LOW VISION TUTORIAL

Low Vision
A Concise Tutorial From Assessment
To Rehabilitation
 Low Vision
A Concise Tutorial From Assessment To Rehabilitation
Contents Page Contents Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Chapter 3: Prescribing . . . . . . . . . . . . . . . . . . . . . . . 18

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Low Vision Devices . . . . . . . . . . . . . . . . . . . . . . . . 18
Author Acknowledgements . . . . . . . . . . . . . . . . . . . . . . .2 Magnification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Spectacles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Chapter 1: Causes and Effects . . . . . . . . . . . . . . . . . . 3 Loupes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Classification/levels . . . . . . . . . . . . . . . . . . . . . . . . . 3 Hand Magnifiers . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Visual Acuity/Visual Field . . . . . . . . . . . . . . . . . . . . 3 Stand Magnifiers . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Functional Implications . . . . . . . . . . . . . . . . . . . . . . 3 Telescopes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Legal Blindness . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Filters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Electronic Devices . . . . . . . . . . . . . . . . . . . . . . . . . 21
Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Adaptive Devices . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Comorbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Vision Rehabilitation:
Lifestyle Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Who, What, When, How, Where . . . . . . . . . . . . . . 25
The Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Chapter 4: I ntegrating Low Vision
Chapter 2: Assessment . . . . . . . . . . . . . . . . . . . . . . . . 7 into the Care You Offer . . . . . . . . . . . . . 27
Importance of Early Detection . . . . . . . . . . . . . . . . . 7 Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Examining the Adult with Low Vision . . . . . . . . . . . 7 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Case History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Testing Visual Acuity . . . . . . . . . . . . . . . . . . . . . . . . 7 Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Refraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Predicting the Add . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Function Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Brief Glossary of Terms (Appendix) . . . . . . . . . . . . . . . . 30
Low Vision Device Recommendation . . . . . . . . . . 10 List of Illustrations (with Credits) . . . . . . . . . . . . . . . . . 31
Examining the Child with Low Vision . . . . . . . . . . 10 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Case History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Testing Visual Acuity . . . . . . . . . . . . . . . . . . . . . . . 10
Ocular Motility, Binocularity and Fixation . . . . . . . 11
Visual Field Testing . . . . . . . . . . . . . . . . . . . . . . . . 11
Refraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Color Vision Testing . . . . . . . . . . . . . . . . . . . . . . . . 12
Contrast Sensitivity Testing . . . . . . . . . . . . . . . . . . 12
Low Vision Devices for Children . . . . . . . . . . . . . . 12
Developing a Plan and Sharing Information . . . . . 15
Case Studies . . . . . . . . . . . . . . . . . . . . . . . . . . 16/17

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 Chapter 1
Introduction Low Vision: A Concise Tutorial from Assessment to
Rehabilitation is the initiative of Richmond Products, Inc,
in Albuquerque, New Mexico and the Good-Lite Company
What this publication is about in Chicago, Illinois. Richmond and Good-Lite develop,
This booklet provides a concise overview of the rapidly manufacture and market eye examination and testing solutions
growing field of low vision care. While the themes of pediatric to a broad user base throughout the world. The low vision
and adult low vision care could each be a tome in its own right, tutorial text was written by Mary Ann Lang, PhD and Karen
this work provides a succinct synopsis and practical information Seidman, MPA of North Star Vision Group. North Star
that many professionals will appreciate. If you are thinking of Vision Group conducts consultations and training worldwide
getting into low vision care, or are curious about how this to foster the development of high quality clinical and vision
important aspect of eye care relates to your practice, this booklet rehabilitation services. Alan Highley, Highley PR, Albuquerque,
will be indispensable. New Mexico was the editor of this booklet.
Definition of Low Vision
Simply stated, low vision is vision that cannot be improved to
within normal limits with standard eyeglasses or contact lenses,
Foreword
medication or surgery. It is not the same as blindness, although
current ‘legal blindness’ definitions in many regions include
Significance of Low Vision
Vision impairment affects an estimated 246 million people
people who still have residual vision. Low vision can be defined
worldwide, 19 million of whom are children below the age
functionally: it exists when a person with a vision problem that
of 15. [WHO] These staggering numbers are overshadowed
can’t be improved through the use of conventional approaches
by the devastating impact of vision loss on individuals, their
has difficulty using vision to do everyday tasks. The World Health
families, friends and caregivers. Issues for people who have low
Organization defines low vision as follows: A person who has low
vision include loss of independence, twice the rate of clinical
vision is one who has impairment of visual functioning even after
depression in older adults with impaired vision, and correlated
treatment and/or standard refractive correction, and has a visual
negative impact on health. Dealing with vision loss also
acuity of less than 6/18 (20/60) to light perception or a visual
influences professionals, who may experience frustration at not
field of less than 10º from the point of fixation, but who uses or
being able to ‘cure’ the problem and at not knowing what to
is potentially able to use, vision for the planning and/or execution
recommend to these patients, some of whom may have been in
of a task. [World Health Organization, WHO/PBL/93.27.
the practice for years.
Geneva: World Health Organization, 1993] Experts estimate that
there are 3 times as many persons with low vision worldwide
Low vision care (also known as low vision rehabilitation) once
than people who are blind.
a low-incidence sub-specialty, is now a growing market, owing
simultaneously to several factors:
The Multi-Disciplinary Nature of Low Vision Care
The objective of low vision care is improving a person’s • the surge in the older adult demographic in developed
ability to function on the tasks important to that person economies worldwide;
through the use of low vision devices (optical, non-optical
• the technological advances that have increased the
and electronic) and a wide range of rehabilitation strategies. survival rate of premature babies;
Diverse professionals are productive partners in the low vision
rehabilitation process. These include ophthalmologists and • the pharmaceuticals that have made it possible to manage
but not yet cure prevalent eye diseases such as Age-related
optometrists, occupational therapists, low vision therapists, Macular Degeneration (AMD), and
nurses, vision rehabilitation therapists, orientation and mobility
specialists, physicians, orthoptists, ophthalmic technicians, • the technological breakthroughs that have allowed
conventional and electronic low vision devices to be more
opticians, social workers, psychologists, technology specialists, effective and better accepted. For example, the general
special educators and others. The patient and his or her family/ public now takes for granted the ability to enlarge images
significant others are important members of the rehabilitation using tablets and smart phones so that many devices used
‘team’ and are vital to the process. by people with low vision no longer appear unusual.
Yet, the field still is viewed erroneously by many as time
Understanding the role of each specialist in habilitation/
consuming, expensive, labor-intensive and requiring an
rehabilitation, being aware of referral procedures and making a
elaborate cadre of professionals in-house in order to engage in
commitment to appropriate communication all help to enhance
the practice. However, others have more accurately recognized
patient care and positive outcomes.
the importance of expanding their services to include low

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Chapter 1
vision care in order to meet a burgeoning demand as well a to
attract new patients.You may well ask what they know that you Author Acknowledgements
need to know. They know that:
Special thanks go to the following for their valuable
• there are evidence-based tools that make patient
assessment accurate and faster than they expected; contributions to this booklet:

• making a reasonable investment in equipment will allow • Michelle Beck, Low Vision Therapist (LVT), Certified
them to handle many low vision patients in their office Orientation & Mobility Specialist (COMS), Department
or clinic;
of Veterans Affairs, New York Harbor Health Care System,
• community-based providers can be part of an unofficial, New York, NY
on-demand ‘team’ to provide a range of services as
needed by patients with low vision. • Luciene Fernandes, MD, Former Chairperson,
We trust that the information presented in this booklet Panamerican Low Vision Society, Minas Gerais, Brazil
explains low vision care and vision rehabilitation, including
the procedures and equipment that assist in assessment and • Michael Fischer, OD, Low Vision Clinical Consultant,
rehabilitation. It is our hope that this practical information will Lighthouse International, New York, NY
make it possible for clinicians from many specialties to help
• Judith E. Gurland, MD, Bronx Lebanon Hospital Center,
patients right away.
Bronx, NY
Mary Ann Lang, PhD, Founding Partner, North Star
• Harlyne Knight Hantman, OD, Private Practitioner, Boca
Vision Group LLC, NY, USA; Formerly Vice President for
Raton, FL
International Programs, Lighthouse International, New York,
NY, USA • Alan Highley, Editor, Highley PR, Albuquerque, NM
Karen R. Seidman, MPA, Founding Partner, North Star • Roberto Valencia, OD, Fundación Colombia para la
Vision Group LLC, NY, USA; Formerly Vice President for discapacidad visual, Colombiana, South America
Continuing Education, Lighthouse International, New York,
NY, USA
• Mark E. Wilkinson, OD, FAAO, Clinical Professor of
Ophthalmology, University of Iowa Carver College of
Michelle Beck, MS, Low Vision Therapist (LVT), Certified
Medicine, Director,Vision Rehabilitation Service, Wynn
Orientation and Mobility Specialist (COMS), Department of
Institute for Vision Research, Iowa City, IA
Veterans Affairs, New York Harbor Health Care System, New
York, NY, USA

Harlyne Knight Hantman, OD, Private Practitioner

specializing in Low Vision Care, Boca Raton, FL, USA

Michael Fischer, OD, FAAO, Low Vision Clinical

Consultant, Lighthouse International, New York, NY, USA

Lea Hyvärinen, MD, PhD, FAAP, Specialist in Vision

Rehabilitation; Professor, Rehabilitation Sciences, Technical
University of Dortmund, Germany

Sarfaraz A. Khan, MD, Consultant in Low Vision Care,

Swarup Eye Hospital, Hyderabad. India; Formerly Director,
Vision Rehabilitation Centres, L.V. Prasad Eye Institute,
Hyderabad, India, Formerly, IAPB-WHO Low Vision Working
Group - Regional Representative for South East Asia

Mark E. Wilkinson, OD, FAAO, Clinical Professor of

Ophthalmology, University of Iowa Carver College of
Medicine; Director,Vision Rehabilitation Service, Wynn
Institute for Vision Research, Iowa City, IA, USA

L o w Vi s i o n : A C o n c i s e Tu t o rial From A ssessment To Rehabilitation

 Chapter 1
Chapter 1: Causes and Effects Functional Criteria
Classifications based on visual acuity/visual field are useful for
the statistical analysis of trends or assignment of government
Classification/levels
benefits. However, classification based on functional parameters
The classification of low vision/vision impairment separates
is more useful to the clinician and more effective for the
into two divergent branches:
patient. In the classification chart [Fig 1], for example, contrast
• Classification according to visual acuity/visual sensitivity is not a factor, despite the fact that it has a profound
field criteria impact on the person’s ability to function in everyday life
(Whittaker in Kooijman, Low Vision, 1994), (Arrighi in
• Classification according to the functional implications of
low vision diseases EurJOph, 2010), (Bodis-Wollner in IOC, Spring 1980). This
classification also does not take into account studies that have
Visual Acuity/Visual Field shown that a best corrected visual acuity (BCVA) of 20/40
In the US and in many countries visual acuity and/or visual may be a more accurate and representative cut-off point for a
field criteria are the basis for the classification of low vision. visual acuity level at which people begin to have problems with
Most note a visual acuity of 20/60 or 20/70 (6/18) or poorer as daily activities (West et al, 1977). In fact, in 2013 the American
denoting low vision.Visual field is also a criterion, in most cases Academy of Ophthalmology revised its definition of low vision
noting a visual field of 20 degrees, or 10 degrees or less from to include patients who have visual acuity of less than 20/40 or
the point of fixation, as distinct levels of vision impairment. scotomas, field loss or contrast loss. (www.aao.org/ppp).
An example from the International Statistical Classification
of Diseases (ICD [http://www.who.int/classifications/icd/ The World Health Organization classification encompasses
en/]), a standard diagnostic tool for epidemiology, health the two parameters of visual acuity/visual field loss and
management and clinical principles, illustrates categories of functional ability:
vision impairment based on visual acuity and/or visual field.
• Low vision is visual acuity less than 6/18 (20/60) and
Category
equal to or better than 3/60 (20/400) in the better eye
Visual acuity with best pos- Or central with best correction.
of visual Classified as
sible correction visual field
impairment
• A person with low vision is one who has impairment of
Maximum Minimum visual functioning even after treatment and/or standard
less than equal to or refractive correction, and has a visual acuity of less than
better than
6/18 (20/60) to light perception, or a visual field less than
1 6/18 6/60 Low vision 10 degrees from the point of fixation, but who uses, or
3/10 (0.3) 1/10 (0.1) is potentially able to use, vision for the planning and/or
20/70 20/200 execution of a task for which vision is essential. (WHO, 1993)
2 6/60 3/60 Low vision Functional Implications
1/10 (0.1) 1/20 (0.05)
A functional approach is most helpful for clinical decision-
20/200 20/400
making. The eye pathologies that result in low vision can be
3 3/60 1/60 (finger 10° or less but Blindness considered according to the effects they have on functional
1/20 (0.05) counting at 1 more than 5°
metre) vision. In the early 1970s, Eleanor E. Faye, MD created a
20/400
1/50 (0.02) classification of low vision that is still in use today. While it is
5/300 clear that there can be a range of variation in the subvarieties of
(20/1200) the major diseases noted, this classification is a useful paradigm
4 1/60 (finger 5° or less Blindness for anticipating prescribing and rehabilitation needs.
counting at 1
metre)
The basic categories noted by Faye are:
1/50 (0.02)
5/300
• Diseases that cause a LOSS of CENTRAL VISION –
5 No light perception Blindness including diseases of the central retina (AMD) and of the
9 Undetermined or unspecified Unspecified optic nerve (Optic Nerve Compression)
* Visual field restriction criteria applicable even if visual acuity is better than for that • Diseases that cause a LOSS of PERIPHERAL VISION
category – including diseases of the peripheral retina (retinitis
Fig. 1. Categories of severity of visual impairment according to the International
pigmentosa), the optic nerve (glaucoma, ischemic optic
Statistical Classification of Diseases neuropathy) and neurologic problems (stroke, brain tumor)

