Characterizing functional complaints in patients seeking outpatient low-vision services in the United States

Near prescribing trends in two low vision rehabilitation clinics over a ten-year period

CLINICAL RELEVANCE

Optical magnification (OM), electronic magnification (EM), and assistive technology (AT) can be prescribed in low vision rehabilitation (LVR) clinics for near vision goals of patients. This study shows the prescription of OM has not decreased with increased availability of EM and AT.

BACKGROUND

Near visual goals are a primary concern for patients with visual impairment. LVR providers can prescribe OM, EM and/or AT to help. With the rapid evolution and availability of EM and AT, we aim to evaluate if there have been changes in the prescription patterns of clinicians with respect to OM over time. We hypothesise that the increased availability of technology may result in declining prescriptions of OM and increasing prescription of EM and AT over time.

METHODS

This retrospective study investigated near prescribing between 2008-2017 for 530 new patients to the LVR clinics. Examinations were performed by optometrists specialising in low vision. Near devices prescribed included OM and EM and AT.

RESULTS

Most patients attending the LVR clinics were female, over 60 years old and had age related macular degeneration. Near visual goals were a primary concern of 97.2% of the patients. OM was most prescribed in the 0-19 and >60-year-old age groups. Within the 20-39-year-old age group there was the greatest number of both EM and AT prescriptions. OM was most prescribed in patients with visual acuity better than 6/60. EM and AT showed a trend of increasing prescription as visual acuity decreased. EM prescription peaked in <6/60 to 6/240 category while AT trended upwards from <6/21 to no light perception and peaked in patients with no light perception. Referral rates for additional rehabilitation services were 75.7%.

CONCLUSIONS

This study shows that the prescription of OM is not declining even as the prescription and the breadth of electronic magnification and assistive technology available is expanding. OM continues to be a viable option for patients, especially in the youngest and oldest cohorts.

Vision Problems As a Contributor to Lower Engagement in Care Among Aging Men Living with HIV

PURPOSE

To investigate vision impairment as a barrier to engagement in medical care among aging persons living with HIV (PLWH) who experience multimorbidity and complex care needs.

SETTING

Multicenter AIDS Cohort Study (MACS), a prospective observational cohort of aging PLWH men.

METHODS

We examined relationships of self-reported vision difficulty with indicators of care engagement: 1) adherence to HIV antiretroviral therapy (ART; defined as taking ≥95% of medications); 2) self-reported avoidance of medical care; 3) self-reported tendency to ask a doctor questions about care (>2 questions at a medical visit), as well as with quality of life. A modified version of the National Eye Institute Vision Function Questionnaire was administered at three semi-annual visits (from October 2017 to March 2019) to assess difficulty performing vision-dependent tasks.

RESULTS

We included 1063 PLWH (median age 57 years, 31% Black). Data on care engagement outcomes were analyzed using repeated measures logistic regression with generalized estimating equations adjusted for race, and at visit values for age, education level, depressive symptoms, alcohol use, and smoking status. Compared to no vision difficulty, those reporting moderate to extreme vision difficulty on at least one task had 2.2 times higher odds (95% CI: 1.4, 3.4) of having less than optimal ART adherence, 1.9 times higher odds (95% CI: 1.1, 3.4) of avoiding necessary medical care and median quality of life scores 8 points lower.

CONCLUSION

These findings suggest vision impairment decreases medical care engagement including HIV care and quality of life among aging PLWH.

COUNTY-LEVEL ANALYSIS OF EYE EXAM ACCESS AND UTILIZATION IN THE UNITED STATES

PURPOSE

The eye exam is a critical tool for the prevention, screening, and diagnosis of ocular and systemic conditions. In this study, we characterize county-level variation in eye exam access and utilization for Medicare patients in the United States.

METHODS

This nationwide study uses the Medicare Physician & Other Practitioners - by Provider and Service dataset. We included all ophthalmologists and optometrists who performed eye exams on Medicare beneficiaries within a United States county in 2019. For every county where exams were performed, we calculated the number of practicing vision testing providers, percentage of providers classified as ophthalmologists, and the number of exams per 100 Medicare beneficiaries. Multiple linear regression was used to characterize associations between these variables and county characteristics, including measures of poverty, education, and income.

RESULTS

In 2019, 28937,540 eye exams were performed by 46,000 providers in 2,291 U.S. counties. In the median county, 34.9 eye exams were provided per 100 Medicare beneficiaries. The average county had 20.1 exam providers, 16.5% of whom were ophthalmologists. There were a median 6.6 eye exam providers for every 10,000 Medicare beneficiaries in the average county. The average provider performed 517.8 exams. Regression showed counties with lower median household incomes, higher poverty rates, or fewer high-school graduates had fewer eye exam providers per 10,000 Medicare beneficiaries and fewer eye exams performed per 100 Medicare beneficiaries.

CONCLUSIONS

We find significant county-level variation in eye exam utilization and provider availability. This reflects broader, well-recognized trends in socioeconomic health disparities in the U.S.

Saffron therapy for the ongoing treatment of age-related macular degeneration

OBJECTIVE

To assess the long-term efficacy and safety of oral saffron, a natural antioxidant, in treating mild/moderate age-related macular degeneration (AMD).

METHODS AND ANALYSIS

Open-label, extension trial of 93 adults (>50 years) with mild/moderate AMD and vision >20/70 Snellen equivalent in at least 1 eye. Exclusion criteria included confounding visual lesions or significant gastrointestinal disease impairing absorption.Participants were given oral saffron supplementation (20 mg/day) for 12 months. Those already consuming Age-Related Eye Diseases Study (AREDS) supplements or equivalent maintained these.Primary outcomes included changes in multifocal electroretinogram (mfERG) response density and latency, and changes in best-corrected visual acuity (BCVA). Secondary outcomes included safety outcomes, changes in mfERG and BCVA among participants on AREDS supplements and changes in microperimetry.

RESULTS

At 12 months, mean mfERG response density was significantly higher in rings 1, 2 and overall (p<0.001 for all) but not in rings 3-6, and there was no difference in response between those taking AREDS supplements and those not (p>0.05). Mean mfERG latency was not significantly different in any of rings 1-6 or overall (p>0.05 for all), again with no difference between those taking AREDS supplements or not (p>0.05). Mean BCVA was 1.6 letters worse (p<0.05) with no difference between those on AREDS supplements or not, and this may have been related to cataract progression. No saffron-related serious adverse events were detected.

CONCLUSION

Saffron supplementation modestly improved mfERG responses in participants with AMD, including those using AREDS supplements. Given the chronic nature of AMD, longer-term supplementation may produce greater benefits.

Latent class of multidimensional dependency in community-dwelling older adults: evidence from the longitudinal ageing study in India

BACKGROUND

Existing studies have used ADL and IADL separately as measures of dependency. However, dependency is a heterogeneous and complex issue, and the dependency of each older adult is a synergistic combination of several functional activities. In this study, we assess the pattern of multidimensional dependency of older adults based on ADL, IADL, visual impairment, difficulty in climbing a flight of stairs, pushing or pulling objects, depressive symptoms, cognitive impairment, marital status, and economic distress. It is important to classify the dependency status of older adults because this will be key to evaluating the needs for care, and plan services that effectively cater for the needs of the older adults. The classification into different latent classes means that older adults within each class have the same needs of dependency but different needs between the latent classes. Our objective is to identify patterns of multidimensional dependency in older adults.

METHODS

Data from the Longitudinal Ageing Study in India (LASI) Wave-1, was used, the analytical sample consisted of 32,827 individuals of age 45 years and above. LCA was used to identify the multidimensional dependency class. LCA was conducted in R statistical package, using the poLCA package. The optimal number of classes was selected based on the comparison of model fit statistics. Independent variables were incorporated to explore the association between these variables and the latent class.

RESULTS

Based on nine indicator variables, three latent classes were identified: "Active Older adults", "Moderately independent" and "Psychological and physically impaired". The "Active older adults" profile is comprised of older adults who have a very low probability of needing help for any ADL, IADL and other activities. The "Moderately independent" class were characterized as those older adults who were visually impaired but less likely to need help for IADL activities. The "Psychological and physically impaired", the smallest of all classes, comprised of older adults with poor dependency status.

CONCLUSIONS

In this study, we found that the dependency status of older adults which is based on several domains of functional activity has been classified into three distinct classes. These three classes have distinct physical, psychological, economic, and socio-demographic characteristics in terms of activities in which help is required.

Daily Functionality of People with Low Vision: The Impact of Visual Acuity, Depression, and Life Orientation-A Cross-Sectional Study

Background

Low vision (LV) has a significant negative impact on the activities of daily life as well as on the psychological health of patients.

Objectives

The objective of this study is to investigate psychological, clinical, and demographic factors that may impact the daily functionality of patients with LV.

Methods

A convenience sample of 53 patients, meeting the WHO criteria for LV, was recruited. Questionnaires on daily functionality, depression, and life orientation (in terms of optimism/pessimism) were administered along with a semistructured personal interview. Key Findings. The main results revealed a significant negative correlation between daily functionality and depression (r = -0.423, p < 0.001). Conversely, there is a positive correlation between daily functionality and visual acuity (r = 0.415, p < 0.001), while years since diagnosis were negatively correlated with depression (r = -0.345, p < 0.001). Depression seems to be a moderate predictor of a person's daily functionality (β = -0.389, p < 0.002), followed by visual acuity (β = -0.344, p = 0.006), explaining the 31.1% of the total variance.

