LOW VISION

ASSESSMENT AND
REHABILITATION
Rebika Dhiman, Itika Garg, Sneha Aggarwal, Rohit Saxena,
Radhika Tandon
Low Vision Services, Dr R P Centre for Ophthalmic Sciences, All
India Institute of Medical Sciences, New Delhi, India

Herin Arini Natalia

Advisor :
dr. Purnamanita Syawal, Sp.M, MARS
dr. Adelina T. Poli, Sp.M, M.Kes
dr. Nursyamsi, Sp.M, M.Kes
dr. Muhammad Irfan, Sp.M, M.Kes
 ABSTRACT
 Low vision and blindness are a growing health problem that
affects quality of life.
 Low Vision Rehabilitation (LVR) is the process of restoring
functional ability and improving quality of life and
independence of a patient with low vision.
1/3 – 1/4 of
the world’s blind
Lack of awareness about population
the low vision services are a
major drawback in the
rehabilitation of a low vision
patient in this country. In this article will discuss
about the methods of
evaluation of a patient with
low-vision and prescription of
low vision aids.
INTRODUCTION
Low Vision (Visual impairment
Categories 1 & 2)
“A person who has impairment of visual functioning even after
WHO treatment and/ or standard refractive correction, and has a
visual acuity of <6/18 to LP , or a visual field <10o from the point
of fixation, but who uses, or is potentially able to use, vision for
the planning and/ or execution of a task for which vision is
essential”

Blindness (Visual impairment

Categories 3, 4 & 5)
“Visual acuity of <3/60 or a corresponding visual field loss of
<10o in the better eye with best possible correction.”
 National Program for Control of
NPCB
Blindness

Low Vision
 “Visual acuity of <6/18 but 6/60 in the better eye with available
correction or a visual field loss <10° from the point of fixation”

Blindness
“Visual acuity <6/60 in the better eye or a corresponding visual
field loss of <10°.”
 EPIDEMIOLOGY

Visual impairment :
161 million
Blind : 37 million India
Low vision : 124 million Blind : 12 million
 Table 1 :
Disease leading to Low Vision : Cornea
Presentation as per Anatomical Microcornea, Adherent Leucoma,
Visual Pathway : Cortical blindness, Site Corneal Opacities, Bullous
Delayed Visual Maturation Keratopathy, Microspherophakia,
Dystrophies

Ocular motility : Squint, Nystagmus Lens

Congenital cataract,
Globe Ectopia Lentis or
Microphthalmos, Dislocated IOL,
Uncorrected Aphakia
Pthisis, Absolute Eye,
Retinoblastoma, Atrophic Bulbi,
Pathological Myopia or High Uvea
Refractive errors, Amblyopia Coloboma of Iris or
Choroid, Uveitis,
Chorioiditis, Aniridia,
Optic Nerve Choroidal Degeneration
Optic Neuropathy (Traumatic, Retina
Ischaemic, Congenital), Vitreous
Heredo-Macular Degeneration, Stargardt’s
Glaucoma Dystrophy, Rod-Cone Dystrophy, Retinitis Persistent Primary
Pigmentosa, Age-Related Macular Degeneration, Hyperplastic Vitreous (PHPV)
Oculo-Cutaneous Albinism, Retinopathy of
Prematurity, Retinal Scars, Fundal Coloboma,
Diabetic Retinopathy
 Low Vision in Indonesia
Cataract (61.3%)
Global Uncorrected refractive error (12.9%)
Vision Amblyopia (12.9%)
impairment
Uncorrected refractive errors
(43%)
Cataracts (33 %)
Glaucoma (2%)
Blind
Cataract (51%)
Glaucoma (8%)
AMD (5%)

Low Vision in India

Retinal diseases (35.2%)
Amblyopia (25.7%)
1. WHO/Global Data of Visual Impairment 2010. Available at https://www.who.int/blindness/publications/globaldata/en/Causes
2. Saw, S.-M. (2003). Causes of low vision and blindness in rural Indonesia. British Journal of Ophthalmology, 87(9), 1075–1078.
3. Dandona, R., Dandona, L., Srinivas, M., Giridhar, P., Nutheti, R., & Rao, G. N. (2002). Planning low vision services in India. Ophthalmology, 109(10), 1871–1878.
Low Vision Rehabilitati on
(LVR)
The process of restoring functional ability
and improving quality of life and
independence of a patient with low vision.