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Chapter 1
• Diseases that cause an OVERALL BLUR – including Total Preva-
diseases that result in cloudy media involving the Prevalence No. of people
WHO popula- lence of
of blind- with low vision
cornea and tear film (dry eyes, irregular astigmatism, Subregion tion (mil-
ness (%) (millions)
low vi-
corneal dystrophy, corneal edema), the pupil/iris (miosis, lions) sion (%)
mydriasis, atrophy, polycoria, iridectomy), the lens Africa-E 360.965 1 10.573 3
(cataract) or the vitreous (hemorrhage, inflammation)
Americas-B 456.432 0.3 7.6 1.7
Legal Blindness Eastern 144.405 0.97 4.116 2
The term ‘legal blindness’ is problematic. In the US it is defined as: Mediterranean-D
Europe-A 415.323 0.2 5.435 1.3
• Visual acuity of 20/200 or worse in the better eye with South-East 1394.045 0.6 28.439 2
correction, or visual field restriction to a 20 degree Asia-D
diameter or less in the better eye Western 1374.838 0.6 26.397 1.9
Pacific-B1
It is important to recognize that low vision can always be
distinguished from blindness. People with low vision do have Fig. 2. Estimates of low vision and blindness in WHO subregions.The capital letters following the
subregion names provide a key to the countries surveyed to develop the information in the chart.
some vision. Determining how useful the vision will be for The full information about prevalence and the specific countries surveyed can be found on the WHO
daily activities and how/whether functional vision can be website (844 Bulletin of the World Health Organization, November 2004, 82 (11)
enhanced optically or electronically are among the goals of the
low vision examination. Comorbidities
It is important to remember that, in the case of older adults, low
Causes vision often coexists with other medical conditions. Aging may
There are many causes of low vision. Some are congenital and involve changes in many body organs and systems. In addition,
others are acquired. The dominant causes found within different the four primary causes of low vision in adults, age-related
age groups also vary with regard to occurrence in developed or macular degeneration (AMD), cataract, glaucoma, and diabetic
developing nations. Overall, the dominant causes of low vision retinopathy, are associated with pathological systemic changes.
in adults (excluding uncorrected refractive error) are macular Arthritis, hearing loss, heart disease, stroke, amputation, and
degeneration, diabetic retinopathy, retinitis pigmentosa, cataracts, hip fracture are prevalent in the population of older adults and
corneal opacity and glaucoma. To a lesser degree, some of these affect assessment and vision rehabilitation.
conditions may also cause low vision in children. Additional
conditions causing low vision in children include albinism, A study in the Journal of the American Geriatric Society (2011
amblyopia, strabismus, coloboma, optic nerve hypoplasia, Leber’s Oct; 59(10):1802-9) looked into the ways that comorbidity
congenital amaurosis, cortical blindness, congenital rubella affects older adults’ experiences in health service and presented
syndrome, cancers such as retinoblastoma and retinopathy a framework to assist clinicians in providing services. The
of prematurity. The effects of these conditions may result in five broad themes it identified can be useful to professionals
life-long low vision. Retinal detachment, trauma, and acquired addressing low vision in older adults. The chart [Fig. 3]
traumatic brain injury may also result in low vision and are summarizes these themes.
gaining attention due to the increasing number of people
engaging in very active sports and high speed activities, and
incidents related to combat.

Prevalence
The World Health Organization (WHO) has accumulated data
from surveys conducted in 55 countries and prepared estimates
of low vision and blindness in WHO subregions. The chart
[Fig. 2] provides a sample of this information.

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 Chapter 1
Theme Description family and society (Gilbert, et al, 2008). Recent estimates suggest
Good Days, Bad Days fluctuating health status
that the global annual loss in GDP (Gross Domestic Product)
may be as high as $22,764 million.
Communication Barriers sometimes due to impairments, sometimes
due to situation
Low vision impacts the workplace, as well. Unfortunately, severe
Feeling Overwhelmed pragmatic and emotional concerns of person
with low vision and caregivers underemployment is characteristic of the population of working
Delays tendency of comorbidities to delay progress age people who are visually impaired and those who are legally
and to add inconvenience blind (http://www.afb.org/section.aspx?FolderID=2&SectionI
Companion Involvement positive value in overcoming barriers D=7&DocumentID=1529) Legislation such as the Americans
with Disabilities Act (1990) and similar legislation worldwide
Fig. 3. Comorbidity effects in older adults
(see sidebars) guarantee equal opportunity for individuals
In children, common comorbidities may include deafness, with disabilities in a range of areas including employment,
physical handicaps, cerebral palsy, cognitive impairment and government services, public accommodations, transportation,
Down Syndrome. Professionals involved in low vision care can and telecommunications, however implementation is always an
provide more effective service to older adults and children with issue. Co-worker sensitivity and practical adaptations are often
low vision by anticipating the functional implications that these all that is needed to make the workplace user-friendly for the
comorbidities can have on low vision device use, adjustment to person with vision impairment, but these may be challenging
vision loss, clinical low vision care and rehabilitation. for the employer. Getting to work may be an issue for the
worker with impaired vision, as well. A thorough low vision
Lifestyle Issues examination geared to assessing the applicability of adaptive
Surveys have consistently shown that people’s fear of vision loss software, environmental modifications and independent mobility
is second only to their fear of cancer (http://www.eyeresearch. can equip a person with low vision for workplace success.
org/resources/NEI_factsheet.html) and that twice as many
people fear losing vision than the number who fear premature The Law
death (http://www.ncbi.ie/news/press-releases/2008-03-07_ In the United States three main laws address low vision.
twice-as-many-people-fear-blindness-more-than-premature- IDEA. The first is the Individuals with Disabilities
death ) It isn’t surprising, therefore, that low vision affects Education Act (IDEA). IDEA was enacted by Congress
every aspect of a person’s life. In studies of older populations in 1975 to ensure that children with disabilities have the
with impaired vision, elderly people reported poorer levels of opportunity to receive a free, appropriate public education
functioning for activities of daily living, symptoms of depression like other children. IDEA has evolved and been amended
many times. There are now rich opportunities and stringent
and feelings of anxiety as compared to the general older
time frames outlined and required throughout the US.
population as well as compared to older patients with different Implementation of IDEA takes place at the local school
chronic conditions. Older people who report vision loss are district level. Up to date, detailed information about
more likely to experience comorbid conditions than people IDEA can be found on the website for the National
without vision loss, with serious consequences for overall health, Dissemination Center for Children with Disabilities (www.
ability to perform tasks, and to participate in social roles (Crews, nichcy.org)
Jones, & Kim, 2006). Among the significant quality-of-life issues Social Security. Patients in the US who are blind or have
reported by adult patients are: loss of the ability to read, to see low vision may be eligible for financial assistance from
faces, to see television, to play cards, to identify medications, to the Social Security Administration. For Social Security
benefit purposes, the term ‘legally blind’ is used. A person
go to the movies, to drive and to live independently.
is considered to be legally blind if his or her vision cannot
be corrected to better than 20/200 in the better eye or the
Vision impairment impacts children in a variety of ways. visual field is 20 degrees or less in the better eye. Even if a
For example, toddlers whose vision is within normal limits person’s vision does not meet the legal definition, he or she
will communicate with one another by imitating each other may still qualify for benefits if the vision problem alone or
(Trevarthen & Aitken, 2001) even hours after observing their combined with other health problems prevents the person
counterparts (Hanna & Meltzoff, 1993). However, children from working. Full information can be obtained from
Social Security: The Official Website of the U.S. Social
with impaired vision can have difficulty modeling conduct Security Administration.
and, consequently, difficulty with social interactions when their
capacity to observe is limited. Concept development also may be Americans with Disabilities Act (ADA). Passed in
1990, the ADA provides people with disabilities with
restricted because low vision may impede access to information protections against discrimination in employment, public
and may curtail the child’s interest in exploring the environment services, public transportation, telecommunications,
(Bishop, 2004).Years of lost economic productivity when vision and places of public accommodation. Regarding vision
impairment goes uncorrected significantly impacts the child, the impairment, ADA proclaims that people with impaired

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Chapter 1
vision have the same rights as anyone else to participate
in a wide variety of activities. However, the ADA provides Legislative Developments in Brazil Benefit People with
relatively little in the way of removing environmental Disabilities
obstacles to such participation. (Asch, Gartner, Lipsky, Luciene Fernandes, MD
Lighthouse Handbook on Vision Loss and Vision Minas Gerais, Brazil
Rehabilitation, 2000) Former Chairperson, Panamerican Low Vision Society
In Brazil, a Declaration of Human Rights dates back to 1948. This
Internationally the laws related to low vision vary enormously. was followed in 1988, 1989 and 2002 by legislation and decrees that
In some of the Scandinavian countries comprehensive health, further defined and established guidelines. These included provisions
for people with impaired vision. For example, Ordinance #1679 of
education, and rehabilitation provisions are coordinated and 1999 detailed the adaptations and support that a student with visual
provided for all citizens. Low vision clinical and other services impairment would need in the academic setting: Braille, large type,
are included in these plans. In other parts of the world, services, use of optical aids and electronic devices, extra time, presence of a
Leader.
coordinated care, and legal protection may not exist or may be
minimal. In 2008, a National Health Policy for People with Disabilities was
put forth as Ordinance #3128 (24 December 2008). This policy
determined the accreditation guidelines for low vision services
The World Health Organization (WHO) and the International and established the State networks of care for people with vision
Agency for the Prevention of Blindness (IAPB) have worked loss. It stipulated that Vision Rehabilitation Services must have
adequate physical facilities and equipment, and a multidisciplinary
together with a wide array of organizations worldwide to team suitably qualified and trained. Further, it mandated that the
develop and implement Vision 2020: The Right to Sight. habilitation/rehabilitation of people with impaired vision must proceed
Vision 2020 is a coordinated plan to define the problems of in a system that coordinates and integrates with regional health care,
as well as access to optical aids.
vision impairment and to address them in an effective fashion
by the year 2020. Low vision is specifically addressed in the A constitutional amendment was added to the Brazilian constitution
in 2011 that institutes a National Plan for the Rights of People with
Vision 2020 plan. From its inception, the developers of Vision Disabilities. This plan strives to remove limitations by articulating,
2020 realized that success in addressing vision impairment integrating and promoting policies, programs and actions that
encourage the full and equal rights of persons with disabilities. It
would not be possible without the commitment of national
makes reference to the International Convention on the Rights of
Ministries of Health. To that end, the Vision 2020 agenda was Disabled Persons of the United Nations of 2006, formally adopted by
presented at the World Health Assembly. In May 2003, the Brazil in 2007. The provisions of the 2011 amendment deal with the
domains of education, work, social assistance, accessibility, health
World Health Assembly unanimously passed resolution WHA and habilitation/rehabilitation.
56.26, which urged Member States to commit themselves
to supporting the Global Initiative for the Elimination of
Avoidable Blindness by setting up, not later than 2005, a
Protecting the Rights of Persons with Disabilities in Colombia,
national Vision 2020 plan, in partnership with WHO and in South America
collaboration with nongovernmental organizations and the Roberto Valencia, OD
private sector, thus giving a highly visible international impetus Colombia, South America
to the prevention of avoidable blindness. National Ministries Fundación colombiana para la discapacidad visual
of Health, regional representatives for Vision 2020 (www.iapb. Statutory Law No. 1618
org/vision-2020 and additional Vision 2020 websites), and your 27 February 2013
local professional associations (e.g., Low Vision Rehabilitation
“…to guarantee the full exercise of the rights of disabled persons.”
Committee of the American Academy of Ophthalmology,
Two prior pieces of legislation by the Colombian government, in
Pan-American Low Vision Society, Low Vision Section of 2007 and 2009 respectively, dealt with these issues, but the 2013
the American Academy of Optometry,Vision Rehabilitation law seeks to expand the former provisions. It mandates steps
Section of the American Optometric Association) are the best that must be taken in pursuit of “human dignity, equal opportunity,
respect, justice, inclusion, protection, solidarity, pluralism and
sources of information about law and practice in your particular accessibility, acceptance of differences…” Law 1618 specifies the
nation or region. rights of disabled children and adults as well as the responsibility of
Society (defined as the family, private businesses, non-governmental
organizations, guilds and society in general) and it highlights the
specific responsibilities of various governmental departments and
agencies in furthering this goal.