Conclusions

The study supports a correlation between daily functionality and both depression and visual acuity. Optimism as a personality characteristic did not factor into the prediction model for daily functionality, but it showed a strong correlation with lower levels of depressive symptoms. This highlights the potential for developing coping strategies for chronic disease management. Recommendations. The study could serve as a useful guide and may urge clinicians to pay attention to the psychological evaluation of these patients, supporting their unique emotional needs. Mental health professionals can use patients' positive resources to provide appropriate counseling and embrace the coping skills that encourage their engagement in activities of daily life.

Use and underuse of mobility aids in individuals with visual impairment: a cross-sectional study of a Norwegian sample

PURPOSE

To examine the use and underuse of mobility aids in individuals with visual impairment.

METHODS

A telephone survey including a probability sample of 736 adults who were members of the Norwegian Association of the Blind and Sighted (response rate: 61%). The interviews took place between January and May 2017, collecting information about access, use, underuse and training in five types of mobility aids (white cane, guide dog, GPS, door-to-door transport and sighted guide). For each mobility aid, we obtained data for underuse defined as non-use despite expecting benefits of use in terms of increased mobility or safety. Participants also answered questions about loneliness (Three-Item Loneliness Scale) and life satisfaction (Cantril's Ladder of Life Satisfaction).

RESULTS

Of the participants, 69% reported using at least one type of mobility aid. Use of specific aids ranged from 12% for the GPS to 52% for door-to-door transport. Estimates of underuse ranged between 14% for door-to-door transport and 28% for GPS. Underuse was not related to lack of resources, as many non-users expecting benefits had access to mobility aids and had undergone training in its use. For example, 81% of non-users of the white cane had access to a cane. In post hoc analyses, non-users who expected benefits from use had lower life satisfaction compared with users.

CONCLUSIONS

Many individuals with visual impairment do not use mobility aids. Strategies that help visually impaired individuals overcome barriers to the use of mobility aids may improve their sense of safety, mobility and quality of life.Implications of rehabilitationThe best mobility aids are those being used. Rehabilitation professionals involved in the provision of mobility aids should be sensitive to the user's lived experiences, and be alert of the cultural meanings of mobility aids and on disability in general.Rehabilitation professionals, social service workers and others need more knowledge of the psychosocial and cultural aspects related to why people do not use their mobility aids.A successful integration of mobility aids in people's daily life cannot be achieved by sufficient accessibility alone. Structured routines for follow-up of those who receive aids should be implemented, so that the aids are actually used.Due to the high rates of underuse and its possible relation to quality of life, promoting regular use of mobility aids should be prioritized.

Social Understanding beyond the Familiar: Disparity in Visual Abilities Does Not Impede Empathy and Theory of Mind

Feeling with our conspecifics and understanding their sentiments and intentions is a crucial part of our lives. What is the basis for these forms of social understanding? If individuals ground their understanding of others' thoughts and feelings in their own perceptual and factual experiences, it could present a challenge to empathize and mentalize with those whose reality of life is significantly different. This preregistered study compared two groups of participants who differed in a central perceptual feature, their visual abilities (visually impaired vs. unimpaired; total N = 56), concerning their social understanding of others who were themselves either visually impaired or unimpaired. Employing an adjusted version of the EmpaToM task, participants heard short, autobiographic narrations by visually impaired or unimpaired individuals, and we assessed their empathic responding and mentalizing performance. Our findings did not reveal heightened empathy and mentalizing proclivities when the narrator's visual abilities aligned with those of the participant. However, in some circumstances, cognitive understanding of others' narrations benefitted from familiarity with the situation. Overall, our findings suggest that social understanding does not mainly rely on perceptual familiarity with concrete situations but is likely grounded in sharing emotions and experiences on a more fundamental level.

Typologies of dependency, household characteristics, and disparity in formal and informal care use: analysis of community-dwelling long-term care insurance claimants in an urban municipality of China

BACKGROUND

A comprehensive understanding of subgroups of community-dwelling older adults and their long-term care (LTC) utilization can help to promote equality in the long-term services and support system. Dependency and household characteristics were found to affect the LTC utilization of homebound older adults. However, few studies considered the typologies of dependency of older populations according to co-occurring limitations, and little is known about differences in LTC use among elderly of typologies of dependency under distinct household conditions.

METHODS

We aimed to identify typologies of dependency of older adults living at home and explore the disparities in formal care and informal care use among typologies of dependency by income and living situation. In this cross-sectional study, we used the public long-term care insurance (LTCI) database of Yiwu, Zhejiang Province, China, and included 1675 individuals aged ≥ 60 years living at home. Cluster analysis was conducted to determine typologies of dependency among older adults. A two-step multilevel analysis was used to examine disparities in formal and informal care use related to household income and living status among typologies of dependency.

RESULTS

Seven dependency clusters were identified. Pro-wealthy inequalities in both formal and informal care use were found in the least dependent cluster and the limited-locomotion cluster. Pro-poor inequalities in formal care use were found in the fully dependent cluster without impaired vision and the cluster with intact continence and vision. Living with family members was positively associated with receiving formal care for the fully dependent cluster. Older adults in most clusters were more likely to use informal care when living with family members, except for the least dependent cluster and the limited-locomotion cluster.

CONCLUSIONS

Our findings suggest that household inequalities in LTC use varied among typologies of dependency of older adults, which may provide insights for researchers and policymakers to develop tailored LTC and targeted LTCI programs for older adults living at home and their family caregivers, considering both typologies of dependency and household characteristics.

Diagnosis and Management of Patients With Geographic Atrophy Secondary to Age-Related Macular Degeneration: A Delphi Consensus Exercise

Geographic atrophy (GA) is a progressive and irreversible retinal disease with no comprehensive recommendations for diagnosis or monitoring. We used a Delphi approach to determine consensus in key areas around diagnosis and management of GA. A steering committee of eight retina specialists developed two sequential online surveys administered to eye care professionals (ECPs). Consensus was defined as agreement by ≥ 75% of respondents. Up to 177 ECPs from eight countries completed one or both surveys. Consensus was achieved in several topics related to diagnostic imaging, including the use of optical coherence tomography, and the urgent need for treatments and beneficial interventions to reduce the associated burden. Currently, low-vision aids and smoking cessation are considered the most beneficial interventions. We demonstrate consensus for diagnosis and management of patients with GA including best practices in patient identification and monitoring, and unmet needs. [Ophthalmic Surg Lasers Imaging Retina 2023;54:589-598.].

Screen Magnification for Readers with Low Vision: A Study on Usability and Performance

We present a study with 20 participants with low vision who operated two types of screen magnification (lens and full) on a laptop computer to read two types of document (text and web page). Our purposes were to comparatively assess the two magnification modalities, and to obtain some insight into how people with low vision use the mouse to control the center of magnification. These observations may inform the design of systems for the automatic control of the center of magnification. Our results show that there were no significant differences in reading performances or in subjective preferences between the two magnification modes. However, when using the lens mode, our participants adopted more consistent and uniform mouse motion patterns, while longer and more frequent pauses and shorter overall path lengths were measured using the full mode. Analysis of the distribution of gaze points (as measured by a gaze tracker) using the full mode shows that, when reading a text document, most participants preferred to move the area of interest to a specific region of the screen.

Multi-center validation of Catquest-9SF visual function questionnaire in Ontario, Canada

PURPOSE

To investigate the psychometric performance and responsiveness of Catquest-9SF, a patient-reported questionnaire developed to evaluate visual function as related to daily tasks, in patients referred for cataract surgery in Ontario, Canada.

METHODS

This is a pooled analysis on prospective data collected for previous projects. Subjects were recruited from three tertiary care centers in Peel region, Hamilton, and Toronto, Ontario, Canada. Catquest-9SF was administered pre-operative and post-operatively to patients with cataract. Psychometric properties, including category threshold order, infit/outfit, precision, unidimensionality, targeting, and differential item functioning were tested using Rasch analysis with Winsteps software (v.4.4.4) for Catquest-9SF. Responsiveness of questionnaire scores to cataract surgery was assessed.

RESULTS

934 patients (mean age = 71.6, 492[52.7%] female) completed the pre- and post-operative Catquest-9SF questionnaire. Catquest-9SF had ordered response thresholds, adequate precision (person separation index = 2.01, person reliability = 0.80), and confirmed unidimensionality. The infit range was 0.75-1.29 and the outfit range was 0.74-1.51, with one item ('satisfaction with vision') misfitting (outfit value = 1.51). There was mistargeting of -1.07 in pre-operative scores and mistargeting of -2.43 in both pre- and post-operative scores, meaning that tasks were relatively easy for respondent ability. There was no adverse differential item functioning. There was a mean 1.47 logit improvement in Catquest-9SF scores after cataract surgery (p<0.001).

CONCLUSION

Catquest-9SF is a psychometrically robust questionnaire for assessment of visual function in patients with cataract in Ontario, Canada. It is also responsive to clinical improvement after cataract surgery.

