lens has only one uni­
ing through it. If distance objects are blurred and near form pow er throughout the lens, a cylindrical lens has
objects clear, it is a convex lens. Note that because the two powers and is used for the treatm ent of astigm a­
lens com pensates for hyperopia, it w ill have an effect tism. Most clients have a com bination of hyperopia
opposite to the refractive error, m aking objects clear and astigm atism or myopia and astigm atism . The
at near. occupational therapist can easily determ ine if a cli­
ent has astigm atism by looking at his or her eyeglass
Concave Lens (Minus Lens) prescription. A typical prescription for a clicnt with
astigm atism and myopia (nearsightedness) would
A concave lens is th in ner in the m iddle and
look like this:
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
OD: -1.50 - 1.25 x 180
prescription for a convex lens, the m inus sym bol is
OS: -1.50 - 1.50 x 180
used. Concave lenses are used by eye doctors when
prescribing glasses for myopia (nearsightedness), as
This would be read as: Right eye, m inus 1.50 w ith
described in Chapter 2.
-1.25 axis 180 and left eye, m inus 1.50 with -1.50 axis
A typical prescription for a client w ith myopia
(nearsightedness) would look like this:
An exam ple of a prescription for a client w ith astig­
m atism and hyperopia (farsightedness) would look
OD: -1.50
like this:
O S: -1.50

OD: +2.50 - 2.25 x 180

The therapist can quickly check to see if a client has
OS: -2.00 - 1.75 x 180
been prescribed a concave lens for myopia by look­
ing through it. If distance objects look sm aller and
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).

The therapist can quickly check to see if a client has entering the eye are focused behind the retina, which
been prescribed a cylindrical lens for astigmatism by would cause blurred vision. In Figure 5-4, the ciliary
looking through it and slowly turning the lens clock­ m uscle has contracted and allows the light rays to
wise or counterclockwise. If the object being viewed focus on the retina.
changes shape as it is rotated, the correction has a The accommodative ability o f an individual is
cylindrical component to correct for astigm atism. 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
A c c o m m o d a t io n 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
Definition and Description across the population that it is possible for an optom ­
etrist to predict a client's age within several years sim ­
Assum ing that any refractive error has been correct­ ply by m easuring the amplitude of accommodation.
ed with eyeglasses, the human visual system is physi­ The accom m odative am plitude declines gradually
ologically focused for objects at distances of 20 feet with age, and by 40 to 45 years of age the decline is
and greater. If an object is brought closer than 20 feet, significant enough to interfere with the ability to see
a focusing adjustment must be made or the object will small print held at a normal reading distance o f 40 cm
appear blurred. I his focusing adjustment is referred or 16 inches. This is referred to as presbyopia.
to as accommodation. Accommodation is the ability Presbyopia is a condition in which near visual acu­
to change the focus of the eye so that objects at dif­ ity is decreased because of an age-related decline in
ferent distances can be seen clearly. Accommodation accommodative ability. All adults after the age o f 45
occurs by stim ulating the smooth muscle of the ciliary or so have this condition, and require reading glasses
body in the eye to contract, thereby enabling the lens or som e modification of their eyeglasses to account
to change its shape to become more convex. Optically, for it. Reading glasses that supplement accom m oda­
therefore, accommodation is identical to putting a tion position plus lenses in front of each eye. Bifocals
variable plus-lens in front of the eye. Figure 5-3 is a are lenses that add extra plus to a person's distance
cross-section of the human eye show ing the lens and prescription, referred to as reading addition or by the
the ciliary m uscle in its relaxed state. The light rays shorthand term add. Sincc most clients will be older,
occupational therapists working in the field of low Thus, close working distances require a consider­
vision rehabilitation of adults usuallv deal w ith clients able amount of accom m odation. In the adult popula­
who have presbyopia and require a reading addition tion over the age o f 40 years, the ability to accom m o­
to focus at near. date has declined significantly. T h e optom etrist must
In the report from an eyecare practitioner, the read­ consider this when prescribing the optical aid and the
ing addition is specified as the num ber at the end of occupational therapist m ust always be aware o f the
the prescription for refractive error. It alw ays follows issue of accom m odation when instructing clients in
a plus sign, but should not be confused w ith the cor­ the use of optical devices.
rection for hyperopia. An exam ple for a correction for If a client is experiencing difficulty using an optical
1 diopter (D) of hyperopia, 2.25 D of astigm atism , with device, one of the issues to consider is accom m oda­
2.50 D o f reading addition to com pensate for presby­ tion. This w ill be reviewed in detail in Chapter 13.
opia would be as follows:

OD: +1.00 - 2.25 x 180, +2.50 O ptics o f L enses

OS: +1.00 - 2.25 x 180, +2.50
M anufacturers use two different m ethods to label
the power or m agnifying capability of optical devices.
Significance of A ccom m od ation Som e designate the device or lens by its actual power,
for Low Vision Rehabilitation w hile others label the device using the term m agnifi­
cation. T h is inform ation, in w hichever form at provid­
W hen working with optical aids, it is im portant to ed, tells the therapist how to position the device and
consider accom m odation and how it may impact on to instruct the client how to use the optical device. It
the c lie n ts ability to use the device. With som e opti­ is, therefore, im portant to understand various param ­
cal devices, the client is required to accom m odate and eters of lenses, such as focusing power, focal distance,
with others accom m odation is not required. To deter­ and m agnification.
m ine if a client must use accom m odation, one must
consider a num ber of factors, including the working Focusing Power o f a Lens
distance, or the distance from the eye to the material
being viewed. T h e working distance is the distance at The unit of m easurem ent of the focusing power of
which the object being viewed is held from the eye, a lens is called a diopter (D). The definition of a 1 D
always specified in m etric units. If an object is held lens is one that w ill focus parallel light rays entering
at 20 feet (~6 m eters), no accommodation is required. the lens from a distant object to a point focus 100 cm
As the object is brought closer, more and more accom ­ away (Figure 5-5). We refer to this as a 1 D lens. As
m odation is required. We determ ine the amount the power of a lens increases, it focuses parallel rays of
of accom m odation required by using the following light closer and closer to the back surface o f the lens.
formula: We use the follow ing form ula to determ ine the
power of a lens:
Accom m odation Demand = 100/working distance
in centim eters D = 100/d (cm)

E xam ple 1 Exam ples

If a client holds the reading m aterial al 40 cm , the 1. A lens focuses parallel light at 1 m eter - D =
am ount o f accom m odation required is: 100/100 = 1 D
2. A lens focuses parallel light at 50 cm - D =
Accom m odation Demand = 100/distance (cm) 100/50 = 2 D
Accom m odation Demand = 100/40 = 2.50 D 3. A lens focuses parallel light at 33 cm - D =
100/33 = 3 D
E xam ple 2 4. A lens focuses parallel light at 25 cm - D =
If a client holds the reading material at 10 cm, the 100/25 = 4 D
am ount o f accom m odation required is:
5. A lens focuses parallel light at 10 cm - D =
100/10 = 10 D (Figure 5-6)
Accom m odation Demand = 100/distance (cm)
Accom m odation Demand = 100/10 = 10 D
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

Figure 5 -6 . Five exam ples of

convex lenses of varying power

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 1. The focal length of a 1 D lens - = 100/1 = 100
mula for accommodative demand is the sam e because
it measures the required focusing power. 2. The focal distance of a 2 D lens - = 100/2 = 50
Focal Distance (Length) of a Lens 3. The focal distance of a 3 D lens - = 100/3 = 33
Another important term used in optics is the focal
distance of a lens. The focal distance of a lens is the 4. The focal distance of a 4 D lens - = 100/4 = 25
distance at which the lens brings parallel rays to a cm
sharp focus (Figure 5-5). It is the distance between the 5. The focal distance of a 10 D lens - = 100/10 = 10
lens and the point focus. The point or plane at which cm
the lens focuses light is called the focal point of the
lens. The focal distance of the lens is determined by Knowledge of the focal distance is critical for the
the power of the lens in diopters.
occupational therapist because it determ ines the dis­
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
tance at which the client needs to hold the optical
fo llo w in g fo r m u la :
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.
Focal Distance (cm) = 100/D For example, a client is using a 10 D handheld mag­
nifier to read a label on a can of soup. How far from
Thus, the focal distance of a lens is the reciprocal the can of soup should the client hold the m agnifier
of the dioptric power. The greater the power of the
to achieve most m agnification with a sharp focus? To
lens, the closer the image is focused to the back of the
determ ine lens-to-object distance of this magnifier,
use the formula:
Lcns-to-objcct distance = 100/D, lens-to-object d is­ Fortunately, one general convention has emerged
tance = 100/10 = 10 cm in low vision care that helps resolve this problem . The
m agnification of any near device can be described as
In this case, the occupational therapist would the power "equivalent" to the power o f the near read­
instruct the client to hold the m agnifier 10 cm from ing addition. T h is is referred to as equivalent power
the can o f soup. Thus, if the dioptric power of the lens (EP).1 All m ajor m anufacturers now list the EP of
is known, the therapist can determ ine the appropriate their devices. In order to understand how EP relates to
lens-to-object distance of the optical device. m agnification, one must first understand the various
ways that an object can be m agnified to com pensate
Optics o f Magnification for im paired visual acuity.

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
Methods o f Achieving
of 6 D, 10 D, or 20 D. Another method used by m anu­ Magnification
facturers to describe an optical device is by its degree
O ne of the prim ary ways to com pensate for
of m agnification. A device m ight be labeled as a 5X or
im paired visual acuity is to m agnify the object of
10X m agnifier, for example. Unfortunately, the conven­
interest. All methods of m agnification enlarge the
tion used to calculate m agnification is inconsistent.
retinal image of an object. There are four m ethods of
The most com m on form ula used to relate the power
achieving this goal. T hese four m ethods are actually
of a lens to its m agnifying ability is:
variations of cither relative distance or relative size
m agnification. The relationship betw een relative size
M = D/4
and relative distance m agnification form s the founda­
where M = M agnification
tion for understanding all interventions, optical and
nonoptical, that involve m agnification of the object of
interest to com pensate for inadequate visual acuity.
Exam ples
A lens has a power of 20 D. W hat is its m agnifying Relative Size M agnification
In relative size m agnification, the actual size of the
object is increased. To avoid confusion with the many
M = D/4
other definitions of m agnification, the convention is
M = 20/4 = 5X
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
O ther m anufacturers may use the formula:
size of the retinal im age is doubled. To achieve 2X
enlargem ent, therefore, we sim ply enlarge the object
M = D/4 +1
twofold. If a client has trouble reading 8 point font,
but can fluently read the 16 point font typical of large
O th ers m ay use the form ula:
print books, the therapist could print a docum ent on
the computer using 16 point font or use large-print
M= D/2.5
books typically printed with 16 point letters, as long as
the eye-to-object distance rem ained the same.
Thus, the actual m agnification of a device marked
This approach is relatively easy and can be an inex­
as 4X may d iffer betw een m anufacturers depending
pensive option that is generally w ell-accepted because
on the definition used to determ ine the m agnification.
the client does not require any optical aids and can
In addition, for other devices such as telescopes and
read at a normal distance. However, as the m agnifi­
video m agnifiers, m agnification is described as how
cation dem ands grow and the print size for books is
much the im age viewed through the optical device is
increased, the size and weight becom e issues. This
enlarged. For exam ple, a 4X telescope im plies that the
method of m agnification, therefore, is generally best
object size as viewed through the telescope is 4 times
suited for clients with m ild to moderate loss of vision.
larger than the sam e object viewed without the tele­
It is also used in com bination w ith other m ethods of
scope. This inconsistency in term inology is a source
m agnification.
o f great confusion for therapists. Because of this
inconsistency, in this text we use the term m agnifica­
Relative Distance M agnification
tion only in a general qualitative sense, as in “to make
A nother simple m eans o f achieving m agnifica­
som ething appear larg er"
tion of an object is to move closer to it. As an object
is moved closer to the eye, the retinal image of the
Projection M agnification
object increases. If the distance is halved, the retinal
image size doubles and 2X m agnification is achieved. Projection m agnification refers to enlarging an
To achieve 4X m agnification, the therapist would object by projecting on a screen; this is the sam e as
decrease the distance by one-fourth. If a client is hav­ size m agnification. Electronic devices like closed cir­
ing trouble seeing a 20-inch television at a distance cuit televisions (CCTV) increase the size of the image
o f 12 feet, the therapist can suggest that the client to be viewed through the projection process, and like
move to 6 feet aw ay *
T h is would double the size of the size and angular m agnification may be described as
retinal im age of the television and m agnify the image an enlargem ent ratio. A 4X enlargem ent on a CCTV
twofold. screen m eans that the 1.5 mm high, 8 point newsprint
If a client is having difficulty reading a newspaper being viewed under the cam era o f the CCTV w ill be
at 40 cm , bringing the newspaper closer to 10 cm d is­ enlarged 8X to 12 m m on the screen. A CCTV can
tance would m agnify the print 4X. However, moving be used to project printed and graphic m aterials to
the newspaper this close creates another problem. increase their size.
Recall the discussion above about accomm odation. In low vision care rehabilitation, the type o f m ag­
The closer an object is brought to the eye, the more nification used is dependent on many factors that will
accom m odation is required. Although decreasing the be discussed in Chapter 13. It is not unusual to use a
working distance from 40 cm to 10 cm achieves 4X com bination of m agnification system s. For exam ple,
m agnification, the client would experience blurred the eye doctor may prescribe a m agnifier and the
vision if he/she is unable to accom m odate for that therapist may suggest the use of larger print. How
distance. W hile a young child would be able to accom ­ to com bine m agnification will be discussed in the
modate even at 25 cm, this would not be possible advanced optics section o f Chapter 13.
for an adult, particularly an adult age 40 and older. Lovie-Kitchin and W hittaker compared the effect
To solve this problem in adult clients with limited on reading rates o f adults using relative distance ver­
accom m odation, the eyecare practitioner prescribes a sus relative size m agnification.2 They found that the
reading addition or other optical device that focuses reading rates of the subjects with low vision did not
the light on the retina. In this example, the am ount of differ significantly with the two m ethods of provid­
additional plus required to read at 25 cm can be calcu­ ing m agnification if the m agnification provided was
lated using the formula described above. adequate. They also concluded that for most tasks, it
is more practical to enlarge the image optically, rather
Power (Diopters) = 100/D (cm) = 100/25 = 4 D. than to enlarge the reading material physically.2

The am ount of relative distance m agnification can,

therefore, be described in term s of the additional plus Field of V iew
power required to see som ething at a given distance,
otherw ise called equivalent power. Field of view refers to the size of the area that can
be viewed through a lens, m agnifier, or telescope.
Angular M agnification Typically, when we are reading a book, we are able to
A ngular m agnification is the m agnification exp e­ see the entire page at once. Although only the words
rienced when a person looks through a device like a we are looking at are clear, the rest o f the sentence,
telescope. A ngular m agnification also increases the paragraph, and page are visible in our peripheral
size o f the retinal image just like relative size and rela­ vision. This is im portant because it is this peripheral
tive distance m agnification. The advantage of angular vision that helps us know where to move our eyes next
m agnification is that it can be used when moving clos­ to continue to effectively gather visual inform ation.
er to an object or enlarging it is impractical or im pos­ W hen introduced to an optical device for the first time,
sible. Viewing a sporting event is an exam ple of such a clients often are pleased that they can now see detail
situation. If an individual sits far from the action, nei­ better but com plain about the reduced field of view.
ther relative distance nor relative size m agnification is A com m on question is "C an't I find a m agnifier with
possible. However, the use of a telescope or binoculars a larger field of view ?" The answer, unfortunately, is
w ill m agnify the object of interest. W hen view ing simple. W hen a client uses an optical device, the field
objects further than 20 feet, angular m agnification is of view will always be sm aller; the stronger the mag­
an optical method of achieving size m agnification, nification, the sm aller the field o f view. M agnification
and the m agnification specification can be described is like enlarging on a copy m achine when the paper
as an enlargem ent ratio. A 4X telescope produces the size cannot be changed. If the page is doubled in size,
sam e effect as enlarging an object 4X. 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 the use of these devices in ADL. In this chapter, we
reading difficult, interfering with speed, fluency, and reviewed the basic concepts that occupational thera­
com prehension. The reason that larger size handheld pists must know to com fortably work w ith optical
m agnifiers enable people to see with a larger field of devices.
view is generally because larger diam eter lenses gen­
erally have less m agnification.
W hen using optical devices, a num ber of factors R eferences
affect the field of view through the device. These are
listed in Table 5-1. Stronger m agnifiers have sm aller 1. Bailey IL. Equivalent viewing power or magnification? Which is
fields o f view because they must be m ade with sm aller fundamental? The Optician. 1984;188:14-18.
diam eters and must be held closer to the material 2. Lovie-Kitchin Whittaker S. Rdative-size magnification versos
relative-distance magnification; Effect on the reading perfor­
being viewed. The field of view also becom es sm aller
mance of adults with normal and low vision. / Vis Impairment &
if the client moves his or her eyes away from the mag­ Blind. 1998;16:433-446.

