Ratings of importance to the care process (A-C) and ratings of strength of evidence (I-III) are defined at the end of the "Major Recommendations" field.
Vision rehabilitation trains patients to use their residual vision or alternate compensatory techniques effectively and to make practical adaptations in their environment to facilitate reading, activities of daily living, ensure safety, support participation in their community, and enhance emotional well-being. All ophthalmologists have a minimum responsibility to recommend vision rehabilitation as a continuum of their care and to provide information about rehabilitation resources for patients with vision loss that impacts function. [A:III]
The role of the treating ophthalmologist is to evaluate and treat eye disease before referring a patient to vision rehabilitation. The treating ophthalmologist also will reassess a patient's condition periodically to prevent further vision loss because many conditions that result in low vision are progressive. Patients who report vision loss during the course of rehabilitation should be referred to the treating ophthalmologist for evaluation. [A:III]
Vision rehabilitation must be individualized to meet each patient's particular goals, limitations, and resources (e.g., age, finances to purchase devices, and caregivers) and must address reading, activities of daily living, safety, participation in the community, and well-being [A:III].
Initial Evaluation
History
An initial history should include the following elements:
- A medical and ophthalmic history outlining the patient's understanding of the diagnosis, duration of vision loss, and symptoms of visual hallucinations (Charles Bonnet syndrome), falls, and depressed mood [A:III]
- A functional history including difficulties with near, intermediate, and distant vision-related tasks; mobility; falls; fear of falling; driving; vocational and avocational activities; independence; and participation in community activities [A:III]
A functional history may include, but not be limited to, questions concerning the following:
- Problem areas and their significance to the patient
- Near and intermediate vision-related tasks
- Distant-vision-related skills
- Mobility
- Glare
- Participation in community activities
The history should also identify the patient's stated goals, priorities, and values. [A:III] It should include a review of physical impairments relevant to rehabilitation (e.g., tremor, loss of hearing, cognitive deficit, and restricted mobility) and medications. [A:III] The evaluation should also consider the patient's psychosocial history, including his or her living situation, supports, responsibilities, adjustment to vision loss, depression, and fear of the future, and a social history, which includes driving, vocational activities, and avocational activities. The patient may elect to have a friend or family member present during the evaluation process to confirm information and to serve as coach or helper. [A:III]
Examination
A comprehensive adult medical eye evaluation (see the National Guideline Clearinghouse [NGC] summary of the American Academy of Ophthalmology [AAO] Preferred Practice Pattern Comprehensive adult medical eye evaluation) is conducted by the referring ophthalmologist before referring for the low vision evaluation. Elements of the ocular examination relevant to vision rehabilitation may be done as part of the vision rehabilitation care process. [B:III] Specific elements included in a low vision evaluation are visual function, functional implications of visual impairment, and psychological status.
Evaluation of Visual Function
A review of relevant clinical notes, previous diagnosis, and previous ancillary testing such as retinal photographs or visual fields is helpful in evaluating visual function. [A:III] Other components of the evaluation are the following:
- Visual acuity and refraction [A:III]
- Contrast sensitivity [A:III]
- Visual fields, scotomas, and preferred retinal loci [A:III]
Assessment of Functional Implications
The low vision evaluation includes an assessment of the functional implications that correspond with the patient's visual function and eye condition. This includes overall visual impairment with respect to distance and near acuity, contrast sensitivity, and visual field and other relevant physical or cognitive impairments. [A:III] Assessing functional implications should include consideration of the following: [A:III]
- Risk of medication errors, label misidentification/product misuse, diabetic mismanagement, nutritional compromise
- Risk of injury from accidents, including falls, cuts, burns, fractures, or head injuries
- Risk of errors in financial management and/or writing/recordkeeping errors
- Risk of social isolation, depression, or economic hardship
- Potential to benefit from rehabilitation training
Assessment of Psychological Status
The patient's psychological status is important to assess. Factors to consider include:
- Motivation, responsibilities, and supports [A:III]
- Mood, affect, depression, and adjustment to vision loss (Geriatric Depression Scale, Depression, Anxiety and Stress Scale, or other screening question may be used) [A:III]
- Cognitive ability [A:III]
- Stamina, energy, and activity level [A:III]
Refer to the original guideline document for additional information on initial evaluations.
