Safety first - Association for Education and Rehabilitation of the Blind

Karen Squier, OD FAAO
JULY 19, 2012
 To identify and describe elements of the
low vision exam that potentially identify
areas of safety concerns
 To translate exam elements that assist in
identifying need for further rehabilitation
Why Safety?
Here’s why…
 Falls are the leading cause of accidental
death in people over the age of 65
 Over 100,000 people die per year from
accidental overdose or errors in
administration of prescription meds
 Less than 2% use assistive devices to
assist with daily activities to improve
Vision Rehabilitation
 Goal is to improve visual function
 Improve performance of independent skills
 Improve safety in natural environment
 Maintain desired level of quality of life
 Maximize visual potential
 Maintain employment or scholastic goals
Vision Rehabilitation
 Integrates information from multiple
resources to assess patients visual
 Medical Ophthalmologist/Optometrist
 Rehabilitation Optometrist
 Rehabilitation Teacher/Occupational Therapist
 Orientation and Mobility Instructor
 Social Worker
Vision Rehabilitation
 Through rehabilitation process information
regarding patient’s personal safety may
come forward
 Ability to travel safely
 Ability to manage medications
 Ability prepare meals and maintain proper
Safety Goals for patients
 Increase safety awareness in patients with
visual impairment
Safety Goals for Patients
 Identify and educate patients on potential
areas of concern
 Diagnosis
 Cognition
 Exam findings
 Support system
 Family
 Community
Safety Goals for Patients
 Implement rehabilitation plan
 Consider use of assistive devices
 Utilize strategies and training to improve
safety in the home and other environments
 When possible, confer with family members or
other members of support system
 Referral for appropriate community resources
Case History
 The “getting to know you” part of the exam
 Medical history
 Vocational/educational history
 Performance of ADL’s
 Driving status
 Rehabilitation Goals
 Understanding and acceptance of vision loss
Case History
 Most important part of exam
 Start with open ended questions
 Allow patient to give their own description
of difficulties or successes
 Try to remain objective and nonjudgmental with tone or body language
 Uncover patient’s impression of vision loss
Case History
 Also need to ask pointed questions
 Can you travel safely and independently?
Have you had any falls
 Do you drive? Have you had any accidents?
Can you see street signs and lights from a
safe distance?
 Can you prepare your own meals? Are you
able to see the dials on the stove? Have you
ever had any burns?
Case history
 Some areas of questioning may alert the
need for further testing
 Difficulty with memory of activities
 Family members correcting mis-information
 Difficulties with dates and times
 Inappropriate responses to normal questioning
 Defensiveness, anger
Case History
 Consider screening of memory, mental
health and cognition
 May indicate need for assessment with
psychologist or counseling
 Mini-Mental State Exam
 Assessment for adjustment to vision loss or
underlying depressive disorders
Case History
 Potential Referrals
 Department of Human Services
 Department on Aging
 Meals on Wheels
 Psychologist/Social Worker
 Patients may exhibit difficulties with
memory, reasoning and judgment
 Some patients and family members are
forthcoming about such difficulties
 Source of frustration and embarrassment
for some
 Incorporate screening as part of exam for
cognitive impairment
 Helps indicate ability for patient to
independently manage self care
 Time to administer exam will increase as
patient has increased difficulties
 Make sure you have time before starting
Cognitive Screening
 Several tests are available
 Depending of level of vision loss, some
tests may need to be modified.