Approaching rehabilitation in patients with advanced glaucoma

Vision loss from advanced glaucoma is currently irreversible and impairs functional visual ability to effectively perform everyday tasks in a number of distinct functional domains. Vision rehabilitation strategies have been demonstrated to be effective in low vision populations and should be utilized in persons with advanced glaucoma to reduce disability and improve quality of life. Initial challenges to rehabilitation include an incomplete understanding of vision rehabilitation by the physician and patient, motivation to integrate rehabilitation into the plan of care, and availability of suitable providers to deliver this care. Physicians, working with well-trained vision rehabilitation providers can maximize function in important visual domains customized to the patient based on their needs, specific complaints, severity/pattern of visual damage, and comorbidities. Potential rehabilitative strategies to be considered for reading impairment include spectacle correction, visual assistive equipment, and sensory substitution, while potential strategies to facilitate driving in those deemed safe to do so include refractive correction, lens design, building confidence, restriction of driving to safer conditions, and avoiding situations where cognitive load is high. Mobility is frequently disrupted in advanced glaucoma, and can be addressed through careful distance refraction, behavior modification, home modification, mobility aids, walking assistance (i.e., sighted guide techniques), and smartphone/wearable technologies. Visual motor complaints are best addressed through optimization of lighting/contrast, sensory substitution, IADL training, and education. Special rehabilitative concerns may arise in children, where plans must be coordinated with schools, and working adults, where patients should be aware of their rights to accommodations to facilitate specific job tasks.

DETECT: DEveloping and testing a model to identify preventive vision loss among older paTients in gEneral praCTice - protocol for a complex intervention in Denmark

INTRODUCTION

The number of people living with visual impairment is increasing. Visual impairment causes loss in quality of life and reduce self-care abilities. The burden of disease is heavy for people experiencing visual impairment and their relatives. The severity and progression of age-related eye diseases are dependent on the time of detection and treatment options, making timely access to healthcare critical in reducing visual impairment. General practice plays a key role in public health by managing preventive healthcare, diagnostics and treatment of chronic conditions. General practitioners (GPs) coordinate services from other healthcare professionals. More involvement of the primary sector could potentially be valuable in detecting visual impairment.

METHODS

We apply the Medical Research Council framework for complex interventions to develop a primary care intervention with the GP as a key actor, aimed at identifying and coordinating care for patients with low vision. The development process will engage patients, relatives and relevant health professional stakeholders. We will pilot test the feasibility of the intervention in a real-world general practice setting. The intervention model will be developed through a participatory approach using qualitative and creative methods such as graphical facilitation. We aim to explore the potentials and limitations of general practice in relation to detection of preventable vision loss.

ETHICS AND DISSEMINATION

Ethics approval is obtained from local authority and the study meets the requirements from the Declaration of Helsinki. Dissemination is undertaken through research papers and to the broader public through podcasts and patient organisations.

Development and Validation of the Life for Low Vision Questionnaire (LIFE4LVQ) Using Rasch Analysis: A Questionnaire Evaluating Ability and Independence

Low vision (LV) has a substantial impact on an individual’s daily functionality and patient-reported outcome measures (PROMs) are increasingly incorporated into the evaluation of this problem. The objective of this study was to describe the design of the new “Life for Low Vision Questionnaire (LIFE4LVQ)”, as a measure of daily functionality in LV and to explore its psychometric properties. A total of 294 participants completed the LIFE4LVQ and the data were subjected to Rasch analysis to determine the psychometric properties of the questionnaire, including response category ordering, item fit statistics, principal component analysis, precision, differential item functioning, and targeting. Test–retest reliability was evaluated with an interval of three weeks and intraclass correlation coefficients (ICC) were used. The correlation between the questionnaire score and Best Corrected Visual Acuity (BCVA) was examined using Spearman’s correlation coefficient. Rasch analysis revealed that for most items the infit and outfit mean square fit values were close to 1, both for the whole scale and its subscales (ability and independence). The separation index for person measures was 5.18 with a reliability of 0.96, indicating good discriminant ability and adequate model fit. Five response categories were found for all items. The ICC was 0.96 (p < 0.001; 95% CI, 0.93–0.98), suggesting excellent repeatability of the measure. Poorer BCVA was significantly associated with worse scores (rho = 0.559, p < 0.001), indicating excellent convergent validity. The functional, 40-item LIFE4LVQ proved to be a reliable and valid tool that effectively measures the impact of LV on ability and independence.

New insights into visually impaired patients' preferred reading illumination and home-based reading speed with new task-lighting

INTRODUCTION

When optimal lighting is applied to hard-copy materials for visually impaired individuals, laboratory-based reading performance can improve significantly. However, it is not known whether their lighting preferences are related to ocular factors or if laboratory-based reading improvements will translate to home-based environments.

METHODS

Preferences for brightness (lux) and colour temperature (degrees Kelvin; K) with the LuxIQ/2 for 'most comfort' while reading at near were evaluated in-clinic for 71 adults with ocular disease affecting the outer (n = 37; 52%), inner or all retinal layers (n = 34; 48%). Twenty participants received either an OttLite Cobra lamp or a generic gooseneck lamp with a bulb resembling LuxIQ/2 parameters for their preferred reading light, and then completed home-based telephone evaluations using the sustained silent reading test.

RESULTS

Participants with outer retinal disease preferred significantly brighter light intensity by an average of 838 lux versus those with inner retinal disease (95% CI: 331, 1344; p = 0.002). No participants opted for a coloured tint for reading based on the LuxIQ/2 measurements since they preferred white light only; most preferred the OttLite Cobra lamp. At home, reading speed improved significantly by an average of 37 words per minute with the new lamp (95% CI: 12, 62; p = 0.005).

CONCLUSIONS

Patients with outer retinal disease prefered brighter light intensity for reading. Clinic-based lighting preferences yielded improvements in reading speed when using a new task light at home.

The effect of serifs and stroke contrast on low vision reading

PURPOSE

Patients with low vision are generally recommended to use the same fonts as individuals with normal vision. However, we are yet to fully understand whether stroke width and serifs (small ornamentations at stroke endings) can increase readability. This study's purpose was to characterize the interaction between two factors (end-of-stroke and stroke width) in a well-defined and homogenous group of patients with low vision.

METHODS

Font legibility was assessed by measuring word identification performance of 19 patients with low vision (autosomal dominant optic atrophy [ADOA] with a best-corrected average visual acuity 20/110) and a two-interval, forced-choice task was implemented. Word stimuli were presented with four different fonts designed to isolate the stylistic features of serif and stroke width.

RESULTS

Font-size threshold and sensitivity data revealed that using a single measure (i.e., font-size threshold) is insufficient for detecting significant effects but triangulation is possible when combined with signal detection theory. Specifically, low stroke contrast (smaller variation in stroke width) yielded significantly lower thresholds and higher sensitivity when a font contained serifs (331 points; d' = 1.47) relative to no serifs (345 points; d' = 1.15), E(μ_{sans, low} - μ_{serif, low}) = -14 points, 95 % Cr. I. = [-24, -5], P(δ > 0) = 0.99 and E(μ_{serif, low} - μ_{sans, low}) = 0.32, 95 % Cr. I. = [0.16, 0.49], P(δ > 0) = 0.99.

CONCLUSION

In people with low visual acuity caused by ADOA, the combination of serifs and a uniform stroke width resulted in better text legibility than other combinations of uniform/variable stroke widths and presence/absence of serifs.

The Basic VRS-Effect Study: Clinical Trial Outcomes and Cost-Effectiveness of Low Vision Rehabilitation in Portugal

INTRODUCTION

The aim of this study was twofold: (1) to investigate the clinical impact of vision rehabilitation in patients with vision impairment and (2) to investigate the cost-effectiveness of a basic vision rehabilitation service in Portugal.

METHODS

The trial recruited patients diagnosed with age-related macular degeneration or diabetic retinopathy (DR) and visual acuity in the range 0.4-1.0logMAR in the better-seeing eye. Participants were randomised to one of the study arms consisting of immediate intervention and delayed intervention. The intervention included: new refractive correction, optical reading aids, in-office training and advice about modifications at home. Visual ability, health-related quality of life and costs were measured. Economic analysis was performed to evaluate whether the intervention was cost-effective. The trial compared the outcomes 12 weeks after the start in both arms.

RESULTS

Of the 46 participants, 34 (74%) were diagnosed with DR, 25 (54%) were female, and mean age was 70.08 years (SD = 8.74). In the immediate intervention arm visual ability increased a mean of 0.523 logits (SE = 0.11) (p < 0.001). Changes in the delayed intervention arm were not statistically significant (p = 0.95). Acuity in the better-seeing eye, near acuity and critical print size also improved during the study. The mean cost of the intervention was €118.79 (SD = 24.37). The incremental cost-effectiveness ratio using the EQ-5D-5L was 30,421€/QALY and 1186€/QALY when using near acuity.

CONCLUSION

The current study gives evidence of positive clinical impact of a basic vision rehabilitation intervention and shows that a basic vision rehabilitation service is cost-effective. These findings are important to clinical and rehabilitation practices and for planning vision rehabilitation services.

TRIAL REGISTRATION

Retrospectively registered, 21/01/2019. ISRCTN10894889, https://www.isrctn.com/ISRCTN10894889.

