Specialty Vision - Low Vision

Front 1

Australian definition of legally blind

Back 1

VA 6/60 or worse, VF +/- 10 degrees of fixation in better eye

Front 2

Economic Blindness

Back 2

Cannot perform work for which sight is essential

Front 3

WHO Definition of Low Vision

Back 3

6/18 or worse, VF Restriction within 10 degrees

Front 4

Preventable causes of vision impairment (2)

Back 4

Trachoma and Cataract

Front 5

Trends in Blindness Prevalence (First world)

Back 5

Decreased poverty-related blindness, Increase in age related blindness

Front 6

Role of Optometrist and Low Vision (4)

Back 6

Identify Vision Difficulties, Treat where possible, Discussion, counselling and education, Refer where appropriate - ophthal, social worker, etc.

Front 7

Central VA Defect; Functional Consequences (3)

Back 7

Peripheral functions and mobility in tact

Central Vision - TV, reading, detailed tasks

Mobility decreased in reduced contour environment

Front 8

Central VA Defect Adaptation (2)

Back 8

Eccentric fixation

Increase angular magnification (some environments)

Front 9

Peripheral VF Defect; 3 types

Back 9

General Depression (opacities, pupil abnormalities, albinism)

Peripheral constriction (glaucoma, RP)

Visual pathway disease (hemianopia, quadrantanopia)

Front 10

Peripheral VF Defect; Functional Issues (2)

Back 10

Reading (can't keep place)

Mobility

Front 11

Near Magnification (General)

Back 11

Relative magnification; bring things closer (pre presbyopes)

Specs (high add bifocal, SV specs +/- prism)

Magnifiers (hand/stand, loupes, near telescopes, telescope caps, electronic magnifiers)

Front 12

Distance Magnification (General)

Back 12

Relative Magnification; bring things closer

Telescopes (hand-held/spec-mounted, binocular/monocular)

Electronic Magnifiers

Front 13

Non-optical Vision Enhancement (2)

Assists with?

Back 13

Lighting, contrast enhancement

Glare reduction, colour adjustment

Activities of Daily Living (ADL)

Front 14

Demographic of blindness

Back 14

Ageing population

Genetic vs environmental ageing

Front 15

Senses and age

Back 15

Hearing (presbycusis) - talk low and slow

Proprioceptive loss - posture, falls risk

Decrease in taste and smell

Very common disease - cardiac, hypertension, NIDDM

Front 16

Normal Age-related Optical Changes; Pupil Size

Back 16

Senile mitosis, implicates media changes, benefits of high illumination, DFE

Front 17

Age-related Optical Changes; Media changes

Back 17

decreased transmission, increased internal scatter, largest deficit at short wavelengths, increased glare sensitivity, CV changes, CS loss

Front 18

Age-related Optical Changes; Decreased Retinal Illumination

Back 18

Scatter, absorption and miosis

Front 19

Age-related Optical Changes; Neural changes

Back 19

fewer foveal photoreceptors and GC's

Front 20

Age-related Optical Changes; VF

Back 20

depressed static perimetry, VF constriction, decr retinal illumination, neural loss, test - age matched normals

Front 21

Age-related Optical Changes; Dark adaptation

Back 21

Decreased retinal illumination, implications - changing from light to dark (Falls), VA post DFE, ophthalmoscopy, etc

Front 22

Age-related Optical Changes; VA

Back 22

Expect BCVA 6/6 even at 70 (lose <0.2 log units from young adulthood)

Front 23

Age-related Optical Changes; Rx changes

Back 23

Hyperopic shift (changes in accom, latent hyperopia manifests)

Myopic shift (PSCC< slow vs rapid)

Incr ATR astigmatism (Steepening cornea in H meridian, astigmatic axes shift to ATR, reduced eyelid tension/pressure)

Incr anisometropia (breakdown of BV, neural control?)

Front 24

Age-related Optical Changes; Ocular Disease

Back 24

More prevalent in elderly, dilate annually/biannually, baseline fields, ARM, Cataract, glaucoma and diabetic retinopathy

Front 25

Exam Tips (6)

Back 25

Emphasise general health, assist where needed, hearing issues, information processing, simple advice, time management

Front 26

Case History; PC

Back 26

Define specific goals early (motivation), quantify task and how to implement it

Front 27

Visual status with Current devices

Back 27

D and N bailey-lovie VA, consider condition (central vs peripheral loss), measure to threshold, contrast sensitivity

Front 28

Distance Refraction (8)

Back 28

Prelims - preferred rx, Keratometry, Retinoscopy and objective rx, Radical Ret (alter WD for opacities), Larger steps, slower presentation times, health exam first, decr working dist and convert acuity

