Learning how to better interact with and understand your visually impaired residents. Improving Quality of Life for Residents with Low Vision

Presenters Carolanne Roach, OD Vision Rehabilitation Optometrist NewView Oklahoma Graduated 2008 from Southern College of Optometry in Memphis, TN Work experience includes: Work with low vision patients and patients that have had strokes or brain injuries.

Presenters Cassie Rodkey, OT/L- Licensed Occupational Therapy with NewView Oklahoma Graduated from the University of Oklahoma in 1991 with a BS in Occupational Therapy Work experience includes: Assistive Technology, specialized wheelchair seating, early intervention for birth to three and working with patients dealing with low vision to remain independent.

Presenters Kathy Plummer, COTA/L- Certified Occupational Therapy Assistant with NewView Oklahoma Graduated 2007 from Oklahoma City Community College with AAS in OTA Work experience include the areas of Skilled Nursing, Outpatient Rehab, Home Health, and Vision Rehab Therapy

Objectives Learn how age related macular degeneration and other eye conditions affects reading, recreational activities, and other daily living skills. Identify what options are available to guide patients to more independence after a vision condition diagnosis. Practitioners will understand how to communicate with and guide residents with Low Vision or Blindness.

What is Low Vision?

Definition of Low Vision Low vision is defined as a visual impairment that cannot be corrected by medical or surgical intervention which is severe enough to interfere with the performance of activities of daily living but allowing some usable vision (NEI, 1998)

Low Vision/Blindness In % of Oklahomans have low vision or blindness = 109,833 1 in 4 in North America will suffer from vision loss by the age of 75 1 in 4 will have difficulty: Reading the newspaper Driving Watching TV Identifying peoples faces

Low Vision/Blindness Age-related macular degeneration affects more than 1.75 million individuals in the United States. Owing to the rapid aging of the US population, this number will increase to almost 3 million by 2020.

Low Vision/Blindness At least 171 million people worldwide have diabetes, and this figure is likely to more than double by the year 2030, to 366 million. About 50% of persons with diabetes are unaware that they have the condition. After 20 years with Diabetes Melilitus, more than 75% of patients will have some form of diabetic retinopathy.

What do these statistics mean? At 20/70 Visual Acuity, or < 70 degrees Visual Field, drivers will need to switch to a restricted drivers license. At 20/100 Visual Acuity, or < 60 degrees Visual Field, drivers will have to give up their keys Not eligible for services from the state until 20/200.

What do these statistics mean? At 20/200 people are considered legally blind Have to give up their independence Lose hope May suffer from depression or increased anxiety May have increased functional mobility issues- falls, bruises, lacerations & fractures Which may lead to other medical issues

Macular Degeneration Glaucoma Cataracts Diabetic Retinopathy Strokes and Head Injuries Eye Conditions Associated with Low Vision

Macular Degeneration Age related progressive eye condition Most common in those 65+ Comes in two forms Dry – build up of deposits causes scarring Wet – leaky blood vessels form and leaking blood causes damage to surrounding tissue

Macular Degeneration Affects the central part of vision Causes problems in: Reading Printed material Scores on TV Buttons on appliances Seeing faces Seeing fine detail

Macular Degeneration Signs of macular degeneration Slow reading Skipping words or lines when reading Difficulty with writing Trouble threading a needle Trouble telling time Difficulty using a phone to dial a number Identifying money

Macular Degeneration Signs of macular degeneration (cont.) Problems taking the right medication Trouble identifying a curb – reduced depth perception Difficulty identifying food items or reading instructions on food labels Hard to identify faces across the room Hard to see low contrast food on plate

Macular Degeneration Help for macular degeneration Magnifying reading glasses Off center viewing training Hand held magnifiers Electronic magnifiers TV magnification glasses Extra lighting More contrast added to house

Glaucoma Progressive loss of vision from optic nerve damage Caused in part to high eye pressure Lack of oxygen to the nerve Compression of the nerve behind the eye Not age related but is concurrent with other eye diseases

