“There’s nothing more that can be done” is hard for low vision patients to hear. Avoid this phrase and go the extra mile to help your patients stay as independent as possible. Join Dr Sarah Wassnig as she discusses how to help your low vision patients adapt their environment to maximise their vision, navigate their environment safely, and continue to enjoy their favourite activities.
Lecturer: Dr Sarah Wassnig, B.Optom(OcTher), MPH, London, United Kingdom
Transcript
DR WASSNIG: Hi, everyone. I’m just gonna share my screen for you here. Okay. My name is Sarah Wassnig. I’m an Australian optometrist, and I’m currently living in the UK. And I’ve been working with Orbis, teaching optometry, since 2016. So it’s an absolute pleasure to be speaking with you guys again today. Today I wanted to speak about our role in low vision, beyond the exam room and beyond just prescribing visual aids.
Too often I see a patient who is all set up with a visual aid that they could need. They’ve got their best visual acuity and the best visual field they can get. But they’re still walking out of the clinic no better off functionally and no more confidently than when they arrived. As clinicians, we get super excited and carried away with the diagnosis of disease and the mapping of visual space and the prescribing of telescopes, magnifiers, and prisms.
But we really fail to guide our patients, sometimes, on how to adapt their environment to suit their vision. We may have improved visual acuity, and we may have improved the extent of the visual field, but we really failed to provide the patient with functional vision, which I think a lot of the time the patient is disappointed — but is a little bit concerned, a bit worried to face. So that’s what we’re gonna look at today.
Before I start today’s lecture, I received a lot of really interesting questions, fantastic ones, actually. Today’s lecture won’t address some of those questions. However, we will be working to answer them either privately — so either myself or some of my colleagues will answer them privately. Or we’ll also work with the Cybersight team to perhaps present some lectures that more specifically address some of these questions, such as prescribing prisms. I also had a few questions about setting up your own low vision clinic, which I think is a fantastic webinar to present. So I’ll have a chat to some colleagues and a chat to the team, and see if we can set up something like that in webinars to come. I also received a lot of questions that were specific for patient cases that you’re seeing. And I want to encourage those who have questions like that,
either ones that you sent or you have questions that you’re thinking — I would really like to ask someone for some more advice on this — anyone who had specific patient cases, I’d really like you to join our online learning community. So I know you all signed up to the live webinar, most likely going through this website. This is www.cybersight.org. You’ll see on the top corner here it says: Join us. And if you click that, this screen here will come up. You can pop in your name, your details, and make sure you click online courses and expert advice. Once we set you up, you’ll log in through here, like this, and your screen will look something like this. This is me logging in this morning. You can click start a new case. You can see that there are several cases that were started only a few minutes ago, or a few hours ago. People responding to private cases, to general questions. You can click start a new case here. Or down at the bottom. And you’ll see you can click select a subspecialty, so low vision, optometry, pediatrics, you can put in your patient information, age, their visual acuity. Really, when you’re creating new patient cases, the more information you can give the clinician that you want to speak to, the better.
So jam pack this with information. And either if it’s a general patient case, open to the public — someone might generally answer it. Or if you specifically ask for someone, then they will answer you back. They might ask for more information, before they answer the case. And then you can have a little bit of a dialogue about that particular patient. You can also create a general question.
So if you have just something like… Does anyone know how to prescribe prisms in a particular disease, you can send that question out, that general question out, and either again a specific mentor, if you assign them, can answer it, or someone from the community might answer it. So yeah. I just really want you to get involved, as much as you possibly can. We love to hear about patient cases that you’re seeing, and the more cases that you send through, really, the better. So I’m gonna start by asking you to avoid the phrase “there’s nothing more I can do”, because there’s actually a lot more we can do, by providing our patients advice on how to use their vision and how to empower them, and empower them in using their vision in their own environment. There’s really… The amount of advice that we can give to them is endless.
01:06:02 These are just a few resources that I think are really helpful in thinking about how patients can navigate their environment, if they have low vision. Additionally, I’d like to just take a moment to especially thank doctors Alexis Malkin and Nicole Ross and Mr. Darick Wright from the New England College of Optometry. The low vision team at the New England College of Optometry is truly remarkable. Okay.