Clinical and functional Patient’s requirements

assessment of the disease and daily needs

Type of the
visual Individual’s
disability expectations
 Goals of Comprehensive
Identify and evaluate the cause
Low Vision Examination
and Visual Rehabilitation
Assess ocular health

Emphasize the need of the

patient/beneficiary Business
Clinical assessment Model
Your Subtitle Here
Maintain and improve visual function
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Adipicing elit, sed do eiusmd tempor incididunt
Optometric rehabilitation &
labore.
intervention

Counsel and educate

Appropriate visual rehabilitation

 Pati ent Evaluati on
A. Patient History
1. Nature and type of the problem
2. Onset and duration
3. Condition
4. Visual difficulties
5. Chief complaints
6. Visual and ocular history
7. General physical and mental health
8. Social history
9. Use of low vision devices or history of vocational, educational or any
other training
10. General examination
11. Details regarding name, age, address, family members, current
profession, current academic status, financial status and information
about the disorder (cause, time of onset, family history)
Pati ent Evaluati on
B. Visual Acuity Assessment

Monitor the
pathology

Predict the magnification

level of the optical devices Bailey Lovie/LogMAR
Snellen Chart

Legal blindness, driving

privileges, job eligibility
Distance Acuity
Feinbloom Measurement
 Pati ent Evaluati on
B. Visual Acuity Assessment
Specific activities customized

School going children Adult

Mobility Photophobia and glare Light Near Visual Acuity

 Pati ent Evaluati on
C. Refraction

All visually impaired patients should undergo refraction to

ensure optimal correction for achieving BCVA.
Most low vision devices are used in conjunction with
refractive correction. The presence of uncorrected
presbyopia or significant uncorrected refractive error could Tips for refraction in patients with
affect success with low vision devices.
low vision :

Auto-refractors have Keratometry to Previous glasses Retinoscopy is most useful tool for
limited use, due to media determine the amount can be a good refraction for low vision, especially if
problems or eccentric and axis of cylinder. starting point the patient is poor responder.
viewing (off axis fixation).
 Calculate
Magnifi cati on
LogMAR
If VA is measured in a LogMAR notation:

Magnification = (1. 25)n

Where n = number of steps

Example :
If the present acuity = 0.5 and the required
acuity = 0.1
Then Magnification = (1.25)4 = 2.44x
 Calculate
Magnifi cati on
Snellen Chart

Magnification required = Required VA

Present VA

In Snellen notation to improve from 6/60 to 6/6 :

Magnification required = 6 x 60 = 10x

6x6
 Pati ent Evaluati on
D. Ocular Motility and Binocular Vision Assessment

Ocular alignment, binocularity, and stereopsis.

E. Visual Field Assessment

Important for:
 Orientation
 Mobility training
 To guide patient for
preferred retinal
fixation or
environmental
modification.
Pati ent Evaluati on
F. Ocular Health Assesment

External examination Biomicroscopy

Tonometry Fundus examinaton

 Pati ent Evaluati on
F. Supplemental Testing

Glare Testing

To add filters or contrast enchancers to

improve the distance vision.

Objectively : glare acuity tester and auto

refractors

Subjectively : patients’ complaints,

comparing the visual acuity with or
without illumination in vision chart.
Pati ent Evaluati on
F. Supplemental Testing

Contrast Sensitivity

A patient with low contrast acuity will have to be

prescribed a low vision aid with higher than
expected magnification, higher illumination Pelli-Robson contrast sensitivity chart
and/ or absorptive filters or typoscopes. https://www.youtube.com/watch?v=qB20VOxZ7D8

Hiding Heidi contrast test chart Lea contrast flip chart

https://www.youtube.com/watch?v=wgaIC3GIR2g https://www.youtube.com/watch?v=eR6MZx1ewSA
Pati ent Evaluati on
F. Supplemental Testing

Color Vision Testing

It can be done by Ishihara’s pseudoisochromatic color plates, or by

asking the patient to discriminate, match or sort out various color
threads or buttons.

Electrophysiological Tests

Electroretinogram (ERG), Electro-oculogram (EOG), Visually Evoked

potential (VEP) . Very helpful in patients of cortical blindness, LCA,
mentally retarded patients, infants or kids where the visual acuity
cannot be estimated subjectively and has a poor visual prognosis.
 Prescription of Low Vision Aids (LVA)

Define patient’s goals

Develop the skills in

using devices

The basic principle of all

optical low vision device is
Magnification
 Near Opti cal Low Vision
Relative Size Magnification 
Example :
Devices
Original size = 1M  2.
New size = 2M 
Relative Size Magnification (RSM) = 2/1 = Relative Distance Magnification
2x Example :
1.
Original working distance = 40cm 
3. New working distance = 10cm 
Lens Vertex Magnification Relative Distance Magnification (RDM) = 40/10 =
Example : 4x

You view a mountain with a magnifying

glass of focal length f=10 cm. What is the
magnification ?