The use of optical devices is an integral part of
low vision rehabilitation. O ccupational therapists will
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 the field of low vision rehabilitation, depression and
other psychosocial problems are important client fac­
An enduring irony of low vision rehabilitation is tors that must be considered in intervention. Profound
that potential beneficiaries of services often resist par­
or peripheral vision loss that requires focus on non­
ticipation. It is not uncommon to find that once clients visual compensatory strategies presents additional
discover that interventions do not restore vision, they
cognitive demands as well. A s with other disabilities,
drop out of treatment, even though compensatory
occupational therapists address all aspects of per­
low vision rehabilitation is available that mav ¥ restore formance (physical, cognitive and psychosocial, and
nearly all activities of daily living (ADL), most instru­
contextual) when providing low vision intervention3
mental activities of daily living (IADL), and many
and this includes consideration of the psychosocial
leisure and vocational occupations. We feel that this
problems commonly associated with vision im pair­
resistance occurs because psychosocial and cognitive ment. This chapter is designed to provide background
effects of adventitious (later onset) vision loss can information about the psychosocial issues related to
present unique and substantial complications that
vision impairment.
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 Fa c t o r s A ffecting
rehabilitation. Clients who do not cope or adapt well
A d justm en t t o V ision
to vision impairment arc at risk for depression, which
may have a negative impact on rehabilitation. O ne of Im pa irm en t
the very important issues in low vision rehabilitation
is the high prevalence of depression and psychoso­ Clinical reports and mostly retrospective descrip­
cial problems associated with vision impairment.2 tive research indicates a num ber of factors that affect
Occupational therapists are very aware that engage­ the client's adjustment to vision loss and suggests that
ment in occupations and in daily life activities can be 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 disability, and expectations of fam ily for recovery of
engaged in occupation and activities.1-4'7 These fac­ roles and functions vary w ith different cultures. Since
tors are listed in Table 6-1, are briefly explained below, cultural diversity exists w ithin broad ethnic groups,
and should be considered in every evaluation. Issues we find the best strategy is to explore such expecta­
related to any of these factors have the potential to tions by careful interview of the client and the family.
lim it the overall outcom e for a client. Som etim es interpreters can help. Vision im pairm ent
often leads to social problems such as nonacceptance,
Type o f Loss difficulty sustaining relationships, and attitudes of
pity and overprotection by fam ily m em bers.8
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
Life Stage
uncovered a sequential pattern of coping with vision T h e life stage of the client at the onset of the visual
loss (Table 6-2). A review of phenomenological stud­ im pairm ent and at the tim e of intervention has im pli­
ies revealed that these stages often overlap and may cations for psychological adjustm ent. For exam ple, the
occu r in a different sequence.5 Clients w ith recently older adult already faces challenges related to aging
acquired vision loss who are in denial m ay still be and these challenges can be com pounded by vision
hopeful for a cu re that will restore their vision. Many im pairm ent. Low vision rehabilitation involves hard
will also be in stages of m ourning or depression. As work and stress. M any older individuals consider
will be discussed below, m any will becom e “stu ck " in themselves as having retired from stress and hard
a stage of clinically significant depression. The lack of work. Vision loss may interfere with m any of the
initiation, m em ory im pairm ent, and decreased activ­ leisure activities that a retiree expected to enjoy in
ity level associated with depression will invariably the retirem ent years, and for an elderly person living
have a negative impact on rehabilitation designed to alone, vision im pairm ent can lead to the end of inde­
teach the client how to adapt to vision impairment. pendence.
Gradual loss of vision caused by dry m acular degen­
eration m ay be easier to adapt to than the sudden Significant Life Events
loss of wet m acular degeneration, especially if early
Older age involves m any stresses, especially the
rehabilitation intervention enables a client to m aintain
loss of loved ones, other illnesses and the dependence
habits, routines, and occupations.4
of others. Interestingly, older adults appear more resil­
ient than their younger counterparts in adapting to
Cultural and Fam ily Reaction stressful events, a resilience that appears to relate to
The fam ily's reaction to the person's vision loss social support.5 It is im portant to determ ine if there
can have a significant effect on the client's adjust­ have been recent stressful life events. A client who has
ment. This reaction will vary with different cultures. recently been challenged to deal with other stressful
For example, vision loss may cause role changes situations may not have the energy to adjust to the
w ithin the household, causing anger and resentm ent.1 vision impairment and em bark on a vision rehabilita­
Stigm as associated w ith vision loss, perceptions of 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 duce som eone with low vision to searching, scanning
door that one entered when leaving a room, recalling and localization tasks that may, to a norm ally sighted
where a throw rug was located in an u nfam iliar loca­ person, be very easy.
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 V isual Im p a ir m e n t and
after adolescence or profound blindness where high
contrast landm arks cannot be seen have the greatest D epression
difficulty with spatial perception.6
People w ith long-duration blindness tend to move There is a significant body of literature dem onstrat­
few er joints when scan n in g an environm ent, whereas ing a relationship betw een visual im pairm ent and
people w ith recent blindness move the whole arm and depressive illness in adulthood and later life.2'11*18
hand.6 This suggests that a strategy for teaching som e­ Horowitz and Reinhardt suggest two possible rea­
one to locate objects by feel should include careful, sons for this relationship.4'18 The first factor is the
stereotypic arm positioning. An exam ple is pressing relationship betw een chronic illness of any type and
the elbow s to the body and keeping the w rists rigid so functional disability.19'20 T h is concept suggests that it
the hand is moved only by shoulder rotation, and then is not the chronic illness itself that causes the depres­
increm ental, careful shoulder flexion to reposition sion. Rather, it is the loss of independence in ADL
the elbow on a table for a reach. If possible, only the caused by the chronic illness that leads to depres­
hand or digits should be moved to scan sm aller areas. sion. Studies have dem onstrated that adults w ith
By decreasing the joints involved, we suspect, spatial visual im pairm ent are more functionally disabled in
localization can becom e more accurate. ADL than those without vision im pairm ents.4'21'2^5
Adaptive strategies include use of high-contrast W illiam s et al interviewed 86 patients w ith age-relat-
m arkers to help som eone orient to a room or objects ed m acular degeneration (AM D) and found severe
on a table. If som eone has full visual fields but pro­ disabling effects of the disease.25 Patients rated their
found visual acuity loss, sm all bright lights, bright quality of life substantially lower than people with
windows, table lam ps, and streetlights work very well intact vision. These patients were eight tim es more
as markers. Careful organization of objects in the liv­ likely to have trouble shopping, 13 tim es more likely
ing space becom es a critical adaptive strategy. to have difficulty m anaging finances, four tim es more
T h e therapist needs to be careful to respect indi­ likely to have problems with meal preparation, nine
vidual organization schem es and carefully evaluate tim es more likely to have difficulty w ith light house­
a person's ability to locate objects after perform ance work, and 12 tim es more likely to have trouble using
has been evaluated to see if som eone can find given the telephone. Rovner et a l16 found that depressive
objects. The stacks of paper and jumble of objects sym ptom s are more prevalent and persistent am ong
on a table might actually be positioned according low vision patients and appear more highly correlated
to a person’s premorbid organization schem e; any to the disability than to the actual visual acuity loss.
change could devastate perform ance. Fam ily needs Brody et a l1-1 also found that in the group of patients
to be carefullv ¥ instructed not to alter the environ- they studied, visual acuity had little correlation with
mcnt o f a person with visual impairm ent in any way the severity of the depressive sym ptom s. In a study
w ithout directly involving the person in m oving each of 144 subjects, Tolman et a l17 exam ined psycho­
object. Low tables or throw rugs that are normally logical adaptation to vision loss and its relationship
considered hazards m ay not present a safety hazard to depressive sym ptom atology in older adults. Their
to som eone w ho is fam iliar with the location of these findings support the contention that depressive sym p­
items. Indeed, the clicnt may use these objects as tom atology is m ediated by one's perceived sense of
m arkers in orienting to a room. individual control as it relates to intrapersonal factors
D uring m obility training, a person w ith low vision underlying adaptation to vision loss.
can be alerted to sounds and sm ells associated with There is also evidence that vision im pairm ent
landm arks, such as a food cart, reception desk, escala­ may have a more severe im pact than other physical
tor, or busy doorway. disabilities on everyday functioning.4 Furner et al
Learning to use other senses to perform tasks pro­ found that vision im pairm ent and stroke are the most
vides a considerable cognitive challenge to som eone significant in their effect on instrum ental activities of
w ho has lost vision later in life. For this reason, we daily living.26 Ford et al identified vision im pairm ent
suspect individuals w ith recent vision loss may find as second only to arth ritis as a cause o f disability
use of visual devices or visual m arkers m ore help­ in the elderly.27 Thus, there is convincing evidence
ful than a counterpart who has lived with impaired dem onstrating that vision im pairm ent interferes with
vision for m any years. C are m ust be taken to intro­ occupational perform ance, causing loss of indepen­
dence. It is this loss of independence that may be a key These studies indicate that it is reasonable to expect
factor in explaining the high prevalence of depression one out of every three older adult clients with visual
in clients with visual impairment. impairment to have a significant level o f depression
The second factor that may explain the relationship that could interfere with rehabilitation. Occupational
between visual impairment and depressive illness therapists should consider the use o f easily and quick­
is the subjective characteristics of vision im pair­ ly administered questionnaires to assess clients for
ment.-4 Horowitz and Reinhardt4 suggest that the most depression during the low vision evaluation. A brief
unique characteristic of vision impairment is that it is overview of the assessm ent of depression and avail­
a particularly feared disability. In 1995, the Lighthouse able screening tests is reviewed below.
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, M easures o f D epression
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 Definition and Background
the most feared disability by 42% of adults polled.30
Thus, adults who become visually impaired may have The gold standard for a research diagnosis of
internalized this attitude, which influences their reac­ depression is the Structural Clinical Interview (SC1D),
tion and adaptation to vision loss.4 Ainlay suggests a clinical interview that uses the DSM-1II-R criteria
that older adults may assum e that vision loss invari- for illness.35-36 However, because of the tim e and
ably leads to a loss of independence, which then leads level of experience required to adm inister a clini­
to self-imposed social isolation.31 cal interview, self-report questionnaires have been
Another important issue is that vision impair­ developed that can be used by clinicians who are
ment has a negative impact on driving and read­ not in the mental health professions. Three of the
ing, two activities that are very highly valued by most popular self-report measures are the Center
most people.18'32 33 For older adults, the inability to for Epidemiological Studies Depression Scale (CF.S-
drive affects their sense of autonomy, self-worth, and D), the Beck Depression Inventory (BDI), and the
independence.18 Losing the ability to drive has been Geriatric Depression Scale (GDS).
identified as one of the most feared aspects of vision
impairment.33 The Beck Depression Inventory
Thus, the emotion elicited by vision impairment The Beck Depression Inventory (BDI) is a list of 21
plus the relationship between vision loss and func­ sym ptom s and attitudes that are each rated in inten­
tional disability combines to increase the client's sity.37 Examples include: mood, pessimism , sense of
susceptibility to develop clinically significant depres­ failure, lack of satisfaction, guilt feelings, self-dislike,
sion. 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
P revalence o f D epression administered and takes 5 to 10 minutes.

in A dults W ith V ision The Center for Epidem iologic

Im pairm en t Studies Depression Scale
The Center for Epidemiologic Studies Depression
In a small pilot study using a convenience sample Scale (CES-D) was designed to m easure current level
of 70 patients at a low vision clinic, Rovner et al found of depressive symptomatology, and especially depres­
that 38.7% of the patients were clinically depressed.16 sive affect.38 The 20 items were chosen to represent
In another study, Rovner et al prospectivelv studied a all major components of depressive symptomatology.
group o f 51 older patients with recently acquired bilat­ These include: depressed mood, feelings of guilt and
eral AMD using a depression scale and found clini­ worthlessness, feelings of helplessness and hopeless­
cally significant depression in 33% of the cohort.34 ness, loss of appetite, sleep disturbance, and psycho­
Brody et al performed a sim ilar study and found that motor retardation. Each item is rated on 4-point scales
32.5% of the 151 elderly with AMD were found to have indicating the degree of occurrence during the last
a depressive disorder.14 Higher levels of depression week. The scales range from "rarely or none of the
have been associated w ith more recent onset of the tim e" to "m ost all of the time."
vision im pairm ent25
T he G eriatric Depression Scale sessions providing education about the disease, group
discussion, and behavioral and cognitive skills train­
The G eriatric Depression Scale (CDS) is a self-
ing to address barriers to independence.41 H alf of the
report scale designed to be simple to adm inister and
patients were assigned to this group, w hile the other
does not require the skills of a trained interviewer.39
h alf were assigned to a "w aiting list" and received
Each o f the 30 questions has a yes/no answ er, with
no intervention during the 6 weeks. They used a
the scoring dependent on the answ er given. A shorter
variety of questionnaires and inventories to assess
15-item version of the CD S has been devised and is
the patients before and after intervention. The results
probably the most com m on version currently used.40
demonstrated the value of a brief, behavioral self­
For an exam ple of th e/ F | e^ ;^ ^ g ;)E )ep ression Scale, m anagem ent group in reducing distress, enhancing
see ww w .slackbooks.com /otvisionform s 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
As depression responds well to m edication and
a self-m anagem ent program . Patients were followed
counseling, if an occupational therapist suspects a
for 6 m onths after receiving a 12-hour self-m anage-
client is depressed, the client should be referred to a
ment program , a series o f 12 hours of tape-recorded
mental health professional for treatment, and this pro­
health lectures, or a waiting list. T h e prim ary outcome
fessional should collaborate in treatment planning.
m easure was the score on the Profile o f Mood States.
At the 6-m onth follow-up visit, participants in the
Rehabilitation and Depression self-m anagem ent group reported significantly less
Depressed clients m ay be less likely to use optical em otional distress compared with control subjects.
devices and less likely to benefit from vision rehabili­ The incidence of clin ical depression at the 6-month
tation.41 It is, therefore, im portant to try and address follow-up was significantly lower in the self-m anage­
the psychosocial needs of clients as w ell as interven­ ment group than the control group.44
tion aim ed at im proving occupation and ADL. Davis In addition to interventions that specifically address
et al reported that despite vision rehabilitation, per­ an underlying depression, Table 6-3 lists several gen­
sons with long-standing A M D are likely to still show- eral treatm ent strategies we have found help clients
psychosocial dysfunction well after the on set of vision continue to participate in a rehabilitation program
loss.42 They recom mend that therapists should con­ until perform ance goals are attained. In general, we
tinue to assist clients w ith their psychosocial adjust­ have found that a good strategy to encourage resum p­
ment as a follow-up to previous intervention because tion of activity is to ask the patient to start an activity-
vision rehabilitation at the» tim e of vision loss does according to a routine but stop anytim e when tired or
not fully m eet the client's needs. In another study- feeling frustrated. Remember, low vision rehabilita­
designed to evaluate the im portance of addressing tion presents considerable challenges if som eone has
the psychosocial needs of the client, Horowitz et al even mild cognitive lim itations.
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 Summary
to help clients m aintain them selves independently
using a group intervention model. A fter attending This chapter was designed to provide background
this program , participants demonstrated significant inform ation about the psychosocial issues related to
im provem ent in adaptation to vision loss and life sat­ vision im pairm ent. The inform ation provided sug­
isfaction and significantly less sadness or depression. gests that an occupational therapist engaged in vision
T h e study had som e design lim itations, such as the rehabilitation must attend closely to the psychosocial
use of unmasked exam iners, short follow-up, and lack status of his/her client. G oals should be established
o f a control group. Nevertheless, the study suggests to address this issue in rehabilitation. If a therapist
the im portance of addressing broad goals of rehabili­ suspects that a client is significantly depressed, use of
tation to include not only specific functional skills, but one of the sim ple questionnaires should be considered,
fostering global well-being and a better quality of life along with referral to a mental health practitioner.
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 R eferences
study was to assess w hether a self-m anagem ent group
intervention would improve mood, self-efficacy, and I. CraboyesM. Psychosocial implications of visual impairment. In;
activity in people w ith central vision loss due to AMD. Brilliant RL, Ed. Essentials o f Low Vision Practice. Boston, MA:
The intervention involved six w eekly 2-hour group 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 11. Shmuely-Dulit/ki Y, Rovner BW. Screening for depression
eration and depression: a review of recent research. Curr Opin in older persons with low vision. Somatic eye symptoms
Ophthalmol. 2004; 15(3): 181 -183. and the Geriatric Depression Scale. Am I Ceriatr Psychiatry.
3. American Occupational Therapy Association. Occupational 1997;5|3):216-220.
Therapy Practice Framework: Domain and Process. Am / Occup 12. Wells KB, Stewart A. Hays RD, et al. The functioning and well­
Jher. 2002;56<6):609-639. being of depressed patients. Results from the Medical Outcomes
4. I lorowitz A, Reinhardt |P. Mental health issues in vision impair­ Study. IAMA. 1989;262<7):914-919.
ment. In: Silverstone B. et al. Eds. The Lighthouse Handbook on 13. Shmuely-Dulit/ki Y, Rovner BW, Zisselman P. The impact of
Vision Impairment and Vision Rehabilitation. Oxford: Oxford depression on function in low vision elderly patients. Am /
University Press; 2000:1089-1109. Ceriatr Psychiatry. 1996;3:325-329.
5. Ringerini* L, Amaral P. The role of psychosocial factors in adapta­ 14. Brody BL. Gamst AC, Williams RA, et al. Depression, visual
tion to visum impairment and rehabilitation outcomes for adults acuity, comorbidity, and disability associated with age-related
and older adults. In: Silverstone B. et al, Eds. The Lighthouse macular degeneration. Ophthalmology. 2001;108(10i:1893-
Handbook on Vision Impairment and Vision Rehabilitation. 1900; discussion 1900-1.
Oxford Oxford University Press; 2000:1029-1048. 15. Rovner BW. Shmuely-Dulitzki Y. Screening for depression in
(». Hollins M. Vision Impairment and cognition. In: Silverstone low-vision elderly. Ini I Ceriatr Psychiatry. 1997;12191:955-959.
B, et al. Fds. The lighthouse Handbook on Vision Impairment 16. Rovner BW, Zisselman PM, Shmuely-Dulitzki Y. Depression
j nd \ iм о л Rehabilitation. O x f o r d : O x f o r d U n iv e r s ity 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
2000:339-358. study. I Am Ceriatr Soc. 1996:44(2):18l-184.
7. Tuttle DW, Tuttle NK. Self-Esteem and Adjusting with Blindness. 17. Tolman |, Hill RD, Kleinschniidl ||, Oegg C H . Psychosocial
2nd ed. Springfield, IL: Charles Thomas: 1996. adaptation to visual impairment and its relationship tu depres­
8. Steltens MC, Bergler R. Blind people and their dogs. In: Wilson sive affect in older adults with age-related macular degenera­
CC, Turner DC, Eds. Companion Animals in Human Health. tion. Gerontologist. 2005;45(6>:747-753.
Thousand Oaks, CA: Sage; 1998:149-157. 18. Horowitz A. The prevalence and consequences of vision impair­
9. Kobasa SCO Puccetti MC. Personality and social resources in ment in later life. Topics in Geriatric Rehab. 2004;20:185-195.
stress resistance. ! Pers Soc Psychol. 1983;45(4):839-850. 19. Williamson CM , Schulz R. Physical illness and symptoms of
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Adult. 3rd ed. Thorotare, NJ: SLACK Incorporated; 1996:211.
20. Zeiss AM. Lewinsohn PM, Rohde P, Seeley |K. Relationship of 34. Rovner BW, Casten RJ, Tasman WS. Effect of depression on
physical disease and functional impairment to depression in vision function in age-related macular degeneration. Arch
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21. Bianch LG, Horowitz A, Carr C. The implications for everyday 35. Williams JB, Gibbon M, First MB, et al. The Structured Clinical
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165. 36. Spitzer RL, Williams IB. Gibbon M, Fiist MB. The Structured
22. Gillman AE, Simmel A, Simon EP. Visual handicap in the aged: Clinical Interview for DSM-III-R (SCID). I: History, rationale, and
Self-reported visual disability and the quality of life of residents description. Arch Gen Psychiatry. 1992:49{8):624-629.
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1986;80:533-590. Beck Depression Inventory: Twenty-five years of evaluation.
23. Heinenunn AYV, Colorez A. Frank S, Taylor D. Leisure activity Clinical Psychology Review. 1988;8:77-t00.
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1988;28<2>:181-184. N, Dean A. Ensel WM, Eds. Social Support, tife fw n ts, and
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function. /A m Geriatr SOC- l994;42(3):287-292. dation of a geriatric depression screening scale: a preliminary
25. Williams RA, Brody BL. Thomas RG. Kaplan RM, Brown report. I Psychiatr Res. 1982; t7<0:37-49.
SI. The psychological impact of macular degeneration. Arch 40. Shiekh J, Yesavage JA. Geriatric Depression Scale: recent find­
Ophthalmol. 1998; 116:514 -520. ings in development of a shorter version. In: Brink I, Ed. Clinical
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27. Ford AB, Fnlmar SJ, Salmon KB, Medalie )H, Roy AW. Galazka Brown SI. Age-related macular degeneration: a randomized
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31. Aintav SC. Aging and new vision loss: Disruptions of the here SI. Self-management of age-related macular degeneration at
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Section II

Overview and Review of the Low
Vision Evaluation

Paul B. Freeman, OD, FAAO,

FCOVD, Diplomate, Low Vision

individuals who believe they are visually impaired

O pto m etric Lo w V ision may simply require an eye exam ination and con­
E xam ination ventional eyeglasses. This was demonstrated in the
Baltimore Eye Survey, which found that "the acuity
It is imperative for occupational therapists involved of about three-fourths of the visually impaired whites
in low vision rehabilitation to be fam iliar with the low and tw o-thirds of the visually impaired African
vision examination. The following is a description of A m ericans could have been corrected to better than
the optometric low vision evaluation (Table 7-1). This 20/40 w ith only eyeglasses."1
evaluation can be performed in a variety of settings, Once it is established, however, that the patient has
including a professional office, a rehabilitative facility, a bona fide decrement in visual acuity that cannot
or a personal care facility. be corrected by conventional eyewear, the rem aining
questions explore the impact of this visual deficit on
Case History the patient's ability to visually interact with the envi­
ronment and the challenges facet!. During the case
The history of a visually impaired patient, as with history, the doctor can obtain information about the
any other history, is a snapshot of the patient up to the patient's understanding of the impact of the visual
time of questioning. The general areas that this history impairment, cognitive level, motivation, support sys­
should cover are listed in Table 7-2. This information tems, and previous attempts at vision rehabilitation.
may be obtained from a number of sources, including
the patient, family, friends, caregivers, therapists, and Visual Acuity Information
doctors. Among the most common chief visual com­
plaints of visually impaired patients is the inability to Visual acuity information is generally com m unicat­
see conventional size print, the inability to drive, and ed as a fraction, which can be in either feet (Snellen) or
the inability to recognize people. metric notation. The numerator signifies the actual or
It is always important to determ ine the date and calculated testing distance and the denom inator the
results of the last eye exam ination. In many cases. 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
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 the standard Snellen projected chart can be used, but
fied w as a 200 size letter. A ny of the m odifiers listed when doing so, the specific chart used and actual test­
in Table 7-3 should be included if there is anything ing distance should be noted (Figure 7-1). O ther factors
unusual or pertinent about the m anner in which the that should be considered, including expressive and
acuity was m easured. These findings are typically receptive language skills and cognitive functioning
obtained for each eye independently, if possible, both that can also affect this m easurem ent when assessing
with and w ithout the patient's current eyeglass or visual acuity at distance, are listed in Table 7-3.
contact lens prescription. 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
D istance V isual A cuities what a patient can see. In these cases, a m ore func­
tional approach can be used. For instance, a patient's
Distance visual acuities are m easured to establish ability to fixate and follow a light and/or localize a
the patient's baseline ability to see at a specific d is­ specific sized target (without the actual ability to iden­
tance. Specially designed charts (which allow for bet­ tify it) at a specific distance can be used to indirectly
ter quantification of reduced acuity levels) other than assess visual acuitv. *
Table 7-3.

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

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-

Amsler Grid Testing
im paired patients require assistance revolve around
near work. Therefore, a m easure o f visual acuity Using an Amsler grid (Figure 7-3) can help to deter­
should be done at n ear as well as distance. This infor­ m ine whether a patient is experiencing distortion or
mation ill not only help the occupational therapist has (multiple) areas of scotom a. A scotom a is defined
when tryin g to determ ine an appropriate sized target as "an isolated area o f absent vision or depressed sen­
to work with, but also helps the optom etrist to evalu­ sitivity in the visual field, surrounded by an area of
ate the consistency between d istance and near acuity norm al vision or of less depressed sensitivity."2 The
m easurem ents. As w ith distance visual acuity mea- Amsler grid m easurem ent can provide inform ation
surem ent, all pertinent inform ation about the test (see used to identify the onset of a pathology, m onitor a
Table 7-3) should be made available to anyone review­ pathology, or m odify the ultim ate optical device(s)
ing the data. Additionally, know ing whether the tar­ that m ight be needed by a patient for a specific task.
get size was based on identification (discrim ination) Functionally, the results can also give guidance as to
acuity or actual reading acuity is im portant, as there whether a patient eccentrically view s or needs to learn
can b e a difference. The ability to recognize a letter to do so. Figure 7-4 illustrates an exam ple of the d is­
does not always equal the ability to actually read. 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. Figure 7-4. Distortion ot Am sler G rid.

patient's color vision status can be im portant in educa­

C o l o r V ision T esting tional, vocational, and social planning or training.

