Population aging is a global trend that will increase strain on healthcare systems due to the higher prevalence of chronic health conditions in older adults. Visual impairment is one chronic health condition that systems should be prepared to address. Visually impaired older adults have unique needs that can be considered during a low vision exam to improve the quality of care that is provided. During this live webinar, we will discuss common comorbidities seen in older adults with low vision and best practices in low vision patient care for these individuals.
Lecturer: Dr. Micaela Gobeille, Optometrist, New England College of Optometry (NECO), USA
DR. GOBEILLE: All right. Hello, everyone. Thank you for joining me today to discuss considering comorbidities for low vision management for the older adult patient. Thyme Dr. Micaela Gobeille, Assistant Professor at the New England College of Optometry in Boston, Massachusetts, in the United States. And I’m excited to share my expertise here with all of you on such a global platform. So, let’s kind of jump into our discussion today. We will be discussing kind of the impact of population aging on global ocular disease burden. We’ll understand common comorbidities in low vision patient care, and we’ll also apply that understanding to a low vision patient case. So, we know that the global population is aging. Between 2015 and 2050, the proportion of the world’s population who are 60 or older will nearly double. And in 2020, the number of people 60 years of age and older actually outnumbered children less than 5 years old. So, this phenomenon has been seen certainly in high-income countries. But we’re starting to see this trend in middle and low-income countries as well. So, advanced age, as we know, is also associated with a number of health conditions. And ocular pathology is amongst the list. So, I’ve kind of highlighted a few studies that show this growing prevalence of ocular disease from an aging population. So, this study is looking at age-related macular degeneration and its growing prevalence in coming years. And we can see the projection of macular degeneration prevalence in these figures here, early AMD shown on the left side of your screen and late AMD shown on the right side of your screen. And we can see the prevalence of late macular degeneration, that with vision loss associated, is going to be increasing exponentially across the next several years. This is happening across all continents, not just in Europe or America. But in Oceania, in Latin America, in Asia, all of these countries are seeing great increases in prevalence of macular degeneration. Similarly, when we look at the burden of glaucoma globally, we can see that worldwide, we’re expecting an expected 35.8 million additional cases of glaucoma. We see that burden is particularly heavy in Asia and Africa. But this is really being seen across the globe. We can also look at the global prevalence of diabetic retinopathy. In this study, looked at just diabetic retinopathy in general and then it also sectioned out vision-threatening diabetic retinopathy. And we can see that we’re expecting an additional 16.3 million cases of vision-threatening diabetic retinopathy. And again, there are different distributions of where this is going to be seen as a more prevalent problem, but globally, this is concerning. So, taken together, we can see that macular degeneration, glaucoma, diabetic retinopathy and other age-related eye disease which is cause vision loss are going to be growing in prevalence in coming years. And this is going to increase the demand for low-vision services as with more ocular disease and more pathology, more people will have vision loss. So, what is low vision? Well, the World Health Organization defines low vision as a visual acuity worse than 6/18, but better than 3/60. With vision worse than 3/60 being considered blind. Or a visual field of less than 20 degrees in the better eye. Low vision rehabilitation exams allow us to evaluate these patients with reduced vision and to identify strategies that can help improve their function. So, I’m going to open up our first poll. So, do you provide low vision services in your clinical practice currently? You do it, you’re beginning to do it and just getting your feet wet. You would like to do it, or not at all. All right. Great. So, it looks like almost half of us are already doing low vision. So, I hope this lecture will be kind of a helpful discussion of some topics surrounding it. And for those of you who are looking to do some, I hope this will help you jump right in. So, low vision exams have a few different components to them from a standard ophthalmology exam. We started by taking a functional case history, and this is typically more involved and comprehensive than a usual case history would be. We certainly elicit a chief complaint to determine what the main problem this patient is experiencing. But we also delve into certain other categories more thoroughly. We ask the patient about reading, if they’re having difficulty, and if they are, what specific reading things they’re having trouble doing? Are they reading great large novels? Or do they just want to read the instructions on food packaging to be able to reheat a meal? We ask about visual information, which is their general seeing. Do their glasses improve their vision? Do they have trouble seeing things that are far away or intermediate distances such as street signs or television or other people’s faces? We ask about mobility, whether the patient is having any trips, bumps, or falls or whether