Introduction to Low Vision Rehabilitation

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Introduction to Low Vision Rehabilitation
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Learning Objectives

• Understand the role of vision in adaptation
• Understand the characteristics of low vision
• Understand how low vision affects occupational
  performance
• Understand how low vision rehab services are
  provided in the US

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What does vision contribute to occupational
performance?
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• The overall function of the brain is to filter,
  organize and integrate sensory information to
  make an adaptive response to the environment.
• Jean Ayres

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Vision is the primary sensory system used to
acquire information about the environment

• 80-90 of all learning occurs through the visual
  channel
• 90 of all sensory information supplied to the
  CNS is visual

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Vision is our most far reachingsensory system

• First to alert to danger or pleasure
• Enables us to be anticipatory
• And plan for situations

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Contributions of Visual Input

• Supplies information needed for cognitive
  functions of problem solving and decision making
• Supplies information needed to interpret social
  interactions
• Supplies input for motor and postural control
• Impetus for motor development
• Warns of upcoming challenges to postural control

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• Supplies speed in information processing
• That speed is critical to the ability to adapt to
  dynamic environments
• Static environment nothing moving but person
• Dynamic environment objects are in motion
  independent of the person

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Contributions of Vision to Occupational
Performance
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Contributions of Vision to Occupational
Performance

• Anticipates/plans
• Drives decision making
• Interprets social interactions
• Supplies speed in information processing
• Dictates motor actions
• Early warning system for postural control

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Visual impairment can occur from

• Disease
• Trauma
• Aging
• Combination of any or all of the above

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Visual impairment can

• Alter the quality and quantity of visual input to
  CNS
• Alter CNS ability to use incoming visual input
• Result in a decrease in the ability to use vision
  for occupational performance
• Alter cognitive performance
• Can cause
• Anxiousness and uncertainty
• Decreased confidence
• Increased passivity

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If vision is so important to occupational
performance, why is visual impairment so often
overlooked in evaluation and treatment?
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A Because it is a hidden disability and its
symptoms are often attributed to other causes
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Because of the importance of vision to
occupational performance, a person with vision no
matter how limited will attempt to use vision to
adapt
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• Therefore it is more natural to train a person to
  use his/her available vision more efficiently
  than to learn to use sensory substitution

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Visual Perception

• Integration of visual input within CNS to turn
  the raw data supplied by the retina into
  cognitive concepts of the perception of objects
  and space which can be manipulated and used for
  decision making

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Visual Perceptual Hierarchy

• Visual perceptual function can be conceptualized
  as being organized into a hierarchy of processes
  that interact and sub-serve each other to
  provide integration of visual information

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Visual Cognition

• Use visual input to develop cognitive concepts
  which we apply in decision making and problem
  solving
• Basis of all academics
• Foundation for many vocations
• Cannot alter vision without altering cognition

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Scanning Searching

• Automatic/reflexive
• Spontaneous search for unexpected moving stimuli.
  
• Safety mechanism
• Voluntary and planned
• Completed in an organized, systematic, efficient
  pattern driven by cognition

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Visual Attention

• Critical component for complex visual processing
• Varies from global to focal depending on type of
  visual analysis needed
• Simultaneously employ at least 2 types of visual
  attention at all times

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Foundation Functions

• Oculomotor control
• Perceptual stability
• Visual acuity
• Visual clarity
• Visual field
• Awareness of objects

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All levels must work together

• Like parts of a car, loss or impairment of one
  level affects the functioning of all other levels
• Especially if a lower level function has been
  impaired

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Changes causing low vision are found at the
foundation level

• Visual field
• Visual acuity
• Oculomotor control

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Processes that comprise visual perceptual
processing
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Processes that comprise visual perceptual
processing

• Visual cognition
• Visual memory
• Pattern recognition
• Visual search and scanning
• Visual attention
• Oculomotor control
• Visual field
• Visual acuity

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What criteria dictate whether visual impairment
will be addressed in therapy?What is the
purpose of an O.T. evaluation?
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A patients visual performance is not significant
in terms of how it deviates from the norm but how
it interferes with occupational performance
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Whether or not a patient has a visual deficit
that requires remediation depends on his/her life
demands
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A patient has a visual deficit if his/her ability
to obtain and/or process visual information has
been altered to the extent it prevents completion
of a necessary activity of daily living
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The purpose of evaluation is not to diagnose or
label the deficit but to link the presence of the
visual deficit to a limitation in occupational
performance
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Observation of the patients functional
performance is the cornerstone of evaluation
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Two Treatment Approaches

• Person centered approach
• Emphasis is on changing the person
• Improving ability to take in and process visual
  information
• Environment centered approach
• Emphasis is on altering the environment to
  achieve a better person-environment fit
• Enable the person to respond with remaining
  capabilities

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Goal never changes.

• Goal is always occupational performance
• Only the method changes
• You will continue to provide occupational therapy

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What criteria dictate whether visual impairment
will be addressed in therapy?
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What criteria dictate whether visual impairment
will be addressed in therapy?

• A whether visual impairment has caused a
  limitation in occupational performance

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What is the purpose of the O.T. evaluation?
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What is the purpose of the O.T. evaluation?