Front 29

When to prescribe? (3)

Back 29

Quality of specs/device, significant improvement in VA, <1DS or <2DC unlikely to sig improve VIP VA

Front 30

Near VA (5)

Back 30

Record monocular, speed and WD, start at +4.00D at 25cm, measure with increased illumination, Amsler grid, advise "good eye" for D and N

Front 31

VF (6)

Back 31

Amsler grid (routine when reading, raw perception), confrontation (Gross assessment), Bjerrum screen, automated, hemianopias (LHS; affects mobility and reading - can't find next line, RHS affects mobility and reading - next word, turn page 90 deg), hemiplegia (hemi-neglect; loss of function without awareness)

Front 32

Other tests (3)

Back 32

CV (not ishihara or central defects, Panel D15), BV (usually absent unless interocular diff >3lines VA, wandering 'blind' eye - discuss patching/frosting), Glare testing (photostress test, OCT)

Front 33

OT role (9)

Back 33

Advice, assistance or devices, social and personal skills, everyday activities, communication, self-care, household activities, handling money, shopping, time and orientation, social and recreational activities

Front 34

Social worker role (6)

Back 34

Assesses needs of VIP, info regarding resources and assistance, counselling (individual and family), lifestyle history, medical and VIP history, goals and referral

Front 35

Orientation and mobility; GDQ (6)

Back 35

Free to VIP and their carer/colleagues, Skills assessment, O&M training, information on living with VIP, education for carers, mobility devices - canes, dogs, electronic devices, telescope training

Front 36

Pensions and Travel Subsidies; Age or Disability Support Pension

Responsibility?

Criteria?

Back 36

Optom or Ophthal

Snellen BCVA 6/60 or worse BE, VF Constriction to central 10 deg in better eye (or both)

Front 37

Pensions and Travel Subsidies; DVA Blind Pension

Responsibility?

Criteria?

Back 37

Ophthal

Same as Age/Disability

CCTV's for free if eligible

Front 38

Pensions and Travel Subsidies; VI Travel Pass

Responsibility?

Criteria?

Back 38

Optom, Ophthal or Medical Practitioner

Same as blind pension

Free public transport for VIP (not carer)

Front 39

Pensions and Travel Subsidies; Taxi Subsidy Scheme

Responsibility?

Criteria?

Back 39

Ophthal

Category 3; Total blindness or severe VI

Half Price taxi vouchers

Front 40

Assessing fitness to drive; VA

Back 40

Private; VA at least 6/12 in one or both eyes

Commercial; 6/9 one eye and 6/18 fellow eye - flexibility with task

Conditional licence if specs required

Snellen or logMAR chart equivalent (5 letters on 6/12)

2+ mistakes - FAIL

3+m testing dist

Front 41

Assessing fitness to drive; Private conditional licence

Responsibility

Criteria; VA and VF

Back 41

Ophthal or optom

VA and VF just below standard, px is alert, normal reaction times, good physical coordination

Front 42

Assessing fitness to drive; VF

Back 42

Private; Horizontal extent of at least 110 and 10 degrease about midline

Commercial; precluded if any defect, condition if binocular field >140 degrees and no scotomas, quadrantanopias, or hemianopia - no flexibility

Screened by confrontation - defect assessed by automated peripmetry, fail --> Estermann Binocular Field Test (HFA)

Front 43

Jet's Law

Back 43

Patient is required to inform authority if condition that affects ability to drive is diagnosed

Fines and licence cancelled, insurance and legal implications

Front 44

Responsibility to report fitness to drive

Back 44

Responsibility to report condition to drivers licence authority if condition affects ability to drive safely and refusing to stop.

Mandatory at 75+yo

Front 45

Telescopic lens (bioptic telescopes) and electronic aids

Back 45

No standards set; may reduce peripheral vision, individual assessment by opthal/optom

Front 46

Practical Driving Assessment

Back 46

OT driving assessor

Front 47

Licensing advice

Back 47

Maintain standards

Px's legal responsibility; risk to self/others/property...

Front 48

Medicare items and LV; Normal codes (9)

Back 48

10910, 10911, 905, 907, 915, 916, 918, 940, 941

Front 49

Medicare Items for Comprehensive Assessment (3)

Back 49

912 - Significant change in visual function - 2 line drop VA, incr in VF loss, or previously undetected VF loss (seen previously)

913 - New signs and symptoms, unrelated to previous consult

914 - progressive disorder (twice per year)

Front 50

Medicare item 10942

Back 50

Specifically for LV; twice/year, claim with 10910/10911, testing residual vision to optimise using specs, CS, glare sensitivity, magnification aids, BCVA < 6/15 or N12 in better eye, or H VF loss <120deg (10deg about H midline)

Front 51

Medicare iten 10926

Back 51

CL as part of telescopic system

CL Consult if VA 6/30 or worse in BE and telescopic CLs

1/36, gives ~2.5x mag

Front 52

10931-10933

Back 52

Domiciliary visits

In conjunction with comprehensive/subsequent consult

Outside of consult room; home, aged care....