they’re concerned about any of these problems. We ask about their daily living activities. Whether they’re having any difficulty with cooking, cleaning, laundry, medication management, or general self-care and bathing and dressing. If these patients are still younger and they’re working or employed, we’ll ask about these factors. And we also want to know about any hobbies these patients might be having difficulty with. Whether it’s reading or crafting or embroidering, there are a number of different activities that patients may want to help with. We then move on to entrance testing. And entrance testing in low vision is similar to regular ophthalmology exam entrance testing. But some things are different. So, we start out by checking acuity. But we use different charts. We can bring — use an ETDRS chart which allows us to bring the chart closer, up to 1 meter so that we can get acuity even for patients with very reduced vision. There’s also this Feinbloom Chart where we can hold the chart as close or as far away as we need to in order to get a vision measurement. And these charts are specially calibrated in order to be used for this purpose. We also evaluate contrast sensitivity using a Pelli-Robson or a Mars Contrast Sensitivity Chart. And this allows us to assess vision when it’s black on white for the first letters, but then the letters fade out to a lighter color which allows us to really get a sense of how that patient’s vision functions in the real world since most real world viewing isn’t maximum contrast black on white, it’s often more gray on white like facial features or cracks in curbs or sidewalks. We also then will evaluate the patient’s reading. When possible, we like to do this using a continuous text card where we ask the patient to read sentences as quickly and accurately as they can because this gives us a bit of a more real world sense of how this patient’s reading functions in real life. After reading, we move on to our trial frame refraction where we ensure that the patient is wearing their best refractive correction. We know that globally, uncorrected refractive error is a major cause of visual impairment so we want to make sure that we have the patient wearing their best correction. And finally, we move on to assess low vision devices like different hand and stand magnifiers, electronic devices, or even some very strong prismatic readers which can help the patient accomplish important tasks. So, now that we have an understanding of what’s done in a low vision exam, let’s talk about who actually attends a low vision exam. This study was a large, multi-center study in the United States enrolling almost 800 patients. And they found that the median age of patients in this study was 77 years. And we can see from this figure here, this histogram, that most of the patients enrolled in the study were on the older end of the spectrum. The majority were 60 years of age or older with only a few in the younger age categories. So, the low-vision patient population is largely an elderly group. Of patients enrolled in this study, almost a quarter rated their general health as poor or fair. And most report a number of comorbidities. These include hypertension, arthritis, heart disease, back problems, and diabetes. And many of these patients had multiple comorbidities, not just one. In addition to the impacted general health, 37% of patients in this study used a mobility adaptation like a cane or a wheelchair. 47% reported forgetfulness. And 22% note difficulty with their emotional adjustment to vision loss. So, of patients who present for low vision, many have other problems going on in addition to their low vision. So, with our population aging, we’re seeing elderly, low vision patients by and large. And these patients often have a complex constellation of health problems, they have multiple comorbidities going on. And these comorbidities can influence low vision rehabilitation management. So, let’s jump into a case to kind of put these concepts into context — into context. So, we have a 75-year-old male with a history of dry macular degeneration presenting for a low vision exam. He has a history of hypertension, heart disease, and he has pretty debilitating arthritis. He’s on seven different medications, but doesn’t know their names and he notes that he has a lot of difficulty telling these medications apart and that he cannot read the labels on the medications. He has difficulty reading. He has difficulty seeing television. But when he moves closer to it, he does well and he’s okay with this. He walks with a cane and has no trips, bumps, or falls. But the majority of his complaints at this visit are related to his daily living activities. And while he is able to reheat his food, maintain his home’s cleanliness and take care of his general grooming tasks, he has a lot of difficulty reading instructions and recipes on food packaging. And he’s also unable to read his medication labels. He notes that he can’t distinguish his medication, saying that there are a bunch of little white pills that all look the same. And that if we drops a pill, he has a large amount of difficulty finding it eventually. He also tells us that he lives at home alone, and it’s really important for him to accomplish all of these tasks by himself in order for him to maintain his independence at home. Or examination, our patients distance visual acuity measure 20/60 in each eye and his contrast sensitivity is moderately impaired at 1.12logCS. You can see the last letter he was able to read circled in that chart in the upper right corner of your screen. We