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 V isual / M o b ilit y F ield T esting
a pathology, or alert a therapist to color deficits that
might im pact a therapeutic regim en for the patient. Perim etry or visual field testing is designed to
evaluate the depth and breadth of an individual's
Color vision deficits are generally not as detrimental
to functioning as other losses such as visual acu­ peripheral vision. Visual field loss can be either abso­
ity, visual field, or contrast. However, know ing the lute or relative. An absolute visual field loss is one in
Figure 7-5. Several tests availa ble to r c o lo r vision test­

Figure 7-6. Illustration of confrontation

field testing.

which no m atter how large and bright the target is, by the doctor sitting opposite the patient, each cover­
it will not be seen w ithin the blind area. A relative ing the eye on the sam e side, and having the patient
visual field loss, on the other hand, is dependent on then dem onstrate aw areness of when the doctor's (or
the size, brightness, and contrast of the target rela­ a third person's) hands (or object) are brought in from
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 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
functional!) into variations of visual field aw areness environm ental conditions should be m ade (see Table
consistency based on environm ental conditions. For 7-3). This type of testing will uncover gross peripheral
exam ple, a person with a relative peripheral visual visual field deficits and is very useful for determ in­
field loss m ight function better under bright illu­ ing the presence o f a hem ianopia (which is absolute).
m ination than under dim lighting conditions or at Confrontation field testing is not as sensitive for
night. I here are several instrum ents that can formally subtle peripheral field loss or for central visual field
quantify the extent of the visual field. However, for disturbances.
initial screening, confrontation field testing (Figure To accurately quantify visual field loss, a formal
7-6) is the method of choice. It is typically carried out 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 The refraction is the exam ination procedure used to
this purpose (Figure 7-7). However, for purposes of determ ine if a patient has a refractive error that needs
determ ining visual disability from a medical-legal to be corrected, as well as the exact lens prescription
standpoint, a m anual G oldm ann visual field test is that is appropriate. A phoropter or a trial fram e with
required.3 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
C o n t r a s t S ensitivity T esting designing low vision optical devices.
As noted previously, we som etim es encounter
Contrast sensitivity testing determ ines the patient's patients who appear to be visually im paired or legally
ability to distinguish borders, eg, a gray car against a blind, but a thorough refraction indicates that the
foggy background or coffee in a dark cup. It is a m eth­ patient simply requires an updated eyeglass prescrip­
od of assessing the qualitative aspects of visual func­ tion to regain normal vision. I cannot em phasize
tioning. This is particularly im portant when follow­ enough the im portance of perform ing a careful refrac­
ing a patient's progress over multiple visits. Patients tion before initiating any low vision rehabilitation
som etim es report that their sight has changed, but activity. For exam ple, a patient who needs a bifocal
on a standard eye chart (which has a m axim um con­ correction and is not w earing it, may not be able to
trast of black and white) there may be no measured see clearly through a "sim ple" stand m agnifier. A
difference. These arc patients w ho are noticing real m isleading conclusion m ight be that the patient is
functional difficulties, even though their measured unable to cognitively handle the task, when in fact it
visual acuity has not changed. In these cases, contrast is simply the om ission of the appropriate refractive
sensitivity m ay dem onstrate a qualitative change in prescription.
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 B in o c u l a r V ision
acuities. Proper lighting is integral to this testing.
E x a m in a t io n
Binocular vision is the ability of the visual system
R efr a c t io n to fuse or com bine the inform ation from the right and
left eyes to form one image. For binocular vision to
Refraction is the term used to describe the evalu­
occur, the inform ation arriving from each eye must
ation of the optical system of the eye. We use the
be identical, with approxim ately equal vision in both
term refractive error to describe any deviation from
eyes. To satisfy these requirem ents, the tw o eyes must
em m etropia. W hen the optom etrist perform s the
be aligned so that they point at the sam e object at
refraction, it can be determ ined w hether the eye
all times, and the visual acuity, optics, or refractive
is em m etropic (absence of refractive error), myopic
error of the two eyes must be approxim ately equal.
(nearsighted), hyperopic (farsighted), or astigm atic.
Therefore, it is understandable that many patients
Table 7-4.

_________ Classification of Strabismic Binocular Vision Disorders

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:

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

Com itant

with vision impairment do not have normal binocular lists the various possibilities, including esotropia (eyes
vision because they lack approximately equal visual turn in), exotropia (eyes turn out), and hypertropia
acuity in both eyes. (one eye turns up).
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. M agnitude o f Strabismus
W hen strabism us occurs, the eyes may drift in, out, This refers to the am ount of the eve turn. W hen an
up, or down. Table 7-4 lists some of the common terms eye turn is large, it is quite obvious, even to a nonpro­
associated with binocular vision problems that an fessional. However, it is im portant to be aware that the
occupational therapist may encounter in a low vision magnitude of a strabism us may be moderate or small
exam ination report. and in such cases the eve ✓ turn mav / be not be visible
or detectable without special testing. The magnitude
Clinical Assessment of Binocular of the strabism us is recorded in prism diopters. For
Disorders example, you might see the following notation in an
optometric report:
Som e of the common tests used to evaluate bin­
ocular vision in patients with low vision include the 25 pd esotropia (or 25.Л)
cover test and tests to assess fusion. Using the cover where pd = prism diopters.
test procedure, an optometrist can determ ine many
key binocular vision characteristics, including the
direction, magnitude, frequency, and com itancy of the 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
Direction o f Strabismus 7-4). For example, it is possible for the eye turn to be
This refers to whether the eyes turn in, out, up, present 100% of the tim e and this would be called a
down, or a combination of these directions. Table 7-5 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
Figure 7-8. Stereopsis test - Random D ot
Stereogram (Steinm an).


S t e nmar.

and enlarging it to fit on a billboard. W hen viewing are held at a closer working distance, the patient
targets at distance, the patient's appropriate refractive must exert additional "m u scu lar" effort (if possible)
correction should always be in place. W hen view ing to accom m odate (focus). T h is effort can lead to d is­
objects at closer distances, a com pensatory lens for com fort and eyestrain after short periods of time.
a specific view ing distance m ust be considered. This Additionally, m any older patients are unable to exert
concept is reviewed in detail in Chapter 5. Therefore, this effort and, along with discom fort, will not see
even when using large print, conventional glasses or clearly. Thus, an appropriate powered lens must be
bifocals mav be needed to see the print clearly, even used for the target to be seen clearly at that distance.
before other form s of optical m agnification are con­ This lens m inim izes or elim inates the need for the
sidered. patient to accom m odate (or focus) the eyes.

Relative Distance Magnification Angular Magnification

This is accom plished by bringing the object of A ngular m agnification is the m agnification expe­
interest closer. It m ight be considered sim ilar to "air­ rienced when a person looks through a device like
plane m agnification," where at 10,000 feet houses look a telescope. T h is form of m agnification is typical of
sm all, but the closer one gets to the ground, the larger a stand m agnifier or a telescope where the relation­
the houses appear. Similarly, a target at 2 inches will ship betw een lenses in the system creates an enlarged
give the appearance of being 8 tim es larger than the image. A ngular m agnification also increases the size
sam e target at 16 inches. Rem em ber that when objects of the retinal im age just like relative size and relative

Maiepian. захищений авторським правом

distance m agnification. The advantage of angular 3. Л com bination of relative size and relative
m agnification is that it can be used when moving distance m agnification could be provided with
closer to an object or enlarging it is im practical or electronic equipm ent like a closed circuit tele­
im possible. View ing a sporting event is an example vision (CCTV). For example, the target can be
of such a situation. If an individual sits far from the made physically larger on the CCTV monitor,
action, neither relative distance nor relative size mag­ and the patient can sit closer (or farther) than
nification arc possible. However, the use of a telescope 16 inches, with the appropriate glasses.
or binoculars w ill m agnify the object of interest. If this individual needed to see the 20/50 sized
Telescopic lenses must be focused properly. To see target at a 20 foot m easured distance, a 4X telescope,
clearly through a telescope, the refractive error must or electronic equipment that could m agnify four tim es
be corrected or compensated for in som e manner. at distance, could be used. The lim iting physical and
T h is can be done by using glasses or contact lenses, optical factors o f these as well as near devices are the
or by adjusting the telescope for the refractive error. weight, appearance, field of view, and lighting con­
It should be noted that focusing the telescope for an straints that these system s impose.
uncorrected eye may m odify the power (or m agnifi­ These are generalities and should be reviewed
cation) of the telescope, even though the image will w ith the optom etrist who has prescribed the devices
be clear. in relationship to what the occupational therapist has
identified as the visual requirem ents necessary for
Electronic or Projection the task.
M agnification
T h is form of m agnification uses electronic equip­
ment and is basically a com bination of relative size
C o n c l u s io n
and relative distance m agnification considerations.
This chapter reviewed the low vision exam ination
O nce again, the application of lenses for the near
that an occupational therapist should expect to be per­
focusing demand must be considered; otherw ise the
formed by the eyecare provider. We have also includ­
target may be made large enough to see, but will be
ed a sample report from a low vision optom etrist,
out o f focus. Big and blurry is not as easy to see as
and Table 7-5 provides a list of comm on abbreviations
big and clear. In som e instances, a clearer image can
used in a low vision exam ination record or report.
be recognized with less m agnification (ie, sm aller on
W hen receiving such a report, if the occupational
the screen), thereby allow ing more inform ation to be
therapist has questions about term inology, test results,
displayed on the screen at one time.
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
D eterm in in g M a g n ificatio n who most need the integrated services of both the low
vision optom etrist and the occupational therapist.
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.
R eferences
For exam ple: An individual has 20/200 distance visu­ 1. Tielsch |M. Prevalence of visual impairment and blindness in the
al acuity, sees the 20/200 near target at 16 inches (with United States. In: Massof RW, Lidoff L, Eds. Issues in Low Vision
appropriate glasses), and would like to see 20/50 size Rehabilitation: Service Delivery, Polk y, and Funding. New- York:
print at near. That requires 4X m agnification, and can American Foundation for the Blind: 2001:13-26.
2. Cline D, I iofstetter 11W, Griffin )K. Dictionary o f Visual Science.
be calculated a num ber of ways:
Newton, MA: Butterworth'Heinemann: 1*197.
1. Using "b illb oard " m agnification (relative size 3. United States Social Security Administration. Code of Federal
m agnification), the target (print size) can be Regulations. 1992.
made four tim es larger. 4. Spalton DJ, Hitchings RA. Hunter PA. Atlas o f Clinical
Ophthalmology. London, England: Gower Medical Publishing:
2. If the 20/200 target is at 16 inches initially, it
can be brought four tim es closer ("airplane" 5. Harley RD. Pediatric Ophthalmology. Vol I and II. Philadelphia,
or relative distance m agnification) to approxi­ PA: W.B. Saunders Co.; 198.3.
mately 4 inches, which would require a lens, or
accom m odation, of approximately +10.00 D.

spian, захищений авторським правом

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 mined that additional m edical/surgical treatm ent will
not be useful. The role of the optom etrist is to try and
T h e objective of this chapter is to present an orga­
m axim ize the client's visual function using a com bi­
nized evaluation approach for the adult low vision
nation of traditional eyeglasses plus low vision optical
client. In 2002, the Am erican O ccupational Therapy
devices. The occupational therapist's role is to deter­
A ssociation (AOTA) published the O ccupational
m ine what the client wants and needs to do, identify
Therapy Practice Framework: Domain and Process.1 The
factors that act as barriers to perform ance, and devel­
Framework w as developed to articulate occupational
op a treatm ent plan to m eet the client's specific needs.
therapy's unique focus on occupation and daily activi­
It is also im portant for the occupational therapist to
ties and the application of an intervention process
interact with the low vision optom etrist. The occupa­
that facilitates engagem ent in occupation to support
tional therapist can provide im portant inform ation to
participation in life.1 In regard to the occupational
the optom etrist about the client's physical capabilities,
therapy evaluation, the Framework states that "the
living environm ent, and needs. T h is inform ation can
evaluation process is focused on finding out what
then be used by the optom etrist to determ ine the
the client wants and needs to do and on identifying
appropriate low vision optical aids.
those factors that act as barriers to perform ance".!
Thus, although the occupational therapist's exam i­
The evaluation that we present below follows these
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
O v er v iew thalm ologist and optom etrist. Rather, the objective
of the occupational therapy low vision rehabilitation
In the model of low vision care we proposed in evaluation is to understand the client's functional
Chapter 1, the ophthalm ologist diagnoses and treats ability before the vision loss, to define his/her current
the eye disease responsible for the vision loss. The low goals, to evaluate the client s ability to participate in
activities of daily living (ADL), leisure, work, play, of assessm ent. The occupational profile/case history
and social and spiritual occupations. In addition, the w ill shape the evaluation strategy, developm ent of the
occupational therapist evaluates social, cultural, and m anagem ent plan, and the form ulation o f the rehabili­
physical context as well as client factors other than tation prognosis. In addition to contributing to better
vision, including m usculoskeletal process and m en­ diagnostic and therapeutic decisions, the foundation
tal/cognitive factors. Although the low vision optom e­ for a good client-therapist relationship is established
trist typically provides the initial device selection and during this time.
estim ation of m agnification, the occupational thera­ O ne im portant issue for occupational therapists is
pist evaluates devices in the context of occupational tim e managem ent. In alm ost all clinical settings, the
perform ance and may recomm end m agnification and am ount of tim e available for the occupational therapy
different devices. The low vision therapist may need evaluation is limited to about 1 hour. This lim itation
to estim ate the m agnification required for perfor­ may be based on high client census or insurance
m ance of som e tasks. It is also im portant to remember guidelines and protocols. It is, therefore, im portant
that under M edicare Part В guidelines, the initial to design an evaluation that can be completed in a
evaluation completed by the occupational therapist is reasonable period of time. To facilitate this objective,
used to determ ine w hether there is medical necessity we suggest the use of a low vision visual function­
for low vision rehabilitation.2 ing questionnaire. Visual functioning questionnaires
To accom plish these goals, the occupational therapy include a series of questions that assess the perfor­
vision rehabilitation evaluation consists of four com ­ m ance of ADL.3 Stelm ack et al recently J described a
ponents: self-report questionnaire designed to m easure the
1. O ccupational profile/case history difficulty visually im paired persons have perform ing
2. Evaluation of visual factors ADL.4 The questionnaire, called the Veterans A ffairs
Low-Vision Visual Functioning Q uestionnaire (VA LV
3. Environm ental evaluation
VFQ -48), was found to be a valid and reliable m easure
4. Evaluation of occupational perform ance of visual ability in low-vision clients with moderate to
O f course, som e clients may have other physical severe vision loss. This questionnaire is not only used
disabilities/issues that need to be addressed and the to m easure perform ance ability, but can also be used
traditional occupational therapy evaluation proce­ to tailor rehabilitation program s to m eet individual
dures should be used to assess these problems. client needs and to m easure outcom es of rehabilitation
program s 4 T h e VA LV VFQ -48 has a strong research
The Veterans A ffairs Low-Vision Visual Functioning basis and its validity and reliability have been estab­
Q uestionnaire [VA IV VFQ-48) and an evaluation lished. The questionnaire can be scored and the occu­
form can be found on www.slackbooks.com/otvi-
pational therapist can, therefore, obtain a num ber that
sionform s 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.
O c c u p a t io n a l P r o file / C ase Thus, in addition to stream lining the evaluation, it is
H isto ry an effective tool for M edicare docum entation.
The VA LV VFQ -48 can be adm inistered over the
T h e occupational therapy evaluation of an adult phone or can be sent to the client, and the client is
w ho is suspected of having low vision begins with asked to bring the completed form to the occupational
the occupational profile/case history. The occupa­ therapy low vision rehabilitation evaluation. The
tional profile/case history is the form alized process questionnaire was not designed for the low vision
o f asking relevant questions to elicit inform ation that client to complete independently. Rather, a fam ily
will contribute to an understanding of the client's m em ber or friend would have to help the client com ­
problem s. Specifically, the objectives of this part of the plete this questionnaire because it is not available in
evaluation are to gather inform ation about the client's large print size. The occupational therapist can review
vision and health status, previous eyecare and low the questionnaire and elaborate on pertinent issues
vision treatm ent, to understand the client's functional raised by the client's responses using the Low Vision
ability before the vision loss, and to define his or her Rehabilitation Evaluation form included in the appen­
current goals. dix. It is im portant, however, to understand that the
An integral part of the evaluation, the occupational VA LV VFQ-48 is not a substitute for interaction with
profile/case history offers a rich source of data for the client. The O ccupational Profile/Case History
case form ulation that is not available from other forms 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 when appropriate, w hile m aintaining sensitivity and
communication. flexibility in listening and pursuing.5
The key areas to be investigated are listed in Table
Interviewing the Client 8-2 and included in the Low Vision Rehabilitation
Evaluation form. These are only suggested start­
The rapport established betw een the occupational
ing points. The occupational therapist will need to
therapist and client will influence the accuracy of the
ask additional questions based on the client's initial
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 The Low Vision Rehabilitation Evaluation form can
occupational therapist's attitude should be one of be found on www.slackbooks.com/otvisionforms
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 Im portant Areas to Be Addressed
barrier to effective communication, which in turn may
have a deleterious effect on the interview process.5
in the Occupational Profile/Case
Breakdowns in communication frequently result in History
failure to comply with a professional's recom m en­
dations.6 Because of the client's visual impairment,
Vision History
interaction is different from that typical of a case his­
tory with a normally sighted person. Sokol-McKay7 It is im portant to determ ine the client's under­
em phasized the importance of implementing certain standing of his or her eye disease and v ision prob­
courtesies and considerations when evaluating an lem. The therapist should ask questions about onset
adult client with low vision. Examples of these courte­ (when did the problem begin), duration (how long
sies are announcing yourself when entering or leaving has the client been visually impaired), the date of the
the room or when beginning or ending a conversa­ last exam ination, and questions to probe the client's
tion, speaking directly to the person, using a normal understanding of the diagnosis, prognosis, and effects
tone of voice, and requesting permission to touch the on performance (Table 8-3). Even if a complete report
person when necessary. Table 8-1 is a list of these sug­ is available from the referring doctor, it is worthwhile
gested courtesies. to gather this information from the perspective of a
Using the VA LV VFQ-48 as a basis for explora­ client. A client's answ ers to these questions will indi­
tion of particular areas of concern, the occupational cate stage of coping, expectations, and many aspects
therapist can begin with broad-based questions with of cognitive functioning. O ne of the critical factors
a progression to more focused inquiries. The strategy determ ining the effectiveness o f vision rehabilitation
is to scan potentially important areas and focus in 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 es and were these services helpful? It is also im portant
problem s, the more likely rehabilitation will be effec­ to determ ine if the client is aware of support groups
tive. After discussing the onset and duration, ask the and other opportunities in the com m unity to receive
client about previous and current treatment. We are help, support, and education about low vision.
prim arily interested in the treatm ent of the resulting
disability, not the im pairm ent or eye disease itself. By H ealth History
definition, this client has been sent to the therapist The health history is an im portant com ponent of
because the underlying eye disease has caused per­ the occupational profile/case history. An understand­
m anent vision loss. ing of the client's other medical problem s is neces­
We need to know the optical or nonoptical devices sary when planning vision rehabilitation. Nonoptical
that have been prescribed or purchased by the client and optical device selections are contingent on the
on his or her ow n, and if the client is able to use these client's physical and health status. Com m on exam ples
devices. Have there been any previous attempts at include: peripheral sensation problem s secondary to
vision rehabilitation? If so, w ho provided these servic­ 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 mild vision loss, or lighting changes, but treatment
devices, hearing problems that may preclude the use often focuses on compensatory strategies, assistive
of assistive devices such as liquid level alert and books devices, and vision rehabilitation that enable occupa­
on tape, and arthritis that may lim it movement and, tional perform ance using different sensory modalities
therefore, the ability to use certain optical devices. or strategies. In most cases, therefore, the client will
O f course, most occupational therapists w ill not need to realize that some significant changes will be
be treating clients w ith only low vision problems. required in lifestyle. Information should be gathered
Because the population of clients seen by the occupa­ about work, sports, and leisure activities.
tional therapist will generally be the older adult, many To understand a client's expectations and to insure
clients will have multiple medical conditions requir­ that the client's chief concern will be addressed, one
ing occupational therapy. It is, therefore, important should begin with a general question such as: "W hy
to question the client about general health status. The are you here? W hat is it you want us to do for you?"
occupational profile/case history, therefore, should Typical responses include the following:
include questions about hearing loss, diabetes, dialy­ • "I have som ething wrong with my eyes and
sis, previous stroke, hypertension, cardiac problems, want to see better" (the focus is on the im pair­
arthritis, and respiratory ailments. ment).
It is also important to obtain a complete list of the • "I have m acular degeneration, I can't read, I
client's medications. The therapist should review the want to use a computer again'' (the focus is on
medications for potential side-effects that m ight be occupation).
im portant when planning vision rehabilitation. Some
• "M y [doctor, daughter] sent me here" (no clear
drugs affect pupil size and function and can cause
goals, client education needs, psychosocial
blurred vision and photophobia (sensitivity to light).
im pairm ent with coping, cognitive im pair­
ment, or family/caregiver education needs).
Prem orbid Occupational
Perform ance an d History The client's initial response will indicate education
The importance of occupational history has been needs, level of insight, as well as the general stage
sum m arized in the ЛОТА Practice Fram ew ork1 A of coping with the disability. Since the most effec­
person's expectations about vision rehabilitation are tive interventions are often compensatory, a skilled
often closely associated with his/her previous level of clinician will focus this segment of the evaluation
activity, occupation, habits, routines, and roles. Clients on recovery of occupational perform ance with ques­
typically want vision to be the way it was before the tions such as: "W h at did you do before vou vision
eye disease caused the vision loss, rather than focus on loss that ^vou can't do now ?" "W hat do /vou m iss the
lost occupation and roles. In some cases, improvement m ost?" "D o people treat you differently now ?" These
in vision may be possible using optical devices with 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
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 ­ are: 1) the client's acceptance of the need to use opti­
pensatory strategies. cal and nonoptical assistive devices, and 2) motivation
to take an active role learning how to use his or her
Client's N eeds an d Goals rem aining vision.8
Finally, it is im portant to let the client tell you what Table 8-4 lists a series of questions modified from
he/she hopes to achieve through vision rehabilitation. a "personal eyesight evaluation" developed by Paul
A s discussed above, it is not unusual to hear some Freeman, OD. These questions allow the therapists to
unrealistic expectations from clients. Rem ember that help the client system atically develop a list o f realistic
the prior experience of this client w as that new glasses goals for vision rehabilitation. Before m oving on to
always restored clear vision. Clients often expect the the next part of the evaluation, the therapist m ust have
sam e result even when the vision loss is caused bv a list developed by the client o f his or her goals for
disease. They either fail to understand that the vision vision rehabilitation.
loss is perm anent or refuse to accept this prognosis. Exam ples of com m on, realistic perform ance goals
By the tim e the clicnt is being exam ined by the occu­ arc:
pational therapist, he/she m ay have had num erous • I want to be able to read the sports page.
exam inations with an ophthalm ologist and perhaps • 1 want to be able to follow a recipe and cook
a low vision optom etrist. The client has been told that meals for my family.
there arc no m iracle glasses, devices, or drugs that • 1 want to be able to enjoy a m ovie in a movie
will restore norm al vision. Yet, it is not unusual for the theater.
client to say, "I want to be able to see well again" or "I
• 1 want to be able to find products m yself at the
am hoping you can prescribe glasses that w ill help me
superm arket.
see well again".8
Low vision treatm ent and vision rehabilitation are • 1 want to be able to w rite letters to my grandchil­
designed to help clients w ith low vision fulfill realistic dren and read their responses.
vision-related goals.8 Freem an indicates that the two • I want to be able to independently read mail,
prim ary ingredients that determ ine success or failure w rite checks, and handle my finances.
Occupational Therapy Low Vision Rehabilitation Evaluation 109

Table 8-5.