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 Chapter 2
Chapter 2: Assessment discussed in earlier chapters in this book, the causes of low
vision include retinal diseases, optic nerve damage, media
opacities and brain injury. Regardless of the cause, the low
Importance of Early Detection vision clinician can make an important difference to the patient
Early detection of low vision is important for two essential and his/her family by conducting a thorough examination,
reasons. The first is that the eye diseases that result in low vision explaining findings and prognosis, referring patients for vision
require treatment in order to do whatever is possible to control rehabilitation and prescribing helpful devices that improve the
vision loss. This includes the latest treatments for macular patient’s ability to function in the home, at work, school and in
degeneration, glaucoma and diabetic retinopathy to slow their the community.
progress, and cataract surgery as well as treatment for other
anterior and posterior conditions. The second reason is that the The low vision examination includes the following
earlier that vision loss is detected – particularly in progressive components:
conditions -- the better the patient’s vision will be, the greater
the range of available optical and vision rehabilitation solutions • Case history
and often, the easier the patient’s adaptation. • Checking visual acuity

In addition to the difficulty many people – especially older • Refraction and predicting the add
people -- have understanding that any vision loss should be • Function tests: Central visual field, binocular function,
attended to speedily, patients often have trouble distinguishing contrast sensitivity, peripheral visual field and color testing
between the subspecialty care they get to control their eye (as applicable)
disease and the specialty of low vision care/vision rehabilitation. • Evaluation of low vision devices
Studies have documented the public’s lack of awareness of
• Selection of appropriate devices
these services worldwide and the resulting long and debilitating
time many patients suffer through without receiving care. • Instruction in device use
A concomitant difficulty is the delay and sometimes failure • Referrals for additional vision rehabilitation services
of some ophthalmologists, optometrists, nurses and other
• Prescription
gatekeepers to refer patients for vision rehabilitation due to lack
of knowledge about the availability and/or benefit of these vital • Dispensing
services.You can help: • Follow-up
• by clarifying these issues for your patients; Case History
• by delivering basic or comprehensive low vision care Low vision care is particularly task-oriented. As a result, the
yourself or knowing who in your community offers these low vision case history includes the patient’s ocular and medical
services; history but also asks detailed questions about any difficulties
• by providing care in a timely way or referring your the patient may be having with daily activities, both at near
patients as soon as you discover that function is impaired. and at distance. The low vision clinician will want to know
about general health issues, such as diabetes, Parkinsonism,
Examining the Adult with Low Vision neurological problems such as Multiple Sclerosis, or a history
The low vision examination differs from the routine eye health of stroke, as these can affect his/her recommendations. In
examination, and has its own unique tools and procedures. It addition, there will be questions about whether lighting, glare
complements but does not take the place of on-going disease and contrast present difficulties, and any problems there may
treatment. The low vision examination’s goals are three-fold: be with work, school, hobbies or other interests. The patient’s
own opinion of his primary and secondary goals in seeking help
(1) to understand and quantify the patient’s reduced vision;
for his low vision is important information that shapes the low
(2) to improve function by prescribing low vision optical vision clinician’s approach and intervention.
and non-optical devices that match the patient’s abilities
and daily living needs;
Testing Visual Acuity
(3) to recommend vision rehabilitation interventions, The specialized tests that are used for visual acuity testing
including re-training in daily living activity skills, safe travel generally present more optotypes (letters, numbers or symbols)
skills and counseling, as necessary. on a line and more lines for the patient to read than traditional
The result of the low vision examination is not a cure for tests. The geometric progression of the layout of optotypes on
the eye disease; rather what is sought is a positive impact on charts with LogMAR design (Logarithm of the Minimum
the patient’s quality of life despite the patient’s vision loss. As Angle of Resolution) with controlled size and spacing of letters,
space between letters and line spacing, makes these the research

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Chapter 2
standard and best for
clinical work. In low
vision care, test distances
are closer than in regular
vision testing, and the
clinician’s goal is to record
a measurable acuity, even
if it is very low. Charts
exist that will allow visual
acuity measurement to as
low as 20/1600; therefore, Fig. 5. Radical retinoscopy
Finger Counting (FC) as
a recorded measurement Predicting the Add
should be avoided. A basic premise in low vision care is making the retinal image
Projector charts generally larger in order to make it easier for the patient to see. This
are not used, both because can be done by getting closer to the object, by making the
they do not present object larger (such as large print) or through the use of optical
optotypes at high enough magnification. Therefore, following the refraction, the clinician
contrast and because the determines the starting add that the patient will need.  The add
Fig. 4. Distance chart in movable illuminator stand
test distance is not effective is the additional magnifying power that the person may need
in obtaining measurable vision. Low vision is tested at distance in order to see a goal-size object or print.  Several methods
and at near, monocularly and binocularly. The clinician carefully for determining the add exist.  The reciprocal of the patient’s
assesses the patient’s performance as it reveals not only the acuity Best Corrected Visual Acuity (BCVA) for distance can be
level, but also may indicate possible functional problems. For used (eg, the reciprocal of a BCVA of 20/200 is 200/20 = 10;
example, a patient who consistently misses the central letter(s) on ie 10 diopters).  A hand-held near chart that is constructed
the eye chart may have a central scotoma; missing the letters on in LogMAR format can also be used at 40cm with a +2.50
the right or left may indicate a hemianopsia. Observation of the add in place over the patient’s best refractive correction (or a
patient’s eye position or head tilt during the testing also provides +5.00 add at 20cm). The patient is asked to read the lowest
information needed for prescribing. line. This chart is very useful because for each acuity level it
provides a ready calculation of the amount of add that would
Refraction be needed in order for a patient to read 1M print size (the size
Why refract a patient with low vision when you already
of print in many newspapers and magazines.) This amount of
know that vision likely cannot be improved to within
magnification can be presented to the patient in spectacles,
normal limits? It’s a good question. Refraction is central to
hand magnifier or stand magnifier form, as described in the
the low vision examination because giving the patient even
chapter about low vision devices. It is important to note that
a slight improvement may allow access to a wider range of
the predicted add often is just a starting point; the results of
magnifying lenses in lower powers that are easier to use. In
the patient’s contrast testing, central and peripheral visual field
addition to standard retinoscopy, the technique of ‘radical’
testing may have an impact and must be taken into account.
retinoscopy (using a reduced working distance to increase reflex
brightness) can be helpful in low vision. A phoropter can be
helpful, although it does not allow for eccentric viewing. An
autorefractor can be useful to objectively document sphere
and cylinder, or but it may be difficult to use in the presence
of media opacities, when the patient views eccentrically, or has
nystagmus. A trial frame and hand-held lenses are often the
equipment of choice for the freedom they allow the low vision
patient to fixate eccentrically during the test.

Fig. 6. Near vision test card with cord

L o w Vi s i o n : A C o n c i s e Tu t o rial From A ssessment To Rehabilitation

 Chapter 2
Function Tests Color Testing – Color is not routinely tested in the low
Other tests are performed to further flesh out an understanding vision exam of the adult (it is always tested in children),
but may be a part of the adult battery if the case history
of the patient’s functional vision.
or patient’s objectives indicate. In addition to standard
Amsler Grid – This test of the central 30 degrees of visual color tests (Farnsworth/Ishihara/HRR) there is a large-
field is used binocularly first, then monocularly. The test is disc version of the D-15 test that is a more useful size for
done at 33cm with a +3.00 add in place over the patient’s testing low vision patients.
best correction. The Amsler Grid is used in low vision
care to locate scotomas, to get an idea of their size and
density and to compare OU, OD and OS – information
that will be useful in prescribing. It helps the clinician
understand whether the patient will perform best with a
monocular or a binocular correction and/or low vision
device. The sensitivity of the test can be improved by doing
the test binocularly first, by using a grid of a different
color (especially red) that will allow the patient to ‘see’ his
scotoma more vividly or by using a lower contrast grid.
Fig. 9. Panel 16 quantitative color vision test

Glare Testing – While not routinely done, the impact

of glare on visual acuity may be tested if the case history,
diagnosis or patient’s objectives indicate. Glare lights
may be attached to the distance chart illuminator or a
Brightness Acuity Test (BAT), Brightness Acuity Meter
(BAM) or other external light source can be used to
determine the extent to which glare diminishes visual
acuity and performance. Results will influence prescribing
options.

Fig. 7. Amsler grid with recording form

Contrast Sensitivity Testing – This test is essential to

low vision care because its results predict the need for
increased magnification, illumination and/or contrast
enhancement. It predicts which is the better eye, what
the patient’s binocular potential is, and overall, what the
likelihood of success is going to be with optical devices.
Changes in contrast sensitivity also validate patient’s
complaints that there has been a change in vision which is
not otherwise borne out by visual acuity testing. Contrast
sensitivity function has been noted as a better predictor of
patient performance in the real world than visual acuity
(Rosenthal, BP.Visual Acuity vs Contrast Sensitivity
Optometric Management 3/1/06) and often its results are
more important to the patient’s functional vision than those
of visual acuity testing. (Faye, EE. Lighthouse Handbook on
Vision Loss and Vision Rehabilitation, 2000)

Fig. 10. Distance chart with glare lights

Fig. 8. Contrast sensitivity tests

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Chapter 2
Low Vision Device Recommendation The clinician will want to know the child’s educational history,
Once the history is taken and the appropriate testing is as well. Some children are able to answer some questions on their
completed, the clinician is ready to recommend low vision own. Include the child whenever possible.
devices. The patient’s objectives for distance, intermediate
and near activities are considered, as well as the results of the Testing Visual Acuity
tests of visual function and the predicted magnification. The Children will be tested at distance and at near, as appropriate,
characteristics and limitations of the various optical devices such using specialized charts. The selection of the appropriate test
as field of view and working distance are important to include depends on the child’s age and abilities.
in the decision process. Optical devices will be discussed in an
When testing infants to about 18 months of age, preferential
upcoming chapter. Instruction in device use is crucial to the
looking tests such as Teller Acuity Cards and LEA Gratings are
ultimate success of the low vision examination.
used. The infant’s ability to see detail in a moving stimulus can
Examining the Child with Low Vision be evaluated with an Optokinetic (OKN) Drum, and gross
The goal of the pediatric low vision examination is threefold: object awareness can also be evaluated using balls or toys of
(1) to understand the child’s vision (in the context of what is various sizes.
appropriate for the child’s age), (2) to address the interventions
needed for the visual tasks the child has or will have, and
(3) to educate the parents/teachers/other professionals in
the child’s life about the child’s condition and low vision
recommendations. Like the low vision examination of the adult,
the examination of the child requires special equipment and
techniques.