performed a trial frame refraction which yielded no improvement. And then we evaluated his reading using a continuous text reading card. He held this card at 40 centimeters. And with this, he was able to read 2.5M where he first started to slow down. And then ultimately, the smallest line he could read was 1.6M. So, what areas of difficulty do you think we should address during our low vision exam? Do we want to address medication management? Television watching? Driving? Or working? All right. Great. So, many of us identify medication management. Continuing to work is certainly an important low vision goal. But this particular patient is retired. So, he’s no longer interested in working. He just wants to remain at home. And to do so, he needs to be able to manage his medications appropriately. So, a major problem that is experienced for many patients with low vision is polypharmacy. Patients often have multiple comorbidities which require multiple medications. And often these patients are on medications long-term for the duration of their lifetime. Polypharmacy and medication management requires patients to understand their administration schedule and keep track of it. And also, to know the side effects of a medication so that they can be sure that they’re not experiencing any. And if they are, to discuss this with the physician who provided the prescription. Low vision management around medication management involves making sure that the patient is safely and accurately taking all medications. This might involve a pill organizer where the patient can section out which pills need to be taken which day and at which time. It can involve maximizing contrast. So, if a patient is taking a bunch of little white pills and their wife takes the medication out of the bottle and puts it in a small white bowl for them to take, it might be hard for them to see that pill in a little white bowl. But if they switched over and used a black bowl to put these white pills in, the contrast would be much greater and it would be much easier for the patient to see them. Patients will also sometimes use specialized marking systems. So, they might write a large letter on the top of a pill bottle. So, here we can see a pill bottle labeled “E” on the top for evening. So, they take one in the evening. Sometimes patients will use rubber bands around the pill bottle in order to indicate which one it is. And there are other strategies that they can employ. We also need to make sure that the patient can read the medication labels and instructions in some way. Sometimes we’ll recommend a magnifying glass in order to let the patient read what’s written on the medication label. There are also other options. Certain pharmacies will print out large medication labels so that these are more easily legible for patients. And this is a simple strategy to make the task easier without needing to really do all that much from a low vision standpoint. Where I practice, there is also a program called ScripTalk, where medication labels can have these tags embedded in them and then there’s a machine that is able to scan that tag and read aloud from the medication is so that the patient doesn’t need to read the label visually. They can just listen to what it says. So, that’s another way to remove reading difficulty related to medication labels. Of course, with medication labels, we want the patients to be able to access this information in a way that’s very accurate and error-free because inaccurate medication management can lead to all kinds of problems. So, making sure that the patient is able to read their medication labels and accurately and safely take their medications is of critical importance for our patients who are older adults. Diabetes is a condition that often requires multiple medications. As we know, in diabetes, blood sugar is too high and this is harmful. And it can contribute to diabetic retinopathy, which is a leading cause of low vision and blindness. Diabetes is managed through lifestyle modification with diet and exercise as well as multiple medications in order to keep the blood sugar under control. So, systemic managing of diabetes includes blood glucose monitoring, dietary considerations to reduce sugar intake, regular exercise, as well as medications and sometimes self-administration of insulin where patients need to inject themselves with insulin in order to control their blood sugar. So, for patients with low vision, this can be challenging. Patients might require magnification in order to read medication labels as discussed a moment ago. Can also be helpful for reading food packaging to make sure that patients are conforming to the diet requirements related to their diabetes. And sometimes patients will use magnification to read a glucometer for measuring their blood sugar. Insulin management can also be challenging for patients. Some patients prefer to use an insulin pen to administer their insulin because they can count the clicks know how many units they’re administering. Some patients do better with insulin ports that will administer the right number of units to them automatically so they don’t have to worry about it quite as much. And here is another example of something that needs to be done very accurately. So, it’s important to make sure that patients are able to do this in a way that they’re comfortable and easily able to accomplish the goal. A talking or large-print glucometer can also be helpful for patients who don’t want to read the glucometer with a magnifier either because it’s cumbersome or makes it difficult to be accurate. Having