So objectives for the next hour or so, or a little bit less than an hour: First, we want to utilize our patient history to make appropriate recommendations. So listening to the patient, so we’re giving the advice that is specific to their visual needs. Discuss the activities in daily living that become difficult with low vision. Often we take for granted things like drinking out of a cup or filling up the kettle.
Those things seem pretty easy and pretty standard. But we don’t think about actually how difficult they are for someone with low vision. I’d like to equip you with some ideas and helpful hints to help people navigate their visual environment better. This is a huge undertaking, I guess, if you’re gonna sit down and take a patient through all the things that they can do within their home.
Often I’ll give a handout that has all of the things that we’re gonna discuss today written down. And with advice on there. So you can have a small discussion about each thing, and then when they get home with their loved ones and their family and friends and their main careers, they can discuss how they’re gonna adapt their own home. And I just also want to quickly teach you the technique of guiding a low vision person, and also how to teach their caregivers this skill. And also how to help them explore their environment. So first let’s look at utilizing the case history so we can make appropriate recommendations. When we’re treating patients with a reduction in vision, it’s particularly important to ask extra questions on top of our usual case history. And these questions are about how they’re coping with their visual impairment and what daily activities they’d like to do better.
And also how they’re coping with their visual aids. Just because you’ve given them a telescope doesn’t mean that they’re taking it out with them. It doesn’t mean that they’re using it properly. And it doesn’t mean they’re using it to its full potential. Please note in this slide when I’m talking about people with low vision, I’m emphasizing them.
Often people come in, and we’re all guns blazing, we think we know what you want, we think we know what you’re experiencing, and it’s actually really important to listen to what the patient wants and what the patient needs. The number of times I hear from patients “I feel like this is the first time I’ve been listened to” is outstanding. So make sure you’re listening to what they’re asking you.
So during our low vision exam, we’re gonna obtain information about all of these areas. Reading speed, visual acuity, distance and at near. The extent of their visual field, their confidence in using their vision, if they have any contrast restrictions, how well they can move about their environment. With a lot of these things, you can also just observe yourself how confident are they in using their vision, and moving from the waiting room into your exam room, and sitting down in the chair, and how are they managing that, who are they with, and how is that person helping them? If you want more information on how to conduct a low vision examination, there are on the Cybersight website — it’s www.cybersight.org — there are on the Cybersight website a few webinars from a few years back that focus on the low vision exam, and also focuses on low vision devices that you can use, that’s both technology, like our phones and computers, but also looking at magnifiers and telescopes. So now we have all of this information from our exam. We want to know how this applies to the patient’s real life. So first try integrating some of the following questions into your case history. Get to know the patient. What can’t you do anymore, because of your vision?
What are you wanting help with? How has your life changed since you lost your vision? They might say: Well, I was a marathon runner. I did the Boston marathon, the New York marathon, and now I haven’t been running since I lost my vision. Are they living alone? Are they living with family? If they are living at home, have they made changes to their home environment? Or is everything still exactly the same?
So have they made changes to help them get about a little bit easier? Or have they really not altered much at all? When it comes to reading, we want to think about their goals and their needs, but now that they have their visual aids, you’ve already prescribed them, ask how they’re reading at the moment. What are they reading? How difficult is it?
If they could expand their reading, if they could do anything, what would they want to do? Do they want to read books? Letters? Bills? They say… Look, I’m okay with reading, but I’m having trouble really looking at photos of my grandkids. Do they want to go shopping independently? Perhaps at home they’re reading okay, but they would really like to go shopping independently to read the price tag or the packet when they’re at the supermarket.
Also, ask if they have tablets or computers, and if so, if they’re using them with their vision. We’re not gonna really cover this on how they can, although we will very briefly. But how they can use these devices. But if they’re not using them, why. Perhaps they just don’t want them. But perhaps they have one stuck in a drawer or their grandkids have replaced their old one and they’re happy to give Grandma or Grandpa their old tablet.
Teach them how to use that or get their kids to teach them how to use that. You also want to know if they’re experiencing a lot of glare. In our exam, we look at contrast, which is very important, but we want to ask a case history, if they’re experiencing glare. And particularly important if we’re thinking about going from outside to inside or inside to outside. You can imagine if you were going shopping and every time you went from inside the supermarket to outside, you had to stop for a moment. There’s a lot of noise, a lot of people walking around. A lot happening, and all of a sudden you feel blinded by the situation, and you have to just sort of wait until your vision adapts. You can understand that would be incredibly confronting. Ask about TV. TV is often something that people really enjoy. But they’re not really using their TV anymore.