• A To link the presence of a visual impairment to
  a limitation in occupational performance

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List the professions that provide low vision
rehabilitation
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Professions Providing LVR

• Ophthalmologists
• Optometrists
• Orientation and mobility specialists
• Rehabilitation teachers
• Vision teachers

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What is the difference between low vision and
legal blindness?
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Low Vision

• A visual impairment severe enough to interfere
  with occupational performance but allowing some
  usable vision

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Legal Blindness

• Term coined by federal government to describe
  visual impairment criteria qualifying persons for
  benefits and services
• Best corrected visual acuity of 20/200 or less in
  the better eye or
• A visual field of 20 degrees or less in the
  better eye

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WHO Visual impairment Levels ( for medical
coding)

• Normal vision 20/20 - 20/30
• Near normal 20/30 - 20/60
• Moderate impairment 20/80 - 20/160
• Severe impairment 20/160 - 20/400
• Profound impairment 20/400 - 20/1000
• Near blindness 20/1000 - 20/2500
• Blind no light perception

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What is the difference between low vision and
legal blindness?
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What is the difference between low vision and
legal blindness?

• Low vision describes the visual functioning of
  someone for whom regular eyeglasses or medical
  procedures cannot correct vision to within the
  normal range
• Legal blindness is eligibility criterion used to
  qualify persons for services

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Low vision is primarily an acquired condition

• Most persons with low vision grew up, worked,
  reared their families and retired as sighted
  persons

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3 diseases account for 90 of referrals to low
vision clinics

• Macular degeneration
• 60-90 of all referrals
• Glaucoma
• 13 of referrals
• Diabetic retinopathy
• 9, leading cause of blindness adults lt 50

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Disease Characteristics

• Age related
• One in four adults over 80
• Vision loss is permanent
• Treatment consists of management NOT cure

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What is the leading cause of low vision in the US?
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What is the leading cause of low vision in the
US?A Macular Degeneration
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What population cohort makes up the majority of
people with low vision?
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Low Vision Demographics

• For persons over 70, vision loss ranks 3rd among
  chronic conditions causing a need for assistance
  in ADL
• 2/3rds of low vision elderly have a secondary
  chronic physical impairment that affects
  occupational performance

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Vision loss is
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Vision loss is

• A womans issue

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Vision loss is

• A womans issue
• A race/ethnicity issue

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Vision loss is

• A womans issue
• A race/ethnicity issue
• A socioeconomic issue

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Most older adults with low vision live in their
own homes

• 70
• The goal of O.T. is to help them age in place

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What population cohort makes up the majority of
people with low vision?
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What population cohort makes up the majority of
people with low vision?

• A Adults over 65 years of age

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What two systems provide low vision
rehabilitation in the United States?
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Blindness System

• Well developed network of private, state and
  federal services
• Educational/vocational framework
• Primary service providers
• Rehabilitation teachers
• Orientation mobility specialists

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Reimbursement

• Private Sector
• Lighthouse, American Foundation for the Blind,
  Jewish Guild for the Blind etc.
• Veterans Administration
• 5 blind residential tx centers
• 3 blind rehab clinics
• 3 low vision rehab centers-VICTORS

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• State Vocational System
• Established with Rehabilitation Act of 1973
• Separate system for blind and visually impaired
• State commissions or divisions for blind
• 1978 amendment added independent living stream of
  funding
• 11 million dollars for entire US

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Health Care System

• Services reimbursed through medical insurance
• Requires physicians and licensed health care
  providers
• OT, PT, Social Services, Nursing, etc.
• Restorative not educational
• Service delivery not as comprehensive

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Prior to 1991

• Primary providers
• Ophthalmologists
• Diagnose and medically manage disease
• No rehab
• Optometrists
• Prescribed low vision devices
• No reimbursement for training

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After 1991

• HCFA ( now CMS) acknowledged vision loss as a
  physical impairment
• Enabled services provided by licensed health care
  providers to be reimbursed by Medicare
• Brought OT back into the field

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Current OT Structure in LVR

• No specific restrictions on treatment settings
• Can be provided in all settings covered by
  Medicare and third party payers
• Most programs are outpatient, hospital based
• Ophthalmology is the primary referral source

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• Older adults make up the majority of referrals
• Some programs see both brain injury and age
  related diagnosis
• Medicare is the primary payer source

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Healthcare vs. Blindness

• Consistent, adequate funding
• Adequate manpower
• Elderly are primary consumer
• Widely distributed services

• Funding limited and often sporadic
• Manpower shortages
• Working age and children are primary consumers
• Services limited to urban areas

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Challenges of treating elderly through either
system

• Elderly have multiple disabilities
• Complicates provision of services
• Professionals in blindness system are not trained
  to work with other disabilities
• Professionals in healthcare are not trained to
  work with vision impairment
• Low vision elderly often fall between the cracks
  of the two systems

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Demand for OT services

• OT trained to address issues of aging and
  disability
• With specific training in visual impairment, can
  meet the diverse needs of the elderly population
• Creating potential for great demand for services
  of OT trained in LVR

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OTs entrance into LVR

• Not embraced with open arms by blindness
  professionals
• David vs. Goliath
• 2,500 vs. 85,000
• Has prompted traditional providers to seek better
  reimbursement and standing
• Optometry obtained physician status for medical
  referral

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Medicare Vision Rehabilitation Services Act of
2001

• HR 2484
• Grants healthcare provider status to
• Orientation mobility specialists
• Rehabilitation teachers
• Certified low vision therapists
• OT status as independent provider is untouched
• Ties all referral to ophthalmology and optometry

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What two systems provide LVR in the United States?
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What two systems provide LVR in the United States?

• A Blindness and Healthcare systems

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What does the typical consumer of low vision
rehab look like?
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What does the typical consumer of low vision
rehab look like?

• 70 plus years of age
• Caucasian
• Female
• Widowed
• Living alone in her own home
• In an urban area