The components of the pediatric low vision examination are:

Front Side Back Side
• Case history
Fig.11A. LEA GRATINGS, a preferential looking test (front and back)
• Visual acuity testing
• Ocular motility, binocularity and fixation testing
• Visual field testing
• Refraction
• Color vision testing
• Contrast sensitivity testing
• Eye-hand coordination testing
• Low vision device recommendation
• Device instruction
• Recommendation of other services Fig.11B. LEA GRATINGS, a preferential looking test in use

• Counseling parents/teachers/other professionals

• Follow-up
Case History
The pediatric case history is the foundation of the low vision
examination. The clinician will obtain most information from
the adult (parent, grandparent, caregiver) who has brought the
child to the examination. Questions should be asked concerning
the child’s ocular history, medical history, developmental history,
and whether the child is receiving any other services such as
occupational therapy, physical therapy or speech therapy.
Fig. 12. Optokinetic (OKN) drums

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 Chapter 2
Preferential looking tests are applicable for some toddlers (18 Some children under 5 years of age and most school-age
months to 3 years), but tests of recognition acuity can also be children (+5 years of age) can recognize letters and can be
introduced, such as the LEA Symbols which are not culturally- tested using the HOTV letters, numbers or other standard
bound and use the simple symbols of a square, apple, house and distance and near letter and distance charts in LogMAR format.
circle as optotypes. The LEA Symbols have the distinction of all Continuous text at an appropriate level can also be used.
blurring to circles when the child can no longer distinguish the
optotype. During testing the child can either name the symbols,
point to the appropriate symbol on a response card held in the
lap, or touch, lift or otherwise indicate the 3D puzzle piece that
confirms the symbol seen.

Fig. 17. HOTV Near and Distance Charts

Fig. 13. LEA Single Symbol Book Fig. 14. LEA Puzzle

For pre-schoolers (3-5 years of age) LEA Symbol presentation Ocular Motility, Binocularity and Fixation
is available for low vision (to 20/1600), in distance charts in Many targets can be used for testing ocular motility, binocularity
LogMAR format (to 20/200), single symbol and crowded and fixation in the child with low vision. A penlight or
symbol books (to 20/200) and on near charts, flash cards and transilluminator, finger puppets, the child’s favorite toy or other
domino cards. Another advantage is that the 3D puzzle and objects are effective. The clinician will assess basic fixation
domino cards that are part of the LEA Symbols test system give and following and may check for binocular alignment using
the illusion of a play situation while the child learns the symbols the Hirschberg or Krimsky tests, and for angle deviations and
or engages in the test. Symbols are also presented in crowded amblyopia using the Bruckner test. A cover test will also be done.
format to mimic continuous text. Similar to the LEA Symbols,
LEA Numbers are another option and are available for low Visual Field Testing
vision, standard distance testing and near testing. Younger children can be tested using a portable arc perimeter
with fun targets, and also through gross confrontation screening
with colored objects in a lighted room. Techniques for using
lighted targets in a dim room in a preferential looking scenario
can also be very helpful. Older children can be tested using
standard confrontation testing (having the child indicate when
he/she sees the clinician’s wiggling or stationery fingers), or
by using the Flicker Wand [Fig. 18A]. Goldmann perimetry,
presented as a game, is also effective with older children. The
Amsler Grid can be used to test central visual field in children
who can comprehend the instructions.

Fig. 15. LEA Numbers low vision book

Fig. 18A. LEA Flicker Wand

Fig. 16. Continuous text chart

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Chapter 2
Contrast Sensitivity Testing
Contrast Sensitivity Testing is very important to the pediatric
low vision examination and has prognostic value for the
clinician. ‘Hiding Heidi’ is a test that presents a simple line
drawing of a smiling girl’s face in levels of contrast from 1.25%
to 100%. The test is presented in a preferential looking format.
The LEA Symbols are also available in a contrast test flip chart
that presents one size symbol at five levels of contrast: 1.25%,
2.5%, 5%, 10%, and 25%. For older children who know letters
or numbers, standard reduced contrast letter or number cards
can be used.

Fig. 18B. LEA Flicker Wand in use

Refraction
Just as with adults, refraction is a critical part of the pediatric
low vision examination. Of particular help when working
with children is the use of interesting targets such as videos
across the room, animated toys or having the parent keep the
child’s attention. These complement procedures such as the
Mohindra Technique for near retinoscopy. This technique
involves performing retinoscopy in a darkened room at 50
cm (20 inches) with the child fixating the retinoscope light
monocularly (the other eye is occluded). Distance retinoscopic
Fig. 20A. Hiding Heidi Low Contrast Face Test
refraction is derived by adding −1.00 D to the value found by
near retinoscopy. This allows the clinician to take into account
the working distance and the state of accommodation in the
dark. Cycloplegic refraction will be conducted on a percentage
of children, in addition to keratometry.

Fig. 20B. Hiding Heidi Low Contrast Face Test in use

Low Vision Devices for Children

Not all children with low vision use (or need) low vision
devices. In considering whether to prescribe a device, the
Fig. 19. Color vision screening and testing clinician evaluates whether the child can be taught how to
use the device, whether the child can be responsible with the
Color Vision Testing
device, whether the parents are supportive, what the child’s
While color vision testing is only sometimes performed during
lifestyle is, whether a device is the best option to meet the
the examination of the adult with low vision, it is critically
child’s needs, and cost. All low vision devices are possible
important when testing children. Since so much of the child’s
clinician recommendations, including low vision spectacles,
learning and concept development in the early years will be
hand magnifiers, stand magnifiers and telescopes. Of these,
dependent on color, knowing whether there are any color
dome magnifiers are particularly effective for children.
deficiencies is important to the teacher, the parent and the child.
Electronic devices offer significant advantages for children, in
Once again, the particular test for a child will be based on the
particular tablets that allow easy screen magnification, scalable
child’s age and abilities.
font size and speech output.

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 Chapter 2
Sharing Information
Talking to Parents of Children with Impaired Vision
Once all of the evaluations have been completed, the low
Judith Gurland, MD
vision clinician takes the very important step of summing up New York, USA
the findings for the patient’s parents/caregivers, and writing • Remember this could be your child or grandchild
reports that help teachers and other professionals involved in the
• Ask the child and then the parent(s) about specific needs and/or
child’s care. issues with learning
– Types of learning material
Parents’ focus on prognosis is understandable. However, in the – Physical set-up of learning areas
case of very young children the recommendation may be to – Social issues related to vision impairment
watch for changes over time. The most important step is to take • Remember to ask for and to listen for their concerns and their fears
the time to explain – and, if possible, to demonstrate – WHAT • Speak quietly and at a normal pace: do not be patronizing or
the child sees at the time of the low vision examination. solicitous and be patient
This can enhance the interactions between parent and child • Let the child show you and the parent(s) what works visually for
or teacher and child, reducing frustration and increasing him/her
effectiveness. - Adopting a particular head position
- Using the low vision devices that the child prefers
• Offer to communicate with teachers
– Look at schoolwork/books/other teaching material
• Stick to ‘what’s so’ rather than making anything up but don’t be
cruelly honest either
• Remember to speak with and include the child in at least some of
the conversation
• Check in with the parent(s) and child during the conversation to
assure that they are still listening and that they understand what
Fig. 21. PowerDome dome magnifier
you are saying
• MAKE and KEEP eye contact with the parent(s) and/or the child
North Star Vision Group wishes to acknowledge the contribution when you are interacting with them
of Michael Fischer, OD in the development of the process for the • TURN OFF ALL ELECTRONIC EQUIPMENT – both yours and
assessment and prescription for children with low vision described in theirs. You do not want to be distracted by an incoming call!
this text.The reader is directed to the article below by Dr. Fischer • Ask if they have questions and address them, as best you can, and
for additional suggestions for working with children with low vision. then ask if you have actually answered them

Fischer, Michael. Low Vision Examination of Children. • If appropriate, have the parent experience what the world may look
like to their child
[http://www.lighthouse.org/for-professionals/practice-management/ • Become familiar with available vision rehabilitation services, relevant
patient-management-pediatrics/low-vision-examination-children] websites, local or internet support groups and share these with
families when appropriate

13

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Chapter 2

North Star Vision Group, LLC’s Low Vision Exam Flow Chart™
What Will You Do?
Why? What Will You Use? How This Differs From A Special Considerations
Steps In The Low Vision Routine Eye Exam For Children
Rationale Chart Or Technique
Exam
History To determine presenting Intake/History form In addition to routine questions, Getting information from
 complaint(s); establish con- the LV History inquires about parents, caregivers, teachers
straints/needs/goals difficulties with daily tasks and – those who are with the child
activities. daily – is important.
Entering Acuity To establish point of reference; • LogMAR distance chart Projector charts and Snellen Optotypes or test objects that
 Baseline against which to evalu- • Near chart: single word, num- charts are NOT routinely used. are not culturally-bound and that
ate effects of treatment ber, symbol, reading distance make the test situation fun are
preferable.

Refraction Starting point to improve dis- • LogMAR distance chart Closer test distances and spe- A lens bar may be faster to
 tance and/or near vision • JND (Just Noticeable Differ- cially designed charts are used. use than trial lenses, but the
To give patient best vision pos- ence) A greater JND interval is used so disadvantage is that it is also an
sible, even if it is not within ‘nor- that the patient can perceive the interesting item for a young child
• ETDRS single letter, number, to grab. Fun frame occluders can
mal’ limits, in order to increase symbol or single letter/number difference.
device and ADL options facilitate monocular refraction.
book Getting the parent or caregiver’s
help to hold young children or
to cover each eye as needed is
useful.
Predict the add (for 1M print or To improve functional vision for • Single letter, number, symbol Concentrates on the additional When appropriate, a child who
other goal-size print or activity) goal-related tasks chart (with cord) magnification the patient will faces a lifetime of low vision
 • Continuous text need in order to do daily tasks. device use should be introduced
to magnification. In addition,
electronic devices already popu-
lar with the child’s peers may
offer an acceptable option.
Do Function tests: To quantify and understand Function tests: Tests are performed because Child-friendly optotypes are
• Contrast Sensitivity aspects of vision that may affect • Letter/number contrast test they have direct application to available for contrast testing.
final Rx and rehabilitation recom- the functional difficulties the Confrontation testing can also
• Amsler Grid mendations  msler charts manual
•A patient may have, and to address be done with familiar objects.
• Visual Field (optional) the prescription of low vision Color identification is particularly
 oldmann, Humphrey or
•G devices. important for young children,
• Color because color is often made a
Octopus
 key component in early learning.
• Confrontation Color test using child-friendly
• Large D-15 optotypes is available.
Trial of Devices and Recom- To match device to task; to eval- Sequential presentation of More than one device may need Consider the child’s readiness
mendation uate patient’s initial response to devices to be prescribed for a patient. to use a low vision device and
 each type of device Unlike routine spectacle Rxs, whether there is support to use a
low vision devices are each task- device from parents or caregivers
specific. The case history elicited before prescribing. Dome magni-
from the patient and discussion fiers are a helpful starting device
during the exam help with device for many children.
recommendation.
Training in device use (LV To develop patient’s skills and Dedicated LV instruction session Critically important in low If a child is competent to be
Instruction) understanding; provide guid- as part of initial visit, and as vision care so the patient can prescribed a low vision device
 ance to patient/family; assess focus of subsequent visits; report understand exam findings, ask (consider age, maturity, need,
proficiency; make plan back to doctor questions, evaluate device rec- parental support) the child, the
ommendations and be engaged parents and/or caregiver should
in the learning process. have instruction in how to use
Using real-life items (newspa- and care for the device. The
pers, local utility bills, hobby- child’s teacher may also ben-
related items) allows patient to efit from this information about
see potential to integrate device device(s), so that he/she can
use into daily life. Demonstrate reinforce the child’s use of the
lighting/ contrast enhancement. device in the classroom setting,
if appropriate.

