Safety first - Association for Education and Rehabilitation of the Blind
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Transcript Safety first - Association for Education and Rehabilitation of the Blind
Karen Squier, OD FAAO
AER INTERNATIONAL
JULY 19, 2012
SAFETY FIRST: MAINTAINING
SAFETY IN LOW VISION PATIENTS
Objectives
To identify and describe elements of the
low vision exam that potentially identify
areas of safety concerns
To translate exam elements that assist in
identifying need for further rehabilitation
Why Safety?
Here’s why…
Falls are the leading cause of accidental
death in people over the age of 65
Over 100,000 people die per year from
accidental overdose or errors in
administration of prescription meds
Less than 2% use assistive devices to
assist with daily activities to improve
safety
Vision Rehabilitation
Goal is to improve visual function
Improve performance of independent skills
Improve safety in natural environment
Maintain desired level of quality of life
Maximize visual potential
Maintain employment or scholastic goals
Vision Rehabilitation
Integrates information from multiple
resources to assess patients visual
abilities
Medical Ophthalmologist/Optometrist
Rehabilitation Optometrist
Rehabilitation Teacher/Occupational Therapist
Orientation and Mobility Instructor
Social Worker
Vision Rehabilitation
Through rehabilitation process information
regarding patient’s personal safety may
come forward
Ability to travel safely
Ability to manage medications
Ability prepare meals and maintain proper
nutrition
Safety Goals for patients
Increase safety awareness in patients with
visual impairment
Safety Goals for Patients
Identify and educate patients on potential
areas of concern
Diagnosis
Cognition
Exam findings
Support system
Family
Community
Safety Goals for Patients
Implement rehabilitation plan
Consider use of assistive devices
Utilize strategies and training to improve
safety in the home and other environments
When possible, confer with family members or
other members of support system
Referral for appropriate community resources
Case History
The “getting to know you” part of the exam
Medical history
Vocational/educational history
Performance of ADL’s
Driving status
Rehabilitation Goals
Understanding and acceptance of vision loss
Case History
Most important part of exam
Start with open ended questions
Allow patient to give their own description
of difficulties or successes
Try to remain objective and nonjudgmental with tone or body language
Uncover patient’s impression of vision loss
Case History
Also need to ask pointed questions
Can you travel safely and independently?
Have you had any falls
Do you drive? Have you had any accidents?
Can you see street signs and lights from a
safe distance?
Can you prepare your own meals? Are you
able to see the dials on the stove? Have you
ever had any burns?
Case history
Some areas of questioning may alert the
need for further testing
Difficulty with memory of activities
Family members correcting mis-information
Difficulties with dates and times
Inappropriate responses to normal questioning
Defensiveness, anger
Case History
Consider screening of memory, mental
health and cognition
May indicate need for assessment with
psychologist or counseling
Mini-Mental State Exam
Assessment for adjustment to vision loss or
underlying depressive disorders
Case History
Potential Referrals
Department of Human Services
Department on Aging
Meals on Wheels
Psychologist/Social Worker
Cognition
Cognition
Patients may exhibit difficulties with
memory, reasoning and judgment
Some patients and family members are
forthcoming about such difficulties
Source of frustration and embarrassment
for some
Cognition
Incorporate screening as part of exam for
cognitive impairment
Helps indicate ability for patient to
independently manage self care
Time to administer exam will increase as
patient has increased difficulties
Make sure you have time before starting
exam!
Cognitive Screening
Several tests are available
Depending of level of vision loss, some
tests may need to be modified.
