The Role of Occupational Therapists in Low Vision Evaluation

Vision and Aging

• Normal changes as adults age

  • Difficulty reading mail, newspapers, signs etc.

  • Need for more light

  • Problems with glare

• These and other changes may also indicate more serious problems, like glaucoma or diabetes related eye damage

• Individuals can’t tell the difference – an eye doctor can!

Low Vision Rehabilitation Services

• Enable people of all ages to make best use of remaining vision

• Help people adjust to low vision or blindness

• Introduce skills, strategies, and technology to maximize vision function and independence

• Customized to meet individual needs; provided at home and in the community

• Usually, the first step in vision rehabilitation is a low vision examination (will have to come into the doctor’s office for this)

Low Vision Evaluation

• Focuses on visual function, patient goals, and abilities in daily activities

• A variety of low vision charts and tests can be used to measure…

  • visual acuity (sharpness),

  • visual field (what you’re seeing overall),

  • and contrast sensitivity

• Results determine need for optical devices (e.g., glasses), non-optical aids (e.g., lamps), technology, and vision rehabilitation services

Health Center Services

• Low Vision Optometry

• Primary Care

• Diabetes Care (endocrinology and podiatry)

• Occupational Therapy

• EyeCare EyeWear Eyeglass Shop

Low Vision Rehabilitation Services: Training Programs

Enable people to remain safe, independent and active at any stage of life

• Services include:

  • Independent Living Skills Training

  • Orientation and Mobility Instruction

  • Academic Skills: Preparing for high education

  • Adaptive Technology Center: Specialized training and computer modifications

  • Career Services: Training and placement

Behavioral Health Clinic

Offers in-person and tele-mental health services, with expertise in caring for people with vision loss, traumatic brain injury, diabetes and other chronic medical conditions

• Services include:

  • Individual, couple and family psychotherapy

  • Psychiatric evaluation

  • Psychopharmacology and medication management

  • Group psychotherapy

  • Crisis intervention 24/7

  • Tele-support groups for adults with vision loss

Adult Day Health Care

• Services available to adults ages 18 and older who have been diagnosed with a chronic medical condition

• Offers an alternative to nursing homes

• A team of licensed professionals provide:

  • Nursing care

  • Physical, occupational, and speech therapy

  • Medication management

  • Morning snack and noon meal

  • Social and therapeutic activities

  • Vision rehabilitation therapy

Tele-Support Network

• Connects people of all ages from across the country to share resources, experiences, and support

• Groups meet regularly via zoom and are led by licensed professional

• Tele-Support Groups for:

  • Parents of Children with Vision Loss

  • Teens, ages 14-18

  • Young Adults, ages 20 to 35

  • Adults, ages 35 and older

• Additional Remote Offerings:

  • Virtual Book Club

  • Tele-Support Talks Monthly Series

  • Tech Talk Tuesday Monthly Series

  • Ask the TVI Monthly Series

eLearning for Professionals

Enables professionals to keep up with the latest technological advances and research findings for people with vision loss

• programs for:

  • Ophthalmologists

  • Ophthalmology residents

  • Optometrists

  • Nurses

  • Social workers

  • Occupational therapists

  • Physician assistants

  • Teachers

  • Communicators

Technology Centers

Our new state-of-the-art-facility offers:

• Assessments by Lighthouse Guild experts to determine visual capacity, lifestyle, personal goals, and comfort with technology

• Opportunities to learn how to use cutting-edge and basic technology devices

  • e.g., using AI meta-glasses, CCTV, etc.

• Training by experienced occupational therapists

• Technology Workshops with our tech experts

  • e.g., pairing things to bluetooth

• Tech Pals

When to Seek Services or Make a Referral

• Significant complaints about difficulties with activities of daily living

• Complaints about contrast or night vision

• Feelings of anxiety, depression or hopelessness

• Legal blindness, 20/200 or less in the better seeing eye

• Individuals who have not had a physical or eye examination within the past year

Definition of Low Vision

3 million Americans ages 40 and older have low vision - a permanent visual impairment that can't be fully corrected with glasses, contact lenses, medication, or surgery

Definition of Legal Blindness

In the United States, legal blindness is defined as visual acuity of 20/200 or less in the better eye with corrective lenses, or a visual field of 20 degrees or less