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 Chapter 2
What Will You Do?
Why? What Will You Use? How This Differs From A Special Considerations
Steps In The Low Vision Routine Eye Exam For Children
Rationale Chart Or Technique
Exam
Referral To engage those professionals In-house or external network Unlike the subspecialty referrals Other vision rehabilitation
 who provide counseling, Orienta- made intermittently in routine specialists are integral to low
tion & Mobility, ADL training, care, other vision rehabilitation vision care and should always
visual skills enhancement in specialists are integral to low be considered for youngsters.
order to help patient reach goals vision care and should always Often these services are pro-
be considered. All specialists do vided through the school system,
NOT have to be within the same however, it should not be as-
practice. sumed that they are in place. A
recommendation from the vision
care professional may be needed
to initiate appropriate support
services for the child.
Follow up To troubleshoot; intervene as Return visit(s); phone call(s); Unlike routine care, the low Children who will use low
 necessary online contact vision episode of care nearly vision devices should be seen
always includes follow up initi- for follow up until the instructor
ated by the clinician and/or and clinician are satisfied that
instructor. Explain to the patient the device can be used properly.
that a change in vision or visual Explain to parents/caregivers
demands may require a new de- that the child should return for
vice recommendation. Encourage additional low vision care when-
patients to stay in touch with you ever visual demands change, for
to ask about new devices they example, when textbook text
hear about or see online. size gets smaller as the child
progresses in school.
Dispensing To make sure the patient re- Dispenser will reinforce correct Important to have the capability Important to have the capability
ceives the prescribed device(s) device use with patient to dispense in-house or have a to dispense in-house or have a
definite source of devices in the definite source of devices in the
community. Drop-shipping to the community. Drop-shipping to the
patient is not advisable unless patient is not advisable unless
you schedule the patient to bring you schedule the patient to bring
the device for a follow up visit so the device for a follow up visit so
you can reinforce correct use. you can reinforce correct use.
Fig. 22. North Star Vision Group, LLC’s Low Vision Exam Flow Chart™ Copyright © 2013 by North Star Vision Group, LLCSM Used under license from North Star Vision Group, LLCSM

Developing a Plan and Sharing Information In addition, the low vision professional should:
Patient-centered care is essential for low vision services to
• “Test” the patient’s understanding of what he/she has to
be successful since low vision care focuses on optimizing the
do to practice
functional effectiveness of the patient. It is, therefore, important
to find out what the patient views as the problem and what his • Screen for readiness - how confident is the patient that
or her goals are. The care plan that is developed should respect he/she can comply?
and respond to individual patient preferences, needs, and values. • Keep the patient on track – by phone, email, follow up visits
During the history-taking at the start of the assessment, critical
It helps to keep in mind that adults learn best when:
information about what the patient sees as the problem and
what his or her goals are is shared. Information derived from • They have a sense of control (feel safe).
the clinical assessment is used to refine the details about the
• They are involved in the learning process (can set their
problem and goals and to develop the care plan. The low vision own goals, be given freedom to explore options).
professional works with the patient to:
• The task is personally meaningful.
• Agree on the problem
Treating patients as partners, involving them in planning their
• Negotiate reasonable goals health care and encouraging them to take responsibility for
• Generate options their own health has been shown to improve satisfaction with
care, compliance and clinical outcomes. The following case
• Decide on a mutually agreeable and feasible regimen
studies help to illustrate this.

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Chapter 2

CASE STUDY #1 CASE STUDY #2

Patient: Hana (female) Patient: Ray (male)
Age: 45 years old, unmarried Age: 70 years old, married
Diagnosis: Diabetic retinopathy Diagnosis: Age Related Macular Degeneration
Chief complaint: Inability to read. Chief Complaint: Had to stop driving
History: Hana was an avid reader. She lost her job one year prior History: Ray is an active 70 year old man. He is in good general
to her vision loss. She subsequently started a new job as a librarian health. He was not a candidate for AMD treatment. Prior to his
but now feels that the extensive reading required and helping library vision loss, Ray was very involved in driving his wife and other
users has become very difficult. family members to social gatherings, on shopping trips and to
appointments of all kinds. The progression of his AMD has caused
LV Examination: Hana was tested using the Early Treatment him to have to stop driving, an occurrence that he said, “totally
Diabetic Retinopahy Study (ETDRS) LogMAR distance chart at 2 changed my life.” Normally an outgoing person, Ray has become
meters. Her visual acuity was measured to be 2M/40 OD (equivalent withdrawn.
to 20/400 at 2 meters) and 1M/40 OS (equivalent to 20/800 at 1
meter. She was not helped with any refractive correction. With the LV Examination: Ray was tested using the ETDRS LogMAR
ETDRS near chart at 40cm, the predicted add for 1M print was distance chart at 1 meter and his visual acuity was measured to be
+20D for the OD. Her contrast sensitivity was tested using the Mars 1M/40 OD, OS and OU (equivalent to 20/800). With the ETDRS near
Letter Contrast Sensitivity chart, and found to be 0.96 OD (severe chart at 20cm, the predicted add for 1M print was +40D. He was not
loss), 0.40 OS (profound loss), and 1.00 OU (severe loss). helped with any refractive correction. Amsler Grid testing revealed
large central scotomas in each eye. His contrast sensitivity was
LV Recommendations: Although the predicted add was +20D, tested using the Mars Letter Contrast Sensitivity chart, and found to
Hana’s reduced contrast sensitivity required a higher add. She be 0.48 OD, OS and OU (profound loss).
was tested with a +24D (6X) aspheric microscopic spectacle for
her right eye and was able to read 1M continuous text slowly. LV Recommendations: While driving is no longer possible, in
This was prescribed for her for short term reading tasks. She was discussion with the Low Vision clinician it was discovered that Ray
also prescribed a hand-held, focusable, monocular 4x telescope would still be interested in performing routine car maintenance.
for distance spotting, including searching the library stacks. A He was shown two types of videomagnification (CCTV) systems.
consultation was arranged with a job site specialist to evaluate Ray discovered that he could view the markings on the tire gauge
and help her maximize her work environment. She will meet with a and other tools when magnified on the CCTV screen, with reverse
technology specialist to learn about the accessibility features of her polarity (white letters on a black background). He was also able to
work computer and will also get information about speech output use the CCTV to read some of the maintenance manuals, although
software that may speed up her reading at work. in some the print was too small. His adult son, who accompanied
him to the examination, offered to photocopy those manuals to
Outcome: Hana was taught to use the spectacles and the make the print larger. The ability to raise the contrast on the CCTV
telescope. Her reading with the spectacles was slow at first but she screen was also an advantage to Ray. He was also shown a 12X
gradually gained speed and accuracy. She was very pleased with the (+44D) illuminated stand magnifier for short term reading along with
telescope, but found that it was difficult to use when she was in less a reading stand.
well-illuminated parts of the library. Although she was very anxious
about having the job site specialist visit her at work, she found that Outcome: After receiving training in the use of the devices, Ray
consultation to be very helpful. With her employer’s permission and purchased a CCTV and set it up in his garage, where he now reviews
support, she is having speech output software installed on her work maintenance manuals and performs routine maintenance. His son
computer. continues to photocopy any pages where the print is too small, in
preparation for Ray to use his CCTV. He uses the illuminated stand
magnifier less frequently than the CCTV, but likes to have it at his
desk. His mood has improved considerably.

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 Chapter 2
In the case of children with low vision, research has also indicated
CASE STUDY #3 that family-centered practice is critical to the success of early
Patient: Marco, (male)
Age: 7 years old intervention. The family-centered approach is most effective
Diagnosis: Congenital cataracts; prematurity when it addresses both the development of the child and the
Chief complaint: Readiness for next grade in school concerns and priorities of the family. Educators are also integral
History: Marco was born prematurely and was diagnosed with to the success of low vision interventions for many children.
congenital cataracts.  However, he was unable to have timely Information from teachers and their suggestions for the low
cataract extractions due to other health issues and developed vision care plan can enhance the effectiveness of that plan. Many
deprivation amblyopia.  At his last low vision examination, one year
ago, after discussion with Marco’s parents, the clinician prescribed low vision professionals find it helpful to share a written copy of
spectacles and introduced Marco to a 1.8x dome magnifier.  Since the assessment results and the prescription for devices and skill
he will begin first grade soon, his parents are concerned that the development with parents and teachers where appropriate.
smaller text size will be difficult for Marco to read.
LV Examination: At this reexamination visit, Marco’s uncorrected
distance vision was first evaluated using LEA Symbols.
Results at Distance:
OD: 3/120 Manifest trial frame refraction: OD: -1.00-2.00x90 3/60
OS: 3/150 Manifest trial frame refraction: OS: -2.50-2.50x90 3/95
At near, Marco was tested using the LEA Symbols near vision card.
Results at Near:
OD: 6.3M/.40 (a Snellen equivalent of 20/250)
OS: 8M/.40 (a Snellen equivalent of 20/400)
Marco’s contrast sensitivity was tested using the Mars Numeral
Contrast Sensitivity test, since Marco was proficient in identifying
numbers. He was found to have a moderate loss of Contrast
Sensitivity in each eye: OD: 1.48 OS: 1.08.
LV Recommendations: Since many first grade beginning reading
primers use text with a print size between 3.2M and 4M, Marco
has to be able to see at least 1.6M size print in order to achieve
comfortable reading of the larger size text. Note that this is not
at the threshold of Marco’s acuity because we know that reading
continuous text will be more challenging than single symbols/
letters. In order to go from 6.3M to 1.6M, Marco needed a four-
fold improvement in his reading acuity to read the target print
size comfortably. Several low vision devices that provided 4 times
magnification (+16D) were tried. Marco read best with a +16D (4x)
dome stand magnifier. He was able to read 3.2M LEA symbols easily
and could spot 1.6M print with effort. Task lighting was important
for Marco. A reading lamp with an adjustable arm and a 60 watt
incandescent bulb was recommended and Marco and his parents
were shown how to position the lamp. Marco’s parents will discuss
this with his teacher. A +20D illuminated hand magnifier was also
prescribed for spotting smaller text with poor contrast or to use
when Marco is in a poorly illuminated environment. An electronic,
portable tablet is also a good option for Marco, especially as he gets
older. Marco’s parents will consider arranging for this to be a joint gift
from several family members at Marco’s upcoming birthday.
Outcome: Marco was able to enter first grade. He has been allowed
to have a lamp on his desk at school. His parents’ discussion with
Marco’s teacher led to the teacher showing Marco’s magnifiers to
his classmates. They now do not treat these items as ‘weird’ and
sometimes ask Marco if they can borrow them. Marco will have
special permission to use a tablet in class, should he receive one for
his birthday.

Fig. 23. Pediatric LV examination tools.Top to bottom: fixation cubes, eye patches, and
pediatric Fun Frames occluding glasses

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Chapter 3
Chapter 3: Prescribing Spectacles
The stock spectacles prescribed for low vision range from
+4.00D to +80.00D. Low vision prism spectacles (full
Low Vision Devices
frame / half frame) are available in powers from +4.00D
Low Vision devices are an important part of the vision
to +14.00D. Each has 2 diopters of base-in prism built in
rehabilitation solution for patients with impaired vision.
to facilitate binocular convergence at these higher powers:
Considerations in device prescription include:
+4=6BI, +5=7BI, +6=8BI, +8=10BI, +10=12BI, +12=14BI,
1. The patient’s distance/intermediate/near task objectives, +14=16BI. Lens materials include plastic, glass and hi-index,
as described/discussed with the patient during the and there are several frame styles available.
history and the low vision exam;
Higher power low vision spectacles are also available. These
2. The results of the tests of visual function;
include high plus full field spectacles, microscopic aspheric
3. The amount of magnification required for the target spectacles and a range of higher power microscopic lenses,
print size or object size, as determined during the low including microscopic doublet lenses. The standard high
vision exam;
plus full field series comes in powers of +10.00D, +12.00D,
4. The optical properties of the device(s) being considered; +14.00D, +16.00D, +20.00D in full frame styles for monocular
5. The patient’s capabilities, economic concerns and use. The microscopic aspheric series includes 6x (24D), 8x
preferences. (32D), 10x (40D), 12x (48D), also to be used monocularly.
Unlike routine eyeglass prescriptions that can be made to help The advantages of low vision spectacles are that they are
a patient for distance, intermediate and near, most low vision relatively lightweight, relatively cosmetically acceptable and
devices are task-specific. As a result, many patients with low inexpensive. Their main advantage is that they allow the
vision are prescribed more than one device for their daily tasks. patient’s hands to be free. The disadvantages of low vision
The optimal use of low vision lenses requires that patients spectacles include the close working distance, the difficulty
hold the material to be viewed at the specific focal distance of maintaining focus, particularly in higher powers and for
dictated by the power of the lens. Instruction in device use, task patients who may experience hand or head tremors, significant
application and maintenance/care is essential to successful low aberrations above +16D, and the fact that distance prescriptions
vision care. cannot be incorporated into these stock lenses.
Magnification A number of other specialty microscopic spectacles can be
Magnification is an essential tool in low vision care. prescribed for near work, including doublet lens systems,
Options include: wide angle microscopes, hi add bifocals and press on adds. The
• Relative Size Magnification — enlarging the actual size highest power microscopes go up to +80.00D.
of an object;
• Relative Distance Magnification — Moving the object
of regard closer to the eye so that a larger retinal image is
created; and
• Angular Magnification — the ratio of the angle of
subtense of the image formed by an optical instrument
compared to the actual object.
Low vision optical devices can be grouped into the following
categories:

• Spectacles
• Loupes
• Hand magnifiers
• Stand magnifiers
• Telescopes
• Electronic devices
• Filters
Most devices are stock items. Each category has distinct
advantages and disadvantages. Fig. 24.Types of low vision spectacles in different frames

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 Chapter 3
Loupes Hand Magnifiers
Clip-on and headborne loupes are monocular or binocular Many patients with low vision are prescribed hand held
magnifiers that attach to the patient’s own glasses or are worn magnifiers. They are portable and familiar. With hand
on the head. They allow the desired magnification with a magnifiers, the material is held at the focal point of the lens and
more comfortable working distance. Flip-up styles allow the the image is at infinity. The patient must use his/her distance
magnifying lenses to be moved up and out of the way when not prescription with the magnifier.
needed. Hands-free use and working distance are the greatest
advantages. Disadvantages include fragility of the loupe; difficulty When selecting a hand magnifier the clinician will consider
of attaching the loupe to the glasses and cosmetic appearance. the magnifier’s optical design (spherical, aspheric / bi-aspheric,
aplanatic doublet); illumination (non-illuminated / illuminated);
illumination type (tungsten/LED); and the ergonomic needs of
the patient (type of handle / type of pocket magnifier). Hand
magnifiers are available in powers from +5.00D to +60.00D.
The advantages of hand magnifiers include portability, the
favorable eye-to-lens distance and the possibility of having
illumination included in the magnifier. Disadvantages include
the need to use one hand to hold the magnifier and the need
for the patient to maintain the focal distance of the lens.
Another disadvantage that patients note is the fact that lens
diameter gets smaller as lens power increases.

