Personalized Telerehabilitation for a Head-mounted Low Vision Aid: A Randomized Feasibility Study

Head-mounted Devices for Low Vision: A Review

Head-mounted devices (HMDs) are wearable electronic tools designed to augment the visual experience of low-vision patients who have a decrease in vision not improved by refractive correction. They do so by addressing various principles of visual enhancement, including magnification, illumination, increased field of view, and contrast sensitivity enhancement, among others. Since the introduction of the first HMD 3 decades ago, advancements in technology have made these devices more lightweight and practical for everyday use. More sophisticated features have been developed, including augmented reality, virtual reality, text-to-speech, and blind spot remapping. However, despite these advancements, HMDs still face a host of challenges, including cost, customizability to specific patient factors, and social stigma. In this paper, we present a broad overview of HMDs, review major products available commercially, and discuss the challenges and future directions for this rapidly growing field.

Feasibility of telerehabilitation to address the orientation and mobility needs of individuals with visual impairment: perspectives of current guide dog users

OBJECTIVE

To assess guide dog users' perspectives on the feasibility of telerehabilitation for their O&M needs.

METHOD

An online survey gathered insights from 56 guide dog (GD) users (Mean age = 59, Mean GD used = 4, Mean duration of use = 22 years). Thirteen GD users further participated in interviews or focus groups to explore survey responses. Data were analyzed using content analysis.

FINDINGS

Most (40) were blind, and 16 had low vision, with intermediate (25) and advanced (25) communication technology proficiency. Most GD users (46) underwent residential training, and 10 received one-on-one visits. Qualitative analysis revealed acceptance of telerehabilitation services, citing accessibility as an advantage. However, GD users expressed concerns about safety, potential loss of behavioral observation, and social contact loss. Success depended on the type of technology, service type, and personal attributes.

CONCLUSION

While feasible, telerehabilitation services may not be universally suitable for all training stages. Flexibility and applicability in service design are necessary to accommodate individual preferences and experience levels.

Evaluation of a Retinal Projection Laser Eyeware in Patients with Visual Impairment Caused by Corneal Diseases in a Randomized Trial

PURPOSE

Patients with incurable corneal diseases experience visual impairment (VI) despite having a healthy retina and optic pathway. Low-vision aids (LVAs) can optimize the use of remaining vision through magnification and contrast enhancement, but do not harness the full visual capacity because they rely on the optic media. Therefore, we investigated a novel laser eyewear (LEW) technology that bypasses the anterior segment of the eye. Images captured by an integrated camera are projected directly onto the retina using a low-energy laser. The patient is able to view a full-color video, realized as augmented reality. We aimed to evaluate the efficacy of the LEW to enhance the vision of individuals with corneal diseases.

DESIGN

Prospective, randomized, crossover clinical trial.

PARTICIPANTS

We examined the retinal projection glasses in 21 patients (25-69 years) with VI (0.7 logarithm of the minimum angle of resolution [logMAR] or worse) resulting from corneal diseases. Patients with comorbidities that impact vision, such as retinal disorders, were excluded.

METHODS

Standardized measurements of visual acuity (VA) for near vision (NV) and distance vision (DV) were conducted using ETDRS charts with the respective best correction (BC) and then with LEW. In addition reading speed, vision-related quality of life (QoL) and capacity to carry out daily tasks were assessed at an initial visit and at 2 subsequent visits after a home phase with and without the device. Six weeks after last use of the LEW, an ophthalmologic examination including spectral-domain-OCT or full-field-electroretinography was conducted and compared with baseline findings to evaluate the safety of the device. Four patients participated and completed a subsequent 12-month follow-up phase.

MAIN OUTCOME MEASURES

Improvement of VA using the LEW. Secondary objectives included safety, reading speed, QoL, and usability in daily activities.

RESULTS

The mean VA in patients with VI was improved by 0.43 logMAR in DV using the LEW compared with BC (P < 0.0001). Using the ×2 magnification mode of the LEW resulted in an average improvement of 0.66 logMAR compared with BC (P < 0.0001). In NV, an increase of 0.47 logMAR was achieved compared with BC (P < 0.0001). Although only 4 of 21 participants were able to read with BC, 17 of 21 participants were able to read with the LEW. Quality of life significantly improved in the 17 participants who completed all visits.

CONCLUSIONS

We demonstrated that the retinal projection glasses resulted in enhanced VA for all participants by directly projecting images onto the intact retina. In future, the LEW could represent a new option as an LVA for patients with corneal diseases. No pathological alterations were observed in the safety assessments.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Disability digital divide: survey of accessibility of eHealth services as perceived by people with and without impairment

BACKGROUND

Sustainable and effective eHealth requires accessibility for everyone. Little is known about how accessibility of eHealth is perceived among people with various impairments. The aim of this study was to compare use and perceived difficulty in the use of eHealth among people with and without impairment, and how different types of impairment were associated with perceived difficulty in the use of eHealth.