• This means that a person with legal blindness can only see at 20 feet what a person with normal vision can see at 200 feet

• It also includes those with limited peripheral vision, where the field of vision is restricted to 20 degrees or less

Eye diseases and conditions

• Age-related macular degeneration (AMD)

  • one of the most common with aging

• Glaucoma

  • second-most diagnosed

• Diabetic retinopathy

  • a symptom of diabetes- an inability to see clearly

• Maculopathy

• Retinal detachment

• Retinitis pigmentosa

  • genetic disease (not necessarily associated with aging)

• Stargardt’s disease

• Albinism

• Optic nerve dystrophy

• Visual field defect

macular degeneration

• central visual field problem where you can’t see what’s in front of you

• problems are immediately obvious

• Leading cause of vision loss among Americans age 65+

• Scotoma (blind spots) can vary in size, shape, and number

• Rate of progression varies, but generally does not lead to total blindness

  • hard to predict; some people stable, some people not

• Has a devastating impact on many daily activities

glaucoma

• affects the peripheral visual field and gets worse with time

• problems are noticed gradually (many people don’t even realize they have it)

  • No early symptoms; often diagnosed when damage is severe, irreversible, and too late to address

• Most often caused by fluid build-up and resulting pressure in the eye

• Causes loss of peripheral visual field, increased glare sensitivity, and loss of contrast sensitivity

• Impacts driving, mobility, and increases the risk for falls

(diabetic) retinopathy

• complex impairment where you have multiple blind spots (scotomas)

• Complication of diabetes caused by chronically high blood sugar levels

• Damages the lens, retina, and macula

• Causes multiple vision impairments

• Impact's ability to recognize faces, read, manage medications, and conduct self-examinations

Vision loss impacts a patient’s:

• Independent living

  • Read mail, medication, food labels, and newsprint

  • Write a check

  • Dial a telephone

  • Shop for groceries

  • Prepare meals and cook

  • Participate in hobbies/activities

• Travel and mobility

  • Cross streets

  • Read street and bus signs

  • Drive a car

  • Recognize faces

  • Socialize

• Work and school

  • Use a computer

  • Use a tablet and/or phone

  • Read and write

  • Travel to and from work/school

  • Lost job, income, dignity

  • Dependent on strangers

• Mental health

  • Depressed

  • Isolated

  • Embarrassed

  • Anxious

  • Abandoned

Referral to Occupational Therapy

At Lighthouse Guild, Occupational Therapists collaborate closely with:

• Low Vision Optometrists

• Primary Care Physicians

• Social Workers

• Low Vision Rehabilitation

• Orientation and Mobility

• Adaptive Technology Experts

They also coordinate programs such as

• Tech Pals

• Technology Workshops

• Support Groups

Occupational Therapy Evaluation

Key Questions to Address:

• What are patients’ visual impairments?

• How do these impairments impact their daily activities and life roles?

• What are the patient’s personal goals and priorities?

Occupational Therapy: Evaluation

Deficits and Restrictions in Daily Activities:

• Work and productivity

  • how fast can you complete tasks?

• Educational participation

• Self-care and personal hygiene

• Mobility and travel

• Leisure and social engagement

• Caring responsibilities

Vision Assessments Conducted by an OT

Basic Vision Assessment

• Gather background information (history)

• Determine dominant eye

• Assess visual acuity (intermediate distance)

• Assess contrast sensitivity function

• Assess color sensitivity

• Assess visual field

Advanced Vision Assessment

• Determine if a scotoma exists (if blind spot + if so, where it is)

• Determine if depth perception is affected

• Determine if binocular coordination is affected

• Assess reading performance

• Assess/address handwriting performance

• Determine if glare is affecting performance

Visual Acuity Charts

Contrast Sensitivity Charts

Color Sensitivity- Ishihara Color Vision Test

Visual Field Evaluation

Central Scotoma/PRL Evaluation

MN Read Acuity Test

• Reading Acuity: Smallest print that can just be read

• Maximum Reading Speed: Speed when reading is not limited by print size

• Critical Print Size: Smallest print that still supports maximum reading speed

SK Read Test

• Used to assess the reading performance of adults with:

  • Central or paracentral scotomas

  • Macular degeneration

  • Other conditions affecting the central visual field

Pepper Visual Skills for Reading Rest ( VSRT)

• Designed to assess the reading performance of adult who previously read efficiently but now experience central scotomas due to macular disease, which interfere with fluent reading

ADL Performance Evaluation

The Canadian Occupational Performance Measure (COPM)

• Client-centered assessment tool

• Used to identify a client’s self-perceived occupational performance challenges

• Measures changes in performance and satisfaction over time

• Helps guide treatment planning based on client-identified priorities

Four Levels of Interventions

1. Maximize visual function

   1. (lenses, magnifiers, visual skills training, etc.)

