Making Eye Health a Population Health Imperative Vision for Tomorrow (2016) / Chapter Skim
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8 Meeting the Challenge of Vision Loss in the United States: Improving Diagnosis, Rehabilitation, and Accessibility
8 Meeting the Challenge of Vision Loss in the United States: Improving Diagnosis, Rehabilitation, and Accessibility
Pages 381-426
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From page 381... ...
. However, even if all preventable cases of vision impairment were eliminated, millions of Americans would still live with vision impairment because of limits in the ability to prevent and manage eye disease.
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As noted in Chapter 1, this report will use the term vision impairment, rather than low vision, to describe patients with functional limitations of the eye(s) or visual system that result from vision loss.
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VISION REHABILITATION INTERVENTIONS AND MODELS Overview of the Vision Rehabilitation Process Vision rehabilitation services comprise a wide array of models of care and interventions and services provided by numerous professionals working in varied clinical settings to accomplish a diverse range of goals. According to the National Eye Health Education Program of the National Eye Institute (NEI)
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This overarching model describes vision rehabilitation as a process of care that begins with examination and diagnosis, followed by development of a treatment plan, and then proceeds to management of vision impairment (Markowitz, 2006b)
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. To address these problems, vision rehabilitation treatment plans may include prescription of, and training in the use, of low vision aids and devices, orientation and mobility training, modification of home and work environments to promote functioning and safety, training in adaptive strategies and skills, and counseling, among other interventions and services (Binns et al., 2012; Markowitz, 2006b; Mogk and Goodrich, 2004; Ryan, 2014)
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From page 386... ...
compared the effects of vision rehabilitation to no treatment on reading ability, mobility, visual information processing, and visual motor skills among 126 adults with vision impairment (Stelmack et al., 2008) .3 Over 4 months, participants receiving vision rehabilitation achieved significant improvements in all functional domains, while those receiving no treatment experienced declines in all functional domains.
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From page 387... ...
. Among children ages 6 to 16 with vision impairment, prescription of, and training on, low vision aids significantly improved near and distance visual acuity and self-reported ability to perform activities such as reading textbooks and copying from a blackboard (Ganesh et al., 2013)
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. Low vision therapists and vision rehabilitation therapists may assist patients with vision impairment in adapting their work and
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Furthermore, several types of providers, including low vision therapists and orientation and mobility specialists, are not recognized as providers by Medicare and, as a result, cannot be compensated by Medicare for the care of beneficiaries with vision impairment. The following section describes in greater detail the interventions that clinicians, therapists, and specialists provide in the course of treatment.
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From page 390... ...
Orientation and Mobility Training Performance in mobility-related activities is a common concern among patients seeking vision rehabilitation services. In the Low Vision Rehabilitation Outcomes Study, 16.3 percent of participants reported difficulty with walking or with daily activities outside the home (Brown et al., 2014)
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. Research into the impact of these interventions is limited: a recent systematic review of environmental interventions for individuals with vision impairment found no RCTs or
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For example, one study found that reading performance among study participants with vision impairment consequent to AMD was significantly improved under optimal lighting levels as compared to the lighting level found inside most homes and other buildings (Bowers et al., 2001)
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. A systematic review of the effectiveness of eccentric viewing training for improving performance of daily visual activities in individuals with vision impairment consequent to AMD included five studies that had reported statistically significant improvements in reading speed, maximal reading speed, duration of reading, reading comprehension, and performance in daily activities (Hong et al., 2014)
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From page 394... ...
For example, one study comparing conventional vision rehabilitation services (i.e., examination and provision of low vision aids and support services by a multidisciplinary team) to enhanced services (usual care plus an 8-week self-management program to develop problem-solving and coping skills)
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.7 In a follow-up study, standard low vision therapy (i.e., examination, education on eye disease, training in 7 Moderate to severe vision impairment was defined as visual acuity worse than 20/100 and better than 20/500 in the better-seeing eye.
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. Further research is needed to assess the effectiveness and cost-effectiveness of other components of the VA blind rehabilitation services, including intermediate and advanced vision impairment clinics.
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. Studies on populations outside the United States suggest that selfmanagement education programs can improve perceived security in the performance of several daily activities among patients with vision impairment consequent to AMD, and can increase awareness of low vision aids and practical strategies to optimize use of remaining vision among caregivers of patients with vision impairment (Dahlin Ivanoff et al., 2002; Larizza et al., 2011)
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Subsequently, an optometrist performed an examination and offered low vision aids or rehabilitation services (e.g., occupational therapy, orientation and mobility, peer support, community services) as appropriate.
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Based on the National Health Service Hospital Eye Service model, the Welsh Low Vision Service includes assessment of patient needs and goals, provision of low vision aids, patient education on vision rehabilitation services and interventions, referral to other services, and follow-up care (Ryan et al., 2010)
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BARRIERS AND OPPORTUNITIES IN VISION REHABILITATION There are several potential barriers to developing a universally highquality and accessible vision rehabilitation system. A lack of awareness of the purpose and effectiveness of vision rehabilitation among medical providers, public health workers, and patients may unnecessarily limit the utilization of vision rehabilitation services by patients with vision impairment.
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. Other studies have shown that patients with vision impairment may not attend vision rehabilitation services because they may not believe that vision rehabilitation will be helpful or may not identify themselves as having an impairment, or may believe that vision rehabilitation is only for 9 The survey defined low vision as a visual impairment that is not corrected by standard eyeglasses, contact lenses, medication, or surgery and that interferes with the ability to perform everyday activities.