Front 53

Distance Magnification (Acuity); 2 types

Back 53

Relative enlargement; reduced WD

Telescopes (angular enlargement)

Front 54

VF Manipulation (4 types) and purpose

Back 54

Reverse telescope, negative powered lenses, prismatic specs, mirrored specs

Orientation and Mobility

Front 55

Disadvantages of Telescopes

Back 55

Reduced FOV; can't use whilst mobile, use for spotting

Light lost at each surface; image is dimmer

Front 56

Magnification of a telescope (equation)

Back 56

M = -F eyepiece/F objective

Front 57

3 numbers to describe telescope

Back 57

Magnification, aperture size (mm), field extent visible through telescope (FOV)

Front 58

Keplerian vs Galilean Telescopes

Back 58

Keplerian; Astronomical, 2 convex lenses, inverted image rectified with prisms, longer and greater FOV than Galilean

Galilean; Convex objective, concave eyepiece, eyepiece closer than focal length of objective, rays exit parallel erect image, no prisms - cheaper, smaller, more robust

Front 59

Distance Magnification Equation

Back 59

Mag = (angular height of object through magnifier, image)/(angular height of object to eye, object)

Front 60

Prescribing Distance Magnification (3 steps)

Back 60

eg. BCVA 6/60

1. Estimate required acuity (+ some reserve, 6/9.5)

2. Calculate magnification required (e.g. 60/9.5 = 6x)

3. Trial Device

Front 61

Estimated VA for everyday tasks;

Blackboard

Watching TV

Driving

Back 61

6/12-6/15

6/12-6/15

6/12-6/18

Front 62

Assessing telescope of unknown power

Back 62

Magnification; compare one eye mag and normal images; ratio = approx mag

FOV; how much of known object you see at known distance; eg. 60cm at 5m - field in radius = 0.6m/5m radians = 0.12 radians = 6.9 deg

Front 63

Bioptic telescope

Back 63

Telescope mounted on carrier rx lens

Dip head to incr mag

Hands-free drivin

Front 64

Distance electronic magnifiers; Autofocus

Back 64

Attach to VDU to enlarge test

Adjustable magnification, good FOV, auto focussing.

Can increase image brightness/contrast, revers contrast.

Head-mounted/hand-held, binocular/monocular

Very expensive, not as portable

Front 65

CL + Specs

Back 65

High minus CL (eyepiece) and high plus spec lens (objective). Give erect, magnified image

Increase FOV ~ -30 to -45D RGP with +22D Specs (12mm BVD) gives ~2x mag

Front 66

Limitations of Telescopic CL + Specs (5)

Back 66

Ocular intolerance of CL

Cosmetic appearance of high + specs

Limited functional field

Rapid and opposite movement of VF with head movement

Difficult to adapt to extended periods of magnification

Front 67

VF Manipulation; reverse telescope or neg powered lens

How it works?

What it's used for?

What condition requires it?

Back 67

Incr FOV, decr VA (minification)

High neg lens held 10-30cm from eye; Lens = objective, accom = eyepiece, potentially spec mounted (Reverse telescope)

Useful for navigating around objects, doorways, landmarks, hazards

Used in; RP, end stage glaucoma

Require GDQ training

Front 68

VF Manipulation; Prismatic Specs

How it works?

What it's used for?

What condition requires it?

Back 68

Right angled prism; base towards defect, apex to usable field, mounted in front of non-seeing field. Stick on peripheral Fresnal prisms. Vertical separation gives greater peripheral expansion.

Reduced eye/head movements required to scan environment

Hemianopic field loss

Require training and adaptation period

Front 69

Gottleib VF Awareness System (VFAS)

Back 69

One prism only on side of VF loss

Front 70

Non-optical aids (3)

Back 70

Improving contrast

Lighting and other non-optical systems

Refer to other rehabilitation services

Front 71

Near magnification

Back 71

By convention, reference distance ~25cm

M = height image viewed through mag/height object at 25cm

M = F/4 (or M = 1 + F/4, assumes 4D accom)

Fe is equivalent power for thick lens - manufacturers supply BVP or FCP not Fe

>+6D is inaccurate

Front 72

How to prescribe for near

Back 72

1. Dist rx

2. Current, increased and +4.00D near add (25cm) VA

3. Determine good print size and reserve

4. Calculate EVD (log progression or ratios)

5. Test most appropriate device for the EVD

6. Revise device, trial different devices, loan 1/12

7. Review

Front 73

Reading Performance (wpm); Acuity Reserve (logMAR lines) and FOV (# characters) for scrolled and static