Longitudinal Trends in Case Histories and Rehabilitative Device Assessments at Low Vision Examinations

SIGNIFICANCE

Understanding longitudinal changes in why individuals frequent low-vision clinics is crucial for ensuring that patient care keeps current with changing technology and changing lifestyles. Among other findings, our results suggest that reading remains a prevailing patient complaint, with shifting priorities toward technology-related topics.

PURPOSE

This study aimed to understand changes in patient priorities and patient care in low vision over the past decade.

METHODS

We conducted a retrospective study of examination records (2009 to 2019, 3470 examinations) from two U.S. low-vision clinics. Automated word searches summarized two properties of the records: topics discussed during the case history and types of rehabilitative devices assessed. Logistic regression was used to model the effects of examination year, patient age, patient sex, and level of visual impairment.

RESULTS

Collapsing across all years, the most common topic discussed was reading (78%), followed by light-related topics (71%) and technology (59%). Whereas the odds of discussing reading trended downward over the decade (odds ratio, 0.57; P = .03), technology, social interaction, mobility, and driving trended upward (odds ratios, 4.53, 3.31, 2.71, and 1.95; all P 's < 0.001). The most frequently assessed devices were tinted lenses (95%). Over time, video magnifier and spectacle assessments trended downward (odds ratios, 0.64 and 0.72; P = .004, 0.04), whereas assessments of other optical aids increased. The data indicate several consistent differences among patient demographics.

CONCLUSIONS

Reading is likely to remain a prevailing patient complaint, but an increase in technology-related topics suggests shifting priorities, particularly in younger demographics. "Low-tech" optical aids have remained prominent in low-vision care even as "high-tech" assistive devices in the marketplace continue to advance.

The Parietal Lobe in Alzheimer’s Disease and Blindness

The progressive aging of the population will notably increase the burden of those diseases which leads to a disabling situation, such as Alzheimer’s disease (AD) and ophthalmological diseases that cause a visual impairment (VI). Eye diseases that cause a VI raise neuroplastic processes in the parietal lobe. Meanwhile, the aforementioned lobe suffers a severe decline throughout AD. From this perspective, diving deeper into the particularities of the parietal lobe is of paramount importance. In this article, we discuss the functions of the parietal lobe, review the parietal anatomical and pathophysiological peculiarities in AD, and also describe some of the changes in the parietal region that occur after VI. Although the alterations in the hippocampus and the temporal lobe have been well documented in AD, the alterations of the parietal lobe have been less thoroughly explored. Recent neuroimaging studies have revealed that some metabolic and perfusion impairments along with a reduction of the white and grey matter could take place in the parietal lobe during AD. Conversely, it has been speculated that blinding ocular diseases induce a remodeling of the parietal region which is observable through the improvement of the integration of multimodal stimuli and in the increase of the volume of this cortical region. Based on current findings concerning the parietal lobe in both pathologies, we hypothesize that the increased activity of the parietal lobe in people with VI may diminish the neurodegeneration of this brain region in those who are visually impaired by oculardiseases.

Altered eye movements during reading under degraded viewing conditions: Background luminance, text blur, and text contrast

Degraded viewing conditions caused by either natural environments or visual disorders lead to slow reading. Here, we systematically investigated how eye movement patterns during reading are affected by degraded viewing conditions in terms of spatial resolution, contrast, and background luminance. Using a high-speed eye tracker, binocular eye movements were obtained from 14 young normally sighted adults. Images of text passages were manipulated with varying degrees of background luminance (1.3-265 cd/m2), text blur (severe blur to no blur), or text contrast (2.6%-100%). We analyzed changes in key eye movement features, such as saccades, microsaccades, regressive saccades, fixations, and return-sweeps across different viewing conditions. No significant changes were observed for the range of tested background luminance values. However, with increasing text blur and decreasing text contrast, we observed a significant decrease in saccade amplitude and velocity, as well as a significant increase in fixation duration, number of fixations, proportion of regressive saccades, microsaccade rate, and duration of return-sweeps. Among all, saccade amplitude, fixation duration, and proportion of regressive saccades turned out to be the most significant contributors to reading speed, together accounting for 90% of variance in reading speed. Our results together showed that, when presented with degraded viewing conditions, the patterns of eye movements during reading were altered accordingly. These findings may suggest that the seemingly deviated eye movements observed in individuals with visual impairments may be in part resulting from active and optimal information acquisition strategies operated when visual sensory input becomes substantially deprived.

Living Without a Diagnosis: A Patient's Perspective on Diabetic Macular Ischemia

Diabetic macular ischemia (DMI) is a common complication of diabetic retinopathy (DR) that can result in progressive and irreversible vision loss. DMI is associated with damage in the vessels that supply blood to the retina and the enlargement of the foveal avascular zone. Currently, there are no approved treatments specifically for DMI. Furthermore, there is limited published information about the prognosis, prevalence or outcomes of DMI, and there is no consensus regarding diagnostic criteria. It is vital to ensure that there is sufficient, accessible and accurate information available to support patients, caregivers and physicians. To lay the foundation for more research into DMI and its impact on patients, we (a patient with DMI and an expert ophthalmologist) have worked together to interweave our personal perspectives and clinical experiences with a review of currently available literature on DMI. The development of a set of confirmed diagnostic criteria for DMI would assist both patients and physicians, allowing patients to access validated information about their condition and supporting the development of clinical trials for treatments of DMI. Training for physicians must continue to emphasise the importance of treating a patient holistically, rather than only treating their symptoms. Most importantly, developing trust and a healthy rapport between a patient and their physician is important in managing health anxiety and ensuring adherence to beneficial treatments or lifestyle adjustments; physicians must cultivate an open and flexible management approach with their patients. Finally, holistic educational programmes for patients, physicians and the general public around DMI and how it can affect daily functioning would facilitate general understanding and disease awareness.

Diabetic macular ischemia (DMI) is a common problem for patients with diabetic retinopathy that can lead to sight loss. There is very little information available about DMI, particularly from a patient’s point of view. To address the lack of information about DMI, we (a person with DMI and her eye doctor) have worked together to examine what it is like to live with DMI. It is important to provide clear and accessible information about diseases to patients and carers. The lack of information about DMI may be upsetting for some people, and should be addressed with more research. Developing of a set of confirmed signs and symptoms for the diagnosis of DMI would allow people to be more confident in the information that they receive about their disease, and support the development of treatments for DMI. The support of others is central to the wellbeing of people with vision loss. Although people with vision loss may also lose independence, care from loved ones can help to improve quality of life. Most importantly, developing trust between a patient and their doctor is central to managing people’s fears about their eyesight, and making sure that they follow helpful advice. Doctors must use an open and flexible approach with their patients, providing information in an honest and understandable way.

Impact of the COVID-19 Pandemic on Individuals With Low Vision: Life Goes On

This qualitative case study explored the impact of lockdown and social distancing measures used during COVID-19 on the lives of individuals with low vision. A purposive sample of 6 participants with low vision was recruited. Data were collected using in-depth semistructured interviews consisting of 10 open-ended questions. A thematic analysis was conducted to understand the unified subjective experiences of the participants. The analysis revealed 4 themes: (1) Changes, a lot of them; (2) Emotional roller coaster; (3) Life goes on; and (4) Technology as the catalyst. Participants demonstrated ongoing adaptation to meet the changing demands imposed by the pandemic.

Binocularly Asymmetric Crowding in Glaucoma and a Lack of Binocular Summation in Crowding

Purpose

Glaucoma is associated with progressive loss of retinal ganglion cells. Here we investigated the impact of glaucomatous damage on monocular and binocular crowding in parafoveal vision. We also examined the binocular summation of crowding to see if crowding is alleviated under binocular viewing.

Methods

The study design included 40 individuals with glaucoma and 24 age-similar normal cohorts. For each subject, the magnitude of crowding was determined by the extent of crowding zone. Crowding zone measurements were made binocularly in parafoveal vision (i.e., at 2° and 4° retinal eccentricities) visual field. For a subgroup of glaucoma subjects (n = 17), crowding zone was also measured monocularly for each eye.

Results

Our results showed that, compared with normal cohorts, individuals with glaucoma exhibited significantly larger crowding—enlargement of crowding zone (an increase by 21%; P < 0.01). Moreover, we also observed a lack of binocular summation (i.e., a binocular ratio of 1): binocular crowding was determined by the better eye. Hence, our results did not provide evidence supporting binocular summation of crowding in glaucomatous vision.

Conclusions

Our findings show that crowding is exacerbated in parafoveal vision in glaucoma and binocularly asymmetric glaucoma seems to induce binocularly asymmetric crowding. Furthermore, the lack of binocular summation for crowding observed in glaucomatous vision combined with the lack of binocular summation reported in a previous study on normal healthy vision support the view that crowding may start in the early stages of visual processing, at least before the process of binocular integration takes place.

Visual Function, Physical Function, and Activities of Daily Living in Two Aging Communities

Purpose

We report the distribution of visual acuity impairment (VAI), contrast sensitivity impairment (CSI) and their associations with physical health in an aging population.