something that says the blood sugar reading aloud can be really helpful because it allows the patient to be more accurate. Finally, mobility can be a concern. So, for our low vision patients who have visual field loss especially, some report that they don’t go out or exercise because they’re worried about tripping over things or bumping into things, which is a very valid concern. However, in diabetes, patients do really need to have some exercise at play. So, sometimes low vision management might involve making recommendations to improve this patient’s mobility such as orientation and mobility training to improve this patient’s willingness to go out and about and reduce their sedentary lifestyle. Musculoskeletal disorders are common in the low vision patient population as well. Arthritis and back problems are highly prevalent. And sometimes these can lead to the patient sitting through an entire exam. Especially if that exam is lengthy. Patients may have trouble sitting straight if they have certain types of back problems. And arthritis, certainly if it impacts the patient’s hands, can impact their dexterity which might impact their ability to manipulate low vision devices. Mobility can also be a concern related to these musculoskeletal disorders. Patients might have trouble with their balance. This can be related to vestibular problems involving the inner ear. Or it can be related to musculoskeletal problems involving the muscles and the bones and the joints. And many of these patients, as we discussed earlier, use mobility adaptations like a cane or a wheelchair. So, low vision management for the patient with the musculoskeletal problems involves adapting an exam to improve the patient’s comfort. Patients can be examined in examine lanes that are wheelchair accessible. Not all patients will be able to jump from their wheelchair to the exam room chair, so examining the patient in a room where they can stay in their own wheelchair if needed can be helpful. We always ask the patient if they’re able to transition out of their chair. And if they’re not, we want to be able to take care of them regardless. We also want to be able to allow this patient to adjust their positioning. And in a low vision exam, fortunately, much of our testing is done in free space. We do a trial frame refraction, which allows the patient to position themselves as-needed in order to be comfortable. We can also use hand held equipment like a handheld slit lamp or an opthalmoscope in order to examine the patient rather than making them hunch over into different machines that we have. Sometimes these patients need to be examined in multiple shorter exams rather than in just one long, time-assuming exam because sitting in a particular position for too long can be physically uncomfortable or even painful. So, sometimes we’ll have this patient come back more often rather than making them sit for 2 hours. We can also consider these disorders when we recommend devices. For a patient who has a hand tremor or has arthritis that impacts their fingers and impacts their dexterity, we might have a device on the table, a stand magnifier so the patient doesn’t need to hold the device steady which will be less taxing on their hands. Finally, from a mobility perspective, physical therapists can be really helpful. Sometimes patients will come in reporting frequent trips and bumps. But it’s not so much related to their vision, it’s related to their other constellation of health problems. Encouraging patients to talk to their primary care doctor in order to get a referral to the physical therapist can be helpful so that they can work on strengthening and mobility concerns. Hearing loss combined with low vision can be another challenge for older adults. Dual sensory impairment is well-documented as something that can really impact patient’s well-being. Contributing to isolation, depression, reduced independence, even mortality and cognitive impairment. Having hearing loss combined with vision loss can be very troublesome for patients. A major barrier in providing healthcare for these patients is communication. In low vision management, our first job is to reduce communication barriers for these patients. Some patients will have a hearing aid and they might say, oh, just wait a minute. Let me adjust my hearing aid and it’s a great idea to let them do that because it will facilitate communication. Some patients will require an interpreter. For some of our low vision patients who require a sign language interpreter, they need hand-over-hand signing because their vision is reduced such that they can’t see the sign language hand motions that occur as the exam is going on. So, having this ASL interpreter do hand-over-hand signing as is depicted at the bottom of your screen can be really important. We also want to reduce background noise. So, if there’s loud background noises going on in the office, being able to get this patient in a nice, quiet room can really help them to distinguish your voice more clearly when possible. And we also want to talk in a clear and moderate voice. We don’t want to shout. We don’t want to yell. But we do want to talk in a voice that the patient can hear and not mumble or be too quiet. Sometimes in low vision we find ourselves at a point where the patient’s vision is reduced such that they really could benefit from having a non-visual strategy for reading. So, often in this scenario, we turn to devices that have both magnification and read aloud capabilities. However, for a patient who has both hearing and vision loss, this may not be an appropriate strategy because if we’re depending on hearing to help, that won’t be practical here. So, these patients might have more need to learn strategies like Braille or other tactile strategies in order to compensate for their vision loss if the vision loss is so severe. Finally, cognitive impairment can be a consideration for low vision patient management. This can come associated with different comorbidities. Stroke can lead to memory deficits. Dementia, either Alzheimer’s or vascular can occur. And Parkinson’s disease can also contribute to dementia. Memory changes are also common in less severe settings. From that large multi-center US study we were talking about earlier, we know that almost half of patients in that study reported occasional periods of forgetfulness. With age, patients experience changes in their long and short-term memory. And so, it’s important to consider this during a low vision exam. So, during the low vision exam, we do want to recognize the problem if cognitive impairment or memory changes are an issue. We might administer cognitive screening tests as pictured here. I have the Montreal Cognitive Assessment Tool. Or The Mini Mental State Exam is another commonly-used screening test. We can also ask patients about how they feel about their memory. In that multi-center study we were talking about, a similar number of patients self-reported having cognitive impairment as tested as having cognitive impairment on a screening test. So, perhaps just asking the patient if they feel like they’re having trouble with their memory can be a quick and efficient way to get at this information. For patients with significant cognitive impairment, we need to consider this problem’s impact on the rehab plan. Sometimes the timing of the exam can be challenging. So, there is a phenomenon known as sundowning where at a certain time of day patients with severe dementia might experience greater difficulty kind of being engaged and alert. So, having an exam scheduled during this time can be problematic because the patient isn’t at their best. If we have an exam scheduled at a time when a patient is typically taking a break or resting, the patient might not be able to participate as fully as they could if we rescheduled for another time. Aphasia can also impact how we perform an exam. Patients might have difficulty producing spoken language, but still might be able to benefit from a low vision plan. So, finding alternative communication strategies can be important here. During the exam for a patient with significant cognitive impairment, we want to use simple and concise instructions. We want to make sure that we give the instructions as efficiently and understandably as possible. Refraction can be challenging in these patients. Here we want to really rely on our objective findings. I do retinoscopy on every low vision patient to give myself a reliable starting point. And here we really do need to rely on that objective retinoscopy finding. If we feel that the patient is capable of providing some reliable responses, sometimes using larger lens changes or a larger just noticeable difference can be really helpful to make it more obvious when a change is helpful versus unhelpful. I know that there are some other really great webinars in the Orbis Library that go over the whole logistic of doing a trial frame refraction. But sometimes going larger than the calculated just noticeable difference can be helpful. Finally, we want to think about how we’re actually implementing our low vision plan. We certainly evaluate devices and give patients the opportunity to experience different devices. But sometimes patients need a simple approach. They might not want the most complicated device that we show them. They might benefit from something simpler. And sometimes they might need additional training in order to use that device effectively. So, I would say that, you know, this cognitive impairment should be considered during the low vision exam. But it shouldn’t dictate your exam. We should still show the patient the full range of devices, and let them decide what feels comfortable or appropriate for them. Patient motivation and support can be a factor. Some patients just are not interested in anything that’s difficult to use. Or they might need someone else to help them set up the device to turn it on. I’ve had patients who really want to use a tablet for reading, but this is just so complicated. But if they have someone who can open that ebook app on their tablet for them so that they can read, they do just fine. Involving the caregiver in some of our discussions about low vision devices and deciding how we’re going to use them can be helpful in order to determine what will or will not be appropriate. And last but not least, we need to discussion emotional wellbeing and low vision. We know that depression and anxiety are highly prevalent in our low vision patient population. Patients are experiencing vision loss, and as that occurs, these patients grieve their vision loss. It’s associated with decreased independence. In some cases, decreased income. And changes in social interactions. And there’s a whole range of stages of grief that these patients experience related to their vision loss. Additionally, depression has certain symptoms. Some of which are particularly relevant to low vision. Which I’ve highlighted here. So, patients will note decreased interest or pleasure in activities. As well as indecisiveness, poor concentration, or difficulty thinking. And these can really play a role in low vision where we ask patients what they want to do and what kinds of activities they find pleasure in performing. Whether a patient has depression, they just might not feel enjoyment from many activities that they previously did partake in. So, during the low vision exam, what we want to do is acknowledge the patient’s experience, especially related to grieving their vision loss and empathize. I’ve had so many patients who are just shocked and really kind of comforted when we acknowledge that losing vision can be a grieving process. From there, we want to move on to provide low vision recommendations that will facilitate meaningful tasks. So, if our patient expresses that they are depressed because they can’t read books and they used to be an avid reader and they really miss that pastime and they feel this loss really deeply, providing magnification devices that allow them to read that book can be really meaningful and important. We also want to consider referring to a mental health provider wherever possible. This might involve a therapist or a social worker. Or often I’ll coordinate a referral through the patient’s primary care provider so that they can obtain this really beneficial service. So, with this discussion completed, let’s go back to our case. Our 75-year-old male with a number of comorbidities and great difficulty managing his medications. So, he primarily noted difficulty reading his medication labels and food packaging and instructions and the need to do all of these things independently because he lives at home alone. As we recall, his distance acuity is over 20/60, his contrast sensitivity was moderately impaired at 1.12logCS. And he was able to read fairly large print. So, what types of strategies should we try for this patient’s goal of reading and medication management? Is it magnification? Use of a pill organizer? Use of high contrast? Or all of the above? Great. I love that we almost all agree on all of the above. So, magnification is certainly the first strategy that we’ll use. But we’ll also recommend other things to help with that medication management. So, we started out by evaluating this patient using an 8diaptor LED illuminated hand magnifier. With this device, he was able to read .8M, which is about 40/20 print on the continuous text reading card. He read an example medication label easily and accurately. But he did note this was difficult to maintain for an extended period of time due to his arthritis. Health that it was sufficient for reading a medication label, but food packaging would be too difficult to read using this because his arm would get too tired. We next evaluated this patient’s reading using a 3x stand magnifier while the patient was wearing his 2.50 add. He was able to again read that .8M, or 20/40 line on the continuous text card and felt that this was better for extended, more strenuous use. With this, he was able to read food package instructions and he was excited to try it out in other scenarios as well. We also talked about simple strategies for medication management. The magnifier would be really helpful for reading medication labels and instructions. But we felt that if he wanted to contact his pharmacy to get large print medication labels that might be even easier because it removes that difficulty all together. We also talked about a pill organizer because this patient is taking seven different medications which he has trouble telling apart. So, being able to distinguish which pills he’s supposed to take on which day could be helpful to prevent him from making an error in taking his medications. Our patient also told us that when he drops a little white pill on his white countertop, he has a lot of trouble finding it. So, we talked about using a black placemat on top of his countertop that so, that if he drops the bill, it lands on the black surface and it’s easier to find so he’s not crawling around on the ground trying to find it after the fact. So, for this patient, we recommended the hand magnifier for reading medication labels and brief checking activities related to his daily living activities. And we also recommended his stand magnifier for more extended reading. Finally, we recommended a pill organizer to help him keep track of medications. We recommended maximizing contrast to increase visibility. And we also advised that he could request large-print medication labels through his pharmacy which would improve legibility as well. So, from this talk, we’ve seen that population aging is ongoing on a global level and this will increase demand for low vision services and will be related to the increased prevalence of age-related eye disease. We see that the larger elderly low vision population often have multiple health conditions. and that the low vision exam can be adapted for elderly patients with comorbidities and can be used to help identify new ways for patients to maintain independence. And at this point, I can open the floor to any questions. Thank you for your attention. I have a question here that says according to the World Health Organization definition, low vision means visual field less than 10 degrees, but I mentioned 20. That’s a great point. I think we’re having a discrepancy between diameter and radius. I believe their definition is a 10 degree radius which would translate into a 20 degree diameter of visual field. I have another question here that says, how can we manage a low vision patient having central vision loss and requiring high MAG any indication to read? And that’s another great question that we see quite often. In central visual fields loss we use larger and larger amounts of magnification. Studies by Legge et al. show that the more magnification you provide, the better these patients tend to read. So, magnification is, again, the key. There are different ways to do magnification. And which way we use depends on the patient. Some patients do well with hand magnifiers or stand magnifiers. Sometimes if a scotoma is particularly large, we might need to depend more on electronic magnification options. Let’s see… I’m seeing a question: Can Fresnel Prisms be helpful for elderly patients with visual field loss? The literature is pretty mixed. We know that Fresnel doesn’t expand the field. There’s a particular kind of prism, a Peli Prism to help patients with hemianopia to expand the field, and this doesn’t take up the whole lens die yam her. Fresnel Prisms that take up the whole diameter can be useful as yolked prism to shift the image in a particular direction which might be helpful if there’s a head or eye turn to minimize that demand. Or it can be useful in patients with nystagmus to achieve a null point. But it’s not the primary intervention for visual field loss. Let’s see. I’m seeing a question: Any specific strategy for reducing falls due to low vision among elders? And that’s a great question. So, of course, this depends on the specific patient. Patients with visual field loss or mobility concerns might benefit from orientation and mobility training where patients receive instruction on how to use adaptive, non-visual strategies in order to compensate for their vision loss. So, that’s one strategy. Some patients who are older might have difficulty with mobility less related to their vision and more related to other comorbidities. And sometimes these patients benefit from just being encouraged to use a cane because this does provide some preview of what’s coming up next. Or a walker. In order to give them that increased stability. There’s also a lot of thought about falls and bifocals where if the patient is looking down through the bottom of a bifocal, things will be out of focus because they’re looking for their reading prescription. Some patients do better with separate pairs of distance and reading glasses. But the jury is still out and it’s kind of dependent on the person. There’s a question here that says to elaborate between the relationship between arthritis and low vision. So, arthritis is really common in patients with low vision. It’s a pretty common condition all together. So, for patients with low vision who have arthritis, they might have some dexterity issues that limit their usage of their hands. So, this might make it particularly difficult to manipulate devices. So, a magnifying glass then needs to be held in the patient’s hand might be really difficult to use. Or a reading glass that requires reading material to be held very close to the patient can be quite difficult because the patient needs to hold it at a certain difference and maintain its stability and that might not be feasible for a long period of time. Or a CCTV device that has a lot of different dials and buttons to press might be difficult for the patient to manipulate those buttons. So, there are other options like using something that has a stand in it, that will keep it held at a fixed distance that can be helpful. Like the stand magnifier that we talked about like in the case shown here. There’s a question about how to manage RP patients who have peripheral visual field loss. And I’ve seen a few other questions about how to manage peripheral field loss in general. So, for these patients, we can use magnification, but we want to do it within limits. Of course if we magnify things too much for a person with a visual field loss, they will only get a letter or two at a time and it can be counterproductive. Providing the lowest amount of magnification possible for reading is important. Patients often benefit from orientation and mobility training to learn how to use non-visual cues to evaluate their environment and avoid tripping over and bumping into things. RP patients often have difficulty with glare and often need different tint strategies for different scenarios. So, managing that glare sensitivity as well. Really with any patient with field loss, we want to maximize the central vision that they do have and compensate for the missing field loss. There’s a question about whether we calculate magnification before evaluating devices. And yes, I do calculate magnification based on the inverse of the critical print size or the point at which the patient slowed. So, in my slides, I did a reading assessment. And the patient slowed at 2.5M held at 40 centimeters. So, then I would divide the 2.5 divided by .4 for the 40 centimeters to get a predicted add of 6.25. We did try a 6 diopter hand magnification, but it wasn’t quite strong enough, we moved up a step to the 8 diopter magnifier which the patient ultimately appreciated. So, there is a question saying compared to optical aids, do you see an advantage of suggesting electronic magnifiers? That’s a great point. So, their optical aids are really great tools. They tend to be less expensive than some of the electronics and they don’t require you to charge them and plug them into a wall overnight. So, they can be a little bit more flexible. They’re less likely to run out of battery on you. And when they run out, they’re certainly easy enough to change the batteries. So, optical aids certainly have their place in low vision. However, they do degrade contrast. So, any time you’re looking through a lens, there’s some light that’s reflected off the front surface of the lens and that’s lost and does not contribute to your vision. So, a electronic magnifier bypasses that problem. I commonly go to electronic magnifiers for patients who have severe contrast deficits. These patients might benefit more from devices that maximize contrast and make things both bolder and brighter as well as magnifying. Yeah. So, I’m seeing a really thoughtful question here of how do we handle the stigma related to cane usage. This is a challenging question and something I face every day. Patients don’t want to use white canes and it’s a did disabilities. Anybody on the street would note know they have a visual impairment. However, when we ask someone to get them to use a cane, it’s a white cane. This is certainly challenging. I don’t think there’s anything that truly replaces cane usage. Cane usage is kind of a first step in learning these strategies. There are things that supplement cane usage. There are some — there’s a device called a Sunu Band uses radar that comes off a bracelet that looks similar to a Fitbit. And that can detect some obstacles ahead of the patient. But most patients use that in conjunction with a cane. There are other devices attached to a cane that can provide additional Sonar to detect things that are up and coming. But again, this is typically done if had conjunction with a cane. In orientation and mobility training, patients often will learn other adaptive strategies like using certain hand positions to protect themselves. Hold their hand in front of themselves in a certain way to avoid head collisions and behind themselves to avoid back collisions. But really the cane is a mainstay of management. Some patients, once they learn how to use a cane, ultimately can reduce their use of it or only use it in certain scenarios. But there’s still that hurdle to get over to convince this patient to accept cane use and training in cane use as a whole. You know, I do see several questions around, you know, calculating magnification and standard methods for calculating magnification and there are quite a few ways to do this. I would direct you to some of the previous Orbis lectures, some I more colleagues from NECO have done that. I will leave that to the existing library. Let’s see. There are also a few questions surrounding low vision management for children. And these are really well-addressed in some of the other Orbis Library lectures on working with children who are visually impaired and pediatric low vision exams. There is a question about glare reduction techniques in patients with low vision. So, glare reduction typically depends on finding specific strategies that are most appropriate for the patient. This might involve blocking oncoming glare or using different tint options in order to control glare. Glare can vary based on environmental setting. So, patients might be bothered by glare in a certain way on a bright, sunny day, but less bothered by glare in a different way on a cloudy day. So, Patients might need different glare control strategies for different sets. So, patients may require different tint options and didn’t frame options. There is a patient — there’s a question on here about how to manage low vision patients with diabetes. Some of the strategies we talked about here involving medication management, making sure that the patient can tell their medications apart is important. Making sure that they can read their glucometer. Making sure that they can manage their insulin if they’re doing this is important. We also want to make sure that they’re able to manage their diet appropriately since these patients are often required to reduce their sugar intake or carbohydrate intake. So, making sure they can read medication labels is important. So, magnification can be really important here. All right. Well, I think that seems like — oh, here’s another question. You administer quality of life questionnaires for your low vision patients? I love this question. There is actually an area of research interest for myself. So, quality of life questionnaires ask patients to rate the importance and difficulty of different activities. My usual go-to questionnaire is the Activity Inventory developed by Robert Massof over at Wilmer Eye Institute. The others ready IV, the impact visual questionnaire, the IVFQ, there’s quite a few of them out there. I don’t actively use these commonly in my current practice. Largely because they’re not the most practical to administer at this moment. You know, I hope to see them become more used in clinical practice and they’re really powerful research tools. But commonly not used in practice. I’m seeing a question about if had what conditions we use head-mounted devices. That’s a great question. Head-mounted devices like the iris vision or the other, you know, virtual reality headset-type goggles that patients wear that have magnification displays in them can be really helpful. But often they’re pretty big and clunky and patients can’t walk around with them. I won’t say they’re my mainstay go to low vision management strategy. But they are a useful tool to have available. I commonly show them to patients that have been looking for a — low vision strategy that want to have the flexibility of focusing. I decide less based on a diagnosis and more based on the kind of the facts that the patient has told me during the exam about how they use their vision and how they want to use their vision. All right. So, at this point, it’s 9:59, I think it’s a good point to stop. Thank you for your attention and your many wonderful questions and for joining me around the world. Have a great day or evening. Thank you.