Spot (40)

Fluent (80)

High fluent (160)

Optimum

Back 73

Acuity Reserve - FOV scrolled - FOV static

1 - 1 - 2

3 - 2-5 - 5

5 - 4-6 - 12

8-12 - 4-6 - 16-20

Front 74

Approx print sizes; Snellen (40cm), logMAR (25cm), Uses

N5

N6

N8

N10

N12

N16

Back 74

6/9.5 - 0.4 - Small ads, bibles

6/12 - 0.5 - telephone book

6/15 - 0.6 - Newspaper

6/19 - 0.7 - Magazines/books

6/24 - 0.8 - typed print

6/30 - 0.9 - Children's books

Front 75

Calculating EVD

Back 75

equivalent viewing distance - similar to focal distance in optical system (inverse of power). EVD (cm) = (req'd print size/current print size) x curr WD (cm)

Or cross multiply

By log steps

Front 76

Determining Near Mag

Back 76

1. Define goal; specify performance objective

2. Measure current near VA and WD with appropriate add

3. Calculate EVD

Front 77

Calculating High Near Addition

Back 77

Pick an add to allow them to see EVD from spec; total add for pre-presbyope

Need to calculate for pre-presbyope - 1/2, 1/3, no reserve amps

Front 78

Issues with near adds (5)

Back 78

Single vision or adds in specs up to 50D

Better in young pxs than old

Postural and psychological issues

Try as first option

Binocularity; Adds >8D need BI prism, rule of thumb: 1∆ for every D over 4D, Prism = near rx - 4

Front 79

Hand magnifier; How it works

How to alter

What it depends on

Back 79

Object at focal length; bring eye closer to magnifier to increase FOV, emergent vergence = 0 (light is not collimated)

If magnifier too close to page; 1 - need to accommodate (emerging light divergent), 2 - magnification is less, but FOV Is increased

Magnification depends on eye-lens distance (EVD varies), Px needs to be focussed on image - requires near add; Near add = 1/(eye-image distance)

Front 80

Stand magnifier;

Back 80

Look up tables (old), calculations based on WD, EVD, most manufactured for +2.50 or +4.00 Add (based on eye-image distance)

Front 81

Calculating Stand magnifier Add

Back 81

Try appropriate add (1/eye-image distance), Existing near rx

Front 82

Stand vs Hand Magnifiers

Back 82

Hand; smaller, flexible, but require steady hand, can augment with spec add

Stand; fixed distance, bulkier but steady, may have to augment with spec add

Front 83

Near telescopes

Back 83

Modify distance telescope by screwing on plus lens (lens cap), can use diet and near task with same telescope - usually small EVD (4-5cm)

Front 84

EVD of near telescope

Back 84

Treat lens cap as hand magnifier or add and calculate EVD, then take into account magnification of telescope; EVD system = EVD lens cap/M telescope

Front 85

FOV considerations of near magnification

Back 85

eye-lens distance approx inversely proportional to FOV. FOV approx proportional to lens diameter

Specs and adds should have best FOV - then loupes

Front 86

Magnifiers FOV

Back 86

Increased Eye-lens distance - more comfortable, smaller FOV

High power mags - need to get close to magnifier to get usable FOV

Power increased, overall diameter decreases, FOV decreases

Front 87

CCTV

Back 87

Desktop/computer connected, 2-70xmag, variable, large FOV, distortion free. Pos and Neg contrast enhancement, flexible viewing distance, use for near tasks - one hand to move xy platform/camera, expensive $3-10k

Front 88

Portable hand-held electronic magnifiers

Back 88

D/N, portable, distortion free, contrast enhancement, glare reduction, colour adjustment

Expensive $500-$4000

Front 89

VDU-Connected Digital Camera

Back 89

Camera on flexible arm, D/N viewing, high levels mag, save images to VDU, magnified and enhanced images, lightweight, slightly portable, some models and software enable test to speech, refreshable braille, expensive $5000

Front 90

Software

Back 90

Inbuilt, enlargement (Free-$1k), text to speech ($2-5k)

Front 91

E-readers/tablets (4)

Back 91

Magnification, talk to text, apps, refreshable braille

Front 92

Funding for Low Vision Aids/CCTV

Back 92

Outside Medicare, tax deductible, some health funds up to $500, QBA financial assistance, DVA, work aids fully funded

Front 93

Onward referral (6)

Back 93

Quantum or Humanware, QBA, Lifetec, GDQ, Vision Aus, Mac Degen Foundation

Front 94

Lighting as a non-optical aid; how it helps

Advice (5)

Back 94

Big difference, intensity and position of source; inverse square law - l = 1/d^2, increased intensity, decr distance (or both).