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For example, one study found that among Australian patients with vision impairment who followed up on a referral to vision rehabilitation services, 85.4 percent cited receiving a referral to and/or information about vision rehabilitation services as a facilitating factor in the decision to attend vision rehabilitation (O'Connor et al., 2008)
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Figure 8-2 depicts how the relationship between vision rehabilitation services and the surgical and medical services described in Chapter 7 could evolve toward an integrated model in which vision rehabilitation gradually assumes priority over medical and surgical care as functional limitations associated with chronic vision impairment increase.
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This workforce includes public health officials; epidemiologists; health policy analysts; nonprofit groups working in health care, vision care, or patient advocacy; insurance providers; administrators of health care organizations; research organizations; and health economists. The potential benefit derived from imparting knowledge about vision rehabilitation to the population health workforce is that members of each class of actor could use this information in accordance with their own interests, competencies, and professional obligations.
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Workforce Education and Capacity In considering ways to improve the value and increase the uptake of vision rehabilitation services for an increasing number of Americans with chronic vision impairment, the potential barriers related to the development of a competent multidisciplinary workforce should be addressed. The relatively limited number of optometric or ophthalmic residency or fellowship programs focused on vision rehabilitation may be one such barrier.
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. Another study found that 44.9 percent of vision rehabilitation patients had problems with emotional or psychological adjustments related to vision impairment and that 67.7 percent had problems or difficulties with driving (Owsley et al., 2009)
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From page 407... ...
However, studies on vision rehabilitation in Canada and Australia show that these barriers do exist in these other countries' health care systems. Among 702 Canadian adults ages 26 to 100 with vision impairment, those individuals with more education were more likely to be aware of and use vision rehabilitation services (Overbury and Wittich, 2011)
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NOVEL TECHNOLOGIES, NEW THERAPIES, AND PROMISING RESEARCH Between technological advances that increase the effectiveness of low vision aids, an urgent push to integrate counseling and other QOL interventions into models of vision rehabilitation, and research efforts to improve the quality of care, vision rehabilitation is undergoing dramatic and beneficial changes. This section will explore how technological advance, innovative clinical care and care models, and promising research are currently 14 All patients with worse than 6/12 visual acuity, or who reported functional or emotional difficulties because of their vision, were eligible to attend vision rehabilitation services.
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This section explores the current and emerging technologies that promote QOL among populations with vision impairment and discusses the role of intentional design in supporting the development of such technologies. Current and Emerging Technologies As discussed above, compromised reading ability is a common complaint of patients referred to vision rehabilitation services (Brown et al., 2014; Renieri et al., 2013)
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. Ongoing research is needed to support the development of new products and technologies that safely and effectively enhance the functioning and mobility of populations with vision impairment.
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. Addressing these research gaps and opportunities could accelerate development of new assistive technologies that improve independence, functioning, and QOL among individuals with vision impairment.
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Research findings suggest that novel vision rehabilitation treatment plans and training programs for providers working in vision rehabilitation may also improve clinical outcomes and care quality for patients with vision impairment and comorbid depression (Rees et al., 2012; van der Aa et al., 2015)
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New Therapies for General Medical Comorbidity Because most of the diseases that cause chronic vision impairment are age-related, many individuals who need vision rehabilitation have a host of other medical problems. An analysis of participants in the Medicare Expenditure Panel Survey found that "eye disorders" rarely occurred in isolation: more than 80 percent of beneficiaries with eye disorders also had at least one of the four other chronic conditions assessed (heart disease, diabetes, arthritis, or hypertension)
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While the study identified many such challenges related to comorbidity, it also identified potential solutions for each challenge. For example, the issue of "good days, bad days" might be addressed through flexible scheduling options that allow patients to stack appointments on "good days" or through Web-based or takehome materials that can supplement learning that may have suffered on a "bad day." CONCLUSION Vision rehabilitation is essential to maximizing the independence, functioning, participation, safety, and overall QOL of people with chronic vision impairment.
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• Research is needed to identify the vision rehabilitation needs of children, mi nority groups, developmentally disabled populations, individuals with common comorbidities of vision impairment, and populations living in medically under served areas, and to develop vision rehabilitation services and interventions that address these needs. • Research in needed to determine the extent of awareness of vision rehabilita tion among patients, providers, and the public health workforce in the United States, and to develop effective health education campaigns and other pro grams to eliminate lack of awareness of vision rehabilitation.
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2007. Care of the patient with visual impairment (low vision rehabilitation)
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2013. Occupational therapy interven tions to improve leisure and social participation for older adults with low vision: A systematic review.
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1999. Providing timely and ongoing vision rehabilitation services for the diabetic patient with irreversible vision loss from diabetic retinopathy.
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2012. The impact of low vision on activities of daily living, symptoms of depression, feelings of anxiety and social support in community-living older adults seeking vision rehabilitation services.
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2013. Occupational therapy interventions to improve performance of daily activities at home for older adults with low vision: A systematic review.
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2004. The history and future of low vision services in the United States.
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2015. A randomised controlled trial of a self-management programme for low vision implemented in low vision rehabilitation services.
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2013. Occupational therapy interventions to improve the reading ability of older adults with low vision: A systematic review.
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2010. Prevalence and patterns of co morbid cognitive impairment in low vision rehabilitation for macular disease.
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Paper prepared for the Committee on Public Health Approaches to Reduce Vision Impairment and Promote Eye Health. http://www.national academies.org/hmd/~/media/Files/Report%20Files/2016/UndiagnosedEyeDisorders CommissionedPaper.pdf (accessed September 15, 2016)
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