Methods

In this cross-sectional analysis, VAI was categorized as mild (20/40-20/60) and moderate or greater (<20/60) in the better eye for distance and near vision. CSI was categorized as moderate (1.04-1.50 logCS) and severe or profound (<1.04 logCS). Physical outcomes included the short physical performance battery (SPPB) scores, self-reported quality of life (QoL) scores, physical limitations, difficulty with activity of daily living (ADL) and instrumental ADL (IADL). The associations between VAI and CSI with physical outcomes were explored overall and by community.

Results

There were 494 Black Jackson and 558 White Washington County participants. The mean age was 80 years, 63% were female, and 15% had VAIdistance presenting. Moderate or greater VAInear presenting was associated with higher prevalence of greater physical limitations (prevalence ratio, 1.25; 95% confidence interval, 1.09-1.44) and IADL difficulties (prevalence ratio, 1.77; 95% confidence interval, 1.32-2.38), but not ADL difficulties. Associations of VAIdistance presenting with physical limitations and lower SPPB scores, and CSI with physical limitations, IADL difficulties, lower QoL, and lower SPPB scores were found. A stratified analysis showed stronger associations in Jackson.

Conclusions

VAI and CSI were associated with poor physical health. These associations should be understood in the context of community differences.

Translational Relevance

Community-based factors may mitigate the impact of vision loss on physical outcomes. Public health endeavors are needed to address VAI and CSI to optimize physical health in the older adults with poor vision.

Serious Life Events in People with Visual Impairment Versus the General Population

The present study aimed to examine the lifetime exposure to serious life events in people with visual impairment compared with the general population. Data were derived from a telephone survey including a probability sample of 736 adults with visual impairment (response rate: 61%). The lifetime prevalence of direct experiences with seventeen different categories of serious life events (Life Events Checklist for DSM-5 (LEC-5)) were compared to that obtained from the general Norwegian population (N = 1792, 36% response rate). Altogether, 68% of people with visual impairment had been directly exposed to at least one serious life event, with equal rates among males and females (p = 0.59). The prevalence of serious life events was higher than for the general population (60%, p < 0.001), especially for fire or explosions, serious accidents, sexual assaults, life-threatening illness or injury, and severe human suffering. In conclusion, our results indicate that people with visual impairment are more prone to experiencing serious life events. This highlights the need for preventive strategies that reduce the risk of serious life events in this population.

Exploration of dynamic text presentations in bilateral central vision loss

PURPOSE

Dynamic text presentation methods may improve reading ability in patients with central vision loss (CVL) by eliminating the need for accurate eye movements. We compared rapid serial visual presentation (RSVP) and horizontal scrolling text presentation (scrolling) on reading rate and reading acuity in CVL observers and normally-sighted controls with simulated CVL (simCVL).

METHODS

CVL observers' (n = 11) central scotomas and preferred retinal loci (PRL) for each eye were determined with MAIA microperimetry and fixation analysis. SimCVL controls (n = 16) used 4° inferior eccentric viewing, enforced with an Eyelink eye-tracker. Observers read aloud 4-word phrases randomly drawn from the MNREAD sentences. Six font sizes (0.50-1.30 logMAR) were tested with the better near acuity eye and both eyes of CVL observers. Three font sizes (0.50-1.00 logMAR) were tested binocularly in simCVL controls. Text presentation duration of each word for RSVP or drift speed for scrolling was varied to determine reading rate, defined as 50% of words read correctly. In a subset of CVL observers (n = 7), relationships between PRL eccentricity, reading threshold and rate were explored.

RESULTS

SimCVL controls demonstrated significantly faster reading rates for RSVP than scrolling text (p < 0.0001), and there was a significant main effect of font size (p < 0.0001). CVL patients demonstrated no significant differences in binocular reading rate between font sizes (p = 0.12) and text presentation (p = 0.25). Similar results were seen under monocular conditions. Reading acuity for RSVP and scrolling worsened with increasing PRL eccentricity (μ = 4.5°, p = 0.07). RSVP reading rate decreased significantly with increasing eccentricity (p = 0.02).

CONCLUSIONS

Consistent with previous work, reading acuity worsened with increasing PRL eccentricity. RSVP and scrolling text presentations significantly affected reading rate in simCVL, but not in CVL observers, suggesting that simCVL results may not generalise to pathological CVL.

Assessing optimal colour and illumination to facilitate reading: an analysis of print size

PURPOSE

This study examined how optimal colour/illumination conditions and the efficacy of the iPad, LuxIQ and Smart Bulb varied as a function of print size in younger, older and visually impaired adults.

METHODS

Participants with visual impairments and simulated low vision (SLV) read the MNRead using the iPad, LuxIQ and Smart Bulb.

RESULTS

In the impairment condition at 1.20 logMAR, the iPad (M = 9.49, 95% CI [3.18, 19.42]) and LuxIQ (M = 15.95, 95% CI [9.54, 24.86]) improved the reading speeds. At 0.80 logMAR (SLV), all devices improved reading speeds of older adults (iPad (M = 28.70, 95% CI [14.65, 42.51]); LuxIQ (M = 49.63, 95% CI [30.04, 69.68]); Smart Bulb (M = 23.11, 95% CI [3.33, 42.11])), but in younger adults only the LuxIQ (M = 13.04, 95% CI [3.21, 21.27]) did so. In the impairment condition, the iPad (M = 5.54, 95% CI [0.31, 12.13]) and LuxIQ (M = 13.90, 95% CI [7.88, 23.49]) improved reading speeds. In the SLV condition, age was a significant predictor of reading speed at 1.20 logMAR (F_3,164  = 10.74, p < 0.001, Adj. R²  = 0.16). At 0.80 logMAR, age and luminance, but not colour, were significant predictors (F_3,164  = 52.52, p < 0.001, Adj. R²  = 0.49). In the impairment condition, both age and lux were significant predictors of reading speed at 1.20 (F_3,85  = 7.14, p < 0.001, Adj. R²  = 0.20) and 0.80 logMAR (F_3,85  = 7.97, p < 0.001, Adj. R²  = 0.22), but colour was not.

CONCLUSIONS

Light source effectiveness and optimal colour/illumination vary as a function of print size. It appears that print size is the most important factor for improving reading speed. As print size decreases, luminance becomes crucial, and only at the smallest print sizes does the effect of colour become useful.

Seeing Beyond Anatomy: Quality of Life with Geographic Atrophy

Quality of life (QoL) is a complex idea without a clear consensus definition. Generally speaking, QoL refers to several subjective measures of wellbeing that vary by individual and circumstance. QoL can decline noticeably as a disease progresses. This is particularly true for geographic atrophy (GA), an advanced form of age-related macular degeneration. GA leads to vision loss for which there is no currently approved pharmacological treatment. There is a lack of qualitative, patient-driven research on QoL in GA. There is also limited information available to both patients and physicians about GA, existing support groups and available assistive technologies. To address this, we have collated the experiences of a person with GA and those of her partner and carer with the current literature on QoL in GA. We have also outlined some of the wide range of developing technologies available to help people with GA carry out daily tasks and hobbies. It is clear that support, whether through informal or structured care, is vital to the wellbeing of people with GA. Despite this, the general public are often unaware of care work, which may result in this integral role being undervalued and under acknowledged. Furthermore, it is apparent that the general public have fundamental misunderstandings around what vision loss entails and are unaware that blindness is a vast spectrum. This feeds into the seemingly paradoxical mix of isolation and dependence on others that often results from GA and vision loss. Through this qualitative examination of a patient's experiences, we hope to inform and educate both patients and physicians about GA as well as precipitate discussion around the frameworks that should be in place to support both newly diagnosed and long-term patients with GA and other retinal diseases. Seeing beyond anatomy: quality of life with geographic atrophy (WMV 29479 kb).

The impact of low vision on activities, participation, and goals among older adults: a scoping review

PURPOSE

Participation is a key outcome of rehabilitation. However, no reviews have investigated the impact of low vision on the activities, participation, and goals of older adults. This paper aims to review and synthesize available literature on how low vision impacts the activity and participation of older adults.

METHOD

A scoping review was conducted. The key findings were extracted from 30 full-text articles that met the selection criteria. The International Classification of Functioning, Disability and Health was used to frame the findings at the activity and participation levels.

RESULTS

At the activity level, the categories of Walking, Moving around in different locations, and Reading were commonly impacted by low vision. The main domains impacted at the participation level were Community, social and civic life and Interpersonal interaction and relationships. Only one study addressed the goals of older adults with low vision.

CONCLUSION

Low vision impacts reading, walking, and moving around in different locations. Rehabilitation therapists should be aware of and consider assessing these activities. Further research is needed on the impact of low vision on other functional activities, participation, and self-identified goals of older adults to guide clinical practice.Implications for rehabilitationLow vision has an impact on the activity level of older adults, consistently identified in the areas of walking and moving around in different locations and reading for knowledge and leisure.At the participation level, the impact of low vision is less frequently identified compared to the areas identified at the activity level, in the areas of leisure, social interactions and basic and instrumental ADL.Rehabilitation therapists working with older adults with low vision should assess clients' performance of moving around in different locations, in addition to walking, and include screening questions on the impact of low vision on driving.Rehabilitation therapists working with older adults with low vision should determine clients' reading needs and acquire competence in assessing clients' reading ability and providing intervention for different types of reading to enable them to continue participating in various life situations that require the performance of reading.