Recommended Tost of Visual Function

Visual Function Recommended Technique Recommended Technique

Home l iealth Setting Hospital/Nursing Home/Outpatient

Visual acuity at distance Feinbloom Distance Test Chart ETDRS Chart

Reading acuity at near MN Read test MN Read test
Peripheral visual field Confrontation Field Testing Confrontation Field Testing
C ontrast sensitivity Mars Letter Contrast Sensitivity Test Mars Letter Contrast Sensitivity Test
Scotom a assessm ent Clock Face scotoma assessm ent Tangent Screen
Reading assessment/ Pepper Test, MN Read test Pepper Test, MN Read test
reading speed

Psychosocial an d Cognitive devices (optical or electronic) may confuse individu­

als w ith long-standing visual im pairm ent at first, but
Issues acceptance m ight follow w ith repeated practice.
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 Ev a l u a t io n of V isual Fac to r s
many psychosocial issues.9 It is critical, therefore, that
occupational therapists attend to the em otional impact For the occupational therapist to determ ine the
of the vision loss and the client's ability to cope when needs of a client and develop a treatm ent plan, he
providing low vision rehabilitation. In Chapter 7, we or she must have a thorough understanding of the
outlined seven key factors9 that should be reviewed client's visual status. Im portant visual factors include:
by the occupational therapist during the occupational visual acuity at distance and at near; the specific eye
profile/case history. These include: the type of vision disease; visual field; contrast sensitivity; presence,
loss, the fam ily's reaction to the vision loss, the client's size, and location of the central scotom a; reading skill;
life stage, significant life events, the client's expecta­ and reading speed. Depending on the occupational
tions, the client's self-concept, and personality. In therapist's practice setting, much of this inform ation
addition, if the occupational therapist is concerned may be readily available from the referring oph­
about the client's mental health, we suggest using one thalm ologist or optom etrist. O ccupational therapists
of the self-report questionnaires described in Chapter working in an ophthalm ology office, a low vision
7. T hree of the most popular self-report m easures are practice, or any other facility in which an ophthal­
the Center for Epidemiological Studies Depression m ologist and/or an optom etrist is working, will have
Scale (CES-D), the Beck Depression Inventory (BDI), full access to the client's eye records and the required
and the Geriatric Depression Scale (GDS). We recom ­ inform ation. Even if the occupational therapist is not
mend using the GDS because it can be easily adm in­ working directly with an eyecare professional, this
istered in a very short period of time. There is no cost inform ation can be requested from the referring doc­
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 tor. We have included a form in the Appendix that
fu n d s. can be used for this purpose. However, there may
Low vision, especially severe and profound vision be situations in which the necessary data are ju st not
loss, creates unique and substantial cognitive demands, available. In such cases, the occupational therapist
especially w ith spatial perception and use and inter­ will need to perform specific testing to gather this
pretation of other senses. A person with a long-stand­ inform ation. The recom m ended areas and tests are
ing visual im pairm ent m ay have developed an ability listed in Table 8-5. Background inform ation for these
to interpret vision differently, eg, using a hairline and tests is reviewed in Chapter 3. It should be noted that
a person's gait to recognize him, or using blobs of color visual acuity testing should be repeated every session
to orient in a room. These skills are som etim es infor­ to monitor for changes in vision and in cases o f active
m ally called "blur interpretation." Introducing visual pathology.
Figure 8-1. Feinbloom Distance
A cu ity Chart.

O ne additional issue that w ill determ ine the actu­ able to read at least some letters on the visual acuity
al test selection is the therapist's practice setting. chart. This is im portant from a psychological stand­
Therapists working in the client's home will need point. Many clients w ith low vision have had negative
portable tests that can easily be transported and set experiences during visual acuity testing if they were
up in a variety of home settings. Therapists working unable to even see the large "E ." T h is can be depress­
in hospitals, nursing homes, and outpatient settings ing. The client feels that there is no hope if he or she
should be able to establish som e dedicated space in couldn't see the eye chart at all. With the Feinbloom
w hich all of the necessary equipm ent is perm anently chart, however, most clients are able to read quite a
set up and available. Thus, in the following discussion few lines on the chart, leading to a much more posi­
and in Table 8-5 we m ake recom m endations based on tive experience.10'11
practice settings.
Setup an d Procedure
Visual Acuity at Distance— 1. The client should wear his/her usual glasses.
Feinbloom C h art 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
Practice Setting through the top half of the lens for distance
Recom m ended for hom e health setting or any set­ testing.
ting in which portability is im portant. 2. The Feinbloom chart is positioned 10 feet away
and the client's left eye is covered w ith the
E quipm ent Required occluder.
Feinbloom D istance Test C hart 3. The occupational therapist opens the chart to
Occluder the largest num ber (num ber 7 = 20/1400 at 10
feet) and asks the client to call out the num ­
Description ber.
T h is chart (Figure 8-1) is widely used.10 The char­
4. The occupational therapist proceeds until the
acteristics of the chart are reviewed in Chapter 3. client can no longer read the num bers correctly
The Feinbloom chart w as calibrated for 20 feet but is
at 10 feet and records the last level at which
typically used at a 10-foot distance, w hich m eans the
the client can read m ore than 50% of the num ­
acuitv values listed above would be doubled. At a 10-
¥ bers.
foot distance, the acuity range extends from 20/1400
5. The occluder is then held before the client's
to 20/20.
If a client cannot even see the large " 7 " at 10 feet, right eye and then neither eye so that binocular
the chart can be moved to 5 feet. At this distance, the visual acuity
✓ is tested.
acuity range is extended from 20/1400 to 2800 because 6. If the client is unable to see the largest number
each tim e you decrease the distance bv half you dou- at 10 feet, the chart should be moved to 5 feet
ble the denominator. and testing should be attempted again.
A nother major advantage of this visual acuity chart 7. If the client is still unable to see the largest let­
is that because of the large visual acuity range that can ter, test at a 2.5 foot distance.
be assessed, alm ost all clients with low vision w ill be
Figure 8-2. ET D R S Chart.

К D N IR О 80

0.5 ;
= Z К С S V =2 бо

D v о H С 50

0.3 о HV с К 40

0.2 H z с к о 32

0 1 N С К H D 25
и nи ■

-.1 S Z R D N 16
-.2 MCDRO 12.5
-.3 R О О С М 10

Interpretation Visual Acuity at D istance— ETDRS

T h e visual acuity should be recorded as 10 (testing C hart
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 Practice Setting
would be reported as 10/350. To convert this to the Recommended for any setting in w hich the equ ip­
more traditional 20/20 notation, the clinician multi­ ment can be setup permanently.
plies both the top and bottom of the equation by 2.
Thus, 10/350 is equivalent to 20/700. Equipm ent Required
It is appropriate to encourage guessing, eye move­ ETDRS Chart
ments, and eccentric view ing to see the num bers10 as Occluder
a m eans of determ ining the prognosis for rehabilita­
tion. However, when determ ining the visual acuity Description
for M edicare docum entation and coding, the chart T h is chart provides five letters per line and also
should be placed at 20 feet and eccentric view ing and standardizes the separation between letters (Figure
tu rning o f the head should not be perm itted. 8-2). A unique aspect of this chart is its geom etric
progression of size differences betw een lines, referred
Shortcomings o f the Feinbloom to as logM AR progression. O ptotypes on each line
C hart are 0.1 log unit or 25% larger than the previous line.
O ne m ajor problem w ith the Feinbloom chart is This format results in every three lines representing
that it does not have an equal num ber of optotypes a halving or doubling of visual acuity at any given
per acuity level. There is onlv one num ber at the view ing distance, for example, if one starts at 100 and
20/700, 20/600, 20/400, 20/350, 20/300, 20/225 levels, goes down three steps (step 1 = 80, step 2 = 80 to 63,
and only three per line from 20/200 to 20/60. Also, and step 3 = 63 to 50), which is one-half o f 100. These
the letters are not standard, so acuity measured with ch aracteristics allow s for consistent and accurate
the Feinbloom chart m ay not m atch acuity measured evaluation of visual acuity.
w ith another chart. Because of these shortcom ings, The standard test distance is 4 m eters, but for low
the Early Treatment Diabetic Retinopathy Study Chart vision evaluations the test distance is usually halved
(ETDRS) described below should be used when the to 2 m eters to insure a client can read the largest let­
therapist can establish a perm anent work area. ters.
vision on reading, it is im portant to assess both let­
Setup an d Procedure
ter and reading acuity. W hile low vision specialists
1. The client should w ear his or her usual glasses.
routinely adm inister both types o f tests, most eye doc­
The exam iner should be careful to m ake sure tors onlyr
evaluate near letter visual acuity./
Thus, the
the glasses are clean (clean w ith cotton cloth
occupational therapist m ay need to evaluate reading
and water) and adjusted so the client is looking
acuitvУ at near.
through the top half of the lens for distance
A popular test for assessing continuous reading
testing. acuity is the M innesota Low-Vision Reading Test (MN
2. The ETDRS chart is positioned at 4 meters Read Test) illustrated in Figure 8-3. An advantage of
and the client's left eye is covered with the using this test is that it not only provides an assess­
occluder. ment of near visual acuity with continuous text, it
3. The occupational therapist asks the client to also allows the therapist to evaluate the client's read­
call out the letters on the top line. ing speed. Unlike visual acuity, which is not expected
to improve with vision rehabilitation, reading speed
4. T h e occupational therapist proceeds until the
is one function that can be improved. Thus, reading
client can no longer read the letters correctly at
speed is one of the areas for which the occupational
4 m eters and records the last level at which the
therapist may be able to docum ent improvements
client can read more than 50% of the letters.
with treatment and justify additional vision rehabili­
5. The occluder is then held before the client's
tation in M edicare docum entation.
right eye and neither eve so that binocular The M N Read acuity chart can be used to provide
visual acuitv is tested.
a sensitive and reliable m easure o f reading acuity.
6. If the client is unable to see the largest letters Each sentence has 60 characters, which correspond
at 4 meters, the chart should be moved to 2 to 10 standard length words, assum ing a standard
m eters and testing should be attempted again. word length of 6 characters (including spaces). The
reading level of each line is controlled as well. An esti­
Interpretation mate of reading acuity is given by the sm allest print
Testing distances are typically 2 m eters or 4 meters. size at which the client can read the entire sentence
At the 2-m eter working distance, the acuity obtained without m aking significant errors. (U sually reading
can easily perform ance deteriorates rapidly as the acuity limit
у be converted to standard Snellen 20-ft
notation by just adding a zero to the num erator and is approached, and it is easy to determ ine the level
denom inator. For example, a 2/10 acuity measurement where reading becom es impossible). The exam iner
becom es 20/100; an acuity of 32 M at 2 m eters corre­ uses a stopwatch to record the tim e required to read
sponds to a 20-ft equivalent of 20/320. each paragraph and this allow s a determ ination of
A s w ith the Feinbloom chart, it is appropriate to reading speed. A modified graph that can be used for
encourage guessing, eye movements, and eccentric recording results can be found in the Appendices.
view ing to sec the num bers as a m eans of determ in­ The therapist's goal with this test is to determ ine
ing the prognosis for rehabilitation. the best print size for reading at a given distance.
Typically, there are tw o distances at which clients
Reading Acuity (Visual Acuity at often must read. The most com m on distance for con­
tinuous text reading is 16 inches or 40 cm. The second
N ear W ith Continuous Text) com m on distance is about 32 inches or about 80 cm
(arm's length), the usual distance o f stovetop dials and
Practice Setting shelf labels.
Two endpoints should be noted with this test:
Appropriate for any practice setting.
1. Continuous text reading acuity: T h is is the
sm allest print the client can read.
E quipm ent Required
2. Critical print size: The print size just before
M innesota I.ow-Vision Reading Test (MN Read
reading starts to slow, ie, the sm allest print that
results in m axim um reading rate.
If a client is going to regain independence in ADL,
Setup an d Procedure
he or she will need to be able to read again. We also 1. The client should wear his or her usual read­
know that near visual acuity for single letters (let­ ing glasses. The exam iner should be careful
ter acuity) is often different than near visual acuity to make sure the glasses are clean (clean with
for reading phrases and sentences (reading acuity). cotton cloth and water) and adjusted so the cli­
Therefore, to better understand the impact of the low ent is looking through the bottom h alf o f the
Occupational Therapy Low Vision Rehabilitation Evaluation 113


Mtuo S o o lo n kxjWAW

8.0 2 0 .4 0 0 1)

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 2IV2SO 1.1

game before dinner

lenses for near testing if it is a bifocal or pro­ 5. As the client reads sm aller print, encourage
gressive lens (no-line bifocal) design. Л client him to keep reading until he starts m aking
is usually tested under binocular conditions m istakes. The sm allest print at which the c li­
if he or she typically reads w ith both eyes, or ent can read w ith no more than one error is
with the better eye if he or she reads with one continuous text reading acuity.
eve. 6. Using a stopwatch, the exam iner also records
2. The usual distance for the MN Read chart is how long it takes to read each paragraph. This
40 cm from the eyes. If the patient is reading inform ation is used to determ ine the client's
with stronger reading glasses, the test should reading speed. The MN Read Test com es with
be measured at the correct distance for the a conversion table that allow s the exam iner
prescribed glasses. T h is can be calculated to convert the stopwatch m easurem ent into
from the reading addition in the report from words per minute.
the eyecare provider (see Chapter 13). This
inform ation must be accurate before testing Interpretation
proceeds. Make sure the test distance is m ain­
The critical print size is the last paragraph read
tained throughout the testing.
before reading starts to slow. T h is is recorded using
3. Allow the client to move the card side to side, "M " notation. The client continues reading even if he
but be careful to prevent the client from bring­ or she slows down, and the sm allest print at which the
ing the chart closer as the print size becom es client can read with no more than one error is continu­
smaller. ous text reading acuity. T h is would also be recorded
4. Instruct the client to begin reading the para­ using "M " notation as above. Typically, critical print
graphs from top to bottom of the chart. Note size is 3 lines above continuous test acuitv. If distance
the critical print size, the print size just before visual acuitv indicated that the vision in the left eve
the line where reading starts to slow. 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 Setup an d Procedure
test distance of 40 cm , the result would be recorded
as: Part 1 - Testing fo r a H em ianopsia
(Field C ut)
Critical print size: 0.4/1 M (OS) or “ 1 M at 40 cm " 1. The exam iner sits an arm 's length away from
Acuity: 0.4/ 0.5 M (OS) or "0.5 M at 40 cm " the client, or about 80 cm (32 inches).
2. The exam iner's hands should be h alf the d is­
Note that acuity, reading perform ance, and critical
tance betw een him and the client, or about 40
print size m ust alw ays include a specification of test
cm (16 inches).
distance as well as target size.
3. The exam iner and the client w ill see the sam e
Peripheral Visual Field thing, except the exam iner's right is the client's
4. The exam iner instructs the client to "look
Practice Setting
directly into my eye and tell me how many
Appropriate for any practice setting. fingers you see out o f your side vision. Do not
look at my hands, only at mv
* eye".
E qиipm en t R eqиired / «/ 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
Visual field testing is designed to evaluate an
cm from the client and presents 1, 2, or 3 fin­
individual's peripheral vision. Visual field loss can be
gers together, one hand at a time, until the cli­
either absolute or relative. An absolute visual field loss
ent counts them reliably
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 7. The exam in er tests the client's peripheral
relative visual field loss, on the other hand, is depen­ vision using three positions on the right and
dent on the size, brightness, and contrast of the target, three positions on the left (ie, presenting his
relative to the environm ent. This translates function­ fingers at 2, 4, 6, 8, and 10 o'clock positions).
ally into variations of visual field consistency based
on environm ental conditions. For example, a person Interpretation
w ith a relative peripheral visual field loss might A visual field loss is indicated if the client is unable
function better under bright illum ination than under to see the target on one side. If the client is unable to
dim lighting conditions or at night. There are several see the target when presented on the right side until
instrum ents that can form ally quantify the extent of the target is essentially at the m idline, the deficit is
the visual field. These instrum ents are expensive and called a right hem ianopsia. The sam e problem on the
the testing is tim e consum ing. A good alternative for left side is called a left hem ianopsia.
the occupational therapist is confrontation field test­
ing. No equipm ent is necessary for this testing. The C ontrast Sensitivity and Lighting
exam iner sits opposite the client, and the client has to
indicate when he or she can see the exam iner's fingers Evaluation
or hands brought in from the periphery.
W hen eye doctors assess a client's visual field, the Practice Setting
testing is done monocularly, first with the right eye Appropriate for any practice setting.
and then with the left eye alone. However, for the
occupational therapist perform ing peripheral field Equipm ent Required
testing under norm al view ing conditions w ith both
M ars Letter Contrast Sensitivity Test.
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. The M ars Letter Contrast Sensitivitv
Test is a set
of letter charts for testing peak contrast sensitiv­
ity (Figure 8-4). The more fam iliar visual acuity test this happens, encourage the client to guess,
assesses the ability to see sm all, high-contrast objects and score the guesses as ordinary responses.
or print. Symbol contrast sensitivity with sym bols that This will help to insure that the score is based
are well above acuity threshold relates to a person’s on what the client can see and not on what the
ability to see large, lower contrast objects such as client believes he or she can see.
m agnified but lower contrast print, or larger lower 8. The score is given by the contrast sensitivity
contrast shapes like the last step on carpeted stairs. As value of the lowest contrast letter just prior to
such, it is a useful instrum ent in the clinician's arsenal tw o incorrectly identified letters, m inus a scor­
of assessm ent tools. The test consists of three printed ing correction.
charts for independent left eye, right eye, and binocu­
9. The letter just prior to the two consecutive
lar testing. The three forms are identical except for the
m isses is called the final correct letter.
sequence of letters chosen. Figure 8-5 is a sam ple score
sheet. 10. If the client reaches the end of the chart w ith­
The test itself consists of 48 letters arranged in out m aking tw o consecutive errors, then the
eight rows of six letters each. The contrast of each final correct letter is sim ply the final letter cor-
letter gradually decreases reading from left to right, rectlv identified.
and continuing on successive lines. The client simply 11. If the client does not achieve contrast threshold
reads the letters across lines and down the chart, as of 2% or better after the lighting m odifications
in standard letter acuity measurement. Instead of the described below, decrease the distance in half
letters decreasing in size, however, they decrease in once again, and start testing at the last line
contrast. tested above. Record the results as contrast
threshold at 4X acuitv.У
Setup an d Procedure
1. For best results, the chart should be illum inat­ Interpretation
ed uniformly. The patient is tested with both Table 8-6 is used to determ ine the contrast sen­
eyes or the preferred eye as w ith near acuity. sitivity
w for the client. T h is can then be converted to
2. The view ing distance should be selected to contrast threshold. Contrast threshold is defined as
insure that the letters arc at least 2 tim es acu­ an object with the lowest contrast that a client can
ity threshold and more. This is easily done by recognize. A client with norm al vision can usually see
starting far away and m oving the chart closer objects with as little as 2% to 3% contrast. If the con­
until the client can barely recognize the dark­ trast of an object is less than the contrast threshold of
est letter. Move the chart h alf that distance and the client, the object cannot be seen. Contrast sensitiv­
start testing. ity is the reciprocal of the contrast at threshold, ie, one
3. Clients should wear their appropriate eyeglass divided by the lowest contrast at which form s or lines
correction for the test distance and an occluder can be recognized. If a person can see details at very
or patch on the untested eye. low contrast, his or her contrast sensitivity is high and
vice versa. A client w ith a contrast threshold of 2% has
4. To speed up test time, have the patient read
higher contrast sensitivity (1/2 = 50) than a client with
down the left side of the chart. W hen reading
a contrast threshold of 10% (1/10 = 10).
slows, ask the client to read the letters from
O n this test, the contrast o f the final letter before
left to right across each line of the chart. If
which the client m isidentifies two consecutive let­
the client responds with a letter other than
ters, w ith a correction for earlier incorrect responses,
C, D, H, K, N, O, R, S, V, or Z, do not score
determ ines the log contrast sensitivity. Normal values
the response as incorrect. Instead, inform the
of m onocular log CS are about 1.8 (1.6% contrast) in
client of the restricted letter set, and ask for
children and young adults, and about 1.68 (2.0% con­
a n o th e r resp o n se .
trast) for older adults (over 60 years of age). Table 8-7
5. Encourage the client to guess, even when the can be used to interpret the results o f contrast sensi­
letters seem too faint. tivity testing.
6. O n the score sheet (see Figure 8-5), mark in
the grid corresponding to the chart form used, Effect o f Lighting
an X for each letter incorrectly identified. Stop
For patients with vision im pairm ent, lighting can
testing only when the client m akes two con­
have a significant effect on perform ance. Therefore,
secutive errors or reaches the end of the chart
when perform ing these visual acuity or contrast sen­
7. Do not term inate the test because the client sitivity tests, it is useful to m odify the lighting condi­
has given up and has stopped responding. If 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

increasing m agnification of the print. If accept­
1. To determ ine the effect of lighting, place the
able contrast threshold is achieved by relative
M ars Letter Contrast Sensitivity
¥ Test at a dis- distance m agnification, this indicates the client
tance at which the letters are at least 2 tim es
will not only require careful control of light­
the visual acuity threshold. ing, but may require more m agnification than
2. If at this distance the contrast threshold is is typical of someone with his or her visual
worse than 4%, vary the am ount of light to acuitv.
determ ine the range of light levels and type of 9. If contrast threshold never improves to a level
light that produces contrast threshold at better
better than 7%, this indicates that electronic
than 4%.
magnification that enhances contrast may be
3. We recommend the use of an illuminometer, more effective than optical magnification.
which is an inexpensive device that measures
10. A severe loss (contrast threshold worse than
light levels in units called Lux or footcandles.
10%) indicates that fluent reading is unlikely
This allows the therapist to reproduce accept­ even under optim al visual conditions.
able light levels accurately under various treat­
ment situations and make appropriate home
This lighting assessm ent provides an excellent
opportunity to determ ine the effect of usual glare
4. To system atically modify lighting, the thera­
sources, and educate the client. For example, the thera­
pist first finds the type of light (fluorescent,
pist can move the light source so that it shines directly
incandescent, natural light) that produces best into the client's eyes and measure any changes in
contrast threshold, as well as directly illustrate to the
5. O nce the best type of lighting is determined, client the effects of bad lighting.
the therapist varies the intensity by varying
the distance of the light from the material Sunlens Evaluation
being viewed. Som eone w alking outside on a sunny day, driving
6. If an illum inom eter is unavailable, report type into the sun, or trying to recognize a fam iliar place
of light, wattage, and range of distances that in a brightly lit fluorescent dining hall must try to
produce contrast threshold better than 4% to optim ize lighting using sunglasses or sunlenses. An
5%. important component of the occupational therapy
7. If contrast threshold better than 4% to 5% can­ evaluation, therefore, involves having the client try
not be achieved, decrease test distance to the on and select sunlenses under simulations of the
4X distance. conditions that cause problems. The general approach
Table 8-7.