Portable/adjustable lamps +/- built in mags

Advice; back to window (Reduce glare), direct lighting from behind, flexible arm (gooseneck arms), good lighting in falls risk areas, avoid looking directly at bright light

Front 95

Contrast

Back 95

Highlight differences by optimising/enhancing contrast.

Plain (white/non-patterned) b/ground and contrasting (coloured/patterned) foreground

Front 96

Glare; Prevent with (6), relevant in (3)

Back 96

Sunnies, visor/hat, cover shiny surfaces, close blinds, adjust TV viewing position, chair near doorways to dark/light adapt

Relevant in; Cataracts (PSCC), RP, albinism

Front 97

Occupational Therapist; assist with...

Home assessment

Back 97

Assist with ADL; reading/writing, phone, socialising, time, money, shopping, sewing, cleaning

HACC: Home and Community Care officer - home assessment

Front 98

Reading; (6)

Back 98

large print books, audio libraries, podcasts, text to talk, e-Books, 4RPH; 1296AM blind radio station

Front 99

Writing

Back 99

Magnifiers, good to read, hard to write

Large print, tactile address books/organisers

Writing frames, signature guides

Raised line/bold writing paper, thick pens

Future; touch typing with magnification

Front 100

Kitchen (4)

Back 100

Liquid level indicators, talking scales/measures, tactile markers, non-slip trays, food plate surrounds

Front 101

Around the house

Back 101

Talking/tactile watches, clocks, tape measures, needle threaders, games, large phone, money identification, magnified mirrors, diabetes; syringe guides and magnifiers

Front 102

Social worker (3)

Back 102

Information on community resources (Travel, pension, taxis, libraries, community groups)

Counselling client and family

Assess early on and follow up over time

Front 103

Travelling, O&M; Identification Cane

Back 103

Sternum to shin, held in front not touching floor

Identify that this person is VIP

navigate objects in arms reach, thin and lightweight

Front 104

Travelling, O&M; Long/Mobility cane

Back 104

Sternum to ground, rolling ball tip

Held forward with tip on ground

Move side to side to feel terrain and warn of objects

Front 105

Travelling, O&M; Support cane

Back 105

Normal walking stick, painted white

Front 106

Travelling, O&M; Cane Advice (2) and limitations

Back 106

Recommended on referral from O&M training, safety and postural issues

Cane limitations; can't detect objects above waist height or 1+m away

Front 107

Travelling, O&M; Ultrasound

Back 107

Used with cane or guide dog

Can pick out overhead objects or doorways, etc.

Vibration changes with distance to object, different buttons for different heights - training required.

Front 108

Travelling, O&M; Guide Dogs

Back 108

Assist VIP travel, entitled to travel anywhere

VIP with proficient mobility aid ability

Front 109

Communication with VIP (7)

Back 109

Signal presence in a room, announce if you're leaving, speak directly at person, don't shout, ask if they need assistance, refer for O&M always, explore O&M in case hx

Front 110

Psychosocial Implications of VI; Acquired VI

Impact

Coping ability depends on (4)

Modern attitude

Back 110

Impact on QOL and ADL

Type of vision loss (congenital, chronic, stable, etc...), personality (anxious, independent, motivated), Life stage (education, working, retired), Support network (family, friends, carers)

Previously; stigma. Current; realistic, technology, awareness

Front 111

Psychosocial Implications of VI; Patient response

5 Stages

Acquired

Adaptation (3)

Back 111

Denial (multiple opinions, expectations). Grief OR bargaining. Anger. Depression. Acceptance.

Mourning process

Skills to restore independence and control, participation and socialising overcomes depression. Redefining identity

Front 112

Psychosocial Implications of VI; Family Involvement

Advocating (4)

Avoiding (4)

Back 112

Advocating; improve understanding, support, retain and reinforce ideas/strategies, Promote discussion and sense of involvement.