If they do enjoy TV, are they listening to it? Are they watching it? Things as simple as: Is the TV set up so they can use the screen? Is it set up in the right position of the room, compared to their chair? Is the screen too bright for them to really view properly? Or is it perhaps even positioned towards a window, and so they’re getting a lot of glare from the outside light.
And so they can’t really see what’s happening on the TV. You also want to know: Can the patient identify familiar faces? Particularly in crowds. You can imagine that when they’re at home, they can identify somebody who’s just walked into the room that’s familiar, but when they’re outside, and they’re walking with that person, and suddenly they let go, then can they identify that person again?
Because you can imagine that would be incredibly confronting. You also want to ask about how they’re getting around. Are they dependent on someone else in order to get from one place to another? Do they venture outside the house very often? And if they do, do they do it by themselves? Or do they do it with assistance? Can they use a cane? Do they have a guide dog?
Do they use a guide, a family member, or a loved one, to help them guide them as they’re walking outside? And if they’re not using these things, why not? Why are they feeling that they can’t use these things, they don’t want to use these things? And would they like to travel more independently outside, if they could? A lot of people are quite happy not to. But a lot of people would say… Oh, you know what? I wouldn’t mind just going down to the corner store by myself.
I think that would be okay, except how I’m set up right now, I can’t manage it. We also want to ask about the tasks that they’re having trouble with every day. And it’s always good to be specific, to give them ideas about what might be difficult. Often patients have just accepted “I just can’t do that anymore.” So you say: Are you having any troubles with the things you do on a daily basis? They go oh, no.
You might say… Do you cook anymore? And they might say… Oh, no, I absolutely don’t cook. Can you fill a cup by yourself? Oh, absolutely not. So they are having difficulties doing those daily tasks. So give them some ideas and ask them specific questions. So you can get a better idea of what they are doing independently, and what they require someone else to help them out with.
Think about all the things that we do on a daily basis, even. We really do take those things for granted. Like drinking. Eating from a plate. Rather than a bowl. Filling a cup up. With water from the kettle or from the tap, without spilling it everywhere, without overflowing. Putting on makeup or shaving in the morning. Cooking is an obvious one that a lot of patients do give up.
Taking the correct medications. If you take multiple medications, each morning, we really do take for granted that I can read the back of the bottle and I know which one to take and which one not to. Getting dressed in the morning, and also choosing your own clothes to get dressed. We really do sort of take that for granted.
When you’re washing, and bathing, picking up the shampoo rather than the soap or the conditioner, to wash your hair. Cleaning the house. Being able to see the dust and the dirt, vacuuming, being able to vacuum. If you wanted to. I hate vacuuming, so I’m not sure why anyone would want to vacuum, but… Doing the vacuuming. Also putting on the dishwasher or washing the dishes, when everyone is in the kitchen helping out.
Can you wash the dishes anymore? Can you help dry? Can you put things away? These are all really — they’re activities that really with just a small amount of advice, and maybe a small number of adaptations in the house, that patients can really do these things independently, in a lot of cases. Listen to what your patient is saying. So we’re already saying… Listen to what their needs and what their wants are, rather than imposing our own onto them. But also, listen about what they’re saying. Do these complaints correspond with their visual field restrictions? Because they usually — or they should — they should do. So if someone says: I can take stairs going up, but not stairs going down, this suggests a variety of visual field defects. So we can anticipate things they might be having trouble with with an inferior visual field defect.
I bump into doors on my right. Does this correspond to a right visual field defect that they’re having? So think about what they’re saying and how that relates. During this consultation, you will hear a lot of unrealistic requests, like I want to restore my vision to what it was before the accident, before the macular degeneration. What surgery can bring my vision back. It’s only natural that patients will want to ask these questions.
It’s important to be honest. But it’s also important to be kind in your response. And understand that this is really what the patient would like to do, is to go back to what it was like beforehand. But it’s really your job to help them realize that even though their vision won’t be restored fully to what it was, that you can help them get back to the things that they were doing before they lost their vision.