Interpreting Contrast Sensitivity Test Results

Mars Log Contrast Sensitivity Score Interpretation
0.60 or less 25% or higher— severe loss in contrast sensitivity
Reading unlikely unless contrast enhanced and w ith very
careful light control.

0.64 to 1.00 10% to 24% — oderate/severe loss in contrast sensitivity

Fluent reading unlikely

1.04 to 1.28 5% to 9 % — moderate loss in contrast sensitivity

Contrast enhancem ent (electronic m agnification) usually more
effective than optical devices. Lighting evaluation indicated.

1.40 to 1.60 2.5% to 4 % — mild loss in contrast sensitivity

Increased sensitivity to light intensity level and glare

1.64 or greater 1.25% to 2.4% — norm al contrast sensitivity

to a sun len s evaluation involves a trial-and-error car. The therapist provides lenses in pairs for the client
approach under simulated conditions. The "getting to com pare and choose w hich is better, taking care to
started " evaluation equipm ent for a therapist should allow the client to adjust after he dons each sunlens.
include an assortm ent of wrap-around style sunlenses To save time, the lighting evaluation should reveal the
to dem onstrate (see Chapter 16). approxim ate sunlens density required. If a light meter
The sunlens evaluation involves selecting the style, is used, one can hold the m eter behind the lens to
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 quickly locate those lenses that will provide best light
best style of sun len s w raps tightly above and around levels in a given environm ent; otherw ise the therapist
the eyes (w w w .noir-m edical.com ) to block glare and may use gray sunlenses first and then com pare colors
reflections around the lenses. Relatively inexpensive at the selected transm ittance values. O ne should also
or more stylish m odels can be purchased to fit over perform a sunlens evaluation indoors under lighting
conventional eyeglasses. With standard com m ercial conditions where the client has a problem, typically
sunglasses, this glare can be blocked with a hat brim in brightly lit fluorescent room s with shiny tile floors.
or visor. O ne might also use the selected high transm ittance
The density of the sunlens describes the amount of sunlens to cut glare during reading, or with a white
light transm itted through the lens, usually described on black CCTV.
as a light transm ittance percentage w here 100% is
clear and 0% would be completely opaque. Typically, Assessment of Central Scotom a/
the lightest sunlenses have transm ittance values of
50% to 60% ; very dense sunlenses have transm ittance
Eccentric Viewing
values o f approxim ately 10%. Sunlenses also vary in There are several ways to evaluate the central
color. Most clients will respond best to polarized yel­ scotom a and eccentric view ing. The complexity, cost
low or orange sunlenses that decrease glare, or color of equipment, and accuracy varies dram atically from
neutral lenses (Polaroid Gray). Some, however, prefer one technique to another. For exam ple, the m ost accu­
green hues, and occasionally red and blue. Colored rate method uses an instrum ent called the scanning
lenses will degrade color vision, but the yellow hues laser ophthalm oscope. The scanning laser ophthalm o­
will improve perceived contrast and decrease glare. scope takes a picture of the patient's retina, and is able
The sunlens evaluation is tim e consum ing and will to map exactly where scotom as exist and w hich areas
require about 30 m inutes in a separate session. One are used for fixation. The benefits of this procedure
must wait for a sunny day, and evaluate the lens by are its accuracy and that it does not rely on the client's
having the client attempt to identify an object or per­ responses. However, it is very expensive and usually
son next to a glare source, such as reflections off of a only used in large eve clinics. Most private practice
scotoma/eccentric viewing. scotoma/eccentric viewing with scotoma covering ccntrnl

ophthalmologist and optometrists would not have We believe that this is also a valuable evaluation tool.
this instrument available. 1. Draw a clock (numbers 1 to 12) with a star in
Fortunately, less expensive techniques requiring the middle with a black marker on a sheet of
m inim al equipment are available. We recommend paper (Figure 8-6a).
that the therapist use either the clock face technique 2. Occlude the client's left eye and place the clock
or the Tangent screen. about 2 feet awav from the client.

3. If the client has eyeglasses, these should be

Clock Face Technique
worn for this procedure.

Practice Setting 4. Ask the client to look at the clock and so that
the scotoma or unclear area is obscuring the
Recommended for home health setting or any set­
star in the middle of the clock (Figure 8-6b).
ting in which portability is important.
The star should either be unclear or m issing at
this point.
Equipment Required
5. W hile the client m aintains this position, he or
Clock drawn on 8.5 by 11-inch sheet of paper.
she should see that some of the numbers on
the clock are clearer than the star in the middle
(Figure 8-6c).
As described in Chapter 4, macular degeneration is
6. Instruct the client to move his or her eye so that
alm ost alwavs associated w ith a macular scotoma or a
the star is most clear. The client should do this
blind spot in the center of the visual field. This creates
sy stem a tica lly b y lo o k in g up and tow ard the
major difficulty for the client when engaged in any
right at the number 1 on the clock, and contin­
ADL requiring vision. During vision rehabilitation,
ue clockw ise. The client should be able to find
the occupational therapist will teach the client how to
at least one position in which the star is now
look off to the side or to eccentrically view to improve
clearer than when looking straight ahead.
performance. Therefore, it is important during the
evaluation to determine if there is a scotoma and the 7. Once this position is established, instruct the
best position for eccentric viewing. client to look directly at the star again and
notice that it is now blurred or disappears.
Setup an d Procedure Then repeat either eye movement required to
Wright and W atson12 describe the following tech­ regain better clarity.
nique used to teach clients how to eccentrically view.
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.
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
j Figure 8-7; Tangent screen (screen only).

quickly moved from nonseeing to seeing and In Chapter 10, we describe the use o f this procedure
the border of the scotoma is marked several to teach eccentric viewing, which is often incorpo­
times. Typically, the clinician maps at least 4 rated into this testing procedure.
points: 12 o'clock, 6 o'clock, 3 o'clock, and 9
o'clock (Figure 8-8). Reading Assessment/Reading
7. Some clients may shift fixation, eg, from look­ Speed
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 Practice Setting
the target is seen. It is important to instruct the Appropriate for any practice setting.
client to try not to shift the position of his or
her eyes. Equipm ent Required
8. W hen the scotoma is mapped, the edges are The Pepper Visual Skills for Reading Test (Pepper
more clearly marked (with white yarn wrapped VSRT)
around the push pins in the felt board). The
patient is instructed to move his or her eyes to Description
see the outlined scotoma (Figure 8-9). The Pepper VSRT is a test in which clients read
9. I he therapist should instruct the client to look unrelated words aloud (Figure 8-10). T h e words
into different positions and with another let­ increase in length as the reader reads down the
ter or the wand, to demonstrate where the chart. The exam iner records reading rate and also
scotoma has moved. the occurrence and type of errors. W hen comparing
reading perform ance with different optical devices,
10. The client may be coaxed with verbal instruc­
or m onitoring changes in reading perform ance after
tions ("look further to the right"). Som etim es
vision rehabilitation, the Pepper VSRT is the reading
one needs to give the client a target to look
evaluation instrum ent o f choice. The Pepper test has
towards, such as waving the testing spot to the
exceptional test-retest reliability and is very sensitive
right of the fixation target to encourage eccen­
to sm all changes in reading perform ance in clients
tric fixation to the right.

Figure 8-9. Tangent screen showing white yarn used to out­

line the scotoma.
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.

with a 9th grade or higher reading level. A change ing betw een successive items on a single line or the
in reading rate of about 10 words per m inute is sta­ spacing betw een successive lines.
tistically significant when measured by the Pepper
test. In addition, m any compound words are used, Setup m id Procedure
so readers m ay m iss either the beginning or end of 1. The exam iner should select the appropriate
the words. T h is would lead to certain error patterns. test size based on the reader's acuity. The
The exam iner can m ake inferences about underlying appropriate VSRT size is at least one size larger
visual im pairm ents on the basis of the error patterns print than the reader's acuity. T h e authors rec­
based on an analysis of these errors. For example, a ommend using tw o sizes larger or more than
tendency to om it the end of words indicates a scotoma acuity for best perform ance. Therefore, if the
in the right field. reader's acuity is 2 M, the 3 M test is appropri­
The Pepper VSRT engages the client in reading pro­ ate, but 4 M may give better reading ability.
cesses that depend solely, or in part, on visual sources
2. If the reader is using an optical device to read
of inform ation, including: word recognition ability,
the test, then the appropriate test size is one
saccade control, return-sw eep eye movement control,
or two sizes larger than the aided acuity. That
and scotom a placem ent w hile reading.14
is, if the reader is using a 5X m icroscope with
O ne of the three form s of the Pepper VSRT is
an aided acuity o f 0.8 M, the 1 M or 1.5 M test
illustrated in Figure 8-6. Word recognition ability should be adm inistered.
is required because unrelated letters and words are
presented. T h e absence of contextual inform ation 3. To stim ulate the reader to do his or her best,
forces clients to rely on vision to identify the items and to reduce the stress o f the testing situation,
presented. The test becom es increasingly more dif­ encouragem ent can be given consistently at the
end of each line read, or when the reader asks
ficult from top to bottom because line delineation and
spacing, word length, and word spacing change as the for feedback. Such com m ents as, "G ood, keep
client reads successive lines. Both saccadic and return going," "You arc doing w ell," or "That's fine"
are effective. However, praise can be overdone.
sw eep eye m ovem ents are also increasingly more dif­
Most adults know when they У are beyond
У their
ficult because of system atic decreases in either spac­
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 12. The VSRT should be adm inistered in one sit­
clearly. If necessary, the exam iner should point ting. There is a m aximum tim e limit. It is not
out the beginning of the first line as a localiza­ useful to adm inister the test in more than one
tion clue. sitting. If the reader is tired, or for any other
6. The exam iner should sav reason unable to finish the test, the exam iner
¥ to the reader:
should decide w hether to readm inister the test
"I am going to show a card to you with unre­
at another tim e (because of extenuating cir­
lated letters and words on it. The letters and
cum stance), or score the rem ainder of the test
words are not sentences; they have no m eaning
as errors and count the adm inistration as the
when read together. The first line has a black
pretest, and indicative o f the reader's best per­
border around it as a visual guide, but the rest
form ance at the time.
of the lines do not. 1 would like you+ to sav
the letters and words aloud as you see them. 13. As soon as the reader pronounces the last word
Please read the entire test. The first two lines on the test, or the test is term inated, the tim ing
will be letters, and on the third line there will of the test is completed.
be words. W hen you see a word, please say the
word, do not spell it. W hile you are reading Interpretation
the test, I cannot answ er questions about how At the end of the scoring, the exam iner should have
you are doing, but as soon as you finish, we a profile of the readers perform ance that contains the
will talk about how Гyou did. Do Фvou have any w following:
questions before we b egin ?" • A ccuracy of perform ance (mean percent cor­
7. Tim ing for speed using a stopwatch begins as rect)
soon as the reader has the card in focus and is • Reading rate (num ber correct words/minute)
fixing on the b egin nin g letter.
• Line m astery for sym bol length, sym bol spacing,
If a reader asks about the correctness of an line spacing
answ er or how she is doing on the test, the
exam iner should give an am biguous, noncom ­
The reading rate m easure has exceptional test-retest
m ittal response, such as, ’’You are doing a fine
reliability and sensitivity to sm all changes in perfor­
job, keep going."
m ance; change in reading rate o f about 10 w ords per
9. The test has a coding schem e for recording m inute is statistically significant. Four form s of the
errors. For exam ple, if the reader spells the first test are available to enable repeated testing. This test
word instead of saying the word, the instruc­ has been used, therefore, to docum ent im provem ent
tor should indicate that the item is a word in perform ance w ith therapy or provide justification
and asked the reader to pronounce the word for the effectiveness o f reading devices using an objec­
instead of spelling it. If the reader is able to tive m easure of perform ance.
pronounce that word, no error is scored. After An evaluation o f both the accuracy and rate scores
this, however, if the reader spells the word for each reader can provide the clinician with infor­
instead of saying it, the exam iner should score mation to m ake a prelim inary categorization o f the
a "spells word" error. reader's reading perform ance. Typically, low vision
Readers should be encouraged to guess test readers will be reading:
items if they are not im m ediately recognizable. • inaccurately and slowly
If there is no response to an item after 10 sec­ • accurately but slowly
onds, the exam iner should say, "Even if you are
• with both speed and accuracy
not sure, just tell me what it looks like". If the
reader is still struggling, made such a remark T h e VSRT suggests guidelines that may aid the
as, "That is difficult, go to the next item". If the low vision therapist in m aking these categorizations.
O bservations of the VSRT perform ance o f individuals
reader did not read the item, it is considered
an om ission error and is scored as such (check with m acular disease suggest that accuracy scores
score sheet). below 75% correct may be indicative of inaccurate
perform ance and rate scores below 20 words/minute
The last answ er given is the one that is scored.
may be considered slow perform ance
Thus, if the reader spontaneously corrects an
T h e VSRT scoring m anual also has an extensive
incorrect answer, even after leaving the item,
discussion of interpretation and analysis of com m on
credit is given. Also, if the reader changes to a
reading errors, line m astery issues, problem s with
w rong answ er, the item is scored as incorrect.
word length, sym bol spacing, om issions, insertions,
Occupational therapy Low Vision Rehabilitation Evaluation 125

repetitions, jumping or changing word order, and a process, the performance skills and patterns used
variety of other important issues. in performance are identified, and other aspects of
engaging in occupation, such as client factors, activity
demands, and context are assessed.1 The occupational
E n viro n m en tal Evaluation perform ance evaluation involves discussion, observa­
tion, and evaluation of the client's use of vision in
Even a well-developed treatment plan will fail ADL and IADL.
unless the therapist considers the location where the The occupational profile/case history assessm ent
client will habitually perform the goal performance establishes what the client wants and needs to do. This
in question. For example, a client may successfully part of the evaluation is designed to identify deficits
perform a task in an office setting using an optical in perform ance or specific disabilities. By considering
device, while sitting at a desk with a task light and the results of the above evaluation of visual and non­
a reading stand. However, when the client takes the visual client factors, the therapist then identifies client
prescribed device home and sits in his favorite chair factors that act as barriers to perform ance— perfor­
with inadequate lighting, poor support for materials, mance lim iting factors. T he perform ance evaluation
and disabling glare, he may be unable to perform the com bines questioning the client as well as observing
identical task. Fortunately, outpatient low vision reha­ the client engaged in the activities of interest. This
bilitation is a covered service under M edicare В and inform ation will be used to develop a treatment
occupational therapists can provide these services in plan that attempts to remove the barriers and enable
the client's home. This allows the therapist to evaluate occupational performance, thus meeting the client's
the client's environment. specific needs.
As individuals age, they often tend to perform An excellent starting point for this phase is the eval­
tasks in the same place, eg, bill paying is performed uation driven by the client's results on the Veterans
on the dining room table, knitting and reading in the Affairs Low-Vision Visual Functioning Questionnaire
stuffed chair in the living room. Indeed, as people (VA LV VFQ-48). As discussed earlier in this chapter,
age, the space within which they perform most activi­ this has been found to be a valid and reliable m easure
ties decreases to a favorite chair, referred to as the of visual ability in low vision clients with moderate to
"personal surveillance zone."1’ This is a sacred place. severe vision loss. After review ing this questionnaire,
Individuals resist moving from this place or changing the therapist should evaluate the client's actual per­
the layout of the space. An environmental assessment, formance in the areas of concern and also concentrate
therefore, should focus on the preferred living spaces. on what the client has identified as im portant goals.
Careful consideration should be given to: If paying bills is an im portant goal for the client, the
• The available lighting and glare sources therapist should have the client demonstrate w'here
and how he or she pays the bills. The therapist should
• Possible positioning of task lights, reading
carefully observe lighting, contrast, glare, and other
stands, and tables
environmental issues.
• Possible organizational schemes It is also wise to routinely ask clients to perform
• Placement and storage of devices several basic activities that are almost uniform lv J
• Ergonomics when performing a task necessary for all individuals, such as pouring liquid,
reading labels on m edicine bottles, food containers,
• Escape and emergency response
reading the newspaper, reading mail, or using the
The location of the evaluation is an im portant issue
Evaluation o f O ccupational to consider. Ideally, the occupational performance
evaluation should take place in the client's home or
P er fo r m a n c e current living situation. This allows the therapist hi
explore the various areas of occupation and actually
T he final portion of the occupational therapy low observe the client engaged in these activities in the
vision rehabilitation evaluation is designed to evalu­ client's real environm ent (perform ance context). This
ate occupational performance. Occupational perfor­ is particularly im portant because for the low vision
mance is defined as the ability to carry out activities of client, context issues such as lighting, contrast, glare,
daily life, including basic and personal ADL, instru­ home design, appliance setup, and organization are so
mental activities of daily living (IADL), education, critical to an analysis of occupational performance. In
work, play, leisure, and social participation.1 Table 8-8 addition, one should observe perform ance o f fam iliar
sum m arizes these activities. During the evaluation 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
Functional m obility
Personal device care
Personal hygiene and groom ing
Sexual activity
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

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

20/300 falls into the category of severe im pairm ent

(20/200 to 20/400)
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
or VF<=5 degrees 369.68 369.65 369.17 369.13 369.07 369.04 369.03
Total im pairment
(no light perception) 369.63 369.62 369.16 369.12 369.06 369.03 369.01

ID fso

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

Overview of Treatment Strategy

In the low vision rehabilitation model presented

M o d e l o f C are f o r Low below, the ophthalm ologist and optom etrist are pri­
V isio n R e h a b ilita tio n m arily interested in the disorder and impairment,
w hile the occupational therapist and other vision
In Chapter 1, we reviewed our proposed model of rehabilitation professionals m anage the d isability
care for low vision rehabilitation and included a d is­ and handicap, although there may be overlap in some
cussion o f the four terms for defining im pairm ent and areas.
disability proposed by the World Health O rganization
(W H O ).1 This term inology is illustrated in Figure 9-1. Role of the Ophthalmologist
A disorder is an anatom ical deviation from normal T h e role of the ophthalm ologist is to diagnose and
and can be congenital or acquired. Exam ples of visual treat the eye disease. This might involve the use of
disorders causing low vision arc age-related m acular m edication or surgery. W hen it is clear that vision has
degeneration (AM D), diabetic retinopathy, glaucoma, been perm anently impaired due to the eye disease,
and cataract. the ophthalm ologist refers the client to a low vision
Impairment is a loss or abnorm ality in function. The optom etrist for evaluation and treatment. In many
im pairm ent can be either physiological or psychologi­ cases, optom etrists m anage diseases with medical
cal. Visual im pairm ents include decreased visual acu­ interventions as well.
ity, reduced contrast sensitivity, central scotom as, and
constricted visual fields. Role of the Low Vision
Disability refers to a restriction or an inability to
perform a task in the normal way. Examples are d if­ O ptom etrist
ficulty reading newspaper print, recognizing faces, T h e role of the optom etrist is to evaluate the patient
and driving a car. and determ ine w hether a change in the traditional
Handicap is a disadvantage that prevents or limits eyeglass prescription m ight be o f benefit. The low
the fulfillm ent of a role that is norm al for the client. vision optom etrist also perform s a detailed evaluation
Exam ples are the inability to work or engage in hob­ of distance and near visual acuity, contrast sensitivity,
bies, and restricted social interactions.
Definition Term Examples

Anatomical deviation from normal. D isorder Cataract, Age-related m acular

whether congenital or acquired degeneration, Glaucoma

Loss or abnorm ality of function, Visual acuitv

* 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

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

Disadvantage that prevents or limits H andicap Inability to work

fulfillm ent of a role that the indi­ Restricted social interaction
vidual would consider normal G iving up hobbies