Avoiding; hinders patient openness, over-involvement in discussions, doesn't promote independence, confidentiality/privacy issues

Front 113

Psychosocial Implications of VI; Social interactions

Back 113

Central Vision loss especially

(Facial recognition and expression, handwriting, eating, eccentric viewing)

Front 114

Psychosocial Implications of VI; Psychological Adaptation

Back 114

Duration of VI affects acceptance/denial, increased risk of depression

Front 115

Psychosocial Implications of VI; Depression signs/symptoms

Back 115

Mood, irritable, frustrated. Less time with family/friends/enjoyable activities, Awake through night, alcohol and drug use, fatigue and pain, rekless/risk taking

Front 116

Psychosocial Implications of VI; Driving

Back 116

Marker of independence, warn young VIPs of options in the future

Older VIPs giving up licence - plan ahead (public transport), discussion with family/firneds

Front 117

Psychosocial Implications of VI; Assessment of QOL

Back 117

Psychological assessment tools

Vision Specific Assessment tools; AVL (adaptation to age-related vision loss scale), NEI-VFQ 25 (National Eye institute Visual Functioning Questionnaire 25, most common, 3 parts), LVQOL (Developed for LV assessment, 4 parts)

Front 118

Psychosocial Implications of VI; Charles Bonnet Syndrome (CBS)

Back 118

Visual hallucinations, psychological normal px's with significantly decreased vision (central typically), vivid, realistic, aware of non-real nature, frequency/duration varies, trigger is usually change in illumination, 10-40% VIPs

Front 119

Psychosocial Implications of VI; Charles Bonnet Syndrome (CBS)

Risk Factors

Mechanism

Management

Back 119

Risk; 64+yo, social isolation, poor lighting, stroke history

Mechanism; Deprivation theory (reduced input, spontaneous image from cortex), Release theory (abnormal signals from pathology)

Mx; reassurance, sympathy, incr illumination and socialising, refer if suspected neurological disorder

Front 120

Psychosocial Implications of VI; Dementia

Cause

Back 120

Impaired cognitive abilities interfere with occupational and social activities, progressive and degenerative.

Alzheimer's Disease (50-80%), Vascular dementia (7-15%), mixed (10-20%), Other (Lewey Body, Frontal Lobe)

Front 121

Psychosocial Implications of VI; Alzheimer's Disease

4 Stages

Visual Consequences (4)

Back 121

Neurodegenerative disorder

1 - Pre-dementia (mild cognitive impairment. 2 - early-mild AD. 3 - Moderate AD. 4 - Advanced/Late AD

Loss of RGCs, plaques and fibrils in LGN, visual cortex atrophy (retrograde degeneration of cortical neurons - decreased CS, stereopsis, visual hallucinations 25-50% pxs), RNFL Thinning

Front 122

Psychosocial Implications of VI; Alzheimer's

Histopathology (4)

Modify consult

Back 122

Neurofibrillary tangles, amyloid plaques, gross decrease in weight and volume (hippocampus, temporal and frontal lobes), increased ventricle size

Carer present, longer appointments

Front 123

Psychosocial Implications of VI; D/Dx - depression and Alzheimer's

Back 123

Loss of mental sharpness in age can be depression or dementia - involve GP

Rapid mental decline vs Slow

Knows time/date/orientation vs Confused/disorientated

Difficulty concentrating vs difficult short term memory

Normal, slow language, motor skills vs impaired writing, speaking and motor skills

Notices/worries about memory problems vs doesn't

Front 124

Paediatric Low Vision; Prevalence

Causes (4)

Back 124

Low prevalence 2-6% 0-15yo's.

28% cortical vision impairment (&organic pathology), 11% albinism/nystagmus, 7% ROP, 6% optic atrophy

Front 125

Paediatric Low Vision; Cortical Vision Impairment

Definition

Tests

Caused by (5)

Associated impairments (5)

Back 125

Reduced VA/VF due to occipital cortex abnormality.

Confirmatory (imaging/electrophysiological testing) required.

Major causes; asphyxia, brain maldevelopment, head injury, infection, chromosomal anomalies

Assoc; variable responses, peripheral viewing, light gazing or photophobia, preference for colours, respond well to motion

Front 126

Paediatric Low Vision; Albinism

What it is?

Findings

Tx

Back 126

Oculocutaneous (+/- tyrosinase); lack pigment, glare sensitive, +/- Pendular horizontal nystagmus

Usually astigmatic refraction, foveal and ONH hypoplasia, VF 6/30-6/60

Pigmented CL for glare

Front 127

Paediatric Low Vision; ROP

5 Stages

Findings

Tx

Back 127

1 - Demarcation line. 2 - Ridge. 3 - Fibrovascular proliferation into vitreous. 4&5 - Tractional retinal detachment, cicatrical

moderate to severe myopia, VA 6/15-CF

PRP, vitreoretinal surgery if detached

Front 128

Paediatric Low Vision; Optic Atrophy

Causes (3)

D/dx (1)

Hereditary forms (2)

Findings (4)

Back 128

Permanent loss of function to part/all of ON

Metabolic, toxic, nutritional

ONH glioma

Ture congenital (6/6-6/30, slow progressing, stable), Leber's (spontaneous ONH blow out, 6/60, males, late teens-20s)

