Low Vision 2015 - Optometry`s Meeting

5/12/2015
Harvey Richman, O.D., FAAO, FCOVD
Low Vision 2015A Beginner’s Guide to Vision
Rehabilitation Care in Private
Practice
Classification of VA Loss: WHO
 Normal
 Mild vision impairment
 Moderate vision impairment
 Severe vision impairment
 Profound vision impairment
 Near total vision impairment
 Total vision impairment
20/25 or better
20/32 - 20/63
20/80 - 20/160
20/200-20/400
20/500-20/1000
< 20/1000
NLP
Low Vision Statistics
 There are approximately 5.5 million elderly
individuals who are blind or visually impaired.
 Approximately 1.3 million Americans are legally
blind.
 Approximately 93,600 visually impaired or
blind students.
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Diseases Causing Vision Loss
Leading Causes of Legal Blindness
from Birth to 19
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Congenital Cataract
Optic Atrophy
Albinism
Retinopathy of Prematurity
Cone-Rod Dystrophy
Leading Cause of Legal Blindness from
20 to 44
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Albinism
Cone-Rod Dystrophy
Optic Atrophy
Myopia
Retinitis Pigmentosa
Diabetic Retinopathy
Macular Degeneration
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Eye Diseases and Conditions for
the Over 45 year old
 Age-related macular degeneration
(AMD)
 Cataract
 Diabetic eye disease
 Glaucoma
 Dry eye
 Low vision
ARVO 2002: AMD Study predictions
(neovascularization & geographic atrophy)
ARVO 2002: AMD Study predictions
(neovascularization & geographic atrophy)
The Low Vision Examination
 An
optical and functional evaluation to
determine whether a patient’s vision can
be enhanced to participate in desired
activities
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Members of the Rehabilitation Team
 Social Workers
 Education Experts/VI
Teachers
 Occupational Therapists
 Early Intervention
Specialists
 Orientation and Mobility
Specialists
 Rehabilitation Teachers
Patient motivation is most important
factor in determining which patients will
be successful
Factors Affecting Patient Motivation
 Type of Loss
 Family Reaction
 Life Stage
 Significant Life Events
 Self-concept
 Personality
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Exam Modifications

Refraction
–
–
–
Trial frame
refraction
Increase add power
Evaluation for prism
Modifications in a LV exam
 History
–
Patient Medical History
Patient Ocular History
–
Patient Goals
–
Difficulty
performing activities of daily
living
– Education
– Vocation
– Avocation
Exam Modifications
 Visual Acuity
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When a patient has poor acuity .
..
Where to start?
Device Evaluation

Optical vs. Non-optical
Magnification
A logical place to start
Manufacturer Dependant
#1 Point
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As magnification increases . . .
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Working distance decreases
Field of view decreases
Near Magnification

Bifocal Add/Prismatic Reading Glasses
–
Advantages
–
Disadvantages
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Hands free magnification
Decreased working distance
Near Magnification
 Hand-held magnifiers
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Advantages

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Lighted vs. non-lighted
Portability
Disadvantages

Requires dexterity
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Near Magnification
 Stand magnifiers

Advantages

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Lighted vs. non-lighted
Requires less dexterity
Disadvantages

Not as portable as HH
Near Magnification
 Dome magnifiers

Advantages

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Requires less dexterity
Portable
Durable
Disadvantage

Inability to write underneath
Near Magnification
 Coil near reading glasses
 Max Detail
 Loupes
 Advantages
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Hands free
Disadvantages
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Cosmesis
Weight of devices
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Near Magnification
 Electronic magnifiers

Advantages

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Portable
Increase mag without
decrease working distance
Disadvantage

Cost
Distance Magnification
 Hand-held telescopes

Advantages

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
Portable
Good for spotting
Disadvantages

Decreases field of view
Distance Magnification
 Hands - free telescopes

Advantages

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Use for extended periods of
time
Disadvantages
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Cosmesis
Weight of device
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Driving
 Driving is a privilege, not a right
 Access to independent mobility at any level is a
primary goal in vision rehabilitation
States allowing bioptic driving
Bioptic Driving
 Patient is looking through
lenses as he/she is driving
 Bioptic is used like a
rearview mirror
 Head is tilted downward
to look through the
bioptic
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Visual Field
 Central
visual field loss
 Eccentric viewing techniques
Use of scanning laser ophthalmoscope to
locate PRL
 Prisms to assist with eccentric viewing

Light Sensitivity/Glare

Wavelength Specific

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For reading
For mobility/distance
To Ensure Optimal Acuity is Achieved

Illumination-Adequate lighting
– Avoidance of glare
– Adequate lighting
– Allow student to wear hat indoors
• Posture
– Patient should be allowed a close working
distance
– Patient should be permitted to tilt head
and/or paper for optimal acuity
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Non-optical Devices
Behavior Modification
 Physical activity
 Fish consumption
 Greens
 Smaller portions
 Alcohol in moderation
 Nutritional supplements
 Blocking blue light from
reaching retina
Behavior Modification
 Sedentary lifestyle
 Smoking
 Excess Alcohol
 High BMI
 HTN, Cholesterol
 Diet low in fish, green
veggies
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Distance Magnification
 Electronic Magnification
 Advantages
 Disadvantages
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Mobility
Cost
Electronic Magnification
The iPad As A Low Vision Tool
S L I D E S C O U R T E S Y D AV I D L E W E R E N Z , O D , FA A O
N O R T H E A S T E R N S TAT E U N I V E R S I T Y
OKLAHOMA COLLEGE OF OPTOMETRY
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Features for the Visually Impaired Right Out of the Box
Enlarging print with finger gestures
Changing font sizes and types
Siri – the intelligent personal assistant
Enlarging Print with Finger Gestures
"Pinching" and "Spreading" works in
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iWork suite – Pages, Numbers, Keynote
Mail
Web pages
Photos
Many apps
Does not work in
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Home screen
Settings
iBooks
Notes
Contacts
Calendar
Enlarging Print with Finger Gestures
Entire page available for magnification, even the portion not visible on the screen
Amount of magnification is ~3X ‐ 5X, examples
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Pages default 12 point font 1.0M → 3.0M
Mail on default font 1.2M → 5.5M
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Changing Font Size and Type
The font size and type can be adjusted in iBooks, iWorks suite within the application
Examples

