A profile of low vision services in England: the Low Vision Service Model Evaluation (LOVSME) project

"I'm like something out of star wars": a qualitative investigation of the views of people with age-related macular degeneration regarding wearable electronic vision enhancement systems

PURPOSE

This study explores the initial views of people with age-related macular degeneration towards wearable electronic vision enhancement systems.

METHODS

Ten adults with age-related macular degeneration participated in semi-structured interviews, which were analysed using reflexive thematic analysis.

RESULTS

Four themes were identified. Firstly, participants spoke of the wide-ranging impact of sight loss and how current helpful coping strategies still had significant limitations, affecting their desire to seek new solutions. The second theme showed that "other people" offered welcomed support with existing electronic coping solutions and are needed to provide suitable advice and training. However, "other people" limited the acceptability of using new solutions in public places. The third theme captured participants' desire for a wearable aid providing image magnification and enhancement over a range of distances. The final theme covered the reality of some current wearable technology, perceived as heavy, enclosing, or strange in appearance. Appearance caused some to lose interest in use, although others reframed the devices' desired usefulness to solo and sedentary activities.

CONCLUSION

This population are interested in the potential benefits of wearable electronic vision enhancement systems. More work is needed to understand the suitability of current solutions due to participant concerns about training, appearance and performance.

Low Vision Services Provision throughout NHS Trusts in the UK

Background/Aims

The aim of this study was to understand the picture of low vision service provision within NHS Trusts in the United Kingdom, for children and adults.

Method

A survey was distributed to all members of the British and Irish Orthoptic Society (BIOS) and to all Eye Clinic Liaison Officers (ECLOs) through the Royal National Institute for the Blind (RNIB). The survey was also directly emailed to Orthoptic contacts of all 238 Trusts/Health Boards, which covered the four nations of the United Kingdom. The survey asked whether their Trust had a clinical low vision service, which professions were involved in leading and working within it, where it was based, and whether provision was offered to children, adults, or both.

Results

In the United Kingdom (UK), 117 out of 238 (49%) Trusts responded. Of these responders, 94% had a level of Trust-delivered low vision service provision; 90% had services for adults; 83% had services for children; and 79% had services for both adults and children. Service accessibility for patients of all ages had regional and national variation.

Conclusion

Significant variation was found in low vision service provision throughout the UK, with some regions having no NHS-delivered provision for either children, adults, or both. This calls for further research to gain a more comprehensive understanding of low vision service provision and remove inequalities in provision, access and resourcing, aiming to ensure equitable access for all.

Compliance With the Use of Low-Vision Aids in a Greek Population: An Explorative Study

The aim of this study is to investigate the compliance with low-vision aids (LVAs) among patients with low vision (LV) in a Greek population. An explorative study was conducted in a sample of patients with LV attending our outpatient unit at the School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece. Patients' demographics and daily visual demands were recorded, and they were administered with the National Eye Institute Visual Function Questionnaire-25 (VFQ-25) at baseline. Participants were trained in the use of a wide range of LVAs before their prescription. Evaluation of the use of the LVAs was conducted at one year after the baseline using a structured phone survey. A total of 100 LV patients were included, with 68% of them being older than 65 years and 50 being males. The main cause of LV (57.0%) was age-related macular degeneration, and the mean VFQ-25 score at baseline was 49.2 (SD= 17.8). Overall, 75 patients had been prescribed LVAs, with 76.0% of these patients preferring an optical aid. The vast majority (98.7%) of these patients stated using the LVA one year after the baseline, and 62.1% of them reported using the aid often to very often. Significantly, 76% of these patients reported that their quality of life was positively affected by the use of the aid, and 97.3% would recommend the use of LVA to another individual with the same problem. Providing appropriate training before the prescription is of high significance to improve the rate of compliance with the use of LVAs. These results can be used to develop appropriate strategies in this field.

Are wearable electronic vision enhancement systems (wEVES) beneficial for people with age-related macular degeneration? A scoping review

INTRODUCTION

Age-related macular degeneration (AMD) is the most common cause of irreversible visual impairment in the United Kingdom. It has a wide-ranging detrimental impact on daily living, including impairment of functional ability and quality of life. Assistive technology designed to overcome this impairment includes wearable electronic vision enhancement systems (wEVES). This scoping review assesses the usefulness of these systems for people with AMD.