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 tively, the use o f both optical and nonoptical assistive
field. Based on the results of this evaluation and the devices in ADLs, and in som e cases sensory substitu­
case history, the optom etrist begins the process of tion. M anagement of lighting, contrast, and glare arc
determ ining the m agnification needs of the client for also critical roles. The occupational therapist may
various activities of daily living (ADL) and selects and need to refer the client back to the low vision optom ­
prescribes appropriate low vision optical aids. The etrist if he/she finds that the prescribed optical device
optom etrist then refers the client to the occupational is not as effective as desired. O ther potential referral
therapist for training in the use of the prescribe devic­ sources include professionals such as the orientation
es in various ADL. A few ophthalm ologists specialize and m obility (O&M ) specialist, a psychologist or psy­
in low vision rehabilitation .is well. chiatrist, and the social worker.
Although the scenario described above represents
current th in kin g about the interaction between the O ther Vision Rehabilitation
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 In Chapter 1, we described the background, edu­
section below. cation, and history o f vision rehabilitation thera­
pists, O &M specialists, and teachers of the visually
Role of the Occupational impaired. Until 1990, these three professions supplied
all of the vision rehabilitation services in the United
Therapist States through the chronically underfunded blindness
T h e role of the occupational therapist is to determ ine system. This system has had to prioritize services gen­
the cognitive, psychosocial, and physical needs of the erally favoring children and young adults of working
client. The evaluation process described in Chapter 8 age. In addition, the limited num bers of rehabilitation
allows the occupational therapist to evaluate visual professionals in the blindness system prim arily tend
and nonvisual client factors, history, roles, physical to work in m etropolitan areas. Thus, for many older
environm ent, and occupational performance. clients and for those not living in large m etropolitan
Based on the evaluation, the occupational therapist areas, low vision rehabilitation has not been readily
designs a vision rehabilitation program to teach the available through the blindness system .2 Teachers of
client how to function more effectively in ADLs in the visually impaired work with children and are not
spite of the vision loss. Rehabilitation includes edu­ involved in the care of the older client with low vision.
cation about low vision, m anaging the psychosocial However, vision rehabilitation therapists and O&M
issues, referral to com m unity resources, teaching the specialists w ill continue to be actively involved in low
client how to eccentrically view and read more effec­ 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 tive in the early stages o f visual loss. Even if the client
the most effective ways to deal with this issue is to eventually progresses to more serious vision loss, he
encourage the client to attend local support groups. or she has already experienced success in low vision
T h ese support groups not only have educational rehabilitation and is more likclv to be motivated to
presentations, but also provide opportunities for the continue treatment. As a result, earlv ¥
person to interact with other people who have lived encourages people to begin applying relatively easy
with low vision for m any years. com pensatory techniques to m aintain occupations,
The one area where remediation is possible is read­ routines, and roles.
ing rehabilitation (see Chapter 10). Patients with low M cllw aine et al7 found that there was a relation­
vision generally struggle with reading, particularly ship between age and success w ith low vision aids. In
when the underlying disease affects the m acula and their study, there was a significant difference in use
causes a central scotom a. Effective reading is very of aids between clients less than 65 *years and those
linked to the ability to fixate
and m ake accu- greater than 65 years old. O ver one-third of clients
rate, rapid eye movem ents called saccades. Both fixa­ over the age of 65 never used their low vision aids,
tion and saccadic ability are negatively affected after compared w ith only one-sixth of clients under the age
m acular disease such as AMD. Studies demonstrate, of 65 years.7
however, that in spite of the perm anent visual acuity The obstacle to early intervention, however, is that
loss and central scotom a, reading speed and com pre­ many clients are not em otionally ready for rehabilita­
hension can indeed improve, even though the visual tion after initially sustaining visual loss.6 They may
characteristics of the print or a p ersons visual acuity still not accept that the vision loss is perm anent.
does not improve. Indeed, as clients develop skills Patients often schedule appointm ents with other doc­
in using their rem aining vision in functional tasks, tors for additional options, hoping that there m ay be a
m any areas of visual perform ance improve consider­ conventional way of restoring vision.
ably w ith practice. Although some clients m ight claim
their vision improves, these improvements are likely Determ ine Patient Goals
higher order perceptual changes or visual scanning
It is im portant to have the client actively involved
skills, not changes in basic sensory function such as
in development of the specific perform ance goals
visual acuity, contrast sensitivity, or visual fields.
of the treatm ent plan. T h is process actually occurs
during the low vision rehabilitation evaluation. As
Com pensatory Approaches we stated in Chapter 8, the objectives o f the occupa­
Low vision rehabilitation has been successfullyУ tional profile/case history part of the evaluation are to
practiced for many years w ith an em phasis on com­ gather inform ation about the client's vision and health
pensatory techniques. Com pensatory rehabilitation status, previous eyecare and low vision treatm ent, and
strategies include the use of optical and nonoptica 1 understand the client's functional ability у before the
devices; treatm ent of visual skills such as fixation, vision loss to define his or her current goals. We sug­
eccentric view ing, saccades, and scanning; m odifica­ gest the use of the Veterans A ffairs Low-Vision Visual
tion of the environm ent; and education. The research Functioning Q uestionnaire (VA LV V FQ -48).8 This
supporting low' vision rehabilitation is reviewed questionnaire not only m easures perform ance ability,
below. but can also be used to tailor rehabilitation program s
to m eet individual client needs.
Early Intervention Is Critical O f course, it is im portant for the therapist to guide
the client through the process o f establishing goals.
O ne o f the kev
у factors in the success of low vision Patients will typically require guidance because they
rehabilitation is earlv у intervention.7 W hen treatment may not know what rehabilitation strategies are pos­
is initiated earlier in the disease process, visual acuity
sible.9,10 Q uillm an and G oodrich state that people
and visual field loss are generally less severe. With
with recent and severe vision loss m ay not have been
better visual acuity, lower m agnification optical aids
able to think about vision goals as yet.10 They state
can be prescribed and it is easier for clients to learn
that "It is never a good idea for a practitioner to set a
how to use lower power devices because the work­
goal for a client; it is appropriate to help the client set
ing distance is closer to normal and the field of view
his or her own goals." Watson suggests using check­
is wider. In addition, the use of nonoptical assistive
lists or perform ance assessm ent system s to negoti­
devices is more effective because less m agnification
ate betw een felt needs and ascribed needs.9 In some
is required and a wider variety of appropriate devices
cases, the client may be depressed and reluctant to
are available. Sim ple rehabilitation strategies such as
establish his or her own goals. In such cases, it is criti­
organization of the environm ent, improved lighting
cal for the therapist to acknowledge that a significant
and contrast, and elim ination of glare are more effec­
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
4 ■•■a and finally in a sim ulation of her home context, w ith
a report and recom m endations for a final device pre­

Figure 9-2. C lin ical reasoning process.

S eq u en tia l T reatment
loss has occurred, w hile encouraging the client about A ppr o a c h
proper intervention and motivation. Much can be
done to help the client becom e more independent in The seven-step sequential treatm ent approach for
ADL.10 O nce the goals are established, the sequential low vision rehabilitation is sum m arized in Table 9-1,
treatm ent program outlined below can be planned and each phase of this treatm ent approach is described
and initiated. in detail in Chapters 10 through 15.
Recall that m any clients begin therapy skeptically
Clinical Reasoning Process and need to be convinced o f the value of therapy. The
therapist should always begin the rehabilitation pro­
The occupational therapist uses the results of this gram with a careful discussion of perform ance goals
four-part evaluation to develop a treatm ent plan, and, if possible, dem onstrate to the client that achieve­
w hich is described in detail in Chapter 8. We suggest ment of a perform ance goal is possible. Som etim es
the clinical reasoning process illustrated in Figure 9-2. this might be done during an initial evaluation. The
Perform ance goal definition involves consideration of therapist w ill spend tim e discussing the client's par­
occupational history, habits, roles and culture context, ticular eye disease and the expected course o f the
dem and, and finally, the results of current occupa­ disease, but care must be taken not to discourage the
tional perform ance assessm ent.1 It is im portant to client. The goal is to encourage the client to focus on
define observable and m easurable perform ance goals the end, a perform ance goal, rather than the means.
w ithin context, not in the clinic. For example, Ms. For example, a client with AM D might hope for the
Jones, a 72-year-old, w ishes to read a novel fluently day when she will be able to read mystery novels
and com fortably in her favorite chair by the window. again. This client is expecting to read visually. A s will
O ne then refers first to evidence-based research and be discussed in Chapter 10, fluent visual reading is
Table 9-1.

Vision Rehabilitation: Seven-Steo Seauential Treatm ent Plan

Education Nonoptical Assistive Devices
Nature of eye disease Visual
O utlook for the future Tactile
Expectations of vision rehabilitation Auditory

Therapeutic Activities Optical Magnification

Eccentric Viewing Computer Technology in Low Vision Rehabilitation

Reading skills Resources/Handouts

Environmental Modifications
G lare

usually not possible with AMD, although spot read­ target size, are used in this phase o f the rehabilita­
ing is possible after considerable instruction. In the tion. These approaches are described in Chapter 11.
first session, one m ight introduce the client to a tape If one is providing services in an outpatient setting,
recorder and an audiotape from Recordings for the at least one home visit early in the treatm ent is highly
Blind (a free service) as a place to start, em phasizing recom mended not only for treatm ent planning, but
that norm ally sighted people use books on tape and also because several simple home m odifications can
that with rehabilitation she will likely read again but be highly effective and easy to implement. O ne often
it will be very difficult at first. The therapist might finds that removing glare and seating a client closer
also show the client how to perform a simple cook­ to the TV will easily enable one perform ance goal to
ing activity, dial a phone, or find the right cell in her be met.
m edication dispenser— a task that requires little or no O ccupational therapists just becom ing involved in
vision to perform. the field of low vision are som etim es intim idated bv
A large percentage of the clients seen in vision the need to develop a knowledge and understand­
rehabilitation have A M D and, therefore, have a central ing of low vision optical devices. New terminology,
scotom a. W hen dealing with a client with a central an understanding o f optics, and the impression that
scotom a, it is best to begin therapy with eccentric there are so many aids available can potentially cre­
view ing techniques. O nce the client is comfortable ate an obstacle to getting involved. WTe feel that it is
with eccentric view ing, he or she can use these skills im portant to understand that the use of low vision
throughout the rest of the rehabilitation.10 Eccentric optical devices, although very im portant, is just one
view ing, scanning, eye movement training, and read­ aspect of low vision rehabilitation. In m any cases,
ing skills training are covered in depth in Chapter 10. very sim ple environm ental m odifications and the use
O ne o f the easiest and most econom ical treat­ of nonoptical assistive devices can be of great benefit
m ent approaches is the use of environm ental m odi­ to a client. These nonoptical assistive devices include
fications. A client can often achieve substantial gains visual devices and also devices that utilize sensory
w ith improved lighting, contrast and elim ination of substitution, such as tactile and auditory assistive
glare. Therapists will need to evaluate these aspects devices. O ccupational therapists should acquire the
of the client's environm ent, educate the client about various catalogs that are available and include a wide
the im portance of optim al lighting and contrast, variety of available nonoptical assistive devices. This
and then dem onstrate the possible im provem ents by topic, along with inform ation about resources, is cov­
m aking appropriate changes. O ther strategies, such ered in Chapter 12.
as changing the working distance and enlarging
An interesting problem when designing research
Optical Magnification to study the effectiveness of low vision rehabilita-
The use of optical m agnification is, of course, criti­ tion is what to use as an outcome measure, or how
cally important in low vision rehabilitation. Almost to measure the effectiveness o f treatm ent Various
all clients with low vision will be able to perform bet­ strategies have been used, including measurem ent of
ter with the prescription of appropriate optical aids. reading speed,ч-1л1‘Л23 duration,15'19 and com prehen­
These aids will typically be prescribed by the low sion;19 adm inistration of questionnaires that assess
vision optometrist. In the ideal professional environ­ quality of life;20'21'23 compliance with the use of low
ment, however, the occupational therapist will also be vision aids;7' 13'14'22,26 satisfaction with treatm ent;7'1*’-18
involved in the early phase of selection of optical aids. independence in A D L;13'20'21'24'26 and psychological
The occupational therapist can assist in this process adjustment to vision loss.20'26 Even among studies that
by providing critical information about the clients' have used questionnaires as outcome measures, the
ADL problems and goals. If the client has other physi­ actual questionnaires have differed from one study to
cal problems that could interfere with the use of some another. These significant variations in study design
types of aids, the therapist can make suggestions are problematic and make it challenging to compare
about optical aids selection based on these needs as the results of one study to another. Nevertheless, the
well. Chapter 13 covers this topic. research that is available generally suggests that low
just as computer technology has become impor­ vision rehabilitation is indeed beneficial and allows
tant in so many aspects of our lives, it is also gaining clients to read faster and for longer periods of time,
importance in the field of low vision rehabilitation. and leads to improvement in independence in ADL
Every year, more elderly present in the clinic with and psychological adjustment to the vision loss.
premorbid fam iliarity w ith computers. For some, There are numerous studies that demonstrate that
computer use is as fam iliar an activity as cooking. the use of low vision aids is helpful when actually
Once a specialty skill, every low vision therapist now used by clients.13'19'22*24 O f critical importance, how­
needs to understand how to adapt computers for use ever, is the finding that many clients either never use
by people with low vision. Computers themselves the low vision aids that have been prescribed or fail
have become important assistive devices that enable to use them properly. Hum phry27 studied a sample
shopping, leisure, and functional written com m unica­ of visually impaired clients who received low vision
tion regardless of the level of vision loss. This genera­ devices with no training and found that 75% reported
tion will want and need to continue using computers that they never used them. Another study7 found
and will feel com fortable with computer-assisted that 33% of clients who were prescribed aids without
technology for low vision rehabilitation. Thus, the training never used their devices. Training or rehabili­
use of computer technology will become a vital part tation designed to teach clients how to use prescribed
of the sequential rehabilitation treatment plan and is aids in ADL may, therefore, be an im portant com po­
described in detail in Chapter 14. nent of low vision rehabilitation.
The outstanding question is one o f dosage. How
many therapy sessions are necessary? The number
Review o f R e s e a r c h o n Low of training sessions required to achieve m aximum
effectiveness is an im portant question because o f its
V ision R e h a b ilita tio n implications for healthcare costs. Several studies have
been designed to compare limited to more exten­
Research studies have been published report­ sive training.7'15' 19-2* Goodrich et a l19 performed two
ing on the effectiveness of low vision rehabilitation. experim ents and all clients received eccentric view­
However, this research has been impeded by a lack of ing training before starting the research. In the first
standardized measurement tools, and a lack of quality experim ent, they found that five sessions o f optical
research.11-12 Some of the design flaws in the available device training were as effoctivc in im proving reading
research include retrospective design, lack of placebo speed as 10 sessions of training, and seven sessions
groups, the use of unmasked exam iners, lack of stan­ of training to read with a CCTV were as effective as
dardized measurement tools, and sm all sample size. 15 sessions. In the second experim ent, they compared
Most of the available research is limited to investiga­ very short training typically used in private practices
tion of the use of low vision aids with limited train­ (one session of optical device training) to five sessions,
ing sessions,7'13'14 and the use of low vision aids with and two sessions of CCTV training to seven sessions
additional training.15- ’ Few studies have reported of CCTV training. In this study, the shorter number
on the benefits of other services such as occupational of sessions was not as effective as the longer treating
therapy and O&M training.2425 O ne study reported approach for improving reading speed. They con­
on the effectiveness of a self-management interven­ cluded that extended training sessions beyond what
tion program for clients with AMD.26 is typically provided in private practice is beneficial
for the rehabilitation of reading ability in clients with Nevertheless, conventional wisdom suggests that cli­
central vision loss. However, they also found that a ents are more likely to use prescribed optical aids and
moderate am ount of training (five sessions versus 10 perform more effectively in ADL when they receive
sessions w ith optical aids, and seven sessions versus additional rehabilitation from a low vision therapist.
15 sessions with a CCTV) w as as effective as longer Because occupational therapy has only recently
am ounts of training. A problem w ith this study was becom e involved in the field of low vision rehabilita­
that the outcom e exam ination was not performed by tion, there is lim ited research in which occupational
a masked exam iner. A sim ilar study was performed therapists played a significant role in the treatm ent.24
com paring 1 hour to 5 hours of low vision device A study conducted at the M assachusetts Eve & Ear
training.24 The outcom e m easures were reading speed Infirm ary tested the hypothesis that vision rehabilita­
and accuracy and quality of life m easures. T h is study tion using optometry, occupational therapy, and social
also used an unm asked exam iner who knew the work services increases clients' functional ability. The
clients' treatm ent assignm ents. They found that the study also investigated whether involving fam ilies
extended training tim e made a significant difference in the intervention resulted in more successful out­
in reading ability as w ell as the clients' perceptions of comes. N inety-seven subjects w ere studied and were
the quality of their lives. randomized into either individually focused or fam ily
In contrast to these studies, a random ized clinical focused intervention. Table 9-2 lists the services pro­
trial with m asked exam iners was performed com ­ vided by each profession.
paring the effectiveness of conventional low vision All clients received the services listed in Table 9-2.
rehabilitation, conventional low vision rehabilitation For those clients assigned to the individual protocol,
enhanced w ith home training sessions, and a control their family m em bers were excluded from all sessions.
group.20 The conventional low vision rehabilitation Rehabilitation intervention focused solely on the cli­
included dem onstration of low vision aids, use and ent. If the fam ily had questions, these were answered
handling of low vision aids, advice about lighting, in the w aiting room or hallw ay as the clicnt was
providing large print m aterials w ith inform ation entering or leaving the service. In contrast, the fam ily
about lighting, use of low vision aids, and other focused group had fam ily m em bers included with
services. The enhanced group also received this the clicnt in all stages of the rehabilitation process. A
basic care plus three home visits from a rehabilita­ functional assessm ent questionnaire and a functional
tion therapist. D uring these visits, the rehabilitation vision perform ance test were used to m easure the
therapists provided additional training with the low outcom e of the study.
vision aids, dem onstrated additional or alternative 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
low vision aids, and provided additional client sup­ rehabilitation plan involving optometry, occupational
port. Patients assigned to the control group received therapy, and social work services increased the client's
the sam e conventional care plus three home visits level of function as m easured by both an objective
from a com m unity care worker. This individual did observation of perform ance of daily tasks and a self-
not provide any low vision rehabilitation. Instead he report of difficulty and independence in perform ­
o r she discussed the client's ability to cope w ith daily ing ADL and social activities. The gain s in function
activities, leisure activities, and any other problems applied to even predom inantly frail elderly clients.
raised by the participant. The trial found no evidence The study did not support the hypothesis that fam ily
o f benefit from enhanced low vision rehabilitation. involvement in vision rehabilitation increases the level
T h e authors conclude that researchers should be cau­ of functional improvement.
tious about advocating m odified or supplemental
interventions w ithout more in-depth evidence of their
effectiveness. Summary
La Grow21 also com pared traditional com m unity-
based treatm ent from private optom etrists or ophthal­ This chapter presented an overview o f the seven-
m ologists to enhanced treatment. The enhanced or step sequential treatm ent plan for vision rehabilitation
com prehensive treatm ent consisted of train in g in the as well as a review of the research on the effectiveness
use o f low vision aids (1.5 to 2 hours) and nonoptical of low vision rehabilitation. There is an urgent need
assistive devices. The results revealed no significant for additional research to study the im portance and
differences betw een the two groups on visual fu nc­ effectiveness of occupational therapy intervention for
tion questionnaires, quality of life questionnaires, and low vision im pairm ent. This need should be a priority
m easures of independence in ADL. for the profession o f occupational therapy.
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.
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

R eferences and disability in older people with impaired vision: a follow-up
study. / Am Geriatr Soc 1996;44<2>:I8I-184.
I. World Health Organization. International classification ol impair­ 5. Rovner BW, Casten Rl. Tasman WS. Effect of depression on
ment. disabilities, and handicaps: .1 manual o f classification relat­ vision function in age-related macular degeneration. Arch
ing to consequences ot disease. Geneva, Switzerland: W H O ; Ophthalmol. 2002;120(8):1041-1044.
1980. 6. Graboyes M. Psychosocial implications of visual impairment. In:
2 Warren M. An overview of low vision rehabilitation and the Brilliant RL, Ld. Essentials o f lo w Vision Practice. Boston, MA:
role of occupational therapy. In: Warren M, Fd. tow Vision Butterworth-Heinemann; 1999:12-17.
Occupational Therapy Intervention With the Older Adult. 7. Mcllwaine G G , Bell |A. Dutton G N . Low vision aids: is our ser­
Bethesda, MD: American Occupational Therapy Association; vice cost effective? Eye. 1991;5:607-611.
2000:3-21. 8. Stelmack |A, Szlvk |P, Stclmack IR, et al. Psychometric prop­
3. Brody BL. Gamst AC. Williams RA, et al. Depression, visual erties of the Veterans Affairs Low-Vision Visual Functioning
acuity, comorbidity, and disability associated with age-related Questionnaire. Invest Ophthalmol Vis S<i. 2004;45( 111:3919-
macular degeneration. Ophthalmology. 2001;108(10):1893- 3928.
1900; discussion 1900-1901.
9. Watson GR. Older adults with low vision. In: Corn AL. Koenig 19. Goodrich GL. Goldilocks and the three training methods: a
Al, Eds. Foundations o f lotv Vision. Clinical and Functional comparison of three models of low vision reading training on
Perspectives. New York: American Foundation tor the Blind; reading efficiency. Vis Impairment Res. 2004;6:135-152.
2000:363-390. 20. Reeves B. Harper RA, Russell WB. Enhanced low vision rehabili­
10. Quillman RD, Goodrich GL. Interventions tor adults with tation service lor people with age-related macular degeneration:
visual impairments. In: Lueck AH, Ed. Functional Vision: A a randomised controlled trial, fir / Ophthalmol. 2004:88:1443-
Practitioner's Guide to Evaluation and Intervention. New York: 1449.
AFB Press; 2004:423-474. 21. La Grow S). The effectiveness of comprehensive low vision ser­
11. Stelmack |. Emergence of a rehabilitation medicine model for vices for older persons with visual impairments in New Zealand.
low vision service delivery, policy, and funding. Opfomefry. I Vis Impairment X Mind. 2004;98:679-692.
2005;76<5>:318-326. 22. Shuttleworih GN, Dunlop A , Collins |K. lames CR. How effec­
12. Vision rehabilitation: care and benefit plan models. Literature tive is an integrated approach to low vision rehabilitation? Two
review. 2002 [cited 2005 October 7, 2005J, Available from: year follow-up results from south Devon. Ur I Ophthalmol.
http://www.ahrq.gov/clinic/vision/. 1995;79:719-723.
13. D'Allura T, Mclnernev R. Horowitz A. An evaluation of low 23. Scanlan JM. Cuddeford JE. Low vision rehabilitation: a com­
vision services. / Vis Impairment & Mind. 1995:89:487-493. parison of traditional and extended teaching programs. / Vis
14. Leat SI. Fryer A, Rumney N). Outcome of low vision aid pro­ Impairment & Blind. 2004;98:601-611.
vision: The effectiveness of a low vision clinic. Opt Vis Sci. 24. McCabe P. Nason F. Demers Turco P, Friedman D, Seddon JM.
1994;71:199-206. Evaluating the effectiveness of a vision rehabilitation interven­
15. Goodrich GL, Mehr EB. Quillman RD. Shaw HK, Wiley tion using an objective and subjective measure of functional
IK. Training and practice effects in performance with low- performance. Ophthalmic Fpidemiol. 2000; 7(41:259-270.
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1977;54<5>:312-318. of a vision rehabilitation program for older adults with visual
16. Nilsson UL, Nilsson SE. Rehabilitation of the visually handi­ impairment. Topics in Geriatric Rehab. 2004;20(3}:223-232.
capped with advanced macular degeneration. A follow-up 2(». Brody BL, Williams RA, Thomas RG, Kaplan RM. Chu RM,
study at the Low Vision Clinic, Department of Ophthalmology, Brown SI. Age-related macular degeneration: a randomized
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eration. Clin Vis Sci. 1990;6:3-10.
Foundation Skills and
Therapeutic Activities

can indeed improve after vision rehabilitation as the

C om pensating f o r C entral client learns to more effectively use the rem aining
F ield Loss vision. This chapter is designed to present a system ­
atic approach to rehabilitation of eccentric viewing,
This chapter includes the foundation skills for low fixation, scanning, and reading and is the second
vision rehabilitation. In Chapter 9, we stressed the step of the seven-step sequential treatment approach
general rule th.it rehabilitation for vision impairment for low vision rehabilitation that was sum m arized in
is not remedial. Low vision rehabilitation improves Table 9-1.
In occupational therapy, occupation is used as a
performance of activities that typically depend on
vision, rather than improve vision itself. The one means for developing necessary foundation skills and
important exception to this rule is the area of reading abilities. For example, reading and finding an object
and localization of objects in space. Clients with low in a store provide engaging activities that help build
vision generally struggle with reading, particularly foundation visual scanning skills for other activities
when the underlying disease affects the macula and as well. In occupational therapy, the development
causes a central scotoma. Clients with peripheral field of m eaningful occupation is not only a means, but
loss or unilateral field loss struggle with spatial local­ an end, the ultimate outcome. Towards this end, the
ization, finding and localizing objects in their im m e­ occupational therapist will readily consider nonvisual
diate surroundings, and avoiding tripping hazards. as well as visual solutions to enable som eone to enjoy
Effective reading and scanning of one's environment a book or find som ething in a store.
is very closely linked to the ability to fixate and make
accurate, rapid eye movements called saccades. One Central Field Loss and M acular
often must relearn saccade control and scanning in Degeneration
order to recover reading and localization of objects in
Macular degeneration ranks as the most common
space. Studies demonstrate, however, that in spite of
the permanent visual acuity loss and central scotoma, cause of low vision in developed countries.1 As the
a person can learn to fixate more accurately and make disease progresses to the end stage, m acular degen­
more accurate saccades after vision rehabilitation. eration usually restricts dam age to the central visual
Thus, reading and localization of objects in space field, the macula and imm ediately surrounding area,
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
A C e n tra l F ixation 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.