We may not be able to achieve all their goals. There are just some goals that just aren’t possible with the vision that they have. And so let your patient know you will try to help them achieve their goals and to make them as independent as possible. But try and work with sort of one goal at a time. Be clear that things may not be performed the way they were prior to losing their vision.
I’m gonna introduce a lot of ways here to get around, for example, filling up a cup without it overflowing. There are gonna be some things that are involved or some tricks that are involved to help them do that activity, and so the activity itself won’t be performed exactly the same. So there will be a lot of adaptation. It’s also really important to manage their expectations of their main caregiver and their family and friends.
But particularly the main caregiver. Be really respectful when approaching this kind of discussion. Often people have been caring for their loved one with low vision for a really long time. So be mindful that this is most likely the caregiver’s full-time job. And often they’re gonna feel redundant and possibly resistant to change. Even though from your point of view, you’re thinking… But this would be great.
It would make them more independent and thus you more independent. But if you’re involving the main caregiver in the changes that are being made, you might get a little bit of resistance from them. So just be really respectful and mindful that this is affecting their lives too and these changes will be affecting their lives too. And you’ll be relying on the main caregiver to give a lot of — to implement a lot of this advice.
Lastly, it’s always really good to ask your patient and their family if they have any thoughts on what might make their vision worse. Because often you can debunk any untrue old wives’ tales or concerns, such as… I don’t like to go outside, because I know the sun will make my vision worse. Which obviously is not the case. So you can talk them through, about how culturally that’s just an old wives’ tale and it’s not true, or why it’s not true, or why it feels that way, but it’s not true. Often something I hear is: If I wear my glasses too often, my vision will get worse. So you want them to really open up and tell you about the concerns that they’re having. Try not to laugh at them or make fun of them. Be really, really caring and kind. They’re in a really vulnerable position, and they’re being really honest with you. So try not to say… No! You’re wrong! Or that’s not correct!
But just to talk them through and show that this is actually not the case. Also, just very quickly, whilst we’re getting to know our patients, I just want to touch on identifying psychological needs. It’s very important to be aware that both the caregiver and the patient are grieving their independence and the patient is grieving their vision. These are some signs to look for. Denial, guilt, anger, depression, sadness, acceptance, adjustment to vision. How they’re coping.
I’m gonna let you read over this slide yourselves. The slides will be posted up online. After our webinar today. But in many cases, I want you to be aware, because you are the primary practitioner. They’ve seen you, they’ve come to see you for their vision problem, and they may not see someone else for a little while, regarding their vision. You’re really in this perfect position to refer them, if you think they might need counseling. That’s both the caregiver and the patient.
But your role doesn’t just stop there, because your positivity and your encouragement is really vital in empowering the patient. And by providing them tools and tricks, like we’re gonna discuss in a moment, you really empower the patient. And this plays a huge aspect in promoting positive mental health. So I just want you to be aware of the role that you do play in addressing the psychological needs of your low vision patients.
Okay. So we’ve gotten to know our patient. Let’s see how we might help them achieve independence in their daily living. This is a summary of things that we’re gonna look at today in making an environment workable for your patient. So I’ll leave this with you, just to read over, when you have a look at the slides. They’re usually pretty simple, and they’re usually actually pretty inexpensive tricks and tools.
These adaptations not only allow the patient more independence, but it also helps the patient to be a lot safer. For example, the ability to dial a telephone for help. Also a lot of patients — they’re not leaving the home alone. But they do need to be able to evacuate the home in an emergency, without assistance. So by allowing them to have a little bit more independence, you’re also giving them a little bit…
You’re also giving them tools to be a little bit safer when things don’t go as planned. For example, the patient with the inferior field defect, they also need to be able to safely walk around their home without falling over low objects. And so you need to have a chat to them about — you want to make sure that those objects are removed. You want to make sure that people aren’t placing objects where they don’t belong.
Just to prevent them from falling. It’s important to keep them independent as it is to keep them safe. So a good way to start is advising a patient to fix up any hazards in their house, like loose carpeting. If there’s a rug, maybe tacking it down, so the person doesn’t get their foot caught under the lip of the rug and fall over. If there are broken handrails on staircases, make sure they’re fixed.