METHODS

Four databases (Cumulative Index to Nursing and Allied Health Literature, PubMed, Web of Science and Cochrane CENTRAL) were searched to identify papers that investigated image enhancement with a head-mounted electronic device on a sample population that included people with AMD.

RESULTS

Thirty-two papers were included: 18 studied the clinical and functional benefits of wEVES, 11 investigated use and usability and 3 discussed sickness and adverse effects.

CONCLUSIONS

Wearable electronic vision enhancement systems provide hands-free magnification and image enhancement producing significant improvements in acuity, contrast sensitivity and aspects of laboratory-simulated daily activity. Adverse effects were infrequent, minor and spontaneously resolved with the removal of the device. However, when symptoms arose, they sometimes persisted with continued device usage. There are multi-factorial influences and a diversity of user opinions on promotors to successful device use. These factors are not exclusively driven by visual improvement and incorporate other issues including device weight, ease of use and inconspicuous design. There is insufficient evidence of any cost-benefit analysis for wEVES. However, it has been shown that a user's decision to make a purchase evolves over time, with their estimates of cost falling below the retail price of the devices. Additional research is needed to understand the specific and distinct benefits of wEVES for people with AMD. Further patient-centred research should assess the benefits of wEVES in user-led activities when directly compared with alternative coping strategies, allowing professionals and users to make better prescribing and purchasing decisions.

What do individuals with visual impairment need and want from a dialogue-based digital assistant?

CLINICAL SIGNIFICANCE

Optometrists are well-placed to provide helpful advice and guidance to patients with visual impairment but may not know how best to do this. The availability of a reliable and comprehensive conversational agent to which patients could be directed would be a valuable supplement to clinical intervention.

BACKGROUND

The Artificial Intelligence in Visual Impairment (AIVI) Study is a proof-of-concept study to investigate whether ongoing information support for people with visual impairment (VI) can be provided by a dialogue-based digital assistant. The phase of the AIVI Study reported here explored the different dimensions of the information-seeking behaviour of individuals with VI: in particular, their need for information, the methods for obtaining it at present, and their views on the use of a digital assistant.

METHODS

Qualitative data were collected from 120 UK-resident adults who responded to an online survey who were either visually impaired (86.7%), a carer or family member of someone with VI (5.8%), or a professional involved in the support of those with VI (7.5%). In addition, 10 in-depth 1:1 semi-structured interviews explored opinions in more detail. Thematic analysis was used to analyse the findings.

RESULTS

Analysis of information needs identified 7 major themes: ocular condition; equipment, technology and adaptations; daily activities; registration; finance/employment; emotional support; and support for the carer. Participants used a wide variety of methods to access information from many sources and explained the barriers to access. Participants accepted the merit of a dialogue system aiding in a goal-directed search for specific information, but expressed reservations about its abilities in other areas, such as providing emotional support.

CONCLUSIONS

Participants highlighted potential benefits, limitations, and requirements in using a digital assistant to access information about VI. These findings will inform the design of dialogue systems for populations with VI.

Change in rehabilitation needs and activity limitations over time of adults with acquired visual impairment following entry to a low vision rehabilitation service in England

PURPOSE

Longitudinal changes in priority rehabilitation needs, vision-related activity limitation and importance of visual goals were evaluated in a sample of people with a visual impairment over a year following entry to low vision rehabilitation services in England.

METHODS

Participants were adults with newly registered visual impairment within Leicestershire. Priority scores, indicating the level of rehabilitative need, were determined from the importance and difficulty scores of the 48 goals of the Participation and Activity Inventory (PAI). Rasch analysis of the difficulty and importance scores examined activity limitation and importance separately. PAI outcome measures were assessed on entry to rehabilitation services and at 4 and 12 months thereafter.

RESULTS

Forty-eight participants (mean age 74.2, SD 14.1 years) completed three visits. Overall, there was a statistically significant reduction in the perceived need for rehabilitation over time (p < 0.001, η_p ²  = 0.29), driven by reduced perceived difficulty (p < 0.001, η_p ²  = 0.32) but stable importance (p = 0.73) of goals, with most change occurring between baseline and 4 months. PAI goals with greatest rehabilitative need at study entry were reading, mobility and writing, and these remained of highest priority over time. The greatest priority score decrease was for the goal 'Hobbies and crafts'. The largest decrease in importance was for 'Mobility outdoors', whereas 'Relationship with loved ones' increased most.