I Learning Eccentric Viewing

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
в E c c e n tric V iew ing 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
Figure 10-1. A . Illustration of central view ing. B. Eccentric and may not even be aw are of a central blind spot. For
view ing vv/ Noillson technique ndded. Th e letter 'A" is the example, som eone might see a person norm ally in his
fixation target and the cross indicates the scotoma center
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
creating a central scotom a. A scotom a is a “blind spot," field loss often com plain that "th in gs appear and d is­
an island in the visual field with reduced or no vision appear." If the m acular problem is left unm anaged,
that is surrounded by better vision. T h e central por­ reading becom es impossible, as even w ith magnified
tion of our visual field, the m acula, com prises the text, words or parts o f words appear and disappear.
central 15 to 20 degrees of visual angle, an area about Not surprisingly, nearly one out of four o f those with
tw ice the width of a fist at arm 's length.1 With m acu­ this frustrating and confusing im pairm ent develop
lar degeneration, this central region is damaged and clinically significant depression.4 '
creates a central scotoma surrounded by functioning Several studies and clinical experience indicate
more peripheral retina. Investigators have measured that a person with central field loss can learn to use
scotom a sizes to about 30 degrees,2 an area about the his or her peripheral vision rather than central vision
size o f three fist widths. In addition to m acular degen­ to view objects (Figure 10-1). Research indicates that
eration, central field loss also occurs w ith untreated people who have adapted to central field loss will
d iab etic retinopathy and cortical blindness. With prefer to use one or more patches of functioning retina
these conditions, the central field loss m ight be larger outside of m acula called Preferred Retinal Loci or
than the central field loss associated with m acular PRL.8' 1-'’ Som eone using a PRL rather than the fovea
degeneration. will appear to be looking above, below, or to the side
There are tw o types of m acular degeneration. With of a target rather than directly at it. M any use the
the exudative (wet) type of m acular degeneration, term s eccentric viewing or eccentric fixation to describe
retinal sw elling m ight distort the shape of objects how a person's eyes appear when h e or she uses a PRL
being viewed and the person might have multiple (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 tion. The second goal is to teach the client to become
relearning a tennis or golf swing after many years of aware and in some cases visualize the central scotoma.
using another technique. Learning the new task is As this instruction is best done by demonstration, the
conscious and clum sy at first, becoming automatic therapist can instruct the client and evaluate eccentric
and smooth later after considerable practice with feed­ viewing and scotoma size at the sam e time. T h e client
back. At first, if someone sees som ething to the side also requires education regarding the expected prog­
and quickly looks directly at it using the fovea, it will nosis and reassurance that by learning a new way of
disappear. With practice, people with central field loss looking at things, vision will once again become more
will learn to directly look at som ething using the PRL, predictable, although m agnification will be required
but not as quickly or efficiently as someone with intact to read and recognize faces and TV again. Learning
central vision.16 People also can learn to use different to eccentrically * fixate is difficult and can be frustrat-
eccentric view ing positions that optim ize vision for ing. Care must be taken to carefully grade activities to
different conditions.1■ insure early success, to be positive, and to keep train­
Instructional protocols have been shown to rather ing sessions short.
quickly and effectively teach a person with central O ften the visual system "fills in " the central
field loss to develop a PRL that substitutes for loss scotom as; the person with a central scotoma cannot
central retinal function.18*20 These instructional pro­ see the blind area but can be instructed to become
cedures have improved functional reading as well as aware of it. W hen asked to look at a target "so you can
clinical measures of viewing performance. The meth­ see it clearly," the beginner who has not yet developed
ods described below are a blend of those reported by eccentric view ing will tend look directly at the target
Nilsson with methods developed by Gale Watson21-22 and it will disappear, but he or she can still see objects
and personal clinical experience. How the therapist to the side. Scotoma awareness training requires dem ­
teaches eccentric view ing depends on the client's level onstration com bined with explanation. At the end of
of skill when started, as many learn some eccentric scotoma awareness training, the client should be able
viewing without instruction. These steps are sum m a­ to describe the shape of his central blind spot and why
rized in Table 10-1. things appear and disappear. At the end of eccentric
view ing training, the client will voluntarily move the
Scotoma Awareness Instruction blind spot to m ake isolated targets disappear as well
as to position his eye to see an object most clearly.
an d Evaluation o f Vision and
The client who has developed eccentric view ing will
Skills be able to position the eye eccentrically, that is look­
The first and most important step in eccentric view­ ing above, below, or to the side so the target that is
ing training has tw o objectives. The first objective is to straight ahead can be visualized. One case that illus­
determ ine if the client has already developed adaptive trates this skill involves an attractive young woman
eccentric view ing or still has nonadaptive central fixa­ who had adapted to a juvenile macular degeneration
she acquired at age 16. She described one advantage looking around with searching eye movements. The
of m acular degeneration: at a party she could m ake therapist should carefully observe the client's eyes to
unattractive guys “go aw ay" just by looking at them, insure view ing is stable. If the client has steady view­
w hile chocking out the cute ones from the “corner of ing, the third possibility is that the scotoma m ight be
her eye." O ne might say she had m astered scotoma sm all or might be a relative scotom a (reduced central
awareness. vision but enough vision to see shapes). In this case,
There arc several m ethods to approach scotoma the therapist moves the clock fu rther away until the
aw areness training. We describe tw o useful proce­ client reports that the star fades from view (central
dures, the tangent screen and clock face methods. fixation) or som e num bers disappear (eccentric view­
Ideally, instruction should include both techniques. ing). D uring this testing, scotoma aw areness train­
The clock face method is quickly adm inistered; the ing involves explaining to the client about the center
tangent screen m ethod might require approxim ately 5 "blind sp ot" and pointing out how it can be moved by
m inutes. Early in the instructional sequence, a larger looking in different directions.
tangent screen is required and m ay not be practical in
a hom e-based therapy setting. The T angent Screen M e th o d
The tangent screen method (see Figure 10-3 and
The C lock Face M e th o d Chapter 8) also can be used to com bine central field
Wright and Watson developed m ethods available testing and eccentric view ing evaluation w ith scotoma
in a workbook that provides excellent worksheets awareness training. The view ing target is usually a
and resources for eccentric view ing instruction.21 The letter large enough for a client to recognize in the cen­
clock face method involves the use of a picture of a ter of a felt board. The tangent screen method involves
clock (Figure 10-2) w ith a star at the center of the clock. first positioning the view ing target in the center o f the
T h e therapist tells the client to "look at the center of 1-meter square tangent screen. The letter is placed in
the clock so that you can see it." If the client still has the center of a large cross. The client is instructed to
central fixation tendencies, the client will report that “look at the letter so that you can see it most clearly."
center star w ill disappear and that all of the num bers With a large screen, the therapist is able to sit or stand
can be seen. If the client cannot see the num erals, the betw een the client and the screen to carefu lly observe
therapist can move the clock closer until the numeral the client's eyes. The client who has not developed
shapes can be seen, or use a larger picture of a clock. eccentric view ing and is still centrally fixating will
If the client has developed eccentric view ing, when fixate the center of the cross and report that the letter
asked to describe the shape at the center of the clock, disappears. The person with adaptive eccentric view­
the client w ill report that a star can be seen but that ing will report that she sees the letter in the center of
som e o f the num bers are m issing. The m issing num ­ the cross and if the scotoma is large, eccentric view ing
bers w ill indicate the location of the scotoma and should be evident by looking at the eyes. If the client
direction of eccentric view ing. For example, if the generates random searching type movements, gently
num bers 2, 3, and 4 are m issing, the client is eccentri­ instruct the client to “look directly at the center of the
cally fixating to the right (see Figure 10-2). If all of cross— don't worrv J
about the letter." If the client cen-
the num bers can be seen and the client reports seeing trally fixates the cross, the letter will disappear into
the star, then one of three possibilities exist. O ne is the scotoma.
that no scotoma exists. The most likely option is that
the client is not steadily fixating; rather, the client is
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.

If the client has nonadaptive central fixation, while the therapist moves a white testing spot at the end of
the client continues to fixate and position the scotoma a long black wand to where the client appears to be
in the center of the cross, move a dot attached to the looking (see Figure 10-3). It is essential that the thera­
end o f the wand away from the center until the client pist carefully watch the client's eyes to be sure that he
sees it (Figure 10-4). Mark the spot where the wand does not move during this procedure. W hen the white
dot "appears" w ith a pin, and then start at the center wand dot enters the scotom a, the client w ill report that
and quickly move to the edge of the scotom a in all it disappears. Explain to the client that you have found
directions. The pins should be sm all or low contrast so the scotom a and that you will now be m easuring how
they are not visible. O nce all of the pins are in place, large it is. Move the wand dot until it is first seen and
a thick high-contrasl yarn can be placed around the mark the edge of the scotoma w ith a low-contrast
pins to illustrate the size and location of the scotoma. mark or pin (not visible to the client). Q uickly move
Individuals w ho have had central field loss for from nonseeing to seeing and mark the border o f the
several m onths or more may have already started scotoma so that it is mapped in a couple of minutes.
developing eccentric view ing. The client who has The outline of the scotoma should be above, below',
already developed stable eccentric view ing will posi­ or to the side of the letter indicating the direction of
tion the eyes to be looking above, below, or to one eccentric view ing and the size o f the scotoma.
side of the letter and the client will report seeing the It is not unusual for a client with eccentric view ing
whole letter. The client may also move his head. The to shift eye position, for example, from looking above
therapist should be able to predict w here the scotoma to looking below the view ing letter. The therapist can
is expected to be located based on where client's eyes detect these shifts by looking at the eyes and not­
appear to be looking, observing the eyes and not the ing inconsistency in where the target is seen on the
head because often the head is moved in the d irec­ screen. If this occurs, illustrate the new location of the
tion opposite to the eyes. Based on this prediction, scotoma by positioning the white spot in the scotoma's
new location. This dem onstrates to the client that the disappears and the center target appears. Using the
scotom a moved. Gently coax the client back to his disappearing num erals on a clock face for feedback,
original position and com plete mapping. W hen the the client becom es aw are of the direction of eccentric
scotoma is mapped, more clearly mark the edges (with view ing as well as how to control the scotom a position
white yarn wrapped around the push pins in the felt in order to see the central star.
board) and have the client move his eyes to see the Now ask the client which num erals can be seen
outlined scotoma. most clearly w hile he fixates at the m iddle of the clock.
This report indicates the area if the retina w ith best
Eccentric Training With a visual acuity. M oving the eye in the direction opposite
to the numeral most easily seen (area of best vision)
C entral Fixation Cue
will bring the retinal locus o f best vision to the center
This phase of instruction should be done w ith cli­ and the star or shape in the center of the clock will be
en ts who have not developed adaptive eccentric view­ seen most clearly (see Figure 10-2). Again, note that
ing (see Table 10-1). The purpose of this instruction the therapist needs to vary the distance o f the clock
is to teach the client to look in a particular direction face from the eye depending on the expected size of
above, below, or to the side of a target, ie, to eccentri­ the central scotoma. For those with better vision and
cally fixate in order to sec a target that is positioned at a sm aller scotoma the clock should be held further
the center of the screen. Note that to avoid confusion away.
we use the term eccentric viewing target as the word or
shape that the client is tryin g to see using eccentric Tangent Screen M e th o d
view ing. The term central fixation cue refers to targets Frennesson, Jakobsson, and N ilsson2-* described a
used to encourage the client to look in a particular different method that is well-suited for a person in the
direction. Central fixation cues are used w ith begin­ early stages of adaptation with a strong tendency to
ners who have not yet developed eccentric view ing, centrally fixate. T h is method keeps the eccentric view­
and still tend to look directly at objects using the ing target, a letter or number, stable in the center of
m acula even though the m acula no longer functions. the screen and uses a com puter program to move the
T h e central fixation cue is used in conjunction with cross above, below, or to the side o f the letter on a com ­
an eccentric view ing target to stim ulate the client to puter screen. A high-contrast cross made out o f thin
position the eyes in a particular direction so that the dowels attached to the end of a wand m ight work as
client m ight better sec the eccentric view ing target. well with a tangent screen. The client is instructed to
For example, when asked to identify the letter E on always direct central fixation and the scotom a to the
the screen, the beginner will tend to look directly at center of the cross. The cross is then moved until the
it and w ill report that the E disappears. To encourage client reports being able to see the letter. By moving
eccentric view ing, the therapist asks the client to look the cross above, below, or to the side of the eccentric
at the cross above the E using a large cross as a central view ing target, the therapist encourages the client to
fixation cue. W hen the client then looks at the cross, redirect the line of gaze eccentrically so that the letter
the center of the cross disappears, but the E now can can be seen w ith side vision (see Figure 10-4C). O ne
be visualized and recognized using eccentric view ing might think of this technique as enabling the therapist
(Figure 10-4C). Since the client intends to identify the to slowly drag the client's gaze into a desired position.
letter E, it is an eccentric view ing target. T h e cross The letters m ay be replaced with three to four letter
is a central fixation cue. Note that clients who have words placed in the center o f the screen and different
becom e well adapted to a central scotom a will auto­ eccentric positions attempted until the eccentric view­
m atically
w eccentrically
fixate even if instructed to look ing position that produces the best word recognition
directly at a target. is found.
C lock Face M e th o d
Fading Out the Central Fixation
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 Cue an d Introducing N atural
centrally fixate, then the client will report the center Eccentric Viewing Targets
star disappears. The clock distance should be posi­
T h is step is quickly perform ed w ith individuals
tioned so the shapes of all of the num bers can be seen,
who have demonstrated eccentric view ing during
bringing it closer if the num bers cannot be seen. The
initial evaluation. It should be used to verify that the
therapist then directs the client to "look a t" differ­
client can voluntarily adopt different eccentric view­
ent clock num erals; the clock num erals act as central
ing positions in response to verbal instruction. With
fixation cues. W hen the client directs central fixa­
cognitively or linguistically impaired individuals, one
tion to a num eral, he should report that the numeral
might just em pirically determ ine the best view ing
Tabic 10-2.

Instruction on Compensatory Scanning

Compensatory scanning: If also unilateral inattention, add the following:

Search tasks for expected objects. Forced fixation on the side of the deficit.
Search with unexpected objects. Cued fixation to the side of the deficit.
Behavior m odification of right-left scanning.
Holding fixation in the direction of the deficit. Use cued fixation to the side o f the deficit.