Pages
o
o
o
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Minimum 10 pt = 0.7M
Default 11 pt = 0.8M
Maximum 288 pt = 24M
iBooks (average of three I tested)
o
o
Minimum 1.0 M
Maximum 7.2M
Notes, Mail, Messages

Font size controlled in Accessibility Settings, covered later
Siri
Voice activated "intelligent personal assistant"
Available beginning with 3rd Generation iPad and Mini
To launch press "Home" button for 1‐2 sec.
What can it do? Examples
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Ask for information in your Contacts list
Take a note
Set an alarm
Search the web for an answer to a question
Available in 10 languages plus country‐specific for some; can select male or female voice
Accessibility Features
Zoom – Enlarges display with finger taps
Text Options– Change text to larger font; change contrast options
Invert colors – To improve contrast, reduce glare
VoiceOver – Voice description of screen content
Speak Selection
Speak Auto‐text
Triple Click Home and Other
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Apps for the Vis. Impaired Patient
Magnification for reading
Large type browser
Scrolling text
Calculators – large type and talking
Voice readers
Money identification
Mobility
Color identification
Games
Image recognition
Visual stimulation / development
Video Magnifier Stands
Justand $89
Examples of iPad stands from ProComputing Products that can be used for video magnification. Justand V2 $99
Talking Calculators
Talking calculator HD+ (free)
TalkCalc ($0.99)
Talking Calculator ($1.99)
Talking Scientific Calculator ($4.99)
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Voice Readers
Voice Dream
More full function text‐to‐speech program than VoiceOver
More control and options
Many voices available
$9.99
Voice Dream Lite is free, full function version, but requires you to hit the "Play" button every few sentences (300 characters)
Others include NaturalReader ($9.99), Text Aloud ($4.99), Voice Reader Text ($2.99), Voice Magnet ($1.99), Speak it! ($1.99)
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Money Identification
EyeNote (free)
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US Bureau of Engraving and Printing
New version identifies currency immediately in video mode –
no need to take a photo
US currency only
Privacy mode available
Only works on iPhone, iPod Touch and iPad 2?
LookTel Money Reader ($9.99)
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iPhone (5, 4S, 4, 3GS), iPod Touch (4th), iPad (2 and 3)
Identifies currency immediately in video mode – no need to take a photo
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All types of bills from many countries
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http://www.looktel.com/moneyreader
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Apps for the Visually Impaired
GPS for mobility (cell internet required)
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The Seeing Eye by Sendero Group is the 1st fully accessible app $70/yr or $130/3 yrs
BlindSquare ($24)
Navigon ‐ USA ($50), North America ($60)
Aridne GPS ($5.99)
Color Identification
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Color ID Free (free) and Color Identifier ($4.99) from GreenGar speak the names of colors captured by the iPad's camera
Games
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Accessible Mine Sweeper ($0.99) is one of many
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Image Recognition
Take a photo of an object ‐ book cover, historical landmark, consumer product, etc.
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A search will locate the object and provide information about it
Tap Tap See ‐ requires activation of VoiceOver, $4.00 for 50 pictures, $7.00 for 100 pictures, $9.99 for 1 month unlimited use
Google Goggles for Android, iPhone 3Gs and 4
QR and bar code readers
Today
I.
Implantable Telescope Technology
II. Clinical Outcomes
III. Treatment Program – CentraSight™
Implantable Telescope Technology
Anterior Segment Device for Macular
Disease
IMT™ by Dr. Isaac Lipshitz
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Patient Population
 End-Stage AMD
 Disciform Scar or GA
 No Active CNV
 Bilateral Scotomas
 20/160 – 20/800 BCVA
 Age 75 or older
 Phakic in prospective
telescope implant eye
Field of View –
External Telescope vs. Implanted
Implantable Telescope
~ 20-24°
Mounted
Telescope
~ 6 -12°
Mounted
Telescope
~ 6 -12°
How Does It Work?
Bi-ocular Viewing
Telescope Eye = Central Vision
Distance: Recognizing faces, watching TV,
seeing store signage
Near: Reading, playing cards, dining
Retains scanning capability
Other Eye = Peripheral Vision
Allows orientation and safe mobility
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Key Indications/Contraindications
Visual Acuity
 20/160 to 20/800
 Patient must improve with
(respond to) magnification presurgery
Key Indications/Contraindications
Anterior Segment
Operative Eye:
 No hx of intraocular or corneal
surgery; evidence of cataract
 Min. anterior chamber depth,
endothelial cell density
Additional Services
 Vocational Rehabilitation
 Division of Blind Services
 Transportation services
 Books on tape/large print
 Directory Assistance
 Lighthouse
 Braille Classes
 Guide Dogs
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Thank You
 For additional information
 American Optometric Association Vision Rehab Section
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