For example, the patient who has that inferior field defect may be installing a handrail on the staircase in the home, if there is one. So they can hold onto it, as they’re going down the stairs. Non-slip flooring, also really important. They’re not gonna see the spills or anything that are on the kitchen floor or the bathroom floor. And so making sure there’s non-slip flooring is really important.
I did have one question, actually, that came through this morning, about asking like: Where do you start with parents and what advice do you give parents who have children with low vision? And a lot of parents do say… Well, I don’t even know where to start. How do I even do this? And I think my main advice is not to be too quick to help the child when they’re having difficulty.
And to let them sort of explore their visual environment. And to do things independently. To allow them to be a little bit braver and do things independently. Even though it may seem from your point of view a little bit scary to let them go ahead and give that task a shot themselves. Also, I’d like to remind my parents — the parents — just because the child experiences the world differently doesn’t mean that there’s limitations to what they can do.
It just means that they experience the activity slightly differently to what the parent would experience the activity. To start off with, I like to talk to them about helping their child explore their visual environment, and the very last slides of our presentation today will quickly go over that. But also, being consistent in the order of motions, in the surfaces that you use, for example, dressing a child on the same surface.
So the child feels safe and they know what’s coming next. They know what to expect. So let’s start with improving contrast. You want to advise your patients to use contrasting colors in pretty much all activities. It makes life a lot easier. Even activities as simple as eating. As you can see here. We want patients to avoid using patterned backgrounds such as a flowery or checkered tablecloth.
And we want them to serve food on plates that are contrasting, compared to the food. So the patient can find the food on their plate. Again, this is advice that you’re gonna be giving both the caregiver, their family and friends, in addition to the patient. So can you imagine you’re someone with low vision, and you’re confronted with this. Eating off that white plate is gonna be almost impossible, because you can’t see the rice on it. So finding that rice is gonna be incredibly impossible. Whereas eating from the red plate or the green plate is gonna be a little bit easier. How to think about your own homes. We love to color coordinate at home with our floors and benches and tables and walls. And we particularly like functional things to blend in.
Or to match. And this is really unhelpful for a person with low vision. So if you do need to install a safety rail, making sure that safety rail is a different color to the wall that it’s attached to. If patients are being served meals, try not to match the tablecloth or the placemats with the color of the crockery. Your toothbrush. Can they find their toothbrush really easily, against the background of the white bathroom?
Or is the bathroom and what it’s sitting in also white? So you want your patients and your caregivers to start thinking about these things and how they can make these changes. Advise patients to outline changes in their environment, such as stairs, such as going into different rooms. You can — by using tape, you can highlight — okay. Now I’m stepping into the bathroom. I’m now stepping into the kitchen.
You can see going up those stairs is a lot safer with those little orange marks. Sloping walls such as the one that I have here behind me — putting a mark on the wall with tape really helps the patient from hitting their head. Because it doesn’t blend in with the background. But it really stands out a lot easier. This is for safety, and also direction.
If you do have a kid with low vision, enhancing your toys with colored tape or markers, to provide more contrast, and these things — I just traced around the puzzles there. So doing something like that is easy with a Sharpie or a marker. This doesn’t just apply to kids’ toys. Ask your patient what their favorite games are to play at home with family and friends. Do they like playing solitaire or cards with their family?
Do they play games where they’ve got dice? You can get a lot of games that are high contrast. For vision impaired adults. Also, you can see you can trace around a puzzle in a similar sort of way that you would for a child. Obviously using color to highlight ceilings and stairs for safety is really important. But also thinking about advising your patients to get the doorways painted a different color to the walls, so they can identify the doorways as they’re approaching them.
So they can find the light switches. Getting tape around that edge of the light fixture, so they know where to go, to turn the light on and off. Also making sure that things that blend in, like a squatting toilet is a really fantastic example of you accidentally popping your foot into the toilet, rather than to the side where you need to rest your foot. So you want to make sure that they have clear edges.
And so they know where to pop their foot. Also talking about color. Separating things that look very similar, like keys. Using color — you can see we’ve got a pill bottle here. Also some different colored caps. Perhaps some things that they’re using. They’re using color in a way to identify things that look quite similar. Okay. So that’s color and contrast. There are some examples. Again, I like to write these kinds of things down on a handout,
so the patient can go home and have a think with their loved ones about what changes they can make and what changes they want to make. Let’s have a bit of a chat about lighting. You want to advise your patients to have curtains or blinds on their windows, if they’re suffering from a lot of glare, so they can control the level of light in the house during the daytime.