Fig. 26. N
 on-illuminated and pocket hand magnifiers

Fig. 25. Spectacle mounted and headborne loupes

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Chapter 3
Stand Magnifiers Telescopes
Stand magnifiers provide a solution to the problem of Telescopes are the low vision device of choice for patients’
maintaining the focal distance of the lens by fixing the lens distance needs, and some can also be used for near. They may be
into a stand that pre-sets the appropriate distance. The patient monocular or binocular, hand held or spectacle mounted, fixed
places the stand magnifier directly on the page, looks directly focus or focusable. Galilean and Keplerian systems are used in
into the lens and moves the magnifier along the line to read. A low vision care. Galilean systems have a plus objective lens and
reading prescription is used with the stand magnifier, because a minus ocular lens. They are lighter weight and have a shorter
the material is inside the focal length of the lens. This creates a barrel than Keplerian systems, and are available in lower powers
virtual image that is at a finite distance. An angled reading stand (2X to 4X). Keplerian systems utilize plus lenses as the ocular
can create a more comfortable reading environment for the and objective lenses, and use prisms or mirrors to invert the
patient who uses a stand magnifier. image. They are available in powers from 3X to 14X. The barrel
of Keplerian telescopes is longer and they are comparatively
When selecting a stand magnifier the clinician will consider the heavier than corresponding powers that use Galilean design.
power that the patient needs, applicability to the task, the required The difference in the location of the exit pupil in both designs
eye-to-lens distance and field of view, and whether the system dictates the distance from the eye that the telescope must be
will be illuminated or non-illuminated. Battery and plug-in styles held, and the ease or difficulty the patient may experience in
are available, as well as tungsten, halogen, xenon and LED light centrally positioning the telescope.
sources. Like hand magnifiers, the size of the stand magnifier
lens is inversely related to the power of the lens – a larger lens Telescope power is determined with the following formula:
is a weaker lens. Low power stand magnifiers, such as dome
magnifiers and bar magnifiers, are often useful for children. Telescope Magnification = Diameter of Objective lens (mm)
Diameter of Exit Pupil (mm)

The markings on the barrel of most hand held telescopes give

the clinician or the user the telescope’s magnification, the
diameter of the objective lens in millimeters (which indicates
the light-gathering ability of the telescope), and its field of view.

All telescopes share the following characteristics. They offer

the advantages of magnification at a variety of distances,
portability, applicability to distance and sometimes to near tasks
and usefulness for spotting signs, bus numbers, etc. at distance.
The disadvantages of telescopes include: the reduction of the
field of view, more so as the power of the telescope increases;
the loss of light and contrast for the patient when looking
through the system; the potential difficulties of use for patients
with central field loss and/or loss of contrast; and the need to
learn to manipulate the telescope.

Fig. 27. Dome, bar and illuminated stand magnifiers Fig. 28. H
 and-held and spectacle mounted telescopes

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When selecting a telescope for a patient with low vision, Computer accessibility is also a valuable tool for patients with
the clinician considers whether the patient has a stable or a low vision. In addition to add-on programs that give access to
progressive condition, the patient’s task objectives, the level computer navigation and resident software, many useful features
of acuity, visual field limitations (constriction/scotomas), are now standard – built into both Macs and PCs. These include
magnification required, and the patient’s age and motor abilities. the ability to magnify selected parts of the screen, or the entire
screen, as well as speech output. Many of the larger monitors
Filters that are currently available now provide clear, enlarged images,
Filters (also known as absorptive lenses) are used to manage helpful for some patients.
glare and to enhance contrast. They absorb/transmit light at
different spectral frequencies and can be extremely helpful
for use indoors and/or outdoors. Filters are available in full,
wrap-around styles that block light entering from the front,
sides and above. Some are sized to fit over the patient’s spectacle
prescription. Filters are also available in versatile flip-up and
clip-on styles. Photochromic glass lenses can be made up as
single vision lenses, bifocals or trifocals.

Fig. 30. Portable and desktop videomagnifiers

Understandably, high-tech electronic device development is an

area that is constantly changing and improving. At this writing,
ingenious tracking systems mounted on eyeglass frames are
Fig. 29. Filters for adults and children allowing users with vision impairment to see beyond their
current ability and to identify items, colors, street signs and
even faces.
Electronic Devices
The advent of mainstream portable electronic devices that
allow anyone to magnify, have text read aloud, control font size,
color and contrast has brought about big changes. Low vision
patients who use tablets, notepads, smartphones and the like
are finally in the position to have the same tool as the general
public can use. These devices are added to a wide range of
videomagnification systems, called CCTVs, that date back to
the early 1970s. CCTVs have improved significantly over the
years, with technological advances helping to make them more
portable, versatile, with smaller/larger screens, crisper displays
Fig. 31. Portable mini videomagnifier
and lower cost. Some features of currently available electronic
devices include: Handheld cameras, color display options,
headborne video displays, head mounted systems, miniature
flat screens, self contained portable units, simplified controls
and miniature LCD magnifiers, in addition to greatly enhanced
desktop models.

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Chapter 3
Adaptive Devices
Using Technology with Older Adults who have Low Vision
To complete a survey of devices for low vision it is important to
Mark Wilkinson, OD
incorporate the range of other devices that are not optical but Iowa, USA
are enhancements that benefit patients of all ages and which,
in some cases, will be critical to the successful use of optical
Current technology removes significant barriers for older adults with
devices. These include task lighting and illumination controls, low vision, allowing them to engage in activities that would have
writing devices (such as bold-tipped pens, letter/envelope/ been impossible just a few years ago. Another advantage is that
electronic options are in the mainstream and don’t stigmatize the
check writing guides, signature guides), positioning devices user with low vision. For example, despite their small screens and
(such as reading stands or lap desks), contrast enhancement tools keypads, several features built into smart phones and tablets make
(such as yellow filters, contrasting paint/tape), and kitchen tools them easily accessible to users who are blind or visually impaired.
Leading the industry are Apple products that provtide greater
(such as cutting boards, measuring cups) that provide contrast accessibility to users with vision loss through their VoiceOver and
with the ingredients for which they are routinely used. Some Zoom programs.
adaptive devices make use of relative size magnification (such as VoiceOver is a screen reader that uses text-to-speech to read aloud
large numeral clocks, watches, timers, calculators). Other items what is onscreen, confirm selections, typed letters and commands,
help with medical issues (such as a recording/voice output and provide keyboard shortcuts to make application and web page
navigation easier.
device that will tell a patient what is in a particular medicine
The Zoom app magnifies everything onscreen from two to five times
bottle, and tactile, self-adhesive dots to use as markers). its original size, while maintaining their original clarity.
An additional option that increases accessibility is the ‘Large Text’
option that allows the user to select a larger font size (20-56 point)
for any text appearing on their device.
Many individuals with vision loss see better with the high contrast
setting of white on black. Reversing the polarity is often the only
change needed to allow an individual with a visual impairment to
easily read on their phone or tablet.
Finally, for drivers with vision loss who are still eligible for drivers’
licenses, talking GPS technology allows drivers to maintain their
attention on the road and the traffic around them when traveling in
unfamiliar environments.

Fig. 32.Top to bottom: high-contrast measuring spoons, “talking” alarm clock, cordless
task lights, large numeral calculator, writing guides

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North Star Vision Group, LLC’s Low Vision Devices Chart™

Type of Device Characteristics Prescribing Considerations Advantages Disadvantages

Spectacles Stock LV spectacles Consider whether It is too dif- Relatively light weight Close working distance
Powers range from +4.00D to +80.00D ficult for the patient to maintain Relatively cosmetically accept- Difficulty maintaining focus,
focus, particularly in higher able particularly in higher powers
Four types: powers
1. L V prismatic spectacles (full frame Inexpensive Significant aberrations above
Watch for patients who may +16 diopters
/ half frame) available in powers from not be good users because they Patient’s hands are free
+4.00D to +14.00D experience hand or head tremors Distance prescriptions cannot
2 diopters of base-in prism in to each lens or have difficulty maintaining the be incorporated into the stock
facilitates binocular convergence: +4=6BI, focal distance lenses
+5=7BI, +6=8BI, +8=10BI, +10=12BI, Difficulty maintaining focus,
+12=14BI particularly in the higher powers
Lens materials include plastic, glass and
hi-index
Variety of frame styles
2. F ull field high plus spectacles come
in powers of +10.00D, +12.00D, +14.00D,
+16.00D, +20.00D in full frame styles for
monocular use
3. M
 icroscopic aspheric spectacles The
series includes 6x (24D), 8x (32D), 10x
(40D), 12x (48D), for monocular use
4. S
 pecialty microscopic spectacles
for near work, including doublet lens
systems, wide angle microscopes, hi add
bifocals and press-on adds
Loupes Clip-on and headborne loupes are mon- Consider whether it is too dif- More comfortable working Fragility of the loupe
ocular or binocular magnifiers that attach ficult for the patient to attach the distance than spectacles Difficulty of attaching the loupe
to patient’s own glasses or are worn on the loupe to the his/her glasses Flip-up styles allow the magnify- to the glasses
head. Powers from +1.00D to +10.00D The LV doctor and/or the ing lenses to be moved up and Cosmetic appearance
instructor should work with the out of the way when not needed
patient to be sure he/she can Patients’ hands are free
manipulate the loupe
Hand Magnifiers Hand magnifiers are available in powers Consider the magnifier’s optical Familiar Need to use one hand to hold the
from +5.00D to +60.00D design (spherical, aspheric / Portable magnifier
Material is held at the focal point of the lens bi-aspheric, aplanatic doublet); The patient must maintain the
illumination (non-illuminated Favorable eye-to-lens distance
and the image is at infinity focal distance of the lens
/ illuminated; illumination Possibility of having illumination
type: tungsten/LED); and the in the magnifier Lens diameter gets smaller as
ergonomic needs of the patient lens power increases
(type of handle / type of pocket Field of view gets smaller as lens
magnifier) power increases
The patient must use his/her Size of the stand magnifier lens
distance Rx with the magnifier is inversely related to the power
of the lens – a larger lens is a
weaker lens

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Chapter 3

Type of Device Characteristics Prescribing Considerations Advantages Disadvantages