Topical Review: Understanding Vision Impairment and Sports Performance through a Look at Paralympic Classification

SIGNIFICANCE

To provide meaningful competition that is equitable for Paralympic athletes, classification systems are vital to determine which athletes are eligible to compete in adapted forms of sports and to group athletes for competition. Our discussion has important implications to inform how we should approach visual function assessment in sports performance. Sport participation positively benefits individuals with low vision. In particular, adapted sports exist to provide people with visual disabilities an avenue for participating in recreational activity. High-performance low-vision athletes can participate in Paralympic sports but need to be properly classified based on the severity of their vision impairment. The model for Paralympic classification was initiated by Sir Ludwig Guttmann in 1952 in a rehabilitation clinic for soldiers with spinal cord injuries. Today, the International Paralympic Committee mandates that international sports federations develop evidence-based sport-specific classification systems to ensure that eligible disabled athletes have an opportunity for meaningful competition. With the current classification system, only visual acuity and visual field measures are considered to determine an athlete's eligibility to compete, leaving room to expand our understanding of visual function requirements for individual sports. In this topical review, we discuss the origins of Paralympic sports, limitations of current classification methods, and requirements toward achieving evidence-based sport-specific evaluation systems.

The Nexus of Sensory Loss, Cognitive Impairment, and Functional Decline in Older Adults: A Scoping Review

BACKGROUND AND OBJECTIVES

The prevalence of cognitive impairment and sensory loss in hearing or vision increases with age. Based on the Information Processing Model, cognitive impairment coupled with sensory loss may exacerbate disability in late life. Yet this issue has not been systematically studied. The purpose of this scoping review was to examine the literature that studied the relationship between cognitive impairment, sensory loss, and activities of daily living in older adults.

RESEARCH DESIGN AND METHODS

Two reviewers independently screened 1,410 studies identified from five electronic databases (Medline, EMBASE, PsycINFO, CINHAL, and the Web of Science). The search was completed in June 2020. A study was eligible if it included measurements of cognitive function, vision or hearing, and activities of daily living. Additionally, the data analyses must address how cognitive impairment and sensory loss are related to the performance of activities of daily living.

RESULTS

The final review included 15 studies. Findings show an additive effect of cognitive impairment and sensory loss on the activities of daily living. Cognitive impairment or vision loss independently relates to the decline in activities of daily living. Hearing loss relates to the decline only when the loss is severe, or if the daily task is hearing specific.

DISCUSSION AND IMPLICATIONS

Older adults with coexisting sensory loss and cognitive impairment have the highest risk or prevalence of disability, comparing to cognitive impairment or sensory loss alone. This finding highlights the importance of developing interventions to reduce the risk of disability for older adults experiencing multiple impairments.

Vision Impairment and Participation in Cognitively Stimulating Activities: The Health ABC Study

BACKGROUND

Engagement in cognitively stimulating activities is associated with decreased rates of cognitive decline in older adults. However, most cognitively stimulating tasks require good vision, potentially affecting the ability of visually impaired adults to engage in these activities. We examined the relationship between vision and participation in cognitively stimulating activities.

METHOD

Data from the Health, Aging, and Body Composition study (1999-2005) were analyzed. Associations between visual function (visual acuity [VA], contrast sensitivity [CS], and stereo acuity [SA] impairments) and annual rates of change in number of cognitively stimulating activities (by self-report) performed at least once a month were examined.

RESULTS

Analyses included 924 participants aged 75.2 ± 2.8 years. At baseline, impaired CS (27%) and SA (29%) were associated with participation in fewer cognitive activities (β = -0.33, 95% CI = -0.63, -0.03 and β = -0.32, 95% CI = -0.61, -0.03, respectively), while VA (8%) was not (β = -0.34, 95% CI = -0.81, 0.13). In longitudinal models, groups with and without VA, CS, and SA impairments exhibited declines in monthly cognitive activities over time. Annual rates of decline were relatively higher in the VA (β = -0.16, 95% CI = -0.26, -0.05) and CS (β = -0.14, 95% CI = -0.19, -0.09) impaired groups than observed in the respective unimpaired groups (no VA: β = -0.12, 95% CI = -0.15, -0.10; no CS: β = -0.12, 95% CI = -0.15, -0.09), but did not achieve statistical significance. Stereo acuity (β = -0.13, 95% CI = -0.17, -0.09) and no SA (β = -0.13, 95% CI = -0.16, -0.10) groups had similar rates of decline.

CONCLUSIONS

Visually impaired older adults participate in fewer cognitive activities and although participation decline is similar to the non-impaired, lower overall participation indicates a need to identify cognitively stimulating activities accessible to visually impaired older adults.

Comparison of Two Lighting Assessment Methods when Reading with Low Vision

SIGNIFICANCE

Lighting assessments are an important component of low-vision rehabilitation but are rarely studied systematically. Our study indicates that preferred lighting levels support improvements in reading ease and enjoyment, independently of the evaluation technique. To determine preferred illumination level and color temperature, the LuxIQ is quicker to administer and covers broad options of settings.

PURPOSE

The purpose of this study was to determine if preferred lighting, as assessed by the LuxIQ versus a standard lighting assessment, leads to better reading outcomes in individuals with low vision.

METHODS

Preferred lighting was assessed at home with visually impaired persons (mean age, 75.3 years), using the LuxIQ (n = 18) or a standard technique based on trying out light bulbs of various intensity and color temperature (n = 16). Maximum reading speed and reading acuity were measured before the lighting intervention and then under the preferred lighting conditions. A 1-month telephone follow-up evaluated the (1) compliance with the lighting recommendations and, for those who modified their lighting, (2) their level of satisfaction with the length of reading time and eye strain felt during reading.

RESULTS

Compared with usual lighting conditions, most participants preferred a cooler temperature at a higher illuminance level. Neither lighting assessment type appeared to lead to substantially improved objectively measurable reading outcomes. At the 1-month follow-up, 56% of the participants had modified their lighting, having a significant effect on satisfaction (P < .01), independent of assessment method. Of 18 respondents, 16 (87.5%) mentioned that reading was more enjoyable or easier with the lighting modifications.

CONCLUSIONS

Both lighting assessment methods lead to comparable results, but the LuxIQ is easier and faster to use. More research is needed to determine whether the LuxIQ is suitable to be incorporated into clinical practice.

Characteristics of Glaucoma Patients Attending a Vision Rehabilitation Service

PURPOSE

In this study, we describe common demographic and clinical characteristics of the glaucoma patient population attending vision rehabilitation.

DESIGN

Cross-sectional study.

PARTICIPANTS

Patients attending a hospital-based vision rehabilitation center with a primary ocular diagnosis of glaucoma.

METHODS

Participants' charts were retrospectively reviewed. Data extracted from medical records included demographics, referring physician, ocular history, glaucoma diagnosis, past ocular surgery, intraocular pressure, optic nerve findings, results of a functional intake assessing activities of daily living, depression, visual hallucinations, best-corrected visual acuity (BCVA), mean deviation (MD) scores on visual field testing, and log contrast sensitivity (CS).

MAIN OUTCOME MEASURES

Participant demographic information, ocular history, self-reported difficulty with activities of daily living, depression, visual hallucinations, BCVA, visual field, and CS.

RESULTS

The mean age of patients in this study was 77 years and ranged from 8 to 103 years. Ninety percent of patients were referred to vision rehabilitation by an ophthalmologist. Median BCVA was 20/50. Fifty-five percent of patients were functionally monocular, and for all patients, there was a median 9-line difference in BCVA between eyes. Median MD score was -13.95 decibels (dB). Median CS was 1.05. Patients reported having the greatest difficulty with reading (88%), writing (72%), and mobility (67%). Seventy-eight percent of patients stopped driving, and 12% reported difficulty driving. Among those experiencing depression, there was a 4:1 ratio of depressed patients having difficulty with mobility. One-third of patients experienced visual hallucinations.

CONCLUSIONS

Most glaucoma patients attending vision rehabilitation are not legally blind, but many are functionally monocular. This may cause greater difficulty performing functions that require the use of binocularity. Increasing the referral of younger glaucoma patients to vision rehabilitation may help patients learn to cope with the loss of visual function that occurs over time.

Effect of Reading Rehabilitation for Age-Related Macular Degeneration on Cognitive Functioning: Protocol for a Nonrandomized Pre-Post Intervention Study

BACKGROUND

Age-related vision impairments and dementia both become more prevalent with increasing age. Research into the mechanisms of these conditions has proposed that some of their causes (eg, macular degeneration/glaucoma and Alzheimer's disease) could be symptoms of an underlying common cause. Research into sensory-cognitive aging has provided data that sensory decline may be linked to the progression of dementia through reduced sensory stimulation. While hearing loss rehabilitation may have a beneficial effect on cognitive functioning, there are no data available on whether low vision rehabilitation, specifically for reading, could have a beneficial effect on cognitive health.

OBJECTIVE

The research questions are: (1) Does low vision rehabilitation reduce reading effort? (2) If so, does reduced reading effort increase reading activity, and (3) If so, does increased reading activity improve cognitive functioning? The primary objective is to evaluate cognition before, as well as at 6 months and 12 months after, 3 weeks of low vision reading rehabilitation using magnification in individuals with age-related macular degeneration, with or without coexisting hearing impairments. We hypothesize that improvements postrehab will be observed at 6 months and maintained at 12 months for participants with vision loss and less so for those with dual sensory loss. The secondary objective is to correlate participant characteristics with all cognitive outcomes to identify which may play an important role in reading rehabilitation.