Glaucoma Affects the peripheral vision and causes problems with: Seeing in low light Running into objects above/below line of sight Light sensitivity In severe form it affects central vision and the ability to see fine detail

Glaucoma Signs of glaucoma Eye pain from high pressure Running into objects frequently Drawn curtains and wearing sunglasses indoors Unsteady on feet Trouble knowing where a curb is – depth perception is affected

Glaucoma Help for glaucoma The right tint to a pair of sunglasses Orientation and mobility training to help with safely maneuvering through a room Eye dropper guides to help get the right medication in eye for treatment Magnifiers for loss of detail vision

Diabetic Retinopathy Can affect any age, but the longer a person has had diabetes the more at risk they are for diabetic retinopathy. Damage to the eye comes from a lack of oxygen due to excessive sugar in the blood. Leaky blood vessels form and cause bleeding.

Diabetic Retinopathy To stop the bleeding, surgeons do laser surgery to kill off the tissue and decrease the demand for oxygen. This leads to scarring and loss of vision. Diabetes can affect peripheral vision or central vision.

Diabetic Retinopathy Affects of central vision loss: Same as affects from macular degeneration. Affects of peripheral vision loss: Difficulty with mobility trouble detecting the edge of a door trouble running into objects above/below depth perception affected – curbs/sidewalks

Diabetic Retinopathy Signs of diabetic retinopathy For central loss – similar to macular degeneration Problems taking blood sugar readings – seeing the strip, seeing the blood on finger, seeing the screen on meter Difficulty knowing how much insulin to draw up Unable to see sores on feet For peripheral loss – similar to glaucoma May see areas of red – from bleeding

Diabetic Retinopathy Help for diabetic retinopathy For central loss – similar to macular degeneration Talking glucometer Pre-loaded strips Finger pricking techniques to find blood on finger For peripheral loss Orientation and mobility instruction on how to safely move around the house or when outside the house.

Cataracts Age related condition that affects the lens inside the eye Affects a wide range of people from 50+ with varying progression. The lens inside the eye yellows or becomes foggy (like the plastic on head lights)

Cataracts The lens can be surgically removed when it has reached a medically necessary level. Does not usually cause vision problems in the developed world, but can have surgical complications. Once removed it no longer can reoccur

Cataracts Affects of cataracts Reduces contrast sensitivity Makes seeing white items on white objects more difficult Makes seeing on a cloudy day harder Causes glare Makes it more difficult to see when objects are backlit.

Cataracts Help for cataracts Surgical removal is the best treatment When surgery has been completed; however, a lot of patients are more sensitive to light and need to wear tinted lenses to cut that glare When surgery is not an option, magnification can be used in conjunction with extra lighting to help with seeing fine detail such as reading and also help with increasing contrast.

Stroke or Head Injury Can affect several parts of vision depending on where the stroke or head injury occur. Most notable losses of vision are those that affect the visual field and cut either ½ of the field in each eye or ¼ of the field in each eye.

Stroke or Head Injury Signs of vision loss from stroke Running into objects primarily on only one side Trailing of wall when walking down the hall primarily on one side. Offset gait on one side – affected because visual system is not picking up one side of vision to guide movement

Stroke or Head Injury Signs of vision loss from stroke (cont.) Leaning toward one side predominantly Difficulty reading (especially for those with a cut in their vision on the right side). Only eating half of what is on their plate (occurs with a phenomenon called visual spatial inattention/neglect – the person doesnt know the one side exists).

Stroke or Head Injury Help for stroke or head injury Field expansion prism lenses that allow a person to be more aware of what is on the side of vision that is missing. Special prisms to help reorient patients to their visual world and help them stand more upright and assist with mobility. Orientation and mobility training to safely maneuver unfamiliar areas.

The Low Vision Eye Exam A low vision eye exam is an eye exam designed to assess the functional aspects of vision that are affected by eye conditions. A low vision physician works with a referring eye care doctor to provide rehabilitation technique and device recommendations with a team of rehab professionals.

When to Seek Help from Low Vision Professionals

Observations: Do you have: Residents who bump into things? Residents with increased falls? Residents that cant read large print? Residents not recognizing caregiver/family member?

Observations: Do you have: Residents that get more food in the lap than in the mouth on a consistent basis or doesnt know what they are eating? Residents that spill things frequently or knock things over? Residents that mismatch clothing or miss stains on their clothing?

Observations: Can your resident: Sign name on line? Read newspaper or magazine? Identify colors?

Observations: Can your resident: Look around without squinting or shading eyes? Find common object at a distance? Find things on the floor? See the TV?

Symptoms reported to staff Bursts of flashing light Things appear wavy Having a dark spot or out of focus area Blurred vision Double vision

Symptoms reported to staff Increased falling, tripping, bruises Sudden changes in vision Painful reaction to glare/sunlight Night blindness

Contrast Lighting Magnification Reading & Writing Organization & Labeling Orientation and Mobility Basic Areas Covered in Vision Rehab Therapy

Contrast Molding and trim can be painted a highly contrasting color Use contrast door/drawer pulls Hand rail should be a highly contrasting color, also painting the wall below the hand rail should be a different highly contrasting color to the rail and wall above Artwork on the walls can be used to provide contrast

Contrast cont. Carpeting should be a solid color Use a highly contrasting placemat under white dishes to make them pop and easier to see Entry steps, stair handrails, top & bottom steps of stairs In the bathroom use a dark color toilet seat cover

Contrast cont. Put a dark colored bath mat over the edge of the tub or dark color towels on the towel rack to provide contrast Shelf-liner can be cut to fit and used on a countertop to provide contrast, this can be washed in the washer when soiled Put contrasting pillows or a throw over a chair or couch to provide contrast

Lighting Torchier lamps can provide good general lighting in a room but need a good solid base so lights do not tip over easily A good task lamp can provide extra light for reading, tasks in the kitchen/bathroom, and taking medication Should have a metal shade Sturdy base Be adjustable

Lighting cont. Nightlights can provide lighting for walkways in rooms or apartments and in hallways and bathrooms Rope lighting can be used for walkways Use good light bulbs Good Light BulbsPoor Light Bulbs CFL (compact fluorescent)Halogen (provide good light but get too hot) Reveal Bright WhiteLow Wattage (25 watts) Daylight

Magnification Font Size Hand Held Magnifiers Stand Magnifiers Electronic Magnifiers

Screen Magnification Screen Reading Software for Computer Users Accessibility feature for Mac and Windows users MAGIC, ZOOM TEXT, JAWS

Writing 20/20 Pen or Gel Pen Writing Templates Bold Line Paper Print when writing as opposed to writing in cursive

Reading Free digital player from library for the blind & physically handicapped Electronic readers – KINDLE, iPad Change font size – i.e. large print material Remove clutter from printed material Contrast may be necessary Hadley school for the blind & American Printing House for the blind offer free classes in Braille Appliance maps in large bold print

Making Handouts More Readable There are several things we can do to make printed handouts more readable. Use easy to read font, i.e. Arial or Times New Roman Use large font size-18 minimum, larger is often better. Bold typeface is more readable. Avoid columns Avoid glossy paper Mixed upper and lower case is easier to read. Always use white paper and black print.

Labeling One way to make things more visible is by marking them in any number of ways. Some of the things used for marking are rubber bands, bump dots, large print labels, safety pins, puff paint and many other things. There is no standard way to mark objects. It is like everything else, you find what works best for your resident through trial and error. Avoid over marking, just mark what is necessary and most used.

