Optical reading aids for children and young people with low vision

Role of improved distance and near visual acuity with low vision aids to enhance stereopsis in retinal diseases

Purpose:

The purpose of this study was to examine role of improved distance and near best-corrected visual acuity (DBCVA and NBCVA) with use of magnification devices to enhance stereopsis in low vision (LV) subjects having retinal diseases.

Methods:

In a cross-sectional observational study without control, 84 subjects having LV due to retinal diseases were examined for an improvement of BCVA with use of magnifying low vision aids (LVAs) (2X for DBCVA and 3X for NBCVA). The stereopsis scores on titmus fly test were recorded with near refractive correction “on” and then with 3X magnification. The improvement in stereopsis for distance was however estimated through statistical correlation values.

Results:

The DBCVA (P < 0.001), NBCVA (P < 0.001) and stereopsis (P < 0.001) improved statistically significantly (SS) following magnifying LVA. There was no correlation between pre-LVA stereopsis and pre-LVA DBCVA (r = 0.059; P = 0.444;NSS) and post-LVA DBCVA (r = 0.054; P = 0.487;NSS); and no correlation between post-LVA stereopsis and pre-LVA DBCVA (r = 0.042; P = 0.592;NSS) and post-LVA DBCVA (r = 0.08; P = 0.920;NSS). There was no correlation between pre-LVA stereopsis and pre-LVA NBCVA (r = 0.044; P = 0.572;NSS) and no correlation between post-LVA stereopsis and pre-LVA NBCVA (r = 0.108; P = 0.165;NSS). But positive correlation between pre-LVA stereopsis and post-LVA NBCVA (r = 0.347; P < 0.001) and between post-LVA stereopsis and post-LVA NBCVA (r = 0.445; P < 0.001) was SS.

Conclusion:

The use of magnification as LVA improves both the BCVA and stereopsis. The increase in DBCVA with LVA improves the stereopsis for distance though it may not be SS while improvement in NBCVA with LVA enhances stereopsis for near objects in SS manner.

First Evaluation of a Retinal Imaging Laser Eyewear System Based Low Vision Aid

Purpose

We conducted this trial to investigate a new wearable laser-eyewear (LEW). Images of an integrated camera are projected to the retina by a RGB-Laser (<1µW) and MEMS-mirror system. This enables a full-color live video as augmented reality embedded in the field of vision of the wearer. Thin parallel laser beams are projected following the principle of Maxwellian view through the center of the ocular lens to ensure independency of refractive errors. We performed a study with healthy subjects to test this independency.

Materials and Methods

LEW was tested in 20 healthy subjects (aged between 21 and 60 years) with hyperopia, myopia, astigmatism and/or presbyopia. Subjects underwent standardized visual acuity (VA) measurements (ETDRS) without any correction, with LEW and with best correction.

Results

We found no significant correlation between refraction and VA while using LEW in linear regression (r=0.17). Still, younger participants performed better in terms of VA with the device compared to older participants despite no differences in BCVA (p<0.01). The achievable VA with LEW was in general reduced compared to uncorrected VA (0.50 vs 0.40 logMAR). Only myopic subjects reached a significantly higher VA using LEW (p<0.001). Presbyopic subjects showed enhanced near VA (0.25 logMAR) by reading at 15cm with LEW without any further necessary refractive correction. Nearly all patients (80%) showed stereopsis without need for additional adjustments.

Conclusion

Our investigation could verify the independence of LEW of refractive errors. Therefore, the technology seems to be especially useful in patients with untreatable corneal conditions, e.g., after corneal burns, to achieve higher VA since the thin laser should penetrate even corneal opacities with less scattering.

Low vision rehabilitation for better quality of life in visually impaired adults

BACKGROUND

Low vision rehabilitation aims to optimise the use of residual vision after severe vision loss, but also aims to teach skills in order to improve visual functioning in daily life. Other aims include helping people to adapt to permanent vision loss and improving psychosocial functioning. These skills promote independence and active participation in society. Low vision rehabilitation should ultimately improve quality of life (QOL) for people who have visual impairment.