METHODS

We employ a quasiexperimental approach (nonrandomized, pre-post intervention study). A 3x3 design (3 groups x 3 time points) allows us to examine whether cognitive performance will change before and after 6 months and 12 months of a low vision reading intervention, when comparing 75 low vision and 75 dual sensory impaired (vision & hearing) participants to 75 age-matched healthy controls. The study includes outcome measures of vision (eg, reading acuity and speed), cognition (eg, short-term and long-term memory, processing speed), participant descriptors, demographics, and clinical data (eg, speech perception in noise, mental health).

RESULTS

The study has received approval, and recruitment began on April 24, 2019. As of March 4, 2021, 38 low vision and 7 control participants have been enrolled. Lockdown forced a pause in recruitment, which will recommence once the COVID-19 crisis has reached a point where face-to-face data collection with older adults becomes feasible again.

CONCLUSIONS

Evidence of protective effects caused by reading rehabilitation will have a considerable impact on the vision rehabilitation community and their clients as well as all professionals involved in the care of older adults with or without dementia. If we demonstrate that reading rehabilitation has a beneficial effect on cognition, the demand for rehabilitation services will increase, potentially preventing cognitive decline across groups of older adults at risk of developing macular degeneration.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04276610; Unique Protocol ID: CRIR-1284-1217; https://clinicaltrials.gov/ct2/show/NCT04276610.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/19931.

Assessing optimal colour and illumination to facilitate reading

PURPOSE

This study examined the effectiveness of the LuxIQ, the Apple iPad and a smart bulb in assessing optimal colour and illumination to facilitate reading in younger, older and visually impaired adults.

METHODS

Participants read standardised texts at baseline (normal lighting/no device), then using the Apple iPad, LuxIQ and smart bulb, with their normal vision (20/20 condition) and using a simulated reduction in visual acuity/contrast sensitivity (20/80 condition). Visually impaired participants followed the same procedure used in the 20/80 condition.

RESULTS

There was a significant interaction between condition and device in younger, F(1.5, 43.51) = 30.41, p < 0.001, ω²  = 0.34 and older, F(1.5, 4.51) = 4.51, p = 0.03, ω²  = 0.05 adults with normal vision, and there was a significant effect of device, F(2, 58) = 5.95, p = 0.004, ω²  = 0.12 in visually impaired adults. In the 20/20 condition, age and colour predicted reading speed, F(3, 176) = 36.25, p < 0.001, Adj. R²  = 0.37, whereas age, lighting and colour predicted reading speed, F(3, 176) = 36.25, p < 0.001, Adj. R²  = 0.37 in the 20/80 condition. In the visual impairment condition, lighting, colour and impairment severity predicted reading speed, F(3, 85) = 10.10, p < 0.001, Adj. R²  = 0.24.

CONCLUSIONS

The clinical implications of this study are that reading speeds improve in individuals with low vision under improved lighting conditions, specifically, with higher levels of luminance and colour temperature. The effectiveness of the devices varied across groups; however, the LuxIQ was the only device to improve reading speeds from baseline in older adults with visual impairments.

Vision-related quality of life in adults with severe peripheral vision loss: a qualitative interview study

Background

Existing patient-reported outcome (PRO) measures may not be relevant to the full range of functional and vision-related quality of life (VR-QOL) concerns of individuals with vision impairment due to severe peripheral field loss (PFL). Measurement of VR-QOL in severe PFL is important in order to determine the effectiveness of vision rehabilitation interventions for this population. The purpose of this study was to characterize the impact of severe PFL due to retinitis pigmentosa (RP) and glaucoma on VR-QOL as the initial phase in the development of a novel PRO measure.

Methods

Individuals with severe PFL due to RP or glaucoma were recruited from the Kellogg Eye Center and the Association for the Blind and Visually Impaired. Participants completed semi-structured qualitative interviews, the Impact of Vision Impairment (IVI) questionnaire and the RAND 36-Item Health Survey. Interviews were analyzed by two coders using thematic analysis. A matrix analysis was conducted to compare VR-QOL by cause of severe PFL. Sample size was determined by thematic saturation.

Results

The study included 37 participants (19 RP, 18 glaucoma). Median best-corrected visual acuity for those with RP and glaucoma was 20/40 and 20/27.5, while Pelli-Robson contrast sensitivity was 1.2 log contrast sensitivity (logCS) and 1.1 logCS, respectively. Median domain scores on the IVI (reading, mobility, well-being) ranged from a low of − 0.2 to a high of 0.7 logits in those with RP and from 0.5 to 1.2 logits in those with glaucoma. Qualitative interviews identified six VR-QOL themes relevant across participants with both RP and glaucoma, including activity limitations, driving, emotional well-being, reading, mobility, and social function. VR-QOL concerns were largely consistent among those with severe PFL due to RP and glaucoma. These overarching themes contained content relevant to specific challenges related to severe PFL.

Conclusions

There are commonly occurring VR-QOL concerns among individuals with severe PFL due to RP and glaucoma. The outlined themes will serve as the basis for development of the Low Vision Severely Constricted Peripheral Eyesight (LV-SCOPE) Questionnaire.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-020-00281-y.

Low Vision Profile in Jordan: A Vision Rehabilitation Center-Based Study

The aim of this paper is to study the profile of persons with low vision in Jordan based on the clinical records of service users who attended the Vision Rehabilitation Center (VRC) at the German Jordanian University (GJU). A retrospective study was conducted by reviewing the archived data for persons with low vision attending the VRC over the period September 2012 to December 2017. The information collected included age, gender, referral, geographical distribution, chief functional visual problems, and ocular pathology. The records of 725 (28.9 ± 20.3 years old) persons out of 858 persons were analyzed. Almost half (50.6%) of the sample was less than 18 years old. The main cause of the low vision was retinal diseases (53.4%), followed by albinism. Gender and age showed no significant influence on ocular pathology distribution. For the referrals, ophthalmologists (37.8%) were the largest source of referral, followed by institutions for people with disabilities (14.9%). Near tasks were reported as the main functional problems for patients with low vision (74.9%), followed by distance tasks (8.3%). This study sets a precedent for determining the characteristics of persons with low vision in Jordan. Developing an efficient referral system between eye health care professionals and other health caregivers is important to ensure the best multidisciplinary services for low vision.

The relation between self-stigma and loneliness in visually impaired college students: Self-acceptance as mediator

BACKGROUND

Loneliness, a negative emotion that is common in college students, may cause psychological disorders and behavioral issues. Particularly vulnerable are visually impaired college students, who are at an increased risk of loneliness.

OBJECTIVES

This study was aimed at explaining the current situation of loneliness among visually impaired college students as well as its influencing factors and exploring the intermediary role of self-acceptance between self-stigma and loneliness.

METHOD

Seventy-eight college students with visual impairment completed a series of self-report questionnaires, including the Self-Stigma of Disabled Scale (SSDS), the Self-Acceptance Questionnaire (SAQ), and the University of California-Los Angeles (UCLA) Loneliness Scale. Mediation analyses were conducted using PROCESS in SPSS.

RESULTS

Participants' mean loneliness score was 44.97 ± 9.35. Two survey factors were significantly associated with loneliness: visual impairment status and relationship with parents (p < 0.05). When controlling for extent of visual damage and relationship with parents, self-stigma showed a significant predictive effect on loneliness (B = 0.37, t = 4.1023, p < 0.01).

CONCLUSIONS

In China, visually impaired students suffer from a high level of loneliness, and self-acceptance plays a central role in connecting their self-stigma and loneliness.

The inhibitory effect of word neighborhood size when reading with central field loss is modulated by word predictability and reading proficiency

For normally sighted readers, word neighborhood size (i.e., the total number of words that can be formed from a single word by changing only one letter) has a facilitator effect on word recognition. When reading with central field loss (CFL) however, individual letters may not be correctly identified, leading to possible misidentifications and a reverse neighborhood size effect. Here we investigate this inhibitory effect of word neighborhood size on reading performance and whether it is modulated by word predictability and reading proficiency. Nineteen patients with binocular CFL from 32 to 89 years old (mean ± SD = 75 ± 15) read short sentences presented with the self-paced reading paradigm. Accuracy and reading time were measured for each target word read, along with its predictability, i.e., its probability of occurrence following the two preceding words in the sentence using a trigram analysis. Linear mixed effects models were then fit to estimate the individual contributions of word neighborhood size, predictability, frequency and length on accuracy and reading time, while taking patients' reading proficiency into account. For the less proficient readers, who have given up daily reading as a consequence of their visual impairment, we found that the effect of neighborhood size was reversed compared to normally sighted readers and of higher amplitude than the effect of frequency. Furthermore, this inhibitory effect is of greater amplitude (up to 50% decrease in reading speed) when a word is not easily predictable because its chances to occur after the two preceding words in a specific sentence are rather low. Severely impaired patients with CFL often quit reading on a daily basis because this task becomes simply too exhausting. Based on our results, we envision lexical text simplification as a new alternative to promote effective rehabilitation in these patients. By increasing reading accessibility for those who struggle the most, text simplification might be used as an efficient rehabilitation tool and daily reading assistive technology, fostering overall reading ability and fluency through increased practice.