Disk pallor, Kestenbaum's sign, CVD, central/paracentral scotoma

Front 129

Paediatric Low Vision; Assessment

Back 129

Involve parents/teacher

Visual tasks; school work/interests/hobbies

Dist VA; normal paeds

Near VA; school work/writing material

Objective tests; auto-rx, retinoscopy, keratometry

Binocularity; <10% binocular

CV; Panel D-15, City University

VF: verbal children, info for parent/teacher/O&M, eccentric fixation

Front 130

Paediatric Low Vision; Profile of Visual Behaviour

Background

Back 130

Vision conditions, LV aids, Nystagmus/unusual eye movements, head tilt/turn, other conditions (intellectual, hearing, GH, meds)

Front 131

Paediatric Low Vision; Profile of Visual Behaviour

Visual responses

Back 131

Eye contact, looking at own hands, visual response with meals - irritated by touch/sight, objects that elicit visual response, favourite colours, touching own eyes/waving hands

Front 132

Paediatric Low Vision; Profile of Visual Behaviour

Observed Responses to environment

Back 132

Time of day when most responsive, familiar/unfamiliar surroundings

Front 133

Paediatric Low Vision; Disruption of Emmetropisation

Skew

Onset

Back 133

Skewed towards myopia; peripheral +/-central VI - myopia, Central VI - Hyperopia. Normal distribution by 75% rx outside emmetropia.

Earlier onset; increased disruption in refractive development; critical period. Birth/congenital - myopia. 1-30yo; hyperopia. 7+yo; no sig effect on Rx error.

Front 134

Paediatric Low Vision; Prescribing Optical Devices

Principles (2)

Aims (3)

Common Devices (4)

Considerations (3)

Back 134

Same principles as adults; VT/environment, accommodation.

Aim to develop abilities, maximise residual vision, develop self confidence

Specs (bifocals), telescopes, Dome stand magnifiers, electronic magnification (iPad, e-reader, CCTV)

Decrease working distance, enlarged notes, modified VDU's/software, etc.

Front 135

Paediatric Low Vision; Educational Implications

Back 135

Majority of learning through vision

Specialised strategies to learn new skills and more time

consider; presentation format, equipment, technology, time, accessibility, mobility, preview/review material, environment (lighting/glare)

Front 136

Paediatric Low Vision; Qld Govt Support

Back 136

Advisory visiting teachers, specialist support teachers, education programs, community/non-school organisations, Physios, OTs, Speech pathologists

Front 137

Paediatric Low Vision; PLVC - Paediatric Low Vision Clinic

Back 137

Dept Education and training, <6-7yo, specialised vision assessment, support and information, understanding of individual VI and behaviours

Front 138

Paediatric Low Vision; Definition of VI by Dept Education

Back 138

Mild/No VI; >6/18

Moderate VI; 6/18- 6/60

Severe VI; 6/60 - 6/120

Blindness; 6/120 and worse

Front 139

Paediatric Low Vision; Evidence of VI (3)

Back 139

Diagnosed by ophthal, neurologist or paediatrician (CVI)

Document evidence of activity/participation limitation from VI in curriculum/learning enviro by VI trained teacher

Evidence of VI impact on school life by discussions with px, parents, school...

Front 140

Paediatric Low Vision; Narbethong State Special School

Back 140

Education for VI +/- disabled, deaf students

Staff; teachers, aides, therapists, nurse, guidance officer, volunteers

Active learning, use all senses, encourages exploration

Primary and High school

Front 141

Paediatric Low Vision; Braille

3 Levels

Modern

Back 141

Tactile writing, small raised blocks/cells arranged 3x2

3 levels - letter by letter, abbreviations/contractions, personalised shorthands

Refreshable braille; linked to VDU/iPhone

Diminishing use

Front 142

Paediatric Low Vision; Diversional Therapy

Back 142

Recreation and leisure activities, encouraging participation, socialising and wellbeing

Front 143

Paediatric Low Vision; ERG

Back 143

Electroretinography; measures electrical activity of retina when stimulated by light

Active electrode in eye (foil CL), Reference electrode nearby (forehead), Earth (Ear)

Isolate rod/cone response; diagnose Stargardt's etc...

Front 144

Paediatric Low Vision; VEP

Measures

Detects (6)

Reported as... (3)

Back 144

Visually Evoked Potential; electrical potential initiated by brief visual stimuli, recorded by electrodes overlying visual cortex (Scalp)

Measure functional integrity of visual pathways from retina via ON to cortex

Cortical blindness, optic neuritis, optic atrophy, stroke, tumours, amblyopia.