position, and instruct the client to always adopt this evcntuallv* faded out so a client can follow directions
one position. such as "look up" and eventually eccentrically fixate a
centered target without any cues.
T angent Screen M e th o d A nother therapeutic activity that can be used at
In this stage of instruction, the tangent screen this stage of training w ith either the tangent screen or
m ethod is most suitable. The purpose of this step of the clock involves the use of a telescope or sm all d iam ­
the instruction sequence (Table 10-2) is to enable the eter tube. The client looks through a tube of about 1
clicnt to follow verbal instructions to look to each side cm (0.5 inch). If the person w ith a central scotom a cen­
of the target or above and below the eccentric view­ trally fixates through the tube, nothing w ill be seen.
ing target without a central fixation cue. Instruction If the person eccentrically views, then som ething will
begin s w ith a central fixation cue that is faded out and be seen. T h is exercise may be done with a telescope
replaced by verbal cues or no cues. D uring this instruc­ and provides salient feedback as to w hether adaptive
tion, different m eaningful eccentric view ing targets eccentric view ing has been achieved or not.
are used— three to four letter w ords for som eone who
wishes to read, pictures of loved ones, or a TV. Thus, C lock Face M e th o d
during instruction, the therapist can ascertain the Recall that during the initial evaluation, when the
eccentric view ing position that is best for a particular client with adaptive eccentric view ing w as asked to
goal task. At first, a central fixation cue is used such as look at the center star he would report seeing the
a cross at the end of a wand or a laser spot to encour­ center star and that som e clock num erals would d is­
age the person to eccentrically view in a particular appear. At this point, the client who has just received
direction. T h e central fixation cue is positioned at completed instruction should also be able to do the
different points around the eccentric view ing target, same.
encouraging eccentric view ing above, below, and to
each side of the eccentric view ing target w ith verbal Eccentric Viewing Under
instruction. The therapist should place a word on the
N atural Viewing Conditions
tangent screen and instruct the client to “look at the
center of the cross (the central fixation cue) until it d is­ Home exercise or practice also may be performed
appears" and determ ine the position that allow s the w ith pairs of large-print playing cards positioned
words to be seen clearly. Then repeat the movement so that w hile “looking a t" one card, the other card
without the wand. As one teaches the client to move becom es visible. Com puter program s that act like flash
in different positions, one will determ ine the position cards might also help a client practice eccentric view ing
most suitable for reading. Occasionally, one finds a cli­ by them selves (M agnim aster, Hunstad M agnim aster
ent w ith one PRL with a larger field of view more suit­ Reading Improver SMC, Paradis, Norway). The fixa­
able for reading, and another PRL that allow s isolated tion tube, computer program , and clock face m ay also
letters to be seen more clearly. This tangent screen be sent hom e for practice as a home exercise program .
m ethod could be perform ed on a computer screen or At this stage of instruction, the client should be able to
any near card. Variations on the tangent screen can practice by w atching TV, taking care to insure the TV
be im provised by using a w all, laser pointer, and a is close enough to sec.
drawn or real life eccentric view ing target. The eccen­ D uring this training, a client m ay turn his head. This
tric fixation target is centered and a central fixation head turn may be in the direction opposite the direc­
cue (laser spot) is positioned as needed to the side and tion to which the client moves the eves* to eccentrically
view. There is no evidence that head turning presents
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
Figure 10-5. A . Steady eye te ch n iq u e at a reading guided saccades.2=i
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. Tracking an d Viewing Through
a H andheld M agnifier
a problem except to the therapist trying to observe eye A fter the client has demonstrated good steady
position. Head turning may present ergonom ic prob­ view ing and mastered reading scrolled text, tracking
lems and clients can be taught to eccentrically view and scan n in g techniques are used along w ith mag­
without head tu rning during advanced instruction. nification devices. The procedure begin s with steady
Research needs to be done to better understand the view ing. The client attem pts to identify playing cards
effect of head position. However, eccentric view ing is as the therapist pulls each card off the top o f the deck.
a difficult skill to learn, and we feel that focusing too Index cards w ith num bers and short words (four let­
much on technique may be discouraging. ters or less) can also be used. O nce the client can per­
form well with steady view ing, the therapist should
Reading With Scrolled Text add movement to the procedure. To do so, the thera­
Once the client dem onstrates the ability to eccen­ pist holds the cards w hile carefully observing the cli­
trically view and identify a single stationary object ent's eves. The stack of cards is then slowlv moved and
like playing cards or short w'ord cards, large-print the client should track the cards. M aintaining view'ing
text should be used. The print size used should be at with a slowly m oving target w ith a predictable motion
least tw ice the visual acuity level of the client. The cli­ is relatively easy. Recovering eccentric view ing when
ent might also require a m icroscope (strong reading view ing is lost presents the greater difficulty, espe­
glasses), a mounted handheld m agnifier, or a closed cially if the target disappears into the scotom a. If
circuit television (CCTV) for this training period. the client loses visibility of the target during this
W hen practicing with printed text, the client should procedure, the therapist should stop until he recovers
be sitting at a table in front of a reading stand with and then continues. At first the characters should be
the text m ounted on a card that slides horizontally on at least three tim es the client's visual acuity. Starting
the lip of the stand (see Figure 10-4A). The client is from the card position that allow s most consistent
then directed to eccentrically *
view the first word. In eccentric view ing, slowly m ove the cards in various
directions (up and to the right, down and to the right, num bers are printed that are likely to be the am ount
up and to the left, down and to the left), starting with due by the layout of the text. The client then positions
movement awav J from the scotoma because movement the m agnification device in front of the eye to read
toward the scotom a w ill present the most difficulty. the number. Localization will be described in detail in
Increase task difficulty by increasing the speed of the Chapter 13 when discussing optical devices.
target m ovement and then m oving the tracking stim u­ Researchers have found that som e well-adapted
lus unpredictably. To further increase the level of d iffi­ people with central vision loss use different eccentric
culty of the task, decrease print size. Note that people view in g positions after saccades.8 T h is advanced
will som etim es switch from one eccentric view ing technique can be taught if the evaluation reveals dif­
position to another. Let your client know when you ferent functional ability for various eccentric view ing
observe this happening. Rapid alternation between positions, such as one PRL that has better acuity, and
eccentric view ing positions slows reading and should another with a larger horizontal field of view for read­
be discouraged for reading; this strategy, however, ing.
may be adaptable when scan n in g during mobility.
A practical extension of tracking a large stim ulus Finding the Best Eccentric
is to have the client read through a handheld m agni­
Viewing Position
fier or stand m agnifier held at about 20 to 40 cm (16
inches) from the eye. Begin with the client seated, and To teach people to use different PRLs, the therapist
should select targets that are typically involved in
once he can m aster reading w hile seated instruct the
client to attempt reading through a handheld m agni­ real-life tasks. Targets should be carefully selected so
fier or stand m agnifier w hile standing. Recall that that a different visual skill is required to best identify
the handheld m agnifier and the head should rotate the chosen target. For exam ple, one target might be
more easily identified with a PRL that works well
together with the lateral movement of the head as the
m agnifier moves across the page, as if an im aginary with longer words, w hile another target (picture of a
rod connects the m agnifier through the eye and the face) might be more easily identified w ith a PRL that
head. Scanning with telescopic m agnification can also has better acuity. O ften different PRLs have different
visual acuity ability, requiring a change in required
be introduced at this point in the therapy.
m agnification. It is im portant to understand that for
Localizing an d Scanning mobility, the use o f inferior view ing is dangerous
because a scotoma in lower central field puts people at
The most advanced task is to have the client scan a
risk for tripping on objects on the floor.26 Positioning
room using saccadic eye movements. The goal of scan ­
the scotom a above the text is generally thought to be
ning training is to enable the client to m ake an accu­
better for reading.
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,
Equipment for Eccentric Viewing
this type of saccadic control is irreversibly com pro­ Training and Home Exercise
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 Ideally, eccentric view ing instruction involves a d is­
eye movements are inaccurate and several saccades play for stim uli and a method for the therapist to view
m ay be required to scan from one object to the next.8 the client's eye w hile he is attem pting to eccentrically
To practice scanning, a large, high-contrast eccentric fixate. A 1 m eter (3 foot) felt screen that will accept
view ing target can be presented in the periphery pins will work for most techniques, although sm aller
such as a waving hand, a person, or a light in regular, and improvised tangent screens may becom e neces­
predictable positions at first. Eventually the targets sary when a large tangent screen is not practical.
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 A com puter can also be used for eccentric view ing
laser light, flashlight, or flash card works well as an training. The therapist can generate a graphics display
eccentric view ing target at this stage. on a computer screen using a draw program such
A more advanced technique used by individuals as the draw feature in M icrosoft Word. O ne draws
learning to use optical devices is localization. With the four lines of a cross and then uses the "group"
localization, the client scans a room or page of text feature to connect them so that one can click on one
until he fixates a spot where he expects to see som e­ line and drag all four. O ne or two view ing letters or
thing o f interest. Without breaking eccentric view ing, words might be w ritten in a "text box" that can be
the client positions a m agnification device in front of dragged and placed anyw here on the screen with the
the eye so that the object of interest is m agnified. For mouse. Template word docum ents are provided in the
exam ple, he might scan a bill and localize where some 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
/ 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
Role o f Peripheral Vision in
typical visual fields.
However, dam age to the parietal cortex and cer­ Night Vision
tain areas in the frontal cortex may com prom ise this The final basic function o f peripheral vision is
scanning process.28 This problem may m anifest as the role peripheral vision plays in night vision. The
a unilateral visual inattention or visual neglect. For peripheral retina has much greater sensitivity to dim
exam ple, a client named M ary has had a right cerebral light than central retina. Loss o f peripheral vision,
vascular accident. We assum e she has an intact left therefore, leads to night blindness, a severe loss of
field because she responds to a bright light, a waving vision w'hen the light levels drop.30 A person with
hand, or a ball thrown to her on the left. However, an overall peripheral vision loss due to advanced
she does not spontaneously glance in that direction or glaucoma or retinitis pigm entosa, for example, may
notice signs to her left when looking around the room report little problem during the day but severe visual
or when her attention is divided. We would conclude disability at night.
that M arv ✓ has intact visual fields but a unilateral
inattention or visual neglect. In som e cases, people Overall Field Loss
will have both a unilateral inattention and unilateral
field loss. These individuals cannot sec anything on The retinal conditions that lead to overall visual
field loss or "tunnel vision" usually have a gradual
one side and are not aw are of the vision loss or that
objects exist on the side of the vision loss. Note that onset, allow ing the client to progressively adapt w ith
com pensatory scanning. If som eone with restricted
w ith unilateral field loss or inattention, the pattern of
eye movements will be abnorm al, but basic eye move­ visual fields reports problem s bum ping into objects
ment control such as saccade control by itself is not or difficulty finding things, he should be taught com ­
pensatory scanning (Figure 10-6), described below.
necessarily com prom ised. The abnorm al pattern of
saccades is secondary to a basic deficit in the neuro- The usual progression includes searching tasks for
physiological and/or the sensory system that organiz­ objects graded from salient objects, such as bean bags
es the pattern of saccades required for scanning eye on a table, to searching for objects in a cluttered area,
such as a room. The comm on challenge in m anaging
movements. The focus of therapy, therefore, should be
on the visual and attention deficit, not directly on the people with peripheral loss is addressing the loss of
eve movements themselves. the "w arn in g system ." Even when using good scan ­
ning technique, a person with an overall peripheral
Use o f the Visual Periphery as a field loss will m iss an unexpected, quickly moving
hazard from the "blind side." People w ith overall
Warning System peripheral vision loss often experience night blind­
The second basic function of peripheral vision is the ness. As peripheral visual field loss has a gradual
use of the visual periphery as a w arning system. This onset, these clients may deny functional problems
is im portant for driving, w alking in crowds, or mobil­ because of occupational disengagem ent. People with
ity in general in busy areas. O ur ability to respond peripheral visual field loss m ay not go out at night,
to high-contrast moving objects is a phylogenically may avoid crowds or new environm ents, and may
ancient system that allow s creatures to detect and be in denial if the prognosis is total blindness. The
respond to high-contrast m oving objects approaching best com pensation for loss o f the w arning system is
from the side. That flash of fear we all experiences to use a white cane or guide dog, at least to signal to
when som ething unexpected darts rapidly in from others to be careful. M obility training, especially if it
the side illustrates this w arning system. In hum ans, involves the use of a white cane, should be performed
this orienting response includes a saccade toward the by a certified orientation and m obility (O &M ) spe­
suspected threat.29 In our m odern era, these threats cialist. T h e vision rehabilitation therapist, however,
m ay be a child running in front of the car, a car sud­ can and should introduce the client to sighted guide
denly approaching an intersection that we arc trying techniques, use of nonvisual cues, environm ental
to cross, suddenly noticing and avoiding a rolling ball, adaptations, and trailing techniques (sliding the back
or an anim al running in front of us. These events may of the hand along a wall w hile w alking), and convince
occu r very quickly while we are looking som ewhere the client to seek training on the use o f the w'hite cane.
else. If a client has a peripheral field loss and is look­ The denial process that occurs w ith recent on set low
ing straight ahead, the early w arning system w ill not vision com plicates the introduction of techniques
alert him or her to unexpected danger. 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 Figure 10-7. Unilateral field loss w ith and without
ing at n ig h t" when the client is less likely to deny the central sparing during confrontation field testing
problem. People w ill gradually becom e accustomed to (Steinman).
the advantages of using the m ethods, and begin using
many of these techniques at all tim es and w hen vision
linguistic and other cognitive deficits. Brain injury
further declines.
affects a variety o f cognitive and linguistic functions
that might affect visual function such as letter iden­
Unilateral Field Loss tification and reading. People may have difficulty-
Unilateral field loss results from brain injury to reading because o f dam age to linguistic processing
tracks or cortical areas post optic chiasm , often asso­ areas. They may not respond to objects in the periph­
ciated w ith cerebral vascular accident. Dam age to the ery because of im paired visual attention or unilateral
right side of the brain may lead to blindness in the inattention and neglect.28'31 Since unilateral field loss
left visual field of both eyes. Dam age to the left side in often associated w ith unilateral inattention, the
of the brain may lead to blindness in the right visual treatm ents often address unilateral attention as well
field of both eyes. If the blind area com prises nearly as unilateral field loss.
h alf o f the visual field, starting approxim ately at the Unilateral field loss usuallv
j does not cut the field
m idline of both eyes, the condition is called hom ony­ down the m iddle but rather leaves central vision intact,
mous hem ianopia (Figure 10-7). If a quarter of the visual called central sparing (see Figure 10-7). Functionally, an
field is affected, the condition is called homonymous individual with a unilateral field loss w ith central
quadrantanopia. sparing will see m ost of a person's face at about 1
To develop effective treatm ent, sensory deficits m eter (3 feet), but see nothing to one side or the other
m ust be differentiated from perceptual, attention, of the face. People with field cuts and central sparing
usually have normal acuity and only m inor problems Fixate the far finger w ith both eyes, then close each
with reading. These individuals w ill read a single eye to see how the proxim al finger falls into the nasal
line of text norm ally but m ight lose their place when field of each eye. If a client had a binasal field deficit,
reading, or m ay have difficulty scanning a page for he would not see the closer object. With bitemporal
inform ation. In som e cases, people have a unilateral defects, one will not see som e objects further than
field loss that also bisects the central field (see Figure the fixation target, which can be dangerous. If central
10-7). These individuals will report that one h alf of vision is cut, a client will also have difficulty fixating
the exam iner's face can be seen during field testing. an object w ith both eyes at the sam e tim e and will
People w ith "split central fields" w ill only see half of a report double vision.
letter or words they are tryin g to identify as well. The
resultant loss of basic shape, letter, and face recogni­ R em ediation
tion may be confused with higher-order perceptual O ne training technique has been reported to actu­
deficits. People with a right unilateral field loss w ith a ally decrease the size of the blind a r e a '2 5 to 10
split central field will have severe problems w ith read­ degrees in people with a presum ably stable field loss
ing, even though other linguistic functions are intact. of 18 months to several years. T h is instructional tech­
Functionally/ people with unilateral field loss will nique involved having clients detect flashing lights
present w ith disabled visual scanning and periph­ presented at the edge of the scotoma for 1 hour for 3 or
eral w arning system, often w ith the functional effects more days a week for 3 to 6 m onths as part of a home
compounded by an overlay of unilateral visual inat­ program involving specialized training equipm ent.
tention. In addition, a person w ith unilateral field loss The results have not been replicated in studies con­
may present with "w ayfinding deficits," and often trolling for com pensatory scan n in g eye m ovem ents.33
cannot even retrace his steps. A person may have basic Therefore, the evidence for this procedure is question­
problem s with w ayfinding, prim arily due to a unilat­ able at th is time.
eral field loss rather than cognitive deficit. For exam ­ The method that seem s to produce the largest and
ple, if a client w ith a left field loss w alks down a hall functionally greatest increase in peripheral aw are­
for the first time, he will see one side of the hall to his ness is called com pensatory visual scanning. In this
right. W hen he turns around to retrace his steps, the technique, the therapist teaches the client to look
formerly right side of the hall will now be to his blind, with quick saccades in the direction o f the blind
left visual field. The side of the hall that is now in his hem ifield 32 Com pensatory visual scanning docs not
intact right field would never have been seen before. actually increase the size of the intact field.
In effect, he has never seen the route he is retracing.
This problem is exacerbated for people who have split C om pensatory Visual Scanning
central fields and/or unilateral inattention. To com pensate for a unilateral field loss, the cli­
Dam age to the optic chiasm , most often associ­ ent must change habitual eye movement patterns.
ated with pituitary tum or but som etim es associated Norm ally we look at an object and depend on our
w ith traum atic injury, will cause field loss that causes peripheral vision to see on either side. Compensatory-
binasal or bitemporal field loss. With binasal deficit, visual scanning involves frequently and consistently
the client cannot sec objects nasal to the fixation looking in the direction of the blind hem ifield, much
objects with each eye and the temporal fields are like a driver uses a rear-view and side-view m ir­
intact. With bitemporal field loss, the client cannot rors when driving to get a sense o f what is going on
see temporal to the fixation target in each eye and the around the car and beyond the range o f peripheral
nasal fields are intact. If one overlaps the visual fields, vision. As with any therapeutic intervention, the cli­
it appears that the fields are full because one eye ent must be educated about the deficit and provided
w ill see what the other does not. For example, w ith with an explanation for the com pensatory strategy.
binasal defects, the left (temporal) field of the left eye Understanding and verbalizing the problem or dem ­
is intact, and the right (temporal) field of the right eye onstrating im proved perform ance during in stru c­
is intact. At least in theory, if the two eyes look at the tional protocols is not sufficient. The client must
sam e fixation target, the client has an intact right and dem onstrate com pensatory scanning as an ingrained
left field and should have full binocular fields. There habit during real-life activities when attention is on
are, however, subtle but disabling problems. A person the activity, not the eye movement.
with binasal deficits will not see som e objects closer
than the fixation target because closer objects might S canning W ith Expected Then U ne xpe cte d
fall into the nasal field of each eye. O ne can dem on­ O b je cts
strate this by positioning a finger at arm's length and
We suggest a three-step sequence for teaching this
another a few inches from the nose on the midline.
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

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 the color (see Figure 10-8B). T h is cues the client
cnt in various search tasks: looking for speci­ that he is looking in the correct (compensatory)
fied objects in a room , looking for cooking or direction. Once the client can consistently scan
self-care items, sim ple puzzles, dom inoes, or for objects even w ith less fam iliar tasks, the
com pleting cancellation and draw ing tasks. searching and scanning function has been
Exam ples of these treatment strategies have restored.
been well described in the occupational thera­ 2. Step Two
py literature.31'34 This step is quickly mastered Step two involves having the client scan a room
by people with intact visual attention, and where unexpected objects m ight be found, eg,
less easily recovered with clients w ho have
¥ trying to find hazards in a kitchen or picking
attention deficits. W hen grading the activities, up objects on the floor.
easier tasks should be fam iliar and m eaningful
3. Step Three
activities such as brushing teeth. Using tasks
w ith expected objects (the brush, toothpaste, Step three re-establishes the w arning function
and glass) w ill encourage the client to continue of the peripheral retina. T h is step presents
looking until all the com ponents in the visual a greater challenge because responding to
task are found. approaching objects from the affected side
usually requires perform ance during divided
To rem ediate inattention deficit, first one might
attention, which is often im paired with brain
force fixation to the side where there is inatten­
injury or in older individuals. O ne approach
tion by sm earing Vaseline or taping one-half
we have successfully ¥ used involves behavior
of each lens on the intact side with translucent
modification of scanning eye movements. T he
tape (Figure 10-8). This forces the client to
goal is to establish the habit of frequently and
look past the m idline in the direction of the
quickly looking in the direction o f the field
visual field loss, if the head is straight ahead.
defect. Com puter program s and equipm ent
Nonvisual or extravisual cues might be added
has been developed that allow the client to
to direct attention to the affected side as well.
be set up to perform this task independently.
A classic strategy is to place a brightly colored
T h is author has found any num ber of com ­
line and tactile m arker down the edge of the
puter gam es where objects fly in unexpectedly
page or field being scanned and cueing the
from all directions (eg, "Squ ares," w hich is a
client to keep looking until the line is seen.
free gam e found on the Web) that provide an
T h e next stage in this step is to use a method
engaging opportunity for hom e-based practice
described by A ppel35 that involves placing a
as well.
colored filter on one-half of each lens or cut­
ting the lenses of inexpensive sunglasses (see Laser tag transitions the client to m ore real-life
Figure 10-8). W hen the client looks in direction situations. The therapist and client each hold a
of the field loss he w ill see a color change (see laser pointer. The therapist presents the laser
Figure 10-8A). The client is instructed to look spot on a surface such as an uncluttered wall.
The client responds by pointing to the light of equivalent power, is required. Strategies for read­
and tagging the spot w ith his laser pointer. ing rehabilitation with central field cut are discussed
At first, the light is flashed at tw o predictable below.
points in the right and left field. The task is
graded to become more challenging and real­ Field Expansion Devices
istic by moving from predictable positions in
The use of field m irrors and prism have been
an uncluttered area to unpredictable locations
advocated for many years and purportedly work as
in a cluttered area. To further increase dif­
an early warning system, allow ing clients to detect
ficulty, the laser spot targets can be presented
the approach of som ething on the affected side.36*38
at different distances. Finally, the task is per­
Prism, usually Fresnel-type prisms (sec Figure 10-
formed when the client's attention is divided,
8), are pressed onto one spectacle lens with the base
such as in a visually busy environment with
of the prism in the direction of the field defect. The
people w alking around. During this task, the
prism displaces an image awav from the base toward
therapist gradually decreases the frequency of
the point of the prism. (Think of the prism wedge as
presentations and varies the interval between
an arrow that points in the direction in which the
laser spot presentations as well, pausing up
person's view will move.) This prism is attached to
to a minute or two between presentations. At
one lens so that when the client looks into the blind
this point, the client should be w alking with
hem ifield or to the edge o f the blind area, double
frequent automatic glances into the affected
vision will be experienced. O ne image is the normal
hemifield, so that when the light eventually
view as seen by the eye looking through the plain
appears, she detects it within 2 seconds. T his
lens. The eye looking through the prism will see the
instructional sequence should result in the
other image, actually a scene displaced from the blind
client frequently and habitually looking in the
area by the prism usually by no more than about 20
direction of the field deficit.
Holding fixation in the direction of the deficit A major problem with the use of prism is that it
is another strategy that provides early warning causes double vision, and we have found it might dis­
in the direction of the field loss. In this proce­ courage compensatory scanning toward the affected
dure, the client must look over and m aintain side. To m inim ize this problem, Peli suggested that
fixation in the direction of the field deficit, the prism be attached in the superior field above the
using peripheral vision in the intact field to pupil so the double vision is seen peripherally where
look straight ahead and to see into the unaf­ it is less bothersom e (Figure 10-9).48 In theory, the cli­
fected hemifield. The sunglasses procedure or ent should detect objects in the blind field before the
a colored filter on glasses (see Figure 10-8) can object enters the intact visual field.
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
R eading
w alking in crowds, practice crossing intersec­
People with low vision often present upon ini­
tions with supervision, and when walking
tial evaluation with perform ance goals that involve
down the street, a partner might intermittently
reading. The visual requirements and perform ance
and unexpectedly veer into the client and play­
demands of a reading activity vary considerably-
fully bump shoulders if not detected. Success
depending on the particular task. Reading a medicine
is achieved if the client automatically / main- bottle, finding the total on a credit card invoice, medi­
tains most of the fixation between straight
tating on a very fam iliar passage in the Koran alone
ahead and the affected side so as to detect an
during morning prayer, reading the Torah in Hebrew
approaching target within a second or two.
in front of synagogue, locating a sign on the street cor­
ner, and enjoying the latest Tom Clancy novel involve
Instructional Strategies With substantially different assistive devices, motor skills,
Central Field Cut and visual demands. School sy'stems, state offices of
vocational rehabilitation, and medical insurance com ­
A person with a central field cut needs to develop panies must recognize literacy as medically, vocation­
eccentric view ing in the direction of the field deficit ally, and educationally necessary'. Not surprisingly,
and use side vision to expand the field of view. Since reading has become the cornerstone therapeutic activ­
the region of highest visual acuity has been compro­ ity as one develops a treatment plan for a variety of
mised, some magnification, usually under 2X or 5 D 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,-.

Steinm an

is so often the focus of treatm ent because the skills

Reading Evaluation
apparently transfer to other tasks as well.
Although reading is alm ost universally identified
as a visual task, successful rehabilitation requires Overview
the therapist to move beyond the process of typical The steps for evaluation and treatm ent for read­
reading to appreciate the m eaning of reading as an ing rehabilitation are sum m arized Table 10-3. The
"occupation" to each individual. The act of reading evaluation begins w ith consideration o f the context
m ight be viewed as purely functional, the process of in which the reading will occur and the instruction
transm itting inform ation from the printed page into ends in the natural context. If one does not consider
the brain. From this functional perspective, whether context, a successful dem onstration o f good reading
the reader uses vision, hearing, or touch to "read" perform ance in the clin ic will not carry over into the
becom es less significant. A person can acquire the home or workplace. The evaluation of context begins
inform ation printed in a new spaper visually with an w ith the physical and social settings. Then one consid­
optical device, tactilely using a Braille transcription, ers the font characteristics of the reading m aterial and
listening to som eone read, or as auditory reading availability in other media. Is the material available in
using a com puter equipped w ith a screen-reader that large print or as a recording of som eone reading the
reads Web pages aloud. For students, those employed text? Next one considers the task dem and. Does the
w ith productivity dem ands, people who w ant to read client need to read a few words on a label, or relax and
quickly, or people who