Potential screening tests
Mini-Mental State exam (MMSE)
Montreal Cognitive Assessment (MOCA)
Mini-Mental State Exam (MMSE)
Montreal Cognitive Assessment (MOCA)
Cognition
MOCA more sensitive to assessing mild
cognitive impairment than MMSE
With visual impairment, some aspects of
exam change
Does not take into consideration some
visual abilities and its identification of
cognitive delays
Visual Acuity
Vision
Ability to see details, objects and their
environment
Typically measured with high contrast
charts
Snellen most common test in primary care
Test is typically begun at 20 foot distance
Vision
Visual acuity is a valuable measurement
Measures disease progression
Assists in determining magnification
Determines disability
20/200 visual acuity equates to legally blind
status
20/70 visual acuity equates to visual impairment
Useful measure in uncovering spectacle blur
Vision
Changes in visual acuity
Alter ability to perceive environment
Street signs
Dials/buttons on stove
Change depth perception
Reaching for objects
Pouring liquids
Stepping off curbs
Vision deficits
To improve ability for eye to see detail
Best spectacle prescription
Puts vision in best focus
Reduces blur and defocus of light
Need to consider magnification options
Relative size magnification
Relative distance magnification
Angular Magnification
Magnification Strategies
Use relative size magnification
Recommend large print
Use bold pens and print larger
Use relative distance magnification
Use magnifiers and reading glasses
Get closer to objects of interest
Contrast Sensitivity
Contrast Sensitivity
Contrast sensitivity is the measurement of
the ability to discern and detect an object
against its background
Contrast Sensitivity
Measurement to assess ability for patient
to see object against a background
Measures quality of vision
Helps with object detection, recognition
and motion
Contrast sensitivity
Descriptive measurement of visual
ability
Identifies additional layers of visual
performance
Ginsberg et al stated “Contrast
sensitivity is the best predictor of visual
function”.
Potential causes of contrast loss
Glare: Poor lighting, sunlight
Inclement weather: Rain, Fog
Patterns
Poor image quality: faded ink, media
opacity
Age
Contrast sensitivity
Goal for rehabilitation increase threshold
Increase contrast detection and increase
patient sensitivity
Severe contrast loss is when <1.5 or 70 %
Need multidisciplinary approach
Rehabilitation teachers, OT, O&M
Diseases causing contrast loss
Ocular diagnosis
Certain diagnoses are more likely to give
contrast sensitivity measurements than others
Optic nerve conditions
Corneal disease or treatments
Cataracts
Diabetic retinopathy
Retinitis pigmentosa
Glare
Quality of image is degraded by excessive
light
Can be related to quality of light or ocular
health
Poor light position
Warmth of light source
Reflection off of image source
Glare
Recovery from bright lights takes 8 times
longer over the age of 58
Greater than 3 minutes to recover from 1
minute of light exposure.
Poses increased difficulty adjusting from light
to dark and potentially decreased safety
Think of an older man walking indoors from
working in the garden
Contrast sensitivity
Depending on contrast of object of interest
and contrast sensitivity of patient success
may vary
Need to evaluate contrast of object of interest
and compare to contrast sensitivity of patient
Contrast enhancement strategies may
improve appreciation of an object, but not to a
functional level
Dictates whether modifications can be simple
to complex
Recommendations
Poor contrast translates to wide spectrum
of difficulties
OT/RT
O&M
Driver’s Rehabilitation
Assistive Technology assessment
Visual Fields
The visual field is defined as the total area
in which stimuli can be seen in the
peripheral vision from a central point
The binocular human visual field normally
extends horizontally over approximately
180 degrees. The peripheral visual fields
have temporal resolution and motion
detection (Rizzo & Kellison)
Visual Field Loss
With reduction in visual field, people tend
to change their normal gait
Slow speed of walking
Increase step length
Plays a factor when walking on unsteady
ground or ice
Increases difficulty walking in a crowd
(Jansen et al, 2011)
Visual Fields
The visual field facilitates accurately
detecting and locating an object, even in
the periphery, and is more important for
drivers than the ability to clearly detect
details in an object (visual acuity) (Owsley
& McGwin,
Visual field loss
Causes of visual field loss
Optic nerve disease
Glaucoma
Optic Neuropathy
Acquired Brain Injury
Retinal disease
Retinitis pigmentosa
Retinal detachment
Visual Field
Ocular conditions can reduce amount of
peripheral vision
Glaucoma
Retinitis pigmentosa
Diabetic Retinopathy
Brain injury
Vision while walking
Scottish Sensory Center
Think of visual function with these VF….