You want to perhaps have non-reflective surfaces, such as your benches or your work surfaces. Or you want to cover them with a non-reflective material, so you can eliminate the glare coming from overhead lighting. Coming back up at the patient. If you have a patient who’s a student, you want to ask about: Well, where are you studying? Where are you working?
If they’re facing a window, you want to advise them to move that desk so their back is to the window, to avoid the amount of glare that they’re getting from that light. You will also probably be advising your patients to use individual lighting to focus on a specific task. Also, when you’re prescribing magnifiers, have a think if a magnifier with an inbuilt light will help or will hinder the patient in their task.
Often, we want to prescribe the magnifier with the inbuilt light, because we know that will help quite a lot. But show them with and without. And you might actually find that they get a lot more vision out of the magnifier without that light. So you just want to see what best suits the patient. Encourage your patients and their family to be really, really organized, both in their homes and in their workspaces and their learning environments.
You want to return things to the same place, once you’ve used them. You want to make sure that you’re eliminating clutter and unnecessary items. You want to reduce the amount of visual clutter, so you can see here on this open shelf — that’s a lot of information for someone with low vision to take in. And perhaps not something that they need to see. So, by covering their shelf unit with a solid cloth, it really reduces the amount of visual clutter for the patient. Family members will want to help the school team organize the classroom. And one way of doing this — also at home — is by dividing it according to subject areas. Such as music, table work, coloring, snack areas. You want to use rugs and furniture that are brightly colored, and usually very solid colors, rather than being a bit of everything.
To help divide these areas up so the patient can identify where they need to go next. You want to make sure that they can arrange the furniture in a way that it’s easy and safe for the patient to move around the classroom. Also you want to make sure that they’re not regularly moving furniture, particularly without the patient knowing, because they’re likely to have a visual map of what the classroom looks like, and you don’t want them running into things that they’re not expecting. And you want to have designated places for toys and for objects and for things that they’re about to use, so they know exactly where to go to get them. Separating activities into groups is a really fantastic way to make a patient feel a lot safer and a lot more confident in their environment. This even applies to eating, where a patient can easily identify which food they want to eat next.
By having it separated. Always in the same way. You’re gonna want to pass on a lot of this advice to teachers. Particularly teachers who are teaching kids in a mainstream school environment. Kids spend a lot of time in this environment, and it’s really important for them to thrive at school, just because they’ve got low vision doesn’t mean they can’t thrive academically. And you want them to feel comfortable during these learning tasks and to get the most out of them.
So you might want to arrange a sit-down with the teach and the parents as well, or you can write a letter or you can send that same sort of list but maybe tailor it to classroom learning, that the patients’ parents can give to the teaches. Sounds are a really great way of helping a patient navigate their environment. We can use sound to indicate where things are in the environment.
Or if we want to read things, some examples of this is when the cup is full. So you can see over to the left of the screen there, there is a small device that’s placed on the cup, and as the water comes up the side, when it hits the device, then it makes a beeping sound. When it hits the sensor. And so the patient knows to turn the tap off or to stop pouring into the cup. Otherwise it’s gonna overflow.
We have talking clocks. You can press the clock and it says it is currently 4:17. We have talking tape measures that will tell you what the exact measurement is, so you don’t have to read it. We also have these talking readers, where you can scan something that it identifies. For example, this is scanning the yellow marker. And it will say that it’s the yellow marker. Or it might say if you programmed it… Some of them, you can program them, and it can say… It is whatever medication. And it will help patients identify things within their homes that they’ve labeled. Balls. I think they’re very cool. You can buy tennis balls, cricket balls, basketballs, with ball bearings or something inside them, that when they’re moving, they’re making noise. And this helps the patient catch a ball, because they can hear where the ball is within the environment and they can hear it coming towards them.
Advise your patients to make every day items in large print. That’s homework, recipes, calendars, measuring cups. You want to be able to magnify specifically the writing on the medication bottles. You’ve got timers, kitchen timers, here. You’ve got large print games, such as Sudoku, word puzzles, you’ve got super large Boggle here. Super large high contrast cards. These are bingo cards at the top.
