Low Vision News

For low vision specialists and those who consult them

Monthly Archives: August 2009

Opinion piece: Low vision care in a state-funded health system

I have been watching the debate over US health care with interest. I thought it may be interesting to discuss my experiences of working in a state-funded health system, and to provide my honest opinions of its strengths and weaknesses. This is based on my experience of working in a specialist centre in London, and I appreciate that things may not be the same elsewhere in the country.

Low vision care in the state-funded system is free at the point of delivery: this means the cost of the appointment is covered by the government through tax revenue. Every person with visual impairment is entitled to be referred into a low vision clinic either by their family doctor (general practitioner) or by their ophthalmologist. (This may not happen in every area because of knowledge of our services, but that is a different problem). A new appointment would typically be given within 8-12 weeks of referral.

The standard of care is a one-hour low vision consultation with an optometrist during which a full history would be taken, the spectacle refraction checked, magnification needs assessed and magnifiers prescribed. Optical magnifiers are issued on a permanent loan system: they are loaned to the patient for as long as they are useful. Follow-up appointments are made at the discretion of the clinic – if someone is prescribed complex aids, has rapidly changing vision or significant occupational demands, for example, they will be reviewed after a few months.

Lighting, electronic aids and training are not covered by the NHS. Non-optical devices are supplied by the local sensory impairment team, who will make a home visit. Electronic magnifiers such as CCTVs are paid for by the education authority for schoolchildren; by the university disability fund for students; and by a government scheme called “Access to Work” for those in employment (where the employer is legally obliged half of the cost of the devices and the government contribute the rest of the cost).

Visual training (such as eccentric viewing training) is not offered by many NHS clinics because of the time and staff costs involved. However, some charities and local groups provide this training. Orientation and mobility training is provided by the local sensory impairment team.

I will give a hypothetical case to illustrate how the NHS works at its best.

Mrs A is an architect with albinism. Her vision has been stable for many years but its been some time since she had a low vision consultation. She attends her family doctor to ask for a review. The hospital receive the referral, and contact her to discuss a convenient time for an appointment. Mrs A attends an hour long consultation with me, although the clinic is quiet and I spend a little longer with her. I refract her and find a changed prescription, which gives an extra line of distance vision. I prescribe her a large bright field stand magnifier to help with blueprints and drawings, an illuminated hand magnifier to help read menus in dimly lit restaurants and some hyperocular spectacles to read the newspaper at home. I also give her a 4x distance vision monocular telescope to look at airport departure boards. She takes all of these devices away with her. I show her a portable CCTV system and give her information about local agencies who provide grants to assist with the cost of them if needed, but she feels that she would not use one. We also chat about screen magnification and screen reading software – I give her information about the Access to Work scheme, she has a workplace assessment and ends up with a 30″ screen and Zoomtext, paid for by the state and her employer. I make an appointment to see her in a year. Mrs A leaves the clinic with several hundred pounds worth of devices, much more understanding about where to seek further help from, and a script for new spectacles, all at no cost to her.

However, it doesn’t always work like this. There is only limited time for each person seen in the clinic: if someone really needs extended training in device handling or eccentric viewing training they are unlikely to receive this. If they need a CCTV but are unemployed and can’t afford one then they are at the mercy of charities to provide grants for these expensive devices. One of the elements of the clinic is that you don’t see a named person: for review appointments there is no guarantee that you will see the same clinician who assessed you at the first visit, nor can you request to see the most senior or experienced member of staff present rather than a (supervised) member of junior staff. Appointments will only be offered during office hours, Monday to Friday. You may have to wait for half an hour before being seen. The clinic probably won’t look as nice as an American hospital, although it will be clean.

There are centres in the USA that would provide far better low vision care – particularly for people who need extended device training – as long as they have good insurance, are a military veteran and could be seen in a Veterans Administration clinic, or if they are wealthy. My understanding is that Medicare does not cover low vision devices.

The ethos of a publically funded system is that it provides a certain standard of care for everybody, regardless of age, income, insurer or employment status, without direct cost to the patient. National Health Service low vision clinics are not perfect but they are open to every British citizen.

It is frustrating to me that I am able to offer better care to the private patients I see – they know that they will see me rather than another member of staff, they will have less time to wait and they can see me as often as they (or their insurer, or government) can afford.