2. Modify the task or environment to enhance visual performance

   1. (large print, writing guides, better lighting etc.)

3. Modify the task or environment to reduce or eliminate visual performance

   1. (audio books and OCR software, etc.)

4. Eliminate the task

   1. (alternate or substitute approaches)

Occupational Therapy: Environment Modifications

Education on Environmental Safety Modifications:

• Identifying appropriate lighting

• Enhancing the color contrast of surfaces and objects

• Organizing and labeling items for easier access

• Minimizing clutter to improve navigation

• Implementing fall prevention strategies

• Adapting home and work environments to support functional growth

Approaches to improve performance and safety include:

• contrast around doorways; light switches in the bathroom

• handrails and non-skid markings on stairs

• window blinds to control glare

• adequate and consistent lighting

Low Vision Adaptive devices: Meal Preparation

Basic adaptations for meal preparation:

• tactile makings (“hi-marks”)

• increased contrast

• organization techniques

• techniques for using sharps

• liquid level indicators (“say when”)

Low Vision Adaptive Devices: Health and Wellness

Simple approaches for health-related activities include:

• large print and tactile pill organizers

• auto-drop eye drop guide

• talking glucometer for diabetic management

• hand-held magnification for diabetic foot check

Low Vision Adaptive Devices: Reading and Writing

Examples of Interventions

• a magnifier for reading small print

• a hand-held telescope to spot items

• signing name, and going off the line

• using a typoscope as a signature guide

Occupational Therapy: Visual Skills Training

Visual Skills and Compensatory Strategies Training:

• Eccentric viewing training

• Scanning exercises for compensation of visual field constrictions

• Exercises addressing loss of depth perception and eye-hand coordination

• Binocular coordination and convergence tasks

• Visual inattention retraining

Adaptive Technology Evaluation

• Adaptive computer equipment and software

• Video magnification systems

• Tablets and smartphones with accessibility feature

• Apps designed for people with low vision

OT Evaluation and Therapy for Technology

• OT specializing in low vision will meet with the patient to discuss personal goals and visual needs.

• Patient’s history, assessment of their functional vision, and technical aptitude determine which technologies are best

• Once the appropriate technology is identified, OT’s provide technology training to ensure patient is proficient and independent in its use

Occupational Therapy: Technology Evaluation

Identification and Training in Assistive Technology

Focused on individual capabilities, functional needs, and life goals:

• CCTVs

• Head-worn vision enhancement devices

• Text-to-speech devices

• AI devices

• Hybrids

Onyx HD

Optelec Electronic Magnifier with Text-to-Speech

• listen + visually follow what’s on the screen

• magnifies to make big letters

IrisVision

• wearable magnifiers

• good for watch TV, watching theater, watching sports game, other activities to do while sitting

• NOT to be worn when being mobile/trying to drive

eSight

• can switch gaze between looking into the device and looking onto the floor/your feet- so you know where you are; safer!

OrCam

• turn text to speech

• can describe the sceen

• can tell you the color

• has AI functions

Ray-Ban Meta glasses

• can take recordings- mostly used for leisure activites

• AI will describe things you take photos/videos of

• can also do live interpretations/translations of other languages now

Occupational Therapy: Technology Evaluation LVI logo

Training on accessibility features and assistive apps for smartphones and tablets

• apps for navigation, magnification, etc.

ReBokeh App

• magnifying app that can also increase contrast, get more light, and generally make things easier to see with a variety of functions

Seeing AI App

• free

• similar to meta-glasses

• reads text, describes scenes, describes colors, scans barcodes, downloads documents, and has them be read back to you, voice-over features, etc.

Navi-lens Mobility App Testing

Occupational Therapy Interventions for Low Vision

• Environment modifications

• Low vision adaptive devices

• Visual skills and compensatory strategies training

• Assistive technology and accessibility training