 Potential screening tests
 Mini-Mental State exam (MMSE)
 Montreal Cognitive Assessment (MOCA)
Mini-Mental State Exam (MMSE)
Montreal Cognitive Assessment (MOCA)
 MOCA more sensitive to assessing mild
cognitive impairment than MMSE
 With visual impairment, some aspects of
exam change
 Does not take into consideration some
visual abilities and its identification of
cognitive delays
Visual Acuity
 Ability to see details, objects and their
 Typically measured with high contrast
 Snellen most common test in primary care
 Test is typically begun at 20 foot distance
 Visual acuity is a valuable measurement
 Measures disease progression
 Assists in determining magnification
 Determines disability
 20/200 visual acuity equates to legally blind
 20/70 visual acuity equates to visual impairment
 Useful measure in uncovering spectacle blur
 Changes in visual acuity
 Alter ability to perceive environment
 Street signs
 Dials/buttons on stove
 Change depth perception
 Reaching for objects
 Pouring liquids
 Stepping off curbs
Vision deficits
 To improve ability for eye to see detail
 Best spectacle prescription
 Puts vision in best focus
 Reduces blur and defocus of light
 Need to consider magnification options
 Relative size magnification
 Relative distance magnification
 Angular Magnification
Magnification Strategies
 Use relative size magnification
 Recommend large print
 Use bold pens and print larger
 Use relative distance magnification
 Use magnifiers and reading glasses
 Get closer to objects of interest
Contrast Sensitivity
Contrast Sensitivity
 Contrast sensitivity is the measurement of
the ability to discern and detect an object
against its background
Contrast Sensitivity
 Measurement to assess ability for patient
to see object against a background
 Measures quality of vision
 Helps with object detection, recognition
and motion
Contrast sensitivity
 Descriptive measurement of visual
 Identifies additional layers of visual
 Ginsberg et al stated “Contrast
sensitivity is the best predictor of visual
Potential causes of contrast loss
 Glare: Poor lighting, sunlight
 Inclement weather: Rain, Fog
 Patterns
 Poor image quality: faded ink, media
 Age
Contrast sensitivity
 Goal for rehabilitation increase threshold
 Increase contrast detection and increase
patient sensitivity
 Severe contrast loss is when <1.5 or 70 %
 Need multidisciplinary approach
 Rehabilitation teachers, OT, O&M
Diseases causing contrast loss
 Ocular diagnosis
 Certain diagnoses are more likely to give
contrast sensitivity measurements than others
Optic nerve conditions
Corneal disease or treatments
Diabetic retinopathy
Retinitis pigmentosa
 Quality of image is degraded by excessive
 Can be related to quality of light or ocular
 Poor light position
 Warmth of light source
 Reflection off of image source
 Recovery from bright lights takes 8 times
longer over the age of 58
 Greater than 3 minutes to recover from 1
minute of light exposure.
 Poses increased difficulty adjusting from light
to dark and potentially decreased safety
 Think of an older man walking indoors from
working in the garden
Contrast sensitivity
 Depending on contrast of object of interest
and contrast sensitivity of patient success
may vary
 Need to evaluate contrast of object of interest
and compare to contrast sensitivity of patient
 Contrast enhancement strategies may
improve appreciation of an object, but not to a
functional level
 Dictates whether modifications can be simple
to complex
 Poor contrast translates to wide spectrum
of difficulties
 O&M
 Driver’s Rehabilitation
 Assistive Technology assessment
Visual Fields
 The visual field is defined as the total area
in which stimuli can be seen in the
peripheral vision from a central point
 The binocular human visual field normally
extends horizontally over approximately
180 degrees. The peripheral visual fields
have temporal resolution and motion
detection (Rizzo & Kellison)
Visual Field Loss
 With reduction in visual field, people tend
to change their normal gait
 Slow speed of walking
 Increase step length
 Plays a factor when walking on unsteady
ground or ice
 Increases difficulty walking in a crowd
 (Jansen et al, 2011)
Visual Fields
 The visual field facilitates accurately
detecting and locating an object, even in
the periphery, and is more important for
drivers than the ability to clearly detect
details in an object (visual acuity) (Owsley
& McGwin,
Visual field loss
 Causes of visual field loss
 Optic nerve disease
 Glaucoma
 Optic Neuropathy
 Acquired Brain Injury
 Retinal disease
 Retinitis pigmentosa
 Retinal detachment
Visual Field
 Ocular conditions can reduce amount of
peripheral vision
 Glaucoma
 Retinitis pigmentosa
 Diabetic Retinopathy
 Brain injury
Vision while walking
 Scottish Sensory Center
Think of visual function with these VF….
Lund and Rose, Eye, 2012
Useful Field of view
 Area from which one can extract visual
information in a brief glance without
head or eye movement.