CONCLUSIONS

Despite a decline in the perceived need for rehabilitation over the study period, there remains a need for continued support and intervention at 12 months following registration with rehabilitation services, particularly for the key goals of reading, writing and mobility. Early identification and support for individuals' important but difficult goals could prevent such goals being relinquished. Goals concerning relationships and communication became more important over time, indicating that re-evaluation of needs at follow-up is necessary to inform ongoing service provision.

Everyday visual demands of people with low vision: A mixed methods real-life recording study

Research has demonstrated that low vison aids (LVAs) can have a positive impact on the functional sight of those living with sight loss. Step changes in technology are now enabling new wearable LVAs with greater potential than those available previously. For these novel devices to receive increased acceptance and therefore adoption by those with sight loss, visual task demands have to be understood more clearly in order to enable better alignment between device design and user requirements. The aim of this study was to quantify these requirements. Thirty-two participants aged 18 to 87 wore a spectacle-mounted video camera to capture and narrate all everyday situations in which they would use a “perfect” sight aid during 1 week. Captured scenes were analyzed through categorization and computational image analysis. Results showed large variation in activities and lifestyles. Participants reported no available sight aid or coping strategy for 57% of the recorded activities. Reading made up 49% of all recorded tasks, the other half comprising non-textual information. Overall, 75% of captured activities were performed ad hoc (duration of 0–5 minutes), 78% occurred indoors, 58% occurred at home, 48% were lit by natural light, 68% included the object of interest within reach, and 69% required a single focus plane only. Around half of captured objects of interest had a size of 2 degrees visual angle (2.08 logarithm of the minimum angle of resolution [logMAR]) or smaller. This study highlights the need for a sight aid that can make both textual and non-textual scenes accessible while offering flexibility to accommodate individual lifestyles.

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.

Rehabilitation Referral for Patients With Irreversible Vision Impairment Seen in a Public Safety-Net Eye Clinic

Importance

The prevalence of irreversible vision impairment in the United States is expected to increase by 2050. Vision rehabilitation is the primary treatment option. Clinical trials have established its efficacy in improving quality of life. Yet studies indicate that patients experience many barriers to accessing low-vision care.

Objectives

To examine the rate of referral for low-vision rehabilitation services by resident and attending ophthalmologists for adults with irreversible vision impairment and to assess the knowledge, attitudes, and beliefs of patients about vision rehabilitation.

Design, Setting, and Participants

Cross-sectional study with enrollment from June 20, 2016, to January 31, 2017, of 143 adults 18 years or older seen in a publicly funded, comprehensive eye clinic in Jefferson County, Alabama, and having 1 or both eyes with irreversible vision impairment (visual acuity was defined as 20/60 or worse) per the electronic health record.

Exposures

Demographic characteristics; patient questionnaire on knowledge, attitudes, and beliefs about vision rehabilitation; general cognitive status (Short Orientation-Memory-Concentration test); depressive symptoms (Patient Health Questionnaire-9); health literacy (Rapid Estimate of Adult Literacy in Medicine, Revised [REALM-R]); and self-reported difficulty in everyday activities.

Main Outcomes and Measures

Proportion of patients with irreversible vision impairment who were referred by ophthalmologists to low-vision rehabilitation services per the electronic health record.

Results

Of 143 patients enrolled with irreversible vision impairment in 1 or both eyes, the mean (SD) age was 55.4 (11.1) years and 68 (47.6%) were women. Most patients were African American (123 [86.0%]), uninsured (88 [61.5%]), and unemployed (92 [64.3%]); on average, they had normal cognitive status, minor depressive symptoms, and limited health literacy. As noted in the electronic health record, the rate of referral for low-vision rehabilitation services was 11.4% for patients with irreversible bilateral vision impairment (4 of 35 patients) and 1.9% for those with unilateral impairment (2 of 108). Most patients with bilateral (31 of 34 [91.2%]) and unilateral (90 of 97 [92.8%]) impairment indicated that they were bothered by their vision impairment, and most reported difficulty with reading (33 of 34 patients [97.1%] who were bilaterally impaired vs 85 of 104 [81.7%] who were unilaterally impaired).

Conclusions and Relevance

Results of this study suggest a need to better educate ophthalmologists and residents in ophthalmology about referrals to low-vision rehabilitation services for patients with irreversible vision impairment.

Impact of eye clinic liaison officers: a qualitative study in UK ophthalmology clinics

OBJECTIVES

To explore the impact of eye clinic liaison officers (ECLOs, also known as sight loss advisors) on the processes, functions and quality of ophthalmology clinics through the experiences of ophthalmology staff in the UK.

DESIGN

Qualitative study.

SETTING

UK hospital ophthalmology clinics.

PARTICIPANTS

Health and social care professionals in the UK.

RESULTS

ECLOs who had a presence in hospital ophthalmology clinics were seen as valuable in streamlining processes within the clinic, particularly in relation to the certification of visual impairment process, and providing continuity of care for patients when they were discharged from medical treatment. ECLOs also saved staff time in the clinic, as they were often responsible for providing emotional and practical support for patients living with sight loss.

CONCLUSIONS

ECLOs are well placed in ophthalmology clinics. They can relieve pressure on clinical staff by taking on information giving and referring duties, allowing other staff to focus on their clinical responsibilities. The impact of ECLOs may depend on efficient communication with the clinical team, being trusted by other staff and having a good knowledge of local and national sight loss support services outside of the hospital setting. Further research could enhance our understanding of how much time and associated costs ECLOs substitute in the ophthalmology clinic.

Rehabilitation needs and activity limitations of adults with a visual impairment entering a low vision rehabilitation service in England

PURPOSE

To evaluate outcome measures of the Participation and Activity Inventory (PAI) in a sample of adults with acquired visual impairment entering vision rehabilitation. Both Priority Scores, indicating level of rehabilitative need, and Person Measures, indicating goal difficulty, were considered.

METHODS

Participants were newly registered adults with visual impairment within Leicestershire, United Kingdom. The importance and difficulty of 48 goals of the PAI were assessed, as were demographic factors, clinical visual function (visual acuity, contrast sensitivity, reading function) and psychosocial function (adjustment to visual loss, depression, anxiety and fear of falling). Priority scores were calculated as the product of importance and difficulty of each goal. All questionnaires were Rasch analysed, and person and item measures of perceived difficulty with goals were derived.

RESULTS

Sixty people (mean age ± S.D. = 75.8 ± 13.8 years) took part. PAI goals with greatest rehabilitative need were reading (6.82 ± 2.91), mobility outdoors (6.55 ± 3.92), mobility indoors within an unfamiliar environment (5.52 ± 3.93) and writing (5.27 ± 3.02). Greater rehabilitative need was associated with younger age (β = -0.46, p < 0.001), and with higher depressive symptomatology (β = 0.35, p < 0.01; model R² 34%). Goals with greatest difficulty were mending clothing (-1.95 ± 0.35 logits) and hobbies and crafts (-1.32 ± 0.23 logits). Greater difficulty was associated with higher depressive symptomatology (β = 0.39, p < 0.001), lower visual acuity (β = 0.42, p < 0.001) and lower adjustment of visual loss (β = 0.31, p < 0.01; model R² 53%).

CONCLUSIONS

Key rehabilitation needs for adults at entry to services require both optical and non-optical interventions. As rehabilitative need was not associated with the level of visual impairment, eyecare professionals should not wait until the end of medical treatment before referral for support. Similarly, rehabilitative need was associated with younger age, indicating the importance to refer younger people with sight loss at an early stage. The use of structured assessment, such as the PAI, ensures goals that have an impact upon quality of life are specifically identified. Depression screening on entry to rehabilitation is relevant as it predicts both perceived difficulty and rehabilitative need.

Finding your own way around: Experiences of health and social care provision for people with a visual impairment in the United Kingdom

The systems of support for people with a visual impairment in the United Kingdom are complex and can be difficult to access, involving input from a range of health and social care services. In this article, we report qualitative findings from research looking at people’s experiences of accessing health and social care services. These highlight the inconsistencies and variability in existing systems of support for people with a visual impairment, and show that access to services is largely dependent on the agency and initiative of individual service users in establishing networks of support for themselves. This means that those who are less able to do this may find themselves without the support necessary to maintain or improve their quality of life. We argue that health and social care agencies need to be more proactive in addressing the support needs of people with a visual impairment beyond the point of initial diagnosis or registration.

Multisource evaluation of multidisciplinary low-vision services for children and young people

Professional bodies and healthcare commissioners recommend the provision of care for children and young people with sight impairment (SI) as a topic for quality improvement and service evaluation, but no unified evaluation tool is available. We aimed to develop and implement a tool to evaluate the quality of children’s low-vision services (LVS). We identified and reviewed available standards for LVS from government documents and surveys carried out by patient support organisations, developed a clinic proforma and six survey tools for families and professionals, and used these tools to carry out a first service evaluation of multidisciplinary LVS provided by children’s eye clinics, social services, and education teams for SI students in Bedfordshire and London, United Kingdom. The first service evaluation round showed that services provided are of high standard, but also identified specific areas for improvement such as provision of information in preferred format, formation of parent and young people support groups, and an unmet need for emotional support.

Evaluation of an emotional support service for the visually impaired

PURPOSE

To evaluate the impact of a facilitated peer group emotional support service on visual quality of life (VQoL).

METHODS

Consecutive participants in an emotional support service delivered to groups of up to six and facilitated by trained counselors were recruited (n = 29). The VCM1 (Vision Quality-of-life Core Measure) instrument was administered to participants at the start of the service, at the end of the service, and 6 months after completion of the service.

RESULTS

For the group as a whole, VQoL significantly improved between the beginning of the service and the end (F(1,23) = 16.43, p = 0.000) but was no better than at the start 6 months later (F(1,23) = 3.60, p = 0.07). However, those with poorer initial VQoL showed significantly greater improvements after 6 months (1.74 ± 2.21 logits) than those with higher initial VQoL (-0.12 ± 0.71 logits) (t23 = 2.89, p = 0.008). The effect size of the intervention for those with poor initial VQoL was 1.10 at the end of service and 0.92 after 6 months. The items that became and remained easier were "feeling lonely or isolated due to eyesight," "feeling sad or low due to eyesight," and "feeling worried about general safety outside the home."

CONCLUSIONS

This facilitated peer group emotional support service significantly improves VQoL as assessed with the VCM1 over at least 6 months for those with poorer initial VQoL. Different interventions may be needed for those with initially good VQoL and to improve other aspects of QoL not influenced by the service.

Micro-costing the provision of emotional support and information in UK eye clinics

Background

Sight loss has wide ranging implications for an individual in terms of education, employment, mobility and mental health. Therefore there is a need for information and support to be provided in eye clinics at the point of diagnosis of sight threatening conditions, but these aspects of care are often missing from clinics. To meet these needs, some clinics employ an Eye Clinic Liaison Officer (ECLO) but the position has yet to be widely implemented. The aims of this study were:

(1) To evaluate the forms of advice and emotional support in eye clinics provided by ECLOs.

(2) To determine the cost of the ECLO service per patient.

Methods

Micro-costing was carried out using interviews, a survey and administrative data. The survey was completed by 18 of the 49 accredited ECLOs in the UK (37%) and provided information on the activities performed by ECLOs, numbers of patients seen per day, training costs incurred and the salary of the ECLOs.

Results

ECLOs provided information about the services in eye clinics and the community, referral to social services, emotional support to patients and also other advice. The cost of an ECLO per patient per contact was £17.94 based on an average annual ECLO salary of £23,349.60 per year, reviewing on average 9.1 patients per day, in a 42 week year.

Conclusions

This study provides the first costing of support services in hospital eye clinics, providing a range of estimates to suit the circumstances of different clinics. The information can be used by local decision makers to estimate the cost of implementing an ECLO service.

Are rehabilitation services for patients in UK eye clinics adequate? A survey of eye care professionals

PURPOSE

The purpose of this study is to determine whether specific services such as emotional and family support are currently available in the United Kingdom for people with visual impairment.

METHODS

A validated online survey was created and distributed to clinical staff in eye clinics (for example, ophthalmologists and optometrists) and rehabilitation staff (for example, social and rehabilitation workers) in the community, who worked with people with visual impairment. A total of 67 clinical and 42 rehabilitation staff completed the entire survey online.

RESULTS

Only 67% of the respondents claimed their clinics provide emotional support and 44% of respondent's clinics provided family support. Clinical and rehabilitation staff have differences in opinion over what constitutes an essential service for a visually impaired patient. Rehabilitation staff considered emotional support and referral to social services as essential more often than clinical staff (P<0.05). There is some confusion over the type of personnel who provides each type of service, with some services showing substantial repetition.

CONCLUSION

In the clinics sampled, there appears to be an underprovision of emotional support (attentive listening plus constructive suggestions) and family support (emotional support and advice for family members) for visually impaired patients in the United Kingdom. There also seems to be some discrepancy in services that eye care professionals feel are available and previous reports by visually impaired patients of the service they receive. There is a need to develop standardised pathways across the United Kingdom, to solve some of these issues.