OBJECTIVES

To assess the effectiveness of low vision rehabilitation interventions on health-related QOL (HRQOL), vision-related QOL (VRQOL) or visual functioning and other closely related patient-reported outcomes in visually impaired adults.

SEARCH METHODS

We searched relevant electronic databases and trials registers up to 18 September 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) investigating HRQOL, VRQOL and related outcomes of adults, with an irreversible visual impairment (World Health Organization criteria). We included studies that compared rehabilitation interventions with active or inactive control.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 44 studies (73 reports) conducted in North America, Australia, Europe and Asia. Considering the clinical diversity of low vision rehabilitation interventions, the studies were categorised into four groups of related intervention types (and by comparator): (1) psychological therapies and/or group programmes, (2) methods of enhancing vision, (3) multidisciplinary rehabilitation programmes, (4) other programmes. Comparators were no care or waiting list as an inactive control group, usual care or other active control group. Participants included in the reported studies were mainly older adults with visual impairment or blindness, often as a result of age-related macular degeneration (AMD). Study settings were often hospitals or low vision rehabilitation services. Effects were measured at the short-term (six months or less) in most studies. Not all studies reported on funding, but those who did were supported by public or non-profit funders (N = 31), except for two studies. Compared to inactive comparators, we found very low-certainty evidence of no beneficial effects on HRQOL that was imprecisely estimated for psychological therapies and/or group programmes (SMD 0.26, 95% CI -0.28 to 0.80; participants = 183; studies = 1) and an imprecise estimate suggesting little or no effect of multidisciplinary rehabilitation programmes (SMD -0.08, 95% CI -0.37 to 0.21; participants = 183; studies = 2; I2 = 0%); no data were available for methods of enhancing vision or other programmes. Regarding VRQOL, we found low- or very low-certainty evidence of imprecisely estimated benefit with psychological therapies and/or group programmes (SMD -0.23, 95% CI -0.53 to 0.08; studies = 2; I2 = 24%) and methods of enhancing vision (SMD -0.19, 95% CI -0.54 to 0.15; participants = 262; studies = 5; I2 = 34%). Two studies using multidisciplinary rehabilitation programmes showed beneficial but inconsistent results, of which one study, which was at low risk of bias and used intensive rehabilitation, recorded a very large and significant effect (SMD: -1.64, 95% CI -2.05 to -1.24), and the other a small and uncertain effect (SMD -0.42, 95%: -0.90 to 0.07). Compared to active comparators, we found very low-certainty evidence of small or no beneficial effects on HRQOL that were imprecisely estimated with psychological therapies and/or group programmes including no difference (SMD -0.09, 95% CI -0.39 to 0.20; participants = 600; studies = 4; I2 = 67%). We also found very low-certainty evidence of small or no beneficial effects with methods of enhancing vision, that were imprecisely estimated (SMD -0.09, 95% CI -0.28 to 0.09; participants = 443; studies = 2; I2 = 0%) and multidisciplinary rehabilitation programmes (SMD -0.10, 95% CI -0.31 to 0.12; participants = 375; studies = 2; I2 = 0%). Concerning VRQOL, low-certainty evidence of small or no beneficial effects that were imprecisely estimated, was found with psychological therapies and/or group programmes (SMD -0.11, 95% CI -0.24 to 0.01; participants = 1245; studies = 7; I2 = 19%) and moderate-certainty evidence of small effects with methods of enhancing vision (SMD -0.24, 95% CI -0.40 to -0.08; participants = 660; studies = 7; I2 = 16%). No additional benefit was found with multidisciplinary rehabilitation programmes (SMD 0.01, 95% CI -0.18 to 0.20; participants = 464; studies = 3; I2 = 0%; low-certainty evidence). Among secondary outcomes, very low-certainty evidence of a significant and large, but imprecisely estimated benefit on self-efficacy or self-esteem was found for psychological therapies and/or group programmes versus waiting list or no care (SMD -0.85, 95% CI -1.48 to -0.22; participants = 456; studies = 5; I2 = 91%). In addition, very low-certainty evidence of a significant and large estimated benefit on depression was found for psychological therapies and/or group programmes versus waiting list or no care (SMD -1.23, 95% CI -2.18 to -0.28; participants = 456; studies = 5; I2 = 94%), and moderate-certainty evidence of a small benefit versus usual care (SMD -0.14, 95% CI -0.25 to -0.04; participants = 1334; studies = 9; I2 = 0%). ln the few studies in which (serious) adverse events were reported, these seemed unrelated to low vision rehabilitation.