Neither the UK nor the US system works perfectly, and I can’t see how we can get an equitable service with gold-standard care without very high taxation. However I fundamentally believe in the aims of the National Health Service: it seem fairer to me that there is a system where everyone gets standard care (everyone will receive magnifiers and spectacles if appropriate) than a system where one person gets the world’s best care whilst their uninsured neighbour doesn’t even get an illuminated hand magnifier supplied to them.

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What are the best journals which publish low vision research?

A PhD student in our lab is submitting her first paper in the low vision field and we were discussing where she should submit it so that it reaches the right audience. This led to quite a long conversation about what journals publish what type of low vision research. This post gives my subjective “top ten” low vision research journals, and my impression of which journals tend to publish which types of low vision research.

1: OPTOMETRY & VISION SCIENCE
I think OVS is currently the best journal for low vision research. Their papers tend to be clinically relevant and focus on reading, low vision devices, and quality of life research. Their readership is largely optometrists (it is the journal of the American Academy of Optometry) but papers I have published here seem to be cited by non-optometrists. International readership.

2: VISION RESEARCH
Vision Research generally publishes more laboratory based research which furthers our knowledge of the visual system. They are particularly strong in publishing reading research, and many classic papers appear in Vision Research. Its readership is largely vision scientists, biologists and psychophysicists. This may be a more difficult read for the lay person than some of the more clinical journals here.

3: INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE
IOVS is a relatively high impact factor journal and publishes clinical and laboratory work from across all areas of ophthalmology. Only a small proportion of their papers will be relevant to low vision, but they will be of high quality.

4: OPHTHALMOLOGY
Major clinical journal with an international readership. Again, not a huge amount of low vision research is published here, but the papers here are high quality. Tends to publish epidemiological research and studies with many participants.

5: OPHTHALMIC AND PHYSIOLOGICAL OPTICS
OPO publishes a reasonable amount of low vision research, particularly in the optics and devices field. It is the journal of the College of Optometrists in the UK. My perception is that the quality of this journal has slightly decreased recently, which seems to be reflected in a falling impact factor.

6: RETINA
Recently, Retina has published more work of interest to the low vision rehab community. For example, a recent Retina paper which caught my eye discussed changes in referral to low vision services since the availability of new AMD treatments.

7: JOURNAL OF VISUAL IMPAIRMENT AND BLINDNESS
This is one of the more readable journals here and would be a good place to start for someone new to reading scientific papers. Publishes work on education, reading, and daily living with low vision. It is published by the American Foundation for the Blind. Possibly has a less international readership than some of the other journals in this list.

8: BRITISH JOURNAL OF OPHTHALMOLOGY
Another leading clinical journal, with the occasional high-quality low vision paper. International readership.

9: JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT
JRRD is the journal of the Veterans Administration in the USA and often publishes low vision rehab research. Most (if not all) of the papers I have read in here are by employees of the VA.

10: VISUAL IMPAIRMENT RESEARCH
Visual impairment research was the journal of the International Society for Low Vision Research and Rehabilitation. Unfortunately it has ceased publication – maybe because of the large number of alternative journals for low vision research.

Other journals which publish low vision research include Journal of Vision, Neuro-ophthalmology, Clinical & Experimental Optometry and Journal of Optometry — there’s no particular reason why these haven’t made my top 10 other than I read research in the journals above more than these.

Journal article: Management of depression in people with visual impairment

I have noticed an increase in the number of conference presentations in the last 2-3 years concerning depression in visual impairment. It seems reasonably well established that people with low vision are about twice as likely to suffer from depression as the general population.

There is a nice paper in this month’s Optometry and Vision Science by Fenwick and colleagues from Australia which uses qualitative research techniques to explore how staff in a large eye hospital detect and manage depression in people with low vision.

Whilst most of the staff acknowledged that they saw many patients who were depressed, only 11.5% of the staff in the study group had received any training in the management of depression. Other key findings were that there was no clear mechanism for referral or other management of people with depression, and that the volume of patients seen in the clinic was a barrier to spending enough time with each person to effectively build a rapport.

In the hospital where I do my clinical work, there is a counselling service available and several UK charities such as the Macular Disease Society offer a counselling and emotional support service to people with poor vision. However I can certainly identify with the finding that in a busy clinic, there may not be enough time to discuss fully the emotional effects of visual impairment on the individual.