M = 25 cm = 2,5x
10 cm
 Near Opti cal Low Vision
Devices
1. Spectacles Magnifiers
 High powered convex lenses that are
prescribed as reading glasses.
 They can be spherical, aspheric with and
without base-in prisms.
 Reading material is held at a distance
that is equivalent to the focal distance
of the lens.

fixed close reading distance

and a constricted field of view
Near Opti cal Low Vision
Devices
2. Hand Held Magnifiers (Self-illuminated and
Non- illuminated)

 Plus lenses that are held in front of the

spectacle plane.

It is convenient for short

tasks like reading signs,
labels, prices, books,
identifying money etc.
It has a limited field of
view and requires
good hand eye
coordination.
Near Opti cal Low Vision
Devices
3. Stand Magnifiers

 Stand magnifiers are mounted on a rigid stand.

 The patient needs to place a stand magnifier on the
reading material and move across the page to read.

preferred in patients with

constricted visual fields or central
visual field loss.

Too close reading posture makes it

difficult to be used for long hours.
 Near Opti cal Low Vision
Devices
 Magnification device is controlled by a zoom lens attached to the
camera.
4. Digital Devices  Helps in obtaining a higher magnification with a normal reading
distance by varying the addition and the reading distance.
 Closed circuit television (CCTV) may be the only choice for
patients whose vision is too impaired to benefit from routine
optical aids.

A study has reported a faster reading

speed in patients using CCTV than
other optical devices.

Near work such as writing

and typing can be done
more easily

Desktop CCTV
http://www.infinitec.org/video-magnifiers-cctvs
4. Digital Devices Near Opti cal Low Vision
Optelect Compact 4HD Devices
OrCAm

https://www.youtube.com/watch?v=Glrba0nAjfI

Schweizere
Mag43
https://www.youtube.com/watch?v=uvIXWKyBv0w

https://picclick.de/SCHWEIZER-eMag43-E-Mag-43-elektronisc
he-Leselupe-Lupe-Lesehilfe-223983715176.html
 Near Opti cal Low Vision
4. Digital Devices
Devices

• Smartphones
• Tablets
• Electronic readers

Robinson JL, Braimah Avery V, Chun R, Pusateri G, Jay WM. Usage of Accessibility Options for the
iPhone and iPad in a Visually Impaired Population. Semin Ophthalmol 2017; 32:163- 71.
 Low Vision Devices for
Distance
1. Telescopes (Uniocular or Binocular)

 Magnify the apparent size of distant

objects
 Based on two priciples (Galilean or
Keplerian)
 Expensive and have restricted field
of view

It allows the wearers to switch their sight

between their “regular vision” and the Bioptic Telescopes is a system
magnified vision of the device by just a where the telescope is attached to
slight tilt of the head, similar to how one the top of a pair of eyeglasses.
uses bifocal spectacles. https://ocutech.com/driving-with-bioptics/
Principles of Telescopic
System
Low Vision Devices for
Distance
2. See TV Spectacles

 Also known as TV glasses and comes with

2,1 to 3x magnification.
 Useful in student while watching
blackboard, desktop or television.
 Commonly used at a distance of 3 metres.

https://www.webrn-maculardegeneration.com/tv-glasses.html
 Non Optical Devices for
 altering illumination and light
transmission Visual Rehabilitation
 reducing reflection and glare
 enhancing contrast
 linear magnification

Filters or tinted lenses Typewriter-audiologic

equipment

Medical devices with

Talking book, clock,
signal or voice
calculator and watches

Reading Machine Contrast enhancement

Travel device
Notex, typoscope, signature guide
 Low Vision Aid
Before
Patient’s expectation prescribing Explain about the
should limitations of the
be discussed. prescribed device.

After
A thorough training prescription The family should be
should be conducted to counseled for
enable the patients to use environmental modification
the devices smoothly. and supportive services.
Low Vision Service
i n H a s a n u d d i n U n i v. H o s p i t a l
Low Vision Service
i n H a s a n u d d i n U n i v. H o s p i t a l
 Conclusion
Low vision rehabilitation is a new emerging sub-specialty that
aims to improve the functionality and independence of
patients with visual impairment using a multi-disciplinary
approach.

Low vision services still

remain low due lack of
awareness amongst the
patients as well as the
A low vision clinician should be
ophthalmologists.
aware of the range of
specialists, vocational services
and community based services
needed by people with low vision.
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 Near Opti cal Low Vision
Relative Size Magnification  Devices
Example :

Original size = 1M 

New size = 2M  Relative Distance Magnification
Relative Size Magnification (RSM) = 2/1 =
2x Example :

Original working distance = 40cm 

New working distance = 10cm 
Lens Vertex Magnification Relative Distance Magnification (RDM) = 40/10 =
Example : 4x
You view a mountain with a magnifying
glass of focal length f= 10 cm. What is the
magnification ?

M = 25 cm = 2,5x
10 cm