Stand Magnifiers Stand magnifiers have a fixed focal dis- Consider the power that the Patient does not have to main- Lens diameter gets smaller as
tance provided by the stand. Powers range patient needs, applicability to tain the focal distance of the lens power increases
from +1.50D to +76.00D the task, the required eye-to-lens lens since it is fixed by the stand Field of view gets smaller as lens
Patient places stand magnifier directly on distance and field of view, and Low power stand magnifiers, power increases
page, looks directly into lens and moves whether the system will be il- such as dome magnifiers and bar
luminated or non-illuminated Size of the stand magnifier lens
magnifier along the line to read magnifiers, are often useful for is inversely related to the power
Battery and plug-in styles are available, as Consider magnifier shape children of the lens – a larger lens is a
well as tungsten, halogen, xenon and LED Consider ease of changing Portable, although some styles weaker lens
light sources batteries/bulbs, if necessary, in can be cumbersome Posture can become an issue
illuminated styles if patient hunches over stand
The patient must use his/her magnifier to use it. An angled
reading (near) Rx with the stand reading stand can create a more
magnifier comfortable reading environment
for the patient
Telescopes Telescopes are the LV device of choice for Consider whether the patient has Provides magnification at a Reduction of the field of view,
patients’ distance needs; some can also be a stable or a progressive condi- variety of distances moreso as the power of the
used at near tion, his/her task objectives, Portable telescope increases
Telescopes may be: the level of acuity, visual field Loss of light and contrast for the
limitations (constriction/scoto- Can be mounted in a spectacle
• monocular or binocular frame in the upper (bioptic) posi- patient when looking through
mas), amount of magnification the system
• hand held or spectacle mounted required, the patient’s age and tion for seeing at distance
• fixed focus or focusable motor abilities Can be mounted in the central Potential difficulties of use for
Galilean and Keplerian systems are used in (full field) position for seeing at patients with central field loss
low vision care. intermediate or distance and/or loss of contrast sensitivity

Must be used while stationary Can be mounted in the lower Need to learn to manipulate the
(reading) position for seeing telescope
Powers from 2X – 14X
at near Patients cannot walk around
Useful for spotting street signs, while looking through the
bus numbers, etc. at distance, telescope
for reading music and other
intermediate tasks, or for near/
reading tasks
Filters Filters absorb/transmit light at different Consider whether the filter is to Wide range of tints/colors Durability
(absorptive lenses) spectral frequencies. be used to manage glare or to Lightweight Not scratch-resistant
Full, wrap-around styles block light entering enhance contrast, or both
Different ways to use – clipped
from the front, sides and above Can be extremely helpful for use onto glasses, slipped behind
Some are sized to fit over the patient’s indoors and/or outdoors glasses, or fit over glasses
spectacle Rx Subjective choice is made by Effective at blocking glare and/or
Also available in flip-up and clip-on style. patient with guidance from enhancing contrast
clinician
Photochromic glass lenses can be made up
as single vision lenses, bifocals or trifocals
Electronic Devices Tablets Mainstream, portable electronic High contrast, ability to adjust Cost
Notepads devices allow low vision patients many parameters important for In some cases, weight and
to have the same tools as the best vision (contrast, brightness, portability
Smartphones general public uses background color, text color,
Small recording devices font size)
A wide range of videomagnification systems, Speech output capability
called CCTVs that:
• Magnify
• Read text aloud
• Control font size, color, contrast

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Type of Device Characteristics Prescribing Considerations Advantages Disadvantages

Adaptive Devices Include: Consider use with standard low Enhancements benefit patients Knowledge of where to acquire
Task lighting, iIlumination control, writing vision devices, such as reading of all ages and which, in some adaptive equipment
devices (i.e., bold-tipped pens, letter/envel- stands with stand magnifiers cases, will be critical to the suc-
op/check writing guides, signature guides, Consider for communication cessful use of optical devices
“talking” devices) enhancement such as writing
Positioning devices (i.e., reading stands or guides, computer keyboard
lap desks) self-adhesive large print letters/
numbers
Contrast enhancement tools (i.e., yellow
filters, contrasting paint/tape)
Kitchen tools (i.e., cutting boards, measuring
cups) that provide contrast with the ingredi-
ents for which they are routinely used.
Medical issues (i.e . “talking” recording/
voice output device records/stores info
about each medicine bottle
Tactile, self-adhesive dots to use as markers
Some adaptive devices make use of relative
size magnification (i.e., large numeral clocks,
watches, timers, calculators)

Fig. 33. North Star Vision Group, LLC’s Low Vision Devices Chart™ Copyright © 2013 by North Star Vision Group, LLCSM Used under license from North Star Vision Group, LLCSM

Vision Rehabilitation: Who, What, When, How, Where or her own practice by hiring or training someone to provide
In order for the patient to have a successful outcome, the vision rehabilitation services.Vision rehabilitation services are
provider of low vision care must consider to the original reasons generally provided by a team of professionals.
that brought the patient to him or her. Low vision devices may
not be the solution to the patient’s needs or they may only be a The titles of team members are different in different regions of
partial solution. Many times, the missing component to enable the world and sometimes their roles are combined. Regardless
the patient to participate in family, career, and community life is of where they are or what they are called, however, their roles
vision rehabilitation. are important.

Vision rehabilitation is the term used for the training and 

Low Vision Doctor. The low vision doctor assesses usable
counseling services that help a person with vision impairment vision and prescribes low vision devices. The low vision
to develop the skills and strategies needed to accomplish his or doctor has another extremely important role. The low
her own goals. It can help the patient to make the best use of vision doctor is the gateway to the other team members.
existing sight and to use other senses more effectively to carry

Low Vision Therapist. The low vision therapist
out daily tasks efficiently and safely. It can help the patient to
performs functional vision assessments (after clinical low
do the things that originally brought him or her for professional
vision examinations), teaches the use of functional vision,
help. And, it may even open up possibilities for doing things that
introduces non-optical devices, and provides instruction in
patients did not think they would be able to do.
the use of prescribed optical devices. This team member
The role of the low vision clinician and staff is twofold: to make ensures that the patient and, perhaps family members, know
patients aware of what rehabilitation is and what it might do how to use the devices properly to accomplish the specific
for them, and to help patients to connect to available vision tasks that the patient wants to carry out.
rehabilitation services. For some vision specialists the challenge

Orientation and Mobility Specialist. Orientation and
might be greater. They may find that vision rehabilitation
mobility (O&M) specialists teach the patient to move and
services don’t exist or are underdeveloped in their area. In this
travel safely at home or outside the home. They teach the
case, the vision specialist might locate other professionals in the
patient to use remaining vision and other senses, and, if
community, such as occupational therapists, orientation and
needed, to use a sighted human guide, a cane, or dog guide.
mobility specialists or special educators, who might assist the
patient. Or, the vision professional may decide to enhance his

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Chapter 3

Vision Rehabilitation Therapist. Vision Rehabilitation Adaptive Technology Specialist. As computers and
Therapists focus on adaptive living and communications other technology find their way into every area of life, the
skills. They can teach the patient techniques such as safe adaptive technology specialist assumes a larger role in the
new ways to prepare food, operate a stove, carry out vision rehabilitation team. Computers have changed the
personal grooming tasks, use a telephone, and manage world for people with impaired vision. With training, they
medications and money. Making sure that the home is can learn the latest technologies to access the Internet as
a safe environment is usually an area of great concern, well as E-mail and other online services.
especially for family members and friends. Adaptive
home safety techniques developed as part of a vision All the members of the low vision rehabilitation team can
rehabilitation plan can benefit everyone. provide multiple, coordinated interventions to assist a person
with low vision to function more effectively.

Vision Rehabilitation Assistant (Paraprofessional).
The team might also include a Vision Rehabilitation Engaging Adults in Vision Rehabilitation
Assistant (VRA) who is a paraprofessional who works Michelle Beck, VRT COMS
under the supervision of a Vision Rehabilitation Therapist New York, USA
or Orientation & Mobility Specialist to carry out the plan Reading is a fantastic leisure activity. Adults who lose vision
developed by the certified professional. The VRA helps the later in life lament the loss of the tranquility and adventure they
patient to apply and practice adaptive living, communication, once got from reading. I encourage older adults who have large
central scotomas or constricted visual fields to pursue the skills
and in-home orientation and mobility skills.
needed for reading by explaining the mechanics of reading to
them – demystifying eye movement, visual spans, letter and word

Occupational Therapist. The Occupational Therapist recognition.
(OT) helps individuals achieve independence in many
It has worked wonders! With a clear understanding of the problem
facets of their lives. Services typically include:
and the solution, most persevere. It’s so important for people to
understand that practice is key: reading a large print book while
• Customized treatment programs to improve the
learning to use eccentric viewing or taking time to develop fluency
patient’s ability to perform daily activities;
using high power prismatic half frame spectacles will be worthwhile.
• Comprehensive home and job site evaluations with
adaptation recommendations;
• Performance skills assessments and treatment;
• Adaptive equipment recommendations and usage
training;
• Guidance to family members and caregivers.

Counselor. Counselors may also be part of the vision
rehabilitation team. Social workers or psychologists can
help the patient to deal with the sadness and other feelings
associated with the loss of sight. They can also help
family and friends to understand the situation and to be
supportive of the person with impaired vision. Sometimes
support groups can be established to enable people with
impaired vision to assist each other. Career counselors may
also help patients to develop skills and strategies for keeping
their current job or for preparing for a new career.


Optician. In many cases, the optician will play a role in
enabling the person with low vision to function effectively.
Accurate preparation of lens prescriptions, careful fitting
of frames, and training in the use of prescribed optical and
non-optical devices facilitate patient performance and
satisfaction.

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 Chapter 4
Chapter 4: Integrating Low Vision Spectacles, loupes, hand magnifiers, stand magnifiers, telescopes,
absorptive lenses/filters.
Into the Care You Offer Try to envision your practice setting through the eyes of a
patient with low vision. (Vision simulator glasses can help with
Adding low vision care to a practice takes some planning. The
this.) Is there adequate contrast between walls and floor? Are
four most significant considerations are: space, equipment, staff
doorways clearly visible? Does furniture stand out or blend
and patients.
into the background? Is there adequate, adjustable lighting and
bold-tipped pens in places where patients will need to read or
sign forms?

Equipment
Standard eye care equipment such as trial lenses, a trial frame,
retinoscope, ophthalmoscope, transilluminator, occluders are
useful in the low vision examination, as well. As noted earlier,
trial frame refraction is the most adaptable to the eccentric
viewing needs of many patients with low vision, however a
phoropter or an autorefractor may also be of use in some cases.

Other equipment is specific to low vision practice, including

Fig. 34A. Low vision examination room
charts, low vision optical devices, non-optical devices, filters and
some electronic devices. In many cases there is a range of prices
Space for these items which come from different suppliers. Consider
Since most low vision the possibility of having low vision devices in the examining
testing at distance is done room, in the instruction room and others available for sale to
at 4 meters (13 feet) or patients from a dispensary.
less, a standard eye care
lane is often more than Following is a list of the generic equipment that would be
adequate for low vision helpful to have in an intermediate level low vision practice.
care. Distance charts in a Items noted with an asterisk (*) should also be considered for
rolling, illuminated cabinet the instruction room in addition to local newspapers, utility bills
let the examiner adjust the and hobby-related items.
test distance as needed.
It is helpful, though not Testing Materials/Charts
mandatory, to have a Single letter/number LogMAR distance Chart
Single letter/number LogMAR near card*
separate room that can be
Fig. 34B. Low vision examination room Single word/number pocket card*
used for the part of the Continuous text – Adults/Children
low vision process that Contrast chart (letters, numbers or both)
involves training the patient to use low vision devices, and for Amsler Grid
patient/family education. Two rooms also allow the person who Chart Illuminator (LED)
is doing instruction to work with a new or a follow-up patient Chart Illuminator Stand on Wheels
in the instruction room while the clinician goes on to examine Tests For Children
the next patient in the examining room. The low vision devices LEA Single Symbols Pocket Card*
(discussed below) should be kept in a locked cabinet or closet in LEA Grating Paddles
the examining room, so that they are safe and easily accessible LEA Symbols Near Chart*
HOTV Near Chart
to the clinician. An additional set of devices may be kept in LEA Symbols Single Symbol Book
the instruction room, so that the instructor does not have to LEA Symbols Distance Test
interrupt the clinician during a low vision exam. Many people HOTV Distance Chart
find it helpful to organize and store the devices by category: LEA Symbols Contrast Screener
Hiding Heidi Contrast Test

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Chapter 4
Optical Devices (Stock Items) Filters/Absorptive Lenses (Small & Large Sizes)
Grey (light, medium, dark)*
Spectacles (Base in prism) Plum (light, medium, dark)*
+5=7biOU* Yellow*
+6=8biOU* Amber (medium)*
+8=10biOU* Baby frames
+10=12biOU* Electronic Magnification
Spectacles (Aspheric High Plus) CCTV Color/B&W*
+12D OU* Hand held electronic magnifier*
+16D OU* iPad*
+20D OU* Laptop