It would be wrong to imply that everyone with poor vision will become depressed. In particular to say that having low vision causes depression would be inaccurate and would send the wrong message to people. Indeed, there is some thought that depression may be over-reported amongst people with visual impairment because some of the screening questions (eg “have you found less enjoyment from doing things you used to like doing?” may be altered because of visual changes rather than depression). However, this paper reminds us that we should be aware of the identification and appropriate management of people in the low vision clinic who show signs of depression.

What is the future of assistive devices for the visually impaired?

At the forthcoming Envision conference, a pre-conference discussion will be held on “Current Trends in Low Vision and Vision Rehabilitation Research: Where and How Should Scientists be Focusing their Efforts?”. Unfortunately I will not be at Envision until after this session has taken place, but it led me to think about what may happen in the future with assistive devices for people with low vision. Here’s what I came up with…

One of the most frequent complaints I hear from people in clinic is “I walk past my friends in the street and they think I’m being rude because I don’t recognise them”. It may sound a bit science-fictiony but I see no reason why we can’t have a small assistive device which identifies faces and communicates to the user who the face belongs to: “I think David is walking towards you, on the right hand side”. The new version of iPhoto on the Mac has a pretty good face identification system which appears to have some Bayesian learning incorporated: I am sure this technology could be adapted to become a low vision aid.

The possibilities are endless. It could include some expression recognition software, and could be linked to your diary on your iPhone: how about a camera mounted on specs with an earphone saying “David is coming towards you. It was his birthday last week. He looks pretty mad.” Then the user can choose whether to pretend not to walk past David or not!

I’m sure readers have other ideas for the future of devices for low vision users…why not share your thoughts here. Who knows, maybe your ideas will become reality!

Journal article: A versatile optoelectronic aid for low vision patients

There is an interesting article in this month’s Ophthalmic and Physiological Optics by María Dolores Peláez-Coca, Fernando Vargas-Martín and colleagues which presents an electronic low vision aid which performs image processing on the fly (i.e. in real time). The system is called SERBA (an acronym for the Spanish of Reconfigurable Electro-optic System for Low-vision Aid). The device fits on a baseball cap for portable use and is relatively inconspicuous.

One of the manipulations it performs is a digital zoom, however I am more impressed by the augmented view strategy which it incorporates. This enables the user to see a compressed view superimposed upon the “real” view of the scene. The idea is that someone with peripheral visual field loss (as in glaucoma or retinitis pigmentosa) can see a compressed view of a scene within the intact visual field, and can use this view to locate objects of interest. The area of interest can then be seen with the residual field.

The system was shown to expand the visual field by between 1.7 and 4.1 times, as assessed on a tangent screen test.

Of course the real test would be to see how useful it is for people with reduced visual fields in the real world: for catching a bus or watching a sporting event, say. However the lab tests of this system are encouraging and I think it will be very interesting to follow the progress of the SERBA.

Eccentric viewing training: how do we know it works?

I am involved in the design of a randomised controlled trial to assess how useful eccentric viewing training is for people with central field loss. It’s proving to be a much harder question to answer than you may think.

Eccentric viewing is the technique by which people with central vision loss use a specific area of peripheral retina in place of the fovea in order to see. Whilst we have shown that this technique develops naturally in many cases (PDF), it is widely thought that training patients to make this adaptation can increase its use: for example, after training people may be able to use this technique for reading, not just for looking at a fixation target.

Eccentric viewing training is offered by many low vision clinics: notably by Optima in west England; the Veterans Administration in the USA; some centres in Australia; and many places in Scandinavia. One reason that it isn’t more widely used in the UK is that the Health Service require robust evidence (usually in the form of a randomised controlled trial) before agreeing to fund any intervention. This is what we are trying to perform, so that its efficacy can be assessed properly.

The problem is that eccentric viewing training is that it can not be performed in isolation: it can only really be used as part of a complete rehabilitation strategy including prescribing magnification, advice on steady eye strategy, advice on lighting and so on. This makes teasing out the relative effect of EV training versus all of the other elements of low vision rehab hard. We think we have managed to work out an appropriate study design, but it hasn’t been straightforward.

Obviously as a researcher I have to be impartial and I don’t want to speculate on what our results will be. However as a clinician I have seen how important good eccentric viewing is for people with central vision loss and would be surprised if we did not find that EV training is useful. Some of my co-investigators are more sceptical….so watch this space!

Results will be published some time in the next 4 years.