You’ve got large mah jongg tiles. So if your patient — ask your patient what games or what things, activities, they like to play with their family. If they say — look, I used to really enjoy mah jongg, then say you can actually get large mah jongg tiles for you to continue playing that. Or you can continue playing Scrabble or Monopoly with your family. Also keyboards and phones.
All of these can be sourced pretty easily in large print and high contrast. So you’ve got some things that just go over the top of your laptop keyboard. And you’ve got other things that you specifically buy the phone or the keyboard to attach to your main computer. That has larger print on the keyboards.
Labeling. Ask your patient’s caregiver to label all the useful items. This can be done in high contrast, large print labeling. It can also be done in Braille, if your patient is going to learn Braille. This is particularly useful if they’re young. You can see on the top left hand corner that’s a labelmaker for Braille, which is very cool. You can see it’s labeling here… Possibly something that looks like the dishwasher, the on and off button.
Also, these things don’t have to be particularly expensive. Even just by tying a rubber band or a ribbon around something can help your patients easily identify that it’s theirs. Advise caregivers to label clothing and clothing drawers. So the patient can independently dress themselves. And they’re gonna match. Texture. You may not actually be aware of this. And I wasn’t, until I became an optometrist.
But often the sidewalks — there’s a lot of textured markings on the sidewalks, to help those with low vision navigate their way around the sidewalks. And they know when to stop and they know which way is straight and which way is forward. So advise your patients and their loved ones to walk the patient’s route to school, to the shops, to work, and see what cues are available. What tactile symbols and signs are available on their way to that place.
And that’ll help the patient gain a little bit more confidence on the way. Even if they are using a guide to get there. They’ll still feel a lot more comfortable if they know whereabouts they are on that route. By feeling that cue. Back to games and things like that. Texture plays a big role in making games accessible to patients. You can get Uno with Braille. Dice that are textured.
You can get Monopoly, Scrabble pieces, or I think this is Bananagrams pieces, where patients can feel the tiles. Patients can buy watches that have tactile clock faces. Some are quite fancy and some are pretty standard. Depends on what suits the patient best. They can also buy so many things that are adapted for low vision. You can see here this is a map of the United States that perhaps the student is using to learn about the United States.
And it’s raised so they can feel around the areas and where their capital cities are. You have a tape measure here that has little eyelets at the half-inch point. And you have someone who’s measuring here, but they can feel the points at which the centimeters come along. We had a question this morning about writing. And this is… I would say by far the most requested activity after reading.
You want to get your patients to use large clear, clearly lined paper. They can even buy paper like this. Obviously they can make it themselves, if their family and friends are willing. Also, when they’re writing, you want to advise them to use a high contrast pen as well. Because you want them to be able to see clearly what they’re writing.
You can also have writing guides down the bottom here. They can help a patient write a letter. Something that we don’t often think about, but filling out the envelope of the letter. Also filling out and signing a check. If they want to pay by check. So these come in all different shapes and sizes, and they can help patients navigate the things that they’d like to write.
Technology. Using technology as a visual aid has been covered in previous lectures on Cybersight. I think by Nicole or Alexei. But I just want you to be aware of how we can adapt the technology and the visual aids to assist your patient in just everyday activities. Not just reading and writing, which seems to be sort of the main focus. So you can see this lady here is using one of her aids to put her makeup on.
You can see this other lady is using one of her aids to look at a photo of her grandchildren, presumably. So encourage them to explore what they can do with these. There are so many helpful gadgets. You’ve got here an automatic needle threader, which I think is really cool. Also, you have a very cool light box, where you can organize everything that you need in one place, and you can use it either as a light or a light box, depending on the activity that the patient needs to do. Constantly spilling food and water is a very common thing that we hear. It can be extremely embarrassing for patients, getting food and water all over themselves and also all over the table. On the right, we have a spill carrier, for patients to carry water from one room to the other without spilling. And we have a place mate spill guide, that provides a guide for where the edge of the plate is, but also prevents the spilling of food. I just popped down the bottom there where you can buy them. On Amazon and stuff like that. But there’s lots of little things like this. So to end today, we’re gonna quickly talk about orientation and mobility. And we’ve got probably about sort of… 10 to 15 minutes. So orientation refers to how you and other people or other objects are positioned within the space. