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A dip into Low Vision services 

Ms Soniya Srivastava

The subject on ‘Low Vision’ may be one of those specialised topics taught to us in final year of optometry course and then briskly brushed off with merely a month of rotation in the low vision clinic. But have you ever realised that offering low vision services sets us apart from other routine optometrists?  Of course, it takes great time and effort to establish a low vision practice but at the end it all pays off.

 

The good sign is that eye hospitals and other ophthalmic organisations are recognising ‘Low Vision’ as an important sub-speciality and making it as an integral part of comprehensive services that they offer. One may see offering low vision services at par with contact lens services and many times superior to that. 

What is low vision?

Let’s recollect the World Health Organization’s working definition of low vision - “A person with low vision is one who has impairment of visual functioning even after treatment, and/or standard refractive correction, and has a visual acuity of less than 6/18 to light perception or a visual field of less than 10 degrees from the point of fixation, but who uses, or is potentially able to use, vision for the planning and/or execution of a task.” Or in simple words – a person who has hardly any vision with their current conventional spectacles and visual field so small that requires enhancement with either specialised devices or training. 

The need for offering Low Vision services in India

A population based study in southern India has shown that the prevalence of low vision in India is 1.05 percent, implying India is estimated to have a population of over 10.6 million with low vision by the year 2000. As of 2012 it was estimated that India has only 50,000trained optometrists, i.e. one trained optometrist for 200 people with low vision. The important point is, of these 50000 optometrists, not many are competent enough to offer low vision services!  Hence why there is a growing need for well-trained optometrists offering low vision services in variety of settings including eye hospital, private practices, vision rehabilitation organizations and teaching institutions. 

What is required to be a specialist to offer Low Vision services?

Despite the fact that our undergraduate optometry courses gives basic foundations needed to evaluate and provide low vision services, a further training in this speciality will boost one's confidence to practice low vision and render the services.

Where are the courses offered?

Both short term and long term courses on low vision are offered in many institutes across India. Some important institutes that offer these courses include:

  • LV Prasad Eye Institute, Hyderabad, Telangana

  • Aravind Eye Hospital, Madurai, Tamil Nadu

  • Shankar Nethralaya, Chennai, Tamil Nadu

  • Dr Shroff’s Charity Eye Hospital, Delhi

  • Lotus College of Optometry, Mumbai, Maharashtra 

  • Vivekananda Mission Asram, Purba Medinipur, West Bengal

  (Note: Interested candidates are advised to refer to these organisations for complete details of courses offerred)

An optometrist with a team works well!

Providing a comprehensive low vision care is a team approach and needs appropriately trained personnel like special educators, counsellors, orientation & mobility instructors, vision rehabilitation consultants along with optometrists.  This will enable in the successful delivery of services that include instructions to use the devices, training in activities of daily tasks, orientation & mobility, patient education, counselling, and educational and vocational guidance.

Where can you offer your services?

It is certainly effortless if you start offering these services from an eye hospital that offer speciality services, simply because patients who need low vision services are pooled and can readily referred for your specialised care. On the other hand, establishing one’s own specialised low vision clinic is not a bad idea, in which case you need to build a strong network with local speciality ophthalmologists and eye hospitals. 

What resources are needed for a basic low vision clinic set-up?

  • Well-lit examination rooms

  • Log MAR Visual acuity charts for distance (high and  low contrast) and near

  • Universal trial frames and trial lens box with full aperture lenses

  • Distance telescopes for testing purposes

  • Colour vision assessment tools (Ishihara charts, Farnsworth D 15, and any others that are available)

  • Near reading stand

  • Hand-held magnifiers, pocket magnifiers, stand magnifiers with different powers and may or may not be self illuminated

  • Non-optical devices such as bold line note books, letter writing guide, Typoscope, Signature Guide, Notex  etc.

 

Where can one get these devices?

In India and China, the following companies supply the required optical and non-optical devices.

  • Baliwalla & Homi Pvt Ltd, Mumbai, Maharashtra

  • Om Tao Scientific Apparatus, Hyderabad, Telangana

  • Lensel Optics Pvt Ltd, Pune, Maharashtra

  • L V Prasad Eye institute, Hyderabad, Telangana

  • Karishma enterprises, Mumbai, Maharashtra

  • Low Vision Resource Center, Hong Kong, China

  • Soham Low vision Aid & Ocular Prosthesis Center, Kolkata, West Bengal 

What is involved in a typical low vision assessment?

A comprehensive evaluation of a patient’s with low vision is important to plan for an appropriate management plan. This is essential because each patient has specific visual demands and  therefore the low vision assement needs to be customised for every patient. Here is a typical examination pattern and one may modify this as per the need of the patient:

  • Obtaining a detailed history

  • Performing an accurate refraction

  • Assessing visual functions

  • Explaining eye condition

  • Determining patients' needs

  • Designing a management plan

  • Determining the magnification of optical devices needed

  • Selecting low vision devices and training the person in their use

  • Suggesting non-optical interventions and environmental modifications

  • Referral for further training, support and contacting educational or rehabilitation services if needed.

Management of Low Vision

Low vision management differs between cases. It is beyond the scope of this article to get into greater details of management. However, it is simple logic that dispensing low vision devices needs to be coupled with proper instructions on the usage of the devices along with the required environmental modifications, so as to achieve beneficial results for the patients. For example, merely dispensing magnifying glasses to an aged person who has reading may not be useful to them unless suitable alterations like using bright light, large print publications and even enlarging the print on computer screens is recommended. Similarly in children with writing difficulties the use of bold black felt-tip markers, using bold line note books and writing on tablets with bold lines, extra illumination and using reading tables need to be advised. These additional suggestions or rehabilitation strategies are essential to be mentored to the patient as a low vision practitioner.

Some online resources for low vision that may help you:

 

www.lowvisiononline.unimelb.edu.au – a guided learning resource for eye care workers who want to learn more about working with patients with low vision. 

 

www.lighthouse.org/for-professionals/ practice-management – a collection of articles, mainly aimed at ophthalmologists.

 

www.mdfoundation.com.au – practical guides (PDF format) for patients and their careers, with a focus on macular degener­ation. 

 

www.afb.org – advice on living with vision loss.

 

www.svrc.vic.edu.au – for people with low vision who are in education.

 

http://www.ski.org/Colenbrander/Images/Low_Vision_Exam.pdf – practical guidance on performing a low vision assessment, aimed at trained low vision practitioners. 

To strengthen the scope of Low Vision, we have to encourage optometry students and graduates to take up this challenging speciality. We need to act now and train low vision practitioners and other staff to develop and include low vision services in existing eye care systems and create awareness amongst all medical, social, and rehabilitation services to ensure that patients are not sent home with any promise of help.

About the author

Ms Soniya Srivastava is a senior faculty optometrist and in charge of the Vision Enhancement Center (Low Vision Clinic) at Dr. Shroff’s Charity Eye Hospital, Delhi since October 1999. Soniya completed her optometry in 2011 from Vinayaka Mission University, Chennai. She also completed a Fellowship in Optometry from L V Prasad Eye Institute (LVPEI) and received in 1999, she also received a Best Outgoing Fellow Award for that year.

Soniya developed interest in the field of Low Vision ever since she completed her optometry fellowship at LVPEI. She participated in various national and international low vision workshops. In 2013, she represented India as Lions Clubs International Foundation’s National Focal Person Training Course on Low Vision organised by 

Hong Kong Society for the Blind, in Hong Kong, China. She spearheaded the National Low Vision Project (2012-14) under Sightsavers with the objective to establish and strengthen 21 Low Vision Clinics in various eye hospitals across India. 

 

Contact: sonia@sceh.net  or soniyasrivastava16@gmail.com

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