 Limited by
 Poor vision
 Poor attention
 Slower processing or cognitive ability.
 Assistive devices for field awareness
 Orientation and mobility
 Driver’s rehabilitation
Visually impaired drivers
 Drive less
 Take less risks
 Drive in daylight
 Drive in familiar areas
 *Mr. Magoo stereotype is not accurate.
Traffic related injuries
 Visual field loss number one visual factor
related to crashes
 Significant visual field loss increase
likelihood of crash six times
 Cataracts were the number one diagnosis
for at-fault crashes
Driving with visual impairment
 Need to adhere to state requirements for
 Need to be realistic about driving abilities
 Need to realize even the shortest, most
familiar route changes
Driving with poor contrast
 Drivers need to be counseled on contrast
 Contrast sensitivity can alter motion
detection and object perception
 Weather conditions can further degrade
visual function
Traffic related injuries
 Children with visual impairment were 4
times more likely to have an injury as
pedestrians than passengers
 Automobile crash injuries were linked with
visual field loss, poor vision, depth
perception and diagnosis of glaucoma
 Reduce fall and injuries for patients with
visual impairments
 1.7 times more likely to have one fall
 1.9 times more likely to have multiple falls
 Numbers may be much higher
 Workers tend to not report some injuries
 Older adults may not want to concern or alert
family members to a problem
 Children may not think of telling anyone or
don’t want to embarrass themselves
Risk factors for falls
 Poor contrast sensitivity
 Decreased visual acuity
 Diagnosis of Glaucoma*
 One study correlated increased falls in
patients who use glaucoma drops; did not
measure visual abilities
 Decreased depth perception
Risk of falling
 Outside of visual impairment
 Consider type of flooring
 Shoes!!
 Lighting
 Uneven Floors and steps
 Clutter and weather
 Rugs
 Critters
Community Resources
 Requires evaluating patients from a
holistic standpoint
 Utilize current resources, technology, funding
in a manner that enhances role of VI individual
in community
 Develop and integrate strategies to improve
access to resources for VI patients
Department on Aging
 Determines needs and gives resources to
those in need
 Emergency Food, clothing and shelter
 Elder-abuse and Neglect
 Provides support to those who are being
neglected or are in a self neglect situation
 Well-being checks
 In Person or on Telephone
Department on Aging
 Energy assistance program
 Supplemental nutrition program
 Medicare low income subsidy program
 Financial Assistance
 Meals on wheels, Nutrition Sites and Food
Department of Human Resources
 Provide assistance for people with
disabilities to remain employed, attend
school and live independently
 Each individual has specific needs and
need to address each patient individually
 Need to relay patient goals
 Need to understand patient’s motivations and
Department of Human Services
 Referral should have information that is
pertinent to the patient’s performance
 Visual acuity
 Visual Field
 **Consider what pieces of information you
learned through the exam that helped you
change your strategies…helpful to relay those
pieces of information as well.
Resources for Children
 Increasing need that is not being met
 One in three children receive an eye exam
before age 6
 According to Kirchner and Diament, in 1999
57% of children with VI also had another
 Requires education and understanding of
parents and guardians by pediatricians
Referrals for Children
 Make sure school district is aware of
child’s vision impairment
 Vision Teacher
 Orientation and Mobility
 Assistive Technology
 Make sure parent understands the value of
access to this level of care
 In Illinois, lack of support groups and after
school programs for children
Support system
 Essential for patients to have a support
 Aids in understanding education
 Aids in rehabilitation implementation
 Maintains social network and interactions
 Helps point our areas of potential safety
Support Groups
 Aids with acceptance
 Improves social interactions
 Learn new tips and techniques
 Talk about peripheral issues related to
vision loss
 Important to know who is administering
support group
 Safety in patients with vision loss should
be assessed during the low vision exam
 Elements of the eye exam may identify
specific areas that require further
 Referrals to rehabilitation professionals
and community resources should be
Thank you!!!!
Contact information
 Karen Squier, OD FAAO
 [email protected]
 312.997.3686

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