Rehabilitation Interventions and Devices
The rehabilitation team should provide continued opportunities for training and reinforcement, as appropriate, to accomplish sustained success with rehabilitation interventions and devices and must offer hope to patients whose lives have been significantly affected by vision loss. [A:III]
The effectiveness, ergonomics, and appropriateness of the following interventions and devices should be considered and the patient response to each should be noted: [A:III]
- Spectacles, including high plus reading eyeglasses
- Handheld magnifiers
- Stand magnifiers
- Video magnifiers
- Telescopic devices (Szlyk et al., 2000)
- Lighting
- Glare control
- Magnification
- Nonoptical aids, including lighting, contrast enhancement, daily living aids, glare control, large print, and signature templates
- Sight substitutes such as audio books, talking watches, tactile markers, Braille
- Computer adaptations using magnification and audio output
- Support cane or long cane for safe mobility
When considering recommendations for low vision rehabilitation, the clinician and patient should discuss the following topics: [A:III]
- Potential for rehabilitation interventions
- Training, including eccentric fixation, scotoma avoidance, and practical adaptations in activities of daily living
- Mobility instruction and fall prevention
- Driving and transportation alternatives
- Charles Bonnet visual hallucinations
- Home safety and adaptations
- Family concerns
- Support groups and counseling
- Community state programs and other local, national, and online resources
Rehabilitation professionals and staff are facilitators who can provide continued encouragement and support in addition to training and recommendations, but the patient must be an active participant and actually do the work to ensure success and sustained benefit. [A:III]
Patient Education and Support
Patient Well-Being
The evaluation and assessment in vision rehabilitation is framed by the patient's individual goals, skills, and responses to aids and concludes with a comprehensive discussion (Fletcher, 1999). The psychological factors that should be discussed include independence, importance of activity, family interactions, communication, patient attitudes, patient concerns (e.g., fear of blindness), and patient questions, which may include questions about legal blindness, driving status, or how to prevent further vision loss (Williams et al., 1998) [A:III]
Professional assessment should be recommended for patients who report severe change in mood. [A:III]
Internists, family practice physicians, and geriatricians should be informed that when vision loss is not reversible, a patient with vision loss is at high risk for depression. [A:III]
Providers
A multidisciplinary team approach is recommended to effectively address the functional and psychological problems caused by vision loss. [A:III] The physician is the team leader and directs the rehabilitation program, and the patient is an active participant in the rehabilitation process. [A:III]
Academy SmartSight™ Model of Vision Rehabilitation
The rehabilitative needs of patients vary considerably. The setting, level of care, and disciplines required depend on the complexity of the functional problems, psychosocial status, and personal attributes. The Academy outlines a spectrum of clinical care in its SmartSight Initiative three-level model of vision rehabilitation (http://www.aao.org/smartsight). The most important part of the SmartSight model is Level 1, which asks all ophthalmologists seeing patients with less than 20/40 acuity, contrast sensitivity loss, scotoma, or field loss to Recognize and Respond. They should Recognize the functional impact of partial vision loss and Respond by assuring the patient that much can be done to improve their function and giving them the SmartSight Handout rather than letting the patient assume that nothing more can be done. (See Appendices 2 and 3 in the original guideline document for the SmartSight model levels 1, 2, and 3).
For additional discussion of treatment, please see the original guideline document.
Definitions:
Ratings of Importance to the Care Process
Level A, defined as most important
Level B, defined as moderately important
Level C, defined as relevant but not critical
Ratings of Strength of Evidence
Level I: Includes evidence obtained from at least one properly conducted, well-designed randomized controlled trial. It could include meta-analyses of randomized controlled trials.
Level II: Includes evidence obtained from the following:
- Well-designed controlled trials without randomization
- Well-designed cohort or case-control analytic studies, preferably from more than one center
- Multiple-time series with or without the intervention
Level III: Includes evidence obtained from one of the following:
- Descriptive studies
- Case reports
- Reports of expert committees/organization (e.g., Preferred Practice Patterns [PPP] Panel consensus with external peer review)
