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Presentation on theme: "Karen Squier, OD FAAO AER INTERNATIONAL JULY 19, 2012."— Presentation transcript:


2 Objectives  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

3 Why Safety?

4 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 safety

5 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

6 Vision Rehabilitation  Integrates information from multiple resources to assess patients visual abilities  Medical Ophthalmologist/Optometrist  Rehabilitation Optometrist  Rehabilitation Teacher/Occupational Therapist  Orientation and Mobility Instructor  Social Worker

7 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 nutrition

8 Safety Goals for patients  Increase safety awareness in patients with visual impairment

9 Safety Goals for Patients  Identify and educate patients on potential areas of concern  Diagnosis  Cognition  Exam findings  Support system  Family  Community

10 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

11 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

12 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 non- judgmental with tone or body language  Uncover patient’s impression of vision loss

13 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?

14 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

15 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

16 Case History  Potential Referrals  Department of Human Services  Department on Aging  Meals on Wheels  Psychologist/Social Worker

17 Cognition

18  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

19 Cognition  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 exam!

20 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)

21 Mini-Mental State Exam (MMSE)

22 Montreal Cognitive Assessment (MOCA)

23 Cognition  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

24 Visual Acuity

25 Vision  Ability to see details, objects and their environment  Typically measured with high contrast charts  Snellen most common test in primary care  Test is typically begun at 20 foot distance

26 Vision  Visual acuity is a valuable measurement  Measures disease progression  Assists in determining magnification  Determines disability  20/200 visual acuity equates to legally blind status  20/70 visual acuity equates to visual impairment  Useful measure in uncovering spectacle blur

27 Vision  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

28 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

29 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



32 Contrast Sensitivity

33  Contrast sensitivity is the measurement of the ability to discern and detect an object against its background

34 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

35 Contrast sensitivity  Descriptive measurement of visual ability  Identifies additional layers of visual performance  Ginsberg et al stated “Contrast sensitivity is the best predictor of visual function”.

36 Potential causes of contrast loss  Glare: Poor lighting, sunlight  Inclement weather: Rain, Fog  Patterns  Poor image quality: faded ink, media opacity  Age

37 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

38 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  Cataracts  Diabetic retinopathy  Retinitis pigmentosa

39 Glare  Quality of image is degraded by excessive light  Can be related to quality of light or ocular health  Poor light position  Warmth of light source  Reflection off of image source

40 Glare  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

41 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

42 Recommendations  Poor contrast translates to wide spectrum of difficulties  OT/RT  O&M  Driver’s Rehabilitation  Assistive Technology assessment

43 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)

44 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)

45 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,

46 Visual field loss  Causes of visual field loss  Optic nerve disease  Glaucoma  Optic Neuropathy  Acquired Brain Injury  Retinal disease  Retinitis pigmentosa  Retinal detachment

47 Visual Field  Ocular conditions can reduce amount of peripheral vision  Glaucoma  Retinitis pigmentosa  Diabetic Retinopathy  Brain injury

48 Vision while walking  Scottish Sensory Center

49 Think of visual function with these VF…. Lund and Rose, Eye, 2012

50 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.

51 Recommendations  Assistive devices for field awareness  Orientation and mobility  RT/OT  Driver’s rehabilitation

52 Driving

53 Visually impaired drivers  Drive less  Take less risks  Drive in daylight  Drive in familiar areas  *Mr. Magoo stereotype is not accurate.

54 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

55 Driving with visual impairment  Need to adhere to state requirements for driving  Need to be realistic about driving abilities  Need to realize even the shortest, most familiar route changes

56 Driving with poor contrast  Drivers need to be counseled on contrast findings  Contrast sensitivity can alter motion detection and object perception  Weather conditions can further degrade visual function

57 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

58 Falls

59 Falling  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

60 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

61 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

62 Risk of falling  Outside of visual impairment  Consider type of flooring  Shoes!!  Lighting  Uneven Floors and steps  Clutter and weather  Rugs  Critters

63 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

64 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

65 Department on Aging  Energy assistance program  Supplemental nutrition program  Medicare low income subsidy program  Financial Assistance  Meals on wheels, Nutrition Sites and Food pantries

66 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 abilities

67 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.

68 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 disability  Requires education and understanding of parents and guardians by pediatricians

69 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

70 Support system  Essential for patients to have a support system  Aids in understanding education  Aids in rehabilitation implementation  Maintains social network and interactions  Helps point our areas of potential safety concerns

71 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

72 Conclusion  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 assessment  Referrals to rehabilitation professionals and community resources should be pursued

73 Questions??

74 Thank you!!!!

75 Contact information  Karen Squier, OD FAAO   312.997.3686

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