AUTHORS' CONCLUSIONS

In this Cochrane Review, no evidence of benefit was found of diverse types of low vision rehabilitation interventions on HRQOL. We found low- and moderate-certainty evidence, respectively, of a small benefit on VRQOL in studies comparing psychological therapies or methods for enhancing vision with active comparators. The type of rehabilitation varied among studies, even within intervention groups, but benefits were detected even if compared to active control groups. Studies were conducted on adults with visual impairment mainly of older age, living in high-income countries and often having AMD. Most of the included studies on low vision rehabilitation had a short follow-up, Despite these limitations, the consistent direction of the effects in this review towards benefit justifies further research activities of better methodological quality including longer maintenance effects and costs of several types of low vision rehabilitation. Research on the working mechanisms of components of rehabilitation interventions in different settings, including low-income countries, is also needed.

Randomized Trial of Tablet Computers for Education and Learning in Children and Young People with Low Vision

SIGNIFICANCE

Mobile devices such as tablet computers have become widely available as mainstream devices and are also used in some schools, but there is an absence of robust information regarding the efficacy of any optical/electronic low vision device or tablet computer in supporting education of young people with low vision.

PURPOSE

A randomized controlled trial (RCT) is needed to measure the impact of tablet computers on education, specifically on independent access to educational material, in children and young people with low vision. We conducted a pilot RCT to determine the feasibility of conducting a full-scale trial.

METHODS

This was a randomized multicenter pilot trial across two sites in the United Kingdom and one site in India. Forty children and young people aged 10 to 18 years with low vision (best-corrected visual acuity for distance between <20/60 [0.48 logMAR] and 20/400 [1.30 logMAR] in the better eye) in the United Kingdom (n = 20) and India (n = 20) were randomized to two parallel arms, with a 1:1 allocation ratio, to control (n = 20) or intervention (n = 20). Control group participants received standard low vision care. The intervention group received a tablet computer (iPad) with low vision applications and instruction in its use, including accessibility features. Four primary outcomes included (1) 6-month recruitment rate, (2) retention of participants for 3 months, (3) acceptance/usage of device, and (4) accessibility of device.

RESULTS

Nineteen participants (95%) enrolled within 6 months in the United Kingdom, and 20 participants (100%), in India. Retention at 3 months was 85% (n = 17) in the United Kingdom and 95% (n = 19) in India. More than one half of participants reported using a tablet computer at school at least once every day. The majority (90%) found it easily accessible.

CONCLUSIONS

This study demonstrated that it is feasible to recruit children and young people with low vision into an international multicenter RCT of electronic assistive technology. Regardless of geographical location, children and young people with low vision reported using tablet computers at least once a day at school and accessed them easily.

Tablet computers versus optical aids to support education and learning in children and young people with low vision: protocol for a pilot randomised controlled trial, CREATE (Children Reading with Electronic Assistance To Educate)

INTRODUCTION

Low vision and blindness adversely affect education and independence of children and young people. New 'assistive' technologies such as tablet computers can display text in enlarged font, read text out to the user, allow speech input and conversion into typed text, offer document and spreadsheet processing and give access to wide sources of information such as the internet. Research on these devices in low vision has been limited to case series.