Lund and Rose, Eye, 2012
Useful Field of view
Area from which one can extract visual
information in a brief glance without
head or eye movement.
Limited by
Poor vision
Poor attention
Slower processing or cognitive ability.
Recommendations
Assistive devices for field awareness
Orientation and mobility
RT/OT
Driver’s rehabilitation
Driving
Visually impaired drivers
Drive less
Take less risks
Drive in daylight
Drive in familiar areas
*Mr. Magoo stereotype is not accurate.
Traffic related injuries
Visual field loss number one visual factor
related to crashes
Significant visual field loss increase
likelihood of crash six times
Cataracts were the number one diagnosis
for at-fault crashes
Driving with visual impairment
Need to adhere to state requirements for
driving
Need to be realistic about driving abilities
Need to realize even the shortest, most
familiar route changes
Driving with poor contrast
Drivers need to be counseled on contrast
findings
Contrast sensitivity can alter motion
detection and object perception
Weather conditions can further degrade
visual function
Traffic related injuries
Children with visual impairment were 4
times more likely to have an injury as
pedestrians than passengers
Automobile crash injuries were linked with
visual field loss, poor vision, depth
perception and diagnosis of glaucoma
Falls
Falling
Reduce fall and injuries for patients with
visual impairments
1.7 times more likely to have one fall
1.9 times more likely to have multiple falls
Falls
Numbers may be much higher
Workers tend to not report some injuries
Older adults may not want to concern or alert
family members to a problem
Children may not think of telling anyone or
don’t want to embarrass themselves
Risk factors for falls
Poor contrast sensitivity
Decreased visual acuity
Diagnosis of Glaucoma*
One study correlated increased falls in
patients who use glaucoma drops; did not
measure visual abilities
Decreased depth perception
Risk of falling
Outside of visual impairment
Consider type of flooring
Shoes!!
Lighting
Uneven Floors and steps
Clutter and weather
Rugs
Critters
Community Resources
Requires evaluating patients from a
holistic standpoint
Utilize current resources, technology, funding
in a manner that enhances role of VI individual
in community
Develop and integrate strategies to improve
access to resources for VI patients
Department on Aging
Determines needs and gives resources to
those in need
Emergency Food, clothing and shelter
Elder-abuse and Neglect
Provides support to those who are being
neglected or are in a self neglect situation
Well-being checks
In Person or on Telephone
Department on Aging
Energy assistance program
Supplemental nutrition program
Medicare low income subsidy program
Financial Assistance
Meals on wheels, Nutrition Sites and Food
pantries
Department of Human Resources
Provide assistance for people with
disabilities to remain employed, attend
school and live independently
Each individual has specific needs and
need to address each patient individually
Need to relay patient goals
Need to understand patient’s motivations and
abilities
Department of Human Services
Referral should have information that is
pertinent to the patient’s performance
Visual acuity
Visual Field
**Consider what pieces of information you
learned through the exam that helped you
change your strategies…helpful to relay those
pieces of information as well.
Resources for Children
Increasing need that is not being met
One in three children receive an eye exam
before age 6
According to Kirchner and Diament, in 1999
57% of children with VI also had another
disability
Requires education and understanding of
parents and guardians by pediatricians
Referrals for Children
Make sure school district is aware of
child’s vision impairment
Vision Teacher
Orientation and Mobility
Assistive Technology
Make sure parent understands the value of
access to this level of care
In Illinois, lack of support groups and after
school programs for children
Support system
Essential for patients to have a support
system
Aids in understanding education
Aids in rehabilitation implementation
Maintains social network and interactions
Helps point our areas of potential safety
concerns
Support Groups
Aids with acceptance
Improves social interactions
Learn new tips and techniques
Talk about peripheral issues related to
vision loss
Important to know who is administering
support group
Conclusion
Safety in patients with vision loss should
be assessed during the low vision exam
Elements of the eye exam may identify
specific areas that require further
assessment
Referrals to rehabilitation professionals
and community resources should be
pursued
Questions??
Thank you!!!!
Contact information
Karen Squier, OD FAAO
[email protected]
312.997.3686