Low vision rehabilitation: skills for occupational therapists Bethan Collins, University of Liverpool Nicholas Collins, Optima Low Vision Services

Intended Workshop Outcomes Describe the low vision population Describe occupational performance issues commonly associated with low vision Discuss assessment methods Use specific low vision rehabilitation skills Know where to get further information

Functional Effects of Low Vision Central vision loss Peripheral field loss Low acuity without field loss Cognitive & perceptual difficulties Individual nature of low vision

Functional Vision Assessment Distance acuity Near vision acuity Functional field test Contrast sensitivity

Things to consider… Educate about the functional implications of low vision Identify the person’s visual goals Functional visual assessment Teaching of vision rehabilitation strategies and techniques Teaching how to make best use of low vision aids Support and motivate

Occupational Performance Issues Low vision can affect many aspects of occupational performance, typically, Reading and writing Food preparation Orientation and mobility Hobbies and leisure activities Self-care activities

Strategies and Techniques task lighting; eccentric fixation training for central vision loss; low vision aids; correct use and ergonomic positioning of low vision aids; management of disability glare and/or poor contrast sensitivity

The Importance of Task Lighting “[Participants] reported that daily tasks were easier to carry out, but even more striking was the fact that [they] now said they could carry out tasks that they had previously been unable to do… participants referred to better safety in their home. Potentially hazardous areas such as stairs, steps or the bathroom were better lit” (Cooper, 2013, p.1-3)

Eccentric Fixation Eccentric fixation is a key vision rehabilitation skill when working with individuals with central vision loss Identify the clearest area of vision - Preferred Retinal Loci (PRL)

Identifying a PRL 10

Variations of Central Scotoma Central vision loss can manifest itself in many ways, understanding this in terms of its affect on functional vision is essential when determining whether Eccentric Fixation is appropriate for the patient Relative Scotoma Distortion / Oedema Absolute Scotoma Ring Scotoma

Influence of Task Lighting A fundamental element of the low vision assessment For the majority of patients increased illumination can improve reading acuity, and contrast sensitivity As important, when assessing for the need to teach EV, task lighting can change the size and shape of a scotoma ‘Visual field defects for four subjects who show marked changes in scotoma morphology’

Low Vision Aids (LVAs) Problem solving approach needed The right level of magnification For the right task For the right person May require a combination of LVAs depending on an individual’s needs

Ergonomic use of Low Vision Aids Low vision aids issued to individuals are often not used in the most effective way: Ergonomic use and positioning of LVAs Correct working distances of LVAs Simple advice and instruction can make a lasting difference

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The Importance of Working Distances 16

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Cognitive Perceptual Complications An important skill is ability to determine whether difficulties experienced are due to low acuity loss of field of vision cognitive / perceptual Or a combination

Challenges with cognition and perception Rules of thumb to indicate cognitive or perceptual (neurological) issues include: Reading tasks don’t match with observed functional vision. Person describes confusion with reading

Glare and Contrast Filters and tints are important low vision tools which can: Reduce disability glare Improve visual acuity Improve contrast sensitivity In combination improve visual function

Optima Low Vision Services 2006 Colour Spectrum Clour Spectrum Optima Low Vision Services 2006

Case studies: enhancing quality of life and occupational performance

Education Issues Use of spectacles – refraction is different from low vision! Variable vision - factors such as fatigue, blood sugar etc Impact of lighting Family awareness / education Specific conditions such as Charles Bonnet Syndrome

http://www. dailymail. co http://www.dailymail.co.uk/health/article-485170/Simple-eye-exercises-help-blind-again.html

Human stories… differ As with other aspects of occupational therapy, people’s lives and experiences differ. Be wary of ‘training’ that focuses on lived experience alone as this sometimes is not based in evidence.

When to refer on… and to whom? Low vision services across the UK and Ireland are delivered in many ways and by various professionals Hospital based services connected to the ophthalmology department Community based low vision services Multidisciplinary low vision resource centres Refer on and engage in discussions with relevant professionals in your area in order to provide an holistic vision rehabilitation programme

References Colenbrander A & Fletcher DC (1995) Basic concepts and terms for low vision rehabilitation. American Journal of Occupational Therapy 49 (9) 865–869. Collins J K (1999) Homonymous hemianopia in the low vision clinic – which way to turn? Vision Rehabilitation: Assessment, Intervention and Outcomes 99-104. Swets & Zeitlinger Publishers, Abingdon Cooper S (2013) Improving lighting, improving lives. Research Discussion Paper ISBN: 978-1-906464-51-6 (11) 1-3. The Thomas Pocklington Trust Dahlin Ivanoff S, Sonn U & Svensson E (2001) Development of an ADL instrument targeting elderly persons with age-related macular degeneration. Disability and Rehabilitation 23 (2) 69–79. Horowitz A (2004) The prevalence and consequences of vision impairment in later life. Topics in Geriatric Rehabilitation 20 (3) 185–195. Scheiman M, Scheiman M & Whittaker S (2006) Low vision rehabilitation: a practical guide for occupational therapists. SLACK Incorporated.

Contact Details Bethan Collins Senior Lecturer in Occupational Therapy School of Health Sciences, University of Liverpool Bethan.collins@liverpool.ac.uk @bethanhc Nicholas Collins Certified Low Vision Therapist (CLVT) Director Optima Low Vision Services nickc@optimalowvision.co.uk 01803 864218 @OptimaLowVision