METHODS AND ANALYSIS

We will carry out a pilot randomised controlled trial (RCT) to assess the feasibility of a full RCT of assistive technologies for children/young people with low vision. We will recruit 40 students age 10-18 years in India and the UK, whom we will randomise 1:1 into two parallel groups. The active intervention will be Apple iPads; the control arm will be the local standard low-vision aid care. Primary outcomes will be acceptance/usage, accessibility of the device and trial feasibility measures (time to recruit children, lost to follow-up). Exploratory outcomes will be validated measures of vision-related quality of life for children/young people as well as validated measures of reading and educational outcomes. In addition, we will carry out semistructured interviews with the participants and their teachers.

ETHICS AND DISSEMINATION

NRES reference 15/NS/0068; dissemination is planned via healthcare and education sector conferences and publications, as well as via patient support organisations.

TRIAL REGISTRATION NUMBER

NCT02798848; IRAS ID 179658, UCL reference 15/0570.

A Review of Cochrane Systematic Reviews of Interventions Relevant to Orthoptic Practice

AIM

To present an overview of the range of systematic reviews on intervention trials pertinent to orthoptic practice, produced by the Cochrane Eyes and Vision group (CEV).

METHODS

We searched the 2016 Cochrane Library database (31.03.2016) to identify completed reviews and protocols of direct relevance to orthoptic practice. These reviews are currently completed and published, available on www.thecochranelibrary.com (free to UK health employees) or via the CEV website (http://eyes.cochrane.org/) .

RESULTS

We found 27 completed CEV reviews across the topics of strabismus, amblyopia, refractive errors, and low vision. Seven completed CEV protocols addressed topics of strabismus, amblyopia, refractive errors, low vision, and screening. We found 3 completed Cochrane Stroke reviews addressing visual field loss, eye movement impairment, and age-related vision loss.

CONCLUSIONS

The systematic review process presents an important opportunity for any clinician to contribute to the establishment of reliable, evidence-based orthoptic practice. Each review has an abstract and plain language summary that many non-clinicians find useful, followed by a full copy of the review (background, objectives, methods, results, discussion) with a conclusion section that is divided into implications for practice and implications for research. The current reviews provide patients/parents/carers with information about various different conditions and treatment options, but also provide clinicians with a summary of the available evidence on interventions, to use as a guide for both clinical practice and future research planning. The reviews identified in this overview highlight the evidence available for effective interventions for strabismus, amblyopia, refractive errors, and low vision or stroke rehabilitation as well as the gaps in the evidence base. Thus, a demand exists for future robust, randomized, controlled trials of such interventions of importance in orthoptic practice.

Optical reading aids for children and young people with low vision

BACKGROUND

Low vision in childhood is a significant barrier to learning and development, particularly for reading and education. Optical low vision aids may be used to maximise the child's functional vision. The World Health Organization (WHO) has previously highlighted the importance of the use of low vision aids in managing children with visual impairment across the world.

OBJECTIVES

To assess the effect of optical low vision aids on reading in children and young people with low vision.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 12), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to January 2015), EMBASE (January 1980 to January 2015), the Health Technology Assessment Programme (HTA) (www.hta.ac.uk/), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 8 January 2015.We also used manual searching to check the references listed in retrieved articles. Manufacturers of low vision aids were contacted to request any information about studies or research regarding their products.

SELECTION CRITERIA

We planned to include randomised controlled trials (RCTs) and quasi-RCTs where any optical low vision aid was compared to standard refractive correction in children and young people aged between 5 and 16 years of age with low vision as defined by the WHO. We planned to include within-person design studies where the order of presentation of devices was randomised.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the search results for eligibility .

MAIN RESULTS

No studies met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

There is a lack of good quality evidence regarding the use of optical low vision aids in children and young people. As such, no implications for practice can be drawn. We believe future research should include functional outcome measures such as reading speed, accuracy and comprehension, as well as the effect of low vision aids on quality of life, in order to truly assess and compare the effect of these devices on a child's life and development.