Spectacles (Aspheric Microscopes) Non Optical Devices

6X OU* Large print*
8X OU* Reading stand/Lap desk*
10X OU* Reading/Writing/Signature Guides*
Writing tools - bold tip pens*
Loupes Daily living products ( i.e. household items,
+4D binocular* clocks, watches)*
+6D monocular*
+10D monocular* Patient/Family Education Materials
Pamphlets about Low Vision/Eye Diseases*
Hand Magnifiers (Non-illuminated) DVDs: Leo Learns by Doing*
+5D* Vision Simulators*
+7D*
+9D* Staff
+12D* As the prior section noted, the people who are involved in
+16D* the delivery of low vision care worldwide have diverse titles
+20D* and backgrounds. Rather than limiting the staff to particular
professionals it is helpful to consider the constellation of services
Hand Magnifiers (Illuminated)
+16D* a patient with low vision is likely to need, and to think about
+24D* who has (or could develop) the necessary skills. Remember that
all service providers need not be under the same roof.
Stand Magnifiers (Non-illuminated)
+3.5D*
The low vision examination should be conducted by someone
+8D*
+12D* who is legally permitted to examine and prescribe the full
+16D/4X Dome magnifiers* range of low vision devices, including spectacles. This is most
+17.6D* often an ophthalmologist or optometrist who has additional
+20D* training in low vision care. While the low vision doctor can
Stand Magnifiers (Illuminated) instruct patients to use low vision devices, when possible, it is
+12D* helpful to have a different professional teach the patient and
+20D* monitor progress. Depending on the instructor’s qualifications,
+28D* he/she may also teach daily living skills and/or orientation and
mobility techniques, as needed. Opticians may become involved
Telescopes
2.5X hand held* as dispensers of low vision devices and/or in device use training.
2X binocular* Counseling for adjustment to vision loss, family interaction,
4x12 hand held* depression or other emotional issues may be provided by a
6x16 hand held* psychologist, social worker or other counselor, when necessary.
Special educators may be drawn into the provider group when
the patient is a child, along with speech, mobility, physical
therapy and occupational therapy professionals.

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 Chapter 4
Patients and high quality, available and affordable optical, non-optical
Worldwide, few private practices are established exclusively and electronic equipment that make low vision care far more
for the purpose of seeing low vision patients. It is far more accessible to clinicians and patients. In those situations where a
common for low vision care to be one facet of an eye multidisciplinary team is not available under one roof, the use
care practice, whether it is a solo-, group-, community- or of community-based providers still makes it possible to have the
hospital-based practice. Colleges of optometry and non-profit kind of multidisciplinary team that is necessary for low vision
organizations are also sites where low vision services may be care and vision rehabilitation.
offered. The prevalence of low vision problems among elderly
people -- a population that may accept disability as a natural The low vision examination of the adult and of the child detailed
part of aging -- reduces the motivation to seek care for some. in this booklet are formal, replicable procedures. They differ from
Despite this, available services do not meet the current need, routine eye examinations in that there is a far greater emphasis
and fall far short of the demand this growing demographic will on tasks, adaptation and improvement of function in low vision
continue to have. Many patients report lack of knowledge of care. The availability of testing materials and equipment specific
vision rehabilitation services as a significant barrier to getting to the low vision evaluation of young children, older children and
help (http://www.lighthouse.org/research/statistics-on-vision- adults make possible and straightforward the assessment of near
impairment/vision-rehabilitation-service-utilization/). and distance vision, contrast sensitivity, binocularity, central and
peripheral visual fields.
How do patients learn about the services available? One way
is by making sure that colleagues and practitioners who are in Prescribing low vision devices is a critical function and is
the same city but do not themselves offer low vision care have based on examination results. Optical devices in the form
the information they need to make appropriate referrals of their of spectacles, loupes, hand held magnifiers, stand magnifiers
patients for these necessary, specialized services. It is important and telescopes enhance the ability of people with low
to remember that even well-meaning colleagues may not fully vision to function in their daily lives. The proliferation of
appreciate what goes into low vision care, how helpful the electronic devices offers patients of all ages new and acceptable
intervention can be, who is a candidate and when to refer a alternatives. All patients benefit from instruction in the use of
patient. Providing this information to practitioners can boost any prescribed low vision devices. It is important to remember
referrals, as well as sending informative reports to colleagues that low vision devices alone are not necessarily the answer for
on the results of their patients’ low vision visits. Providing many patients.Vision rehabilitation in the form of instruction
information to target populations, such as parents or older in daily living skills, communication skills, orientation and
adults, via newsletters, local newspapers, blogs, webinars and mobility (safe travel) skills, and psychological counseling often
radio programs also encourages service utilization. complete the circle of necessary services for the person with
low vision. Counseling is also helpful for spouses, families and
friends, who may be affected in ways nearly as profound as the
Conclusion effect on the individual.

The estimated 246 million people worldwide who have The techniques and tools outlined in this booklet help
impaired vision are at risk.Vision impairment affects every practitioners to provide needed care for patients with vision
aspect of a person’s life at home, at work and in the community. loss. Appropriate low vision care and vision rehabilitation
It can result in depression, withdrawal, educational delays increase the possibility for people with low vision to function
and issues, and underemployment. Eye care professionals, more effectively in the home, at work, at school and in the
occupational therapists, orthoptists and others are in a unique community at large.
position to intervene.

Low vision care and vision rehabilitation are indispensable

in helping people with impaired vision improve their ability
to function and to manage daily tasks. Rather than the time
consuming, expensive, labor-intensive specialty that low vision
care was thought to be in the past, today there are efficient,
evidence-based tools, streamlined examination procedures

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Chapter 4
Brief Glossary of Terms Glaucoma
A term describing a group of ocular disorders with multi-
factorial etiology united by a clinically characteristic intraocular
Age-Related Macular Degeneration (AMD)
pressure-associated optic neuropathy. If untreated, glaucoma can
A progressive deterioration of the macula lutea, the central,
lead to progressive, permanent vision loss and blindness.
posterior portion of the retina responsible for central, high
resolution detail vision. AMD is a major cause of legal blindness Iridectomy
worldwide, and the leading cause of vision loss in adults over 50 Surgical removal of part of the iris of the eye, most often
years of age in many developed countries. performed to restore drainage of the aqueous humor in
glaucoma or to remove a foreign body or malignant tumor.
Amblyopia
A reduction in the quality of central, corrected vision resulting Miosis
from a disturbance in retinal image formation during the first Constriction of the pupil of the eye, caused by certain drugs or
decade of human life.  It can also be called ‘lazy eye’. pathological conditions OR resulting from a normal response
to an increase in light.
Amsler Grid
A suprathreshold target used to assess the central 20º of the Mydriasis
macula. The grid contains horizontal and vertical white lines Dilation of the pupil due to a physiological papillary response
presented on a black background. The grid is sometimes or non-physiological causes such as disease, trauma or the use of
presented with red lines, designed to enhance the sensitivity of drugs.
the test.
Optic Atrophy
Astigmatism The loss of some or all of the fibers of the optic nerve and the
A vision condition that causes blurred vision due either to end result of any disease that damages nerve cells anywhere
the irregular shape of the cornea or to the curvature of the between the retinal ganglion cells and the lateral geniculate
crystalline lens. body (anterior visual system). Also called optic neuropathy.

Cataract Phoropter
A clouding of the eye’s naturally clear crystalline lens, associated An instrument commonly used during an eye examination,
with aging, injury, inherited genetic disorders, medical containing different lenses used to measure an individual’s
conditions such as diabetes, past eye surgery and long-term use refractive error and determine eyeglass prescription.
of steroid medication.
Retinitis Pigmentosa (RP)
Coloboma A group of inherited, degenerative eye diseases that cause
An abnormality that occurs before birth, characterized by retinal degeneration and lead to severe vision impairment and
missing pieces of tissue, or a hole, in one of the structures of the blindness. Forms of RP and related diseases include Usher
eye, such as the iris, retina, choroid or optic disc. syndrome, Leber’s congenital amaurosis, rod-cone disease,
Bardet-Biedl syndrome, and Refsum disease, among others.
Color Vision Deficiency (CVD)
The inability to perceive certain colors in their true or “natural” Retinoblastoma
representations that results in confusion for the patient. CVD is A rapidly developing cancer that develops from the immature
mostly congenital, but can also be acquired. cells of the retina and is the most common malignant tumor of
the eye in children.
Contrast Sensitivity
The ability of the eye to perceive the difference Diabetic Retinopathy
in luminance and/or color of an object (or its representation in Damage to the retina caused by complications of the systemic
an image or display) from its background. There is evidence that disease of diabetes.
it is a predictor of real-world performance.

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 Chapter 4
Strabismus Fig. 12. Optokinetic (OKN) drums, Richmond Products
A visual defect in which one eye cannot focus with the other
because of unequal alignment of the eyes due to muscular Fig. 13. LEA Single Symbol book, Good-Lite
imbalance. Also known as squint, heteropia, cross-eye and wall-eye.
Fig. 14. LEA Puzzle, Good-Lite
Visual Acuity
Fig. 15. LEA Numbers low vision book, Richmond Products
Sharpness or clarity of vision, measurable with a variety of
standardized tests.Visual acuity is dependent on the sharpness of
Fig. 16. Continous text chart, Optelec
the retinal focus within the eye and the interpretive faculty of
the brain. Fig. 17. HOTV Near and Distance Charts, Good-Lite

Visual Field Fig. 18A. LEA Flicher Wand, Good-Lite

The total area (above, below and to the sides) in which objects
can be seen while the eyes are focused on a central point. The Fig. 18B. LEA Flicker Wand in use, Good-Lite
normal human visual field extends to approximately 60º nasally
(toward the nose, or inward) from the vertical meridian in each Fig. 19. Color vision screening and testing, Good-Lite and
eye, to 100º temporally (away from the nose, or outwards) from Richmond Products
the vertical meridian, and approximately 60º above and 75º
below the horizontal meridian. Fig. 20A. Hiding Heidi contrast sensitivity test, Good-Lite

Fig. 20B. Hiding Heidi contrast sensitivity test, in use, Good-Lite

Fig. 21. PowerDome dome magnifier, Optelec

List of Illustrations and Credits
Fig. 22. North Star Vision Group, LLC’s Low Vision Exam Flow
Fig. 1. Categories of severity of visual Impairment according to Chart , North Star Vision Group
the International Statistical Classification of Diseases
Fig. 23. Pediatric LV examination tools, Good-Lite
Fig. 2. Estimates of low vision and blindness in WHO subregion.
Fig. 24.Types of low vision spectacles in different frames, Optelec
North Star Vision Group based on WHO 844 Bulletin
Fig. 25. Spectacle mounted and headborne loupes, Optelec
Fig. 3. Comorbidity effects in older adults. North Star Vision Group
based on Journal of the American Geriatric Society, Oct, 2011
Fig. 26. Non-illuminated and pocket hand magnifiers, Schweizer
Fig. 4. Distance chart in movable illuminator stand, Good-Lite
Fig. 27. Dome, bar and illuminated stand magnifiers, Schweizer
Fig. 5. Radical retinoscopy, Richmond Products
Fig. 28. Hand-held and spectacle mounted telescopes, Optelec
Fig. 6. Near vision test cards with cord, Good-Lite
Fig. 29. Filters for adults and children, Optelec
Fig. 7. Amsler grid with recording form, Richmond Products
Fig. 30. Portable and desktop videomagnifiers, Optelec
Fig. 8. Contrast sensitivity tests, Good-Lite
Fig. 31. Portable mini videomagnifier, Optelec
Fig. 9. Panel 16 quantitative color vision test, Good-Lite
Fig. 32. Non-optical adaptive devices, Optelec
Fig. 10. Distance chart with glare lights, Good-Lite
Fig. 33. North Star Vision Group, LLC’s Low Vision Devices
Chart™, North Star Vision Group
Fig. 11A. LEA GRATINGS, a preferential looking test (front
and back), Good-Lite
Fig. 34A. Low vision examination room, North Star Vision Group
Fig. 11B. LEA GRATINGS, a preferential looking test in use,
Fig. 34B Low vision examination room, North Star Vision Group
Good-Lite

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Appendix
Notes

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 Appendix
Notes

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Low Vision, A Concise Tutorial From Assessment To Rehabilitation

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