1. Development of a home-based Eccentric Viewing training program for clients with age-related macular degeneration through a researcher-clinician partnership
Marie-Chantal Wanet-Defalque, PhD1,2,3
Josée Duquette, MSc1,3
3rd International SensAge Conference
York, June 23rd 2014
1. Institut Nazareth & Louis-Braille
2. University of Montreal, School of Optometry
3. Center for Interdisciplinary Research in Rehabilitation of Greater Montreal

2. Context 
Age-related macular degeneration (AMD)  most frequent diagnosis
Some patients
spontaneously find a new retinal fixation point (PRL)
Others
need training to understand eccentric viewing (EV) and improve their functional vision
Few materials were available in French to assist in training EV
Structured and standardized EV program  developed and implemented at INLB (VisExc-INLB)
As you know, Age-related macular degeneration (AMD) is the most frequent low vision diagnosis in developed countries.
Although some patients spontaneously find a new retinal fixation point, prefered retinal locus (PRL), some need training to understand EV and improve their functional vision.
Few materials are available in French to assist in training EV.
So, A standardized EV program has been developed and implemented at the INLB, a rehabilation agency in Montreal. It’s called VisExc –INLB.
Research Clinician partnership

3. Purpose and Method
Evaluate the effectiveness of Vis-Exc training program
Characterize the clinical population
 Retrospective study
Then, our purpose was to carry out a follow-up study to characterize the clinical population benifiting from the VisExc training and to evaluate the effectiveness of this home-based program
We used a retrospective, chart based study

4. EV training program The EV program (VisExc-INLB)
at home by qualified low vision rehabilitation specialists
homework exercises given between sessions
The program is provided in two parts:
basic  instrumental activities of daily living (IADL) 4 sessions
optional advanced  reading  3 sessions
The EV program is administered at home by qualified low vision rehabilitation specialists, with homework exercises given between sessions.
The program is provided in two parts: a basic component for instrumental activities of daily living (IADL), followed by an optional advanced reading component.
First part consists of 4 sessions
Second part of 3 session.

5. EV training program
Basic EV program / Instrumental Activities of Daily Living
PRL estimation, near and distance vision
Oculomotor
Hand-eye coordination
Perceptual-cognitive
Spot reading
Magnification device training during final session
So what is the basic program, First it begins without magnification device and with estimation of PRL and position of gaze for Near and distance vision. Then follow the oculomotor and hand-eye coordination training and the perceptual-cognitive training.
The basic EV Training ends with spot reading with eccentric viewing with the use of the prescribed magnification device.

6. EV training program
Advanced program / reading skills in eccentric fixation
Perceptual-cognitive exercise McGill Low Vision Manual (Overbury et al.)
Reading their own material
McGill Low Vision Manual (Overbury et Conrod)
After the completion of the basic program, clients can choose to continue to the reading program, the optional part. Complementary to the basic program, and it’s to improve reading skills according to the specific needs of the client.
For this we use the perceptual-cognitive exercises from the McGill Low Vision Manual and a lot of practice using the reading material of the client.

7. Retrospective study: clients characteristics
Basic only: 54%
Advanced: 46%
Gender
Age
Clinical, sociodemographic, and performance data were collected retrospectively by consulting 158 clients charts. Complete files could be obtained for 136 clients who had received the eccentric viewing training program during the 2 years period considered in the study(between september 2009 and september 2011). Among these clients, 54 % completed the Basic program while 46 continued with the Advanced program. (Total abandon = 22).
2 third of the clients were females and 80% were over 75 years. Average age was 81 years ranging from 30 to 99 years old.
The most frequent diagnosis was AMD with 84 % of the cases (Among central scotoma clients a majority of AMD)
𝑥 81  10 years
Range: years

8. Distance vision acuity, pre-interventions
Visual acuity, ICD-9-CM Ranges of Low Vision
Moderate
20/ /160
49%; n=66
Subjects
Visual acuity horizontal axis: noted with coma as in French
EV studies usually focus only on patients who have a severe level of low vision. However in our study, they represent only half of the population that received the eccentric viewing program of INLB. We have even more clients with a moderate low vision level.
Those with near normal vision were seen mainly for educational purpose. Many of those within the moderate low vision got eccentric viewing evaluation and training because they had ineffective visual fixation due to their scotoma. Those with profound low vision, and even those 5 with near blindness, also benefited from eccentric viewing training.
Visual acuity (logMAR)

9. Visual acuity Distance VA Near VA
Before training : 0.95 log MAR (20/200+)
After training : 0.93 log MAR (20/200+)
 ≠ NS
Near VA
Before training: 1.13 log MAR (4M+ at 33 cm)
After training: 1.15 log MAR (4M+ at 33 cm)
Here are the recorde visual acuity : NS
Meanwhile one can emphasize that usually we observed a long delay between the two measurements: on average 294 days and the testing conditions were not as standardized in the clinic as would be desirable in a research environment. Sometimes, measurements could be made with different charts before or after the training : MNRead vs Lighthouse or the reduce ETRDS.
During this time delay , Change of glasses or Change of vision (with disease progression) could easily happen.

10. Global satisfaction
Thirty-four clients coming for a follow up optometric evaluation did complete a satisfaction questionnaire (administered by an optician): 91% reported being satisfied or very satisfied

11. Clinical assessment of the impact of the basic eccentric viewing training
Comments from central chart; n=87
Improvement of…
Reading skills (fluency, accuracy and speed)
At least 9 subjects resume  advanced reading activities
Instrumental activities of daily living (55)
Leisure / hobbies (24)
Far vision
etc.
functional autonomy and quality of life
When we look a the report of the low vision specialist after EV training we found that it was noted in the chart that :… LIRE
Globally the functional autonomy and QOL was improved.

12. Impact of the advanced program on reading skills
Post basic vs post advanced program (n=28)
Quebec-French assessment tool (ÉCLec-DV)
Reading Speed
150 words text; average speed calculated
Comprehension
Answers 3 questions about the text just read.
ÉCLec-DV
Post
Basic
Post Advanced
P value
Reading Speed (word/min.) 31 40
0,025
Comprehension (/3)
2,04
2,68
0,001
The impact of the advanced program on the reading skills was evaluated with a continuous text reading test of 150 words.
Reading speed and comprehension were significantly improved after the advanced training.
Average reading speed improved: from 31 to 40 words per minute

13. Conclusions
VisExc-INLB: EV training in French; 41 trained professionals
Study on a real clinical population in a real clinical environment
Unexpectedly profound LV or moderate LV
Benefits
Clinical files
Reported satisfaction
Improved reading skills
Limitations:
No standardized testing conditions (clinical environment)
Delay Pre/Post for VA tests
VisExc-INLB structured EV program available for French population in the real rehabilitation system.
The value of this study was that it was done on a real clinical population in a real clinical environment as opposed to a study made in a laboratory setting.
Unexpectedly this program was not only prescribed for clients presenting severe LV: even profound LV or moderate LV clients benefited from EV training.
Various benefits like improvements of the leisure activities etc. were retreived from the written notes in the clinical files. Also a high amount of satisfaction was reported as well as improved reading skills.
Of course this retrospective study had its limitation, like the non standardized testing conditions already mentioned in the clinical environment and the long delay that usually occured between the Pre and Post tests.

14. The story had to be continued…
in the Lab

15. Further research: Prospective study in a Lab environmnent
Evaluate EV training program effect (VisExc-INLB )
standardized measures
OCT-SLO

16. This will make another story… Thank you!