There are many products that are made for organization. Baskets are great to group like items together. Drawer dividers help organize large drawers. Canned food holders can be purchased or made. Train family members to always put things back where they belong. Organize things that are used together in the same area, i.e. coffee pot, coffee, coffee cups, coffee filters all in one area. Organization

Safety Remove throw rugs and clutter Move low tables from walkways in the home environment Maintain good organization/move frequently used items to lower cabinets or place on countertops Mark curbs, steps and handrails as described in the contrast section

Communicating with Residents That Have Visual Deficits

Use Verbal Cues Be descriptive in giving verbal cues Introduce yourself when entering a room Always ask them if they would like assistance Dont use terms over here or over there Do use directions above/below, right/left, forward/backward, in front of or behind Let the resident know you are leaving the room

Use Tactile Cues If you are going to use tactile cues, tell them you are going to touch them before you do I like to let residents feel things around them in their environment Remind them to go slowly and carefully, they may tend to move fast or with force that does not allow them to accomplish a task as easily Have them use a circular or grid pattern when searching for items I like to remind my clients that just because they have lost their vision, to whatever degree, they still have muscle/visual memory for the many tasks that they have done most of their lives.

Use Orientation Cues It is important to orient a new resident to their environment How is their room laid out How do they get to the dining room and other areas of the facility Always keep their items in the same place Organization Educating staff Labeling to help keep things in the same place

Dont worry about using terms in your natural speech that refer to sight, even though your resident doesnt see. This is part of natural speech and usually does not offend.

Basic O&M Skills

Sighted Guide: Step alongside client, could be either left or right side Touch your nearest arm to hers (right to left or left to right) depending on what side you want her in relation to you She takes you in the crook of the arm - put your hand at right angle She should be a step or half-step behind you. This is the most natural position. There are variations for comfort, height, health and other incidental conditions.

Doorway/Narrow Passageways: From the sighted-guide position, bring arm to your back and rest it in the small of your back. Client takes a step or two sideways to put herself directly behind you, sliding her hand down to your wrist Simultaneously you announce door is opening towards you or away from you or hinge is to your left or to your right. Once past the door or passage, return hand to your original sighted-guide position.

Stairs with guide: If going down stairs, put client near a railing and ask her to hold onto it to help her support herself. If going down, be on the step immediately below client, that way you can break her fall. When going up, be on the step behind client so you can also break her fall. If client is falling, in addition to catching her, fall towards client.

Protective Technique: Face: Raise one hand (it does not matter which one) up to your face, turn palm outwards, keep it that way until you are out of danger. Lower Body: Bring hand (any hand) up to the waist area, turn palm outward, keep it that way until out of danger. Sometimes these two are used in combination.

Environment Orientation: Pick a reference position in the building, room, or space where client can stand with her back towards it or leaning against it. A wall is best or some similar object. From that position, the client will determine where she is in relation to other objects (walls, tables, cabinets, cardinal points (N, S, E, & W). This point is where the client will return to in order to redetermine her orientation if she becomes disoriented.

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NewView Vision Services We offer a comprehensive Low Vision exam by an Optometrist specializing in Low Vision. We offer a comprehensive Low Vision Occupational Therapy evaluation. Low Vision Rehabilitation utilizes existing vision and gives instruction in adapted ways to perform: Reading, writing, medication management, cleaning, cooking, & mobility, self care, home management Referral to services within the community, such as Transportation, support groups, housing, employment, & education

Orientation & mobility training Falls prevention by Occupational Therapy & Orientation and Mobility Computer assistive technology training Braille instruction Arts in motion classes for youth & adults, as well as rowing & fencing classes VITAL support group for Veterans with Low Vision Meets monthly Periodic outings Eyes Just Talking Support Group Meets monthly at our Douglas location for individuals and families

Presenter Contact Info NewView Oklahoma 710 W. Wilshire, #102 Oklahoma City, OK Kathy Plummer, COTA/L Cassie Cooper-Rodkey, OT/L Carolanne H. Roach, OD