Affects latency and peak, pattern VEP isolates location

Front 145

Future of LV rehabilitation; Wet ARM - PDT

Back 145

Photodynamic therapy (Visudyne Laser)

Initial tx of wet ARM and chronic CSR, visudyne injected in peripheral vein, activated by laser targeting leaky vessels, risk severe sunburn (no sun 3 days), improvement (if any) slow over months

Front 146

Future of LV rehabilitation; IVI's - Anti-VEGF

Back 146

Wet AMD, DR, occlusive disease.

Macugen (6/52, first, low stroke risk, inhibits one strain VEGF)

Avastin (colorectal cancer, cheap, 1/12 until stable, then prn)

Lucentis (inhibits several strains of VEGF, dose 1/12 until stable, then prn)

Front 147

Future of LV rehabilitation; IVI's - Steroid

Back 147

Kenalog; alone or with Anti-VEGF, macular oedema, posterior uveitis, DR, RVO, slows VA loss rate, risk steroid response

Ozdurec; biodegradable implant, oedema for RVO, uveitis, rapid reduction in retinal fluid post 1-12/12, remains 4/12 - risk steroid response, invasive procedure

Front 148

Future of LV rehabilitation; IVI's - risks

Minor (1)

Major (4)

Back 148

Minor; SPK post betadine wash

Major; infection, intraocular haemorrhage, retinal tear/detachment, IOP spike

Front 149

Future of LV rehabilitation; IVI's - Optom Mx

Back 149

Co-manage px, commitment ($$), frequency, antibiotics, ophthal communication

Front 150

Future of LV rehabilitation; Future of IVI

Back 150

Cheaper, disease-specific medications, fewer doses

Eyelea - dose 2/12 after loading phase (3/12 IVI), comparable VA to 1/12 Lucentis, reduced Px time, cost and discomfort

Combination agents; Anti-VEGF + Steroid, Anti PDGF (platelet-derived growth factor) + Anti-VEGF

Front 151

Future of LV rehabilitation; Pre-clinical Wet ARM Diagnosis (2)

Back 151

Clinical test to predict conversion from dry to wet ARM by blood test - Endothelial progenitor cells (EPCs); rare cell populations, elevated in dry vs wet ARM, examine with fluorescence activated cell sorting (FACs).

Radiation therapy (UK); expensive, 1 treatment, Side effects unexplored

Front 152

Future of LV rehabilitation; Retinal Regeneration/Transplant

Obstacles (4)

Back 152

Donor tissue/stem cells

Animal studies 1940s-1980s

Human studies; no improvement in objective visual function measures

Obstacles; Blood supply, rejection, photoreceptor organisation, vision quality

Front 153

Future of LV rehabilitation; Gene therapy

Back 153

Congenital blindness, key chemical from visual cycle missing, gene augmentation to correct biochemical cascade, virus vector - sub-retinal injection post vitrectomy, good short-term improvement

Front 154

Future of LV rehabilitation; Bionic Eye

2 designs

How it works

Back 154

Wide-field design; navigation, independence, identify large objects (end stage glaucoma and RP)

High resolution design; face recognition, large print (AMD, Central vision loss)

Combination with sub-retinal visual implant; light absorbing elements convert light to electrical impulses (req clear media, no inner-ret or visual pathway pathology)

Camera; digitises image, Processor; reduces noise/image enhancement

Front 155

Future of LV rehabilitation; Bionic Eye issues

Alternative

Back 155

Biocompatability, implant size, accurate placement of implant and protection from heat of electrical current, low contrast/gaps in vision

Tactile corneal stimulation

Front 156

Future of LV rehabilitation; Microperimetry

Back 156

Comine retina function and structure; with Spectralis OCT for adequate morphology/functional prospective information

Front 157

Future of LV rehabilitation; Adaptive Optics

Back 157

Measure and correct aberrations of eye in real time, visualise pathologies and improve VA in VIPs, count active/living cones

Front 158

Future of LV rehabilitation; Technology LV aids

Back 158

VDU (mag, talk/text), CCTV (monitors/speech, portable), Mobile phones (mag, talk/text, colours), eReaders (kindle, iPads), Intraocular telescope (IOL-type implant), Telescopic CL, Braille Smartphone, OrCam (attached to specs, speaks to px), Glaucoma medication delivery (punctal plugs, CLs), Pharmacological CBS agents (low-dose antipsychotics, cholinesterase inhibitors, tricyclic anti-d's, serotonin reuptake inhibitors), Haptic wheelchair (GPS, laser, feedback), Haptic shoe (proximity sensor, direction, vibration), Be My Eyes App, See Eye Vest, Robotic Vision Glasses (Ultrasound, GPS, stereoscopic), Eli Pelli Specs (augmented reality, mag and contrast), Google glass and CL