Visual Impairment and Mental Health: Unmet Needs and Treatment Options

Purpose

An estimated 2.2 billion people are visually impaired worldwide. Given that age-related vision loss is a primary cause of vision impairment, this number is projected to rise with increases in average lifespan. Vision loss often results in significant disability and is associated with a substantial economic burden, reduced quality-of-life, concurrent medical issues, and mental health problems. In this review, the mental health needs of people with vision impairment are examined.

Patients and methods

A review of recent literature on mental health outcomes and current treatments in people with visual impairment was conducted.

Results

Considerable data indicate that rates of depression and anxiety are elevated among people with visual impairments. Moreover, individuals of lower socioeconomic status may be at increased risk for vision impairment and subsequent mental health problems. Existing psychosocial interventions for improving mental health in people with visual impairment show some promise, but are limited by low adherence and lack generalizability.

Conclusion

In order to improve outcomes, a better understanding of the mechanisms linking visual impairment and poor mental health is needed. It will also be essential to develop more effective interventions and expand access to services to improve the detection and treatment of mental health problems in this population.

The association between tactile, motor and cognitive capacities and braille reading performance: a scoping review of primary evidence to advance research on braille and aging

PURPOSE

As the prevalence of age-related visual impairment increases, a greater understanding of the physiological and cognitive capacities that are recruited during braille reading and the potential implications of age-related declines is required.

METHODS

This scoping review aimed to identify and describe primary studies exploring the relationship between tactile, motor and cognitive capacities and braille reading performance, the instruments used to measure these capacities, and the extent to which age is considered within these investigations. English peer-reviewed articles exploring the relationship between these capacities and braille reading performance were included. Articles were screened by two researchers, and 91% agreement was achieved (kappa = 0.84 [0.81, 0.87], p < 0.01).

RESULTS

2405 articles were considered of which 36 met the inclusion criteria. Fifteen investigated the relationship between tactile capacities and braille reading performance, 25 explored motor capacities, and 5 considered cognitive capacities. Nineteen instruments were used to measure tactile capacity, 4 for motor dexterity, and 7 for cognitive capacity. These studies focus on younger participants and on those who learned braille early in life.

CONCLUSIONS

Although this overview underscores the importance of tactile perception and bimanual reading, future research is needed to explore the unique needs of older adults who learn braille later in life.IMPLICATIONS FOR REHABILITATIONThe studies in this review underscore the importance of developing both haptic tactile perception and efficient hand reading patterns early in the braille learning process.Practitioners should consider whether specific pre-braille readiness activities can be used to address the unique needs of older adults who may experience tactile, motor or cognitive declines.Most of the studies in this review require replication before they should serve as reliable clinical guidelines; however, braille reading (like print) is a complex process that draws on multiple capacities that should be developed in unison.The studies in this review focus heavily on younger participants and on those who learned braille early in life, and highlight the need for future research on braille and aging.

Relationship between refractive correction, visual symptoms, and optical device selection for low-vision patients in Taiwan

According to Taiwan optometry act, low-vision services, such as refractive correction and low vision assessment, are now included in Optometric profession. This study was designed to investigate the efficiency of refractive correction and the relationship between refractive correction, eye diseases, visual symptoms, and optical device selection for patients with low vision.

METHODS

This study involved a total of 220 participants aged from 7 to 99, with 119 males and 101 females. All of them were referred from three institutes of Taiwan Resource Portal of Assistive Technology under the supervision of the Ministry of Health and Welfare during Feb 2016 to Jan 2018. Accordingly, 42, 76, and 102 of the participants were identified as having mild, moderate, and severe visual impairments, respectively, by five experienced and licensed optometrists for this comprehensive low vision examination.

RESULTS

The most common eye diseases in this study were retinal disease, cataract, glaucoma, and optic nerve hypoplasia; some of the participants had multiple eye diseases while participating in the study. Except visual acuity decrease, eye diseases were highly correlated with participants' visual symptoms. Refractive correction is the first step in low-vision examination, therefore, it might be much helpful to some types of eye diseases, visual symptoms, and to the decisions of optical devices for low-vision patients. The results herein suggest that color vision and contrast sensitivity should be taken into consideration when calculating the second optical magnifying power after refractive correction.

CONCLUSIONS

Refractive correction is necessary for the treatment of patients' visual symptoms and also for the prescription of low-vision aids.

Responsiveness of the Revised Low Vision Independence Measure (LVIM-R)

IMPORTANCE

The Low Vision Independence Measure (LVIM) was designed to measure the effectiveness of occupational therapy to improve visual ability in low vision rehabilitation.

OBJECTIVE

To validate the Revised LVIM (LVIM-R) as an outcome measure by determining its sensitivity to visual ability changes after occupational therapy.

DESIGN

In this observational study, LVIM-R scores were collected before and after customary low vision intervention.

SETTING

Home health agency or outpatient facility.

PARTICIPANTS

Forty-four participants with a mean age of 80.2 yr (standard deviation = 11.2) and an average length of visual impairment of 6.2 yr. Twenty-three participants (52.3%) were treated in an outpatient setting, and 21 (47.7%) were treated in the home. The majority of participants were non-Hispanic White (92.8%) and had macular degeneration (54.5%).

INTERVENTION

Customary low vision intervention by occupational therapists.

OUTCOMES AND MEASURES

LVIM-R scores were collected before and after intervention, and participants' pre- and posttest scores were anchored into Rasch-calibrated item parameters.

RESULTS

Paired t tests demonstrated significant increases in person measures with large effect sizes for both constructs of the LVIM-R, the visual field or scotoma (t[43] = 6.46, p < .0001; Cohen's d = 0.92) and visual acuity (t[43] = 9.08, p < .0001; Cohen's d = 1.14) constructs.

CONCLUSIONS AND RELEVANCE

The LVIM-R is sensitive to changes in visual ability in clients who have good rehabilitation potential and can be used to examine the effectiveness of occupational therapy for low vision.

WHAT THIS ARTICLE ADDS

The LVIM-R is useful for measuring occupational therapy outcomes in low vision rehabilitation in the home or in outpatient settings.

Functional Difficulties of Patients Seeking Low Vision Services in South India

PURPOSE

The aim of the study was to determine the functional concerns of patients with different clinical and demographic characteristics seeking low vision care in South India.

DESIGN

Cross-sectional clinic-based survey.

METHODS

Consecutive new patients evaluated by the low vision service at Aravind Eye Care System (AECS), Madurai, India, India from September 2016 to March 2017 were recruited. Clinical and sociodemographic data were collected and participants underwent a semistructured survey to determine vision-related functional concerns. Analyses were conducted to determine associations with functional concerns. This study was approved by the AECS Institutional Review Board and all participants provided informed consent.

RESULTS

The study included 419 participants (mean age 42.0 years, 65.2% male). Retinal dystrophy (35.8%) and acquired retinal disease (22.0%) were the most common diagnoses. The most frequently cited functional concerns were reading (37.7%), mobility (19.9%), and facial identification (13.8%). The number of functional concerns did not vary by diagnosis, age, sex, education, occupation, or presenting visual acuity (P > 0.05). Participants with retinal dystrophy were more likely to cite problems with night vision (P < .001). Age was significantly associated with greater difficulty recognizing faces [odds ratio (OR) = 1.20, 95% confidence interval (CI) = 1.01-1.43] and less night vision difficulty (OR = 0.75, 95% CI = 0.60-1.00). Worse presenting visual acuity was significantly associated with reporting a mobility problem (OR = 2.87, 95% CI = 2.09-3.93).

CONCLUSIONS

This study supports the expansion of low vision services in India targeted to common functional concerns including reading, mobility, and facial identification. However, results do not support the use of ocular diagnosis for this purpose.

Mechanisms of protection of retinal pigment epithelial cells from oxidant injury by humanin and other mitochondrial-derived peptides: Implications for age-related macular degeneration

The mitochondrial-derived peptides (MDPs) are a new class of small open reading frame encoded polypeptides with pleiotropic properties. The prominent members are Humanin (HN) and small HN-like peptide (SHLP) 2, which encode 16S rRNA, while mitochondrial open reading frame of the twelve S c (MOTS-c) encodes 12S rRNA of the mitochondrial genome. While the multifunctional properties of HN and its analog 14-HNG have been well documented, their protective role in the retinal pigment epithelium (RPE)/retina has been investigated only recently. In this review, we have summarized the multiple effects of HN and its analogs, SHLP2 and MOTS-c in oxidatively stressed human RPE and the regulatory pathways of signaling, mitochondrial function, senescence, and inter-organelle crosstalk. Emphasis is given to the mitochondrial functions such as biogenesis, bioenergetics, and autophagy in RPE undergoing oxidative stress. Further, the potential use of HN and its analogs in the prevention of age-related macular degeneration (AMD) are also presented. In addition, the role of novel, long-acting HN elastin-like polypeptides in nanotherapy of AMD and other ocular diseases stemming from oxidative damage is discussed. It is expected MDPs will become a promising group of mitochondrial peptides with valuable therapeutic applications in the treatment of retinal diseases.