METHODS

This study used data collected in a nationwide survey in Sweden. Snowball sampling was used to recruit participants with self-reported impairment, from June to October 2019. In February 2020, the survey was posted to people in the general population who were matched to the participants with impairment by age, gender and county of residence. Multiple logistic regression was used to analyse the use of four eHealth services, and perceived difficulty in the use of six eHealth services.

RESULTS

In total, 1631 participants with, and 1084 participants without impairment responded to the survey. Participants with impairment reported less use and more difficulty in the use of all eHealth services as compared to participants without impairment. When comparing types of impairment, booking healthcare appointments online was least used and most avoided by participants with communication, language and calculation impairments (adjusted odds ratio (aOR) use 0.64, 95% confidence interval (95%CI) 0.49-0.83; aOR avoid 1.64, 95%CI 1.19-2.27), and intellectual impairments (aOR use 0.28, 95%CI 0.20-0.39; aOR avoid 2.88, 95%CI 1.86-4.45). The Swedish national web-portal for health information and services, 1177.se, was reported difficult to use the most among participants with communication, language and calculation impairments (aOR 2.24, 95%CI 1.50-3.36), deaf-blindness (aOR 11.24, 95%CI 3.49-36.23) and hearing impairment (aOR 2.50, 95%CI 1.17-5.35).

CONCLUSIONS

The results confirm the existence of an eHealth disability digital divide. People with impairment were not one homogeneous group, but differed in perceived difficulties in regard to eHealth. Based on a purposeful subgrouping of impairments, we showed that people with communication, language and calculation impairments, and intellectual impairments, reported least use and most difficulty in using eHealth. The findings can guide further research in creating eHealth that is accessible for all, including those with the most significant difficulties.

Telerehabilitation for people with low vision

BACKGROUND

Low vision affects over 300 million people worldwide and can compromise both activities of daily living and quality of life. Rehabilitative training and vision assistive equipment (VAE) may help, but some visually impaired people have limited resources to attend in-person visits to rehabilitation clinics to be trained to learn to use VAE. These people may be able to overcome barriers to care through access to remote, internet-based consultation (telerehabilitation).

OBJECTIVES

To compare the effects of telerehabilitation with face-to-face (e.g. in-office or inpatient) vision rehabilitation services for improving vision-related quality of life and near reading ability in people with visual function loss due to any ocular condition. Secondary objectives were to evaluate compliance with scheduled rehabilitation sessions, abandonment rates for VAE devices, and patient satisfaction ratings.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register) (2021, Issue 9); Ovid MEDLINE; Embase.com; PubMed; ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any language restriction or study design filter in the electronic searches; however, we restricted the searches from 1980 onwards because the internet was not introduced to the public until 1982. We last searched CENTRAL, MEDLINE Ovid, Embase, and PubMed on 14 September 2021, and the trial registries on 16 March 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) or controlled clinical trials (CCTs) in which participants diagnosed with low vision had received vision rehabilitation services remotely from a human provider using internet, web-based technology compared with an approach involving in-person consultations.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts retrieved by the searches of the electronic databases and then full-text articles for eligible studies. Two review authors independently abstracted data from the included studies. Any discrepancies were resolved by discussion.

MAIN RESULTS

We identified one RCT/CCT that indirectly met our inclusion criteria, and two ongoing trials that met our inclusion criteria. The included trial had an overall high risk of bias. We did not conduct a quantitative analysis since multiple controlled trials were not identified.  The single included trial of 57 participants utilized a parallel-group design. It compared 30 hours of either personalized low vision training through telerehabilitation with a low vision therapist (the experimental group) with the self-training standard provided by eSight using the eSkills User Guide that was self-administered by the participants at home for one hour per day for 30 days (the comparison group). The trial investigators found a similar direction of effects for both groups for vision-related quality of life and satisfaction at two weeks, three months, and six months. A greater proportion of participants in the comparison group had abandoned or discontinued use of the eSight Eyewear at two weeks than those in the telerehabilitation group, but discontinuance rates were similar between groups at one month and three months. We rated the certainty of the evidence for all outcomes as very low due to high risk of bias in randomization processes and missing outcome data and imprecision.   AUTHORS' CONCLUSIONS: The included trial found similar efficacy between telerehabilitation with a therapist and an active control intervention of self-guided training in mostly younger to middle-aged adults with low vision who received a new wearable electronic aid. Given the disease burden and the growing interest in telemedicine, the two ongoing studies, when completed, may provide further evidence of the potential for telerehabilitation as a platform for providing services to people with low vision.

Acceptability of Telerehabilitation for Magnification Devices for the Visually Impaired Using Various Approaches to Facilitate Accessibility

Purpose

We examined different methods to reduce the burden of accessing technology for videoconferencing during telerehabilitation for magnification devices for the visually impaired.

Methods

During telerehabilitation studies over the past 5 years, vision rehabilitation providers assessed and gave training to visually impaired participants with newly dispensed magnification devices at home who connected to Zoom videoconferencing via loaner tablets or smartphones with assistance from (phase 1; n = 10) investigators by phone, (phase 2; n = 11) local Lions Club volunteers in participants’ homes, or (phase 3; n = 24) remote access control software in a randomized controlled trial with 13 usual care controls who received in-office training. All participants completed the same post-telerehabilitation phone survey.

Results

A significantly greater proportion of phase 3 subjects indicated they strongly or mostly agreed that the technology did not interfere with the session (96%) compared to phase 1 (60%; 95% confidence interval [CI], 1.2–12.5; P = 0.03) or phase 2 (55%; 95% CI, 1.8–188; P = 0.01). The majority indicated telerehabilitation was as accurate as in person (68%), they were comfortable with telerehabilitation (91%) and interested in a future session (83%), and their magnifier use improved (79%), with no significant differences in these responses between phases (all P > 0.10), including comparisons of participants randomized to telerehabilitation or in-office training in phase 3 who reported similar overall satisfaction levels (P = 0.84).

Conclusions

Participants across all phases reported high levels of acceptance for telerehabilitation, with least interference from technology using remote access control in phase 3.

Translational Relevance

With accommodations for accessibility to videoconferencing technology, telerehabilitation for magnification devices can be a feasible, acceptable, and valuable option in countries with resources to support the technology.

Scoping review of remote rehabilitation (telerehabilitation) services to support people with vision impairment

OBJECTIVE

Telerehabilitation for individuals with vision impairment aims to maintain maximum physical and/or psychological functioning through remote service delivery. This review aims to describe the type of telerehabilitation services available to people with vision impairment and summarise evidence on health-related outcomes, well-being and cost-effectiveness.

DESIGN

Scoping review.

DATA SOURCES

CINAHL Plus, MEDLINE, PsycARTICLES, PsychINFO, Embase, PubMed, HMIC and Ovid Emcare were searched, without date restrictions up to 24 May 2021. Charity and government websites, conference proceedings and clinical trial databases were also examined.

ELIGIBILITY CRITERIA

Eligible studies evaluated benefits of telerehabilitation services for adults with vision impairment. Studies were excluded if they were not available in English, or focused on distance learning of visually impaired students.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened articles and extracted data. A risk of bias analysis was performed.

OUTCOME MEASURES

Measures of benefit included performance-based assessment, patient-reported outcomes and cost-effectiveness.

RESULTS

Of 4472 articles, 10 eligible studies were included. Outcomes addressed patient satisfaction (n=4;33.3%), quality-of-life, activities of daily living and well-being (n=4;33.3%), objective visual function (n=2;16.6%) and knowledge relating to ocular symptoms (n=1;8.3%). Two studies addressed multiple outcomes. Cost-effectiveness was addressed in one article (8.3%). Patients were generally satisfied with their experiences, which had a range of positive benefits on functional and quality-of-life outcomes in areas relating to daily activities (eg, reading, making phone calls). Telerehabilitation allowed patients to undertake vision optimisation training to prevent vision deterioration. Grey literature indicated that there are no completed clinical trials relating to low vision telerehabilitation. Charity services had implemented digital skills training to help beneficiaries communicate remotely.

CONCLUSION

While acceptability of telerehabilitation was mostly high, limited real-world data are available which raises questions around the long-term desirability of this approach. Further trials are needed to evaluate telerehabilitation using a robust set of outcome measures.

PROSPERO REGISTRATION NUMBER

CRD42021254825.

Head-mounted Visual Assistive Technology-related Quality of Life Changes after Telerehabilitation

SIGNIFICANCE

Head-mounted low vision devices have become a viable alternative to enhance residual vision. This study supports the use of a head-mounted display to improve aspects of functional vision and quality of life. Much is still unknown regarding the required frequency, duration, or potential effectiveness of this telerehabilitation training protocol or what characteristics best identify optimal users.

PURPOSE

A randomized study explored the effect of telerehabilitation on quality of life and functional vision in individuals with low vision using a head-mounted display.

METHODS

We recruited 57 participants (age, 21 to 82 years; mean, 54.5 years) among new prospective eSight Eyewear users, randomized 1:1 into two parallel groups; the experimental group received the telerehabilitation training provided by a low vision therapist, whereas the control group received the self-training standard offered by the device manufacturer and without involvement of a low vision therapist. The primary outcome measures were the impact of telerehabilitation on validated measures of assistive technology-related quality of life: the Psychosocial Impact of Assistive Devices Scale and the Quebec User Evaluation of Satisfaction with Assistive Technology scale. Exploratory outcomes were the assessment of self-reported functional vision using the Veterans Affairs Low Vision Visual Functioning Questionnaire-48 and cybersickness associated with head-mounted display use with the Simulator Sickness Questionnaire.

RESULTS

Assistive technology-related quality of life was improved when measured by the satisfaction scale but not the psychosocial scale within the first 3 months, independently of training type. Overall, functional vision improvement was observed within the first 2 weeks of device use and maintained during the 6-month study, independently of group type. Cybersickness outcomes were similar between training groups and did not change significantly for 6 months.

CONCLUSIONS

eSight Eyewear, either with telerehabilitation or with the manufacturer self-training comparison, improved functional vision and increased users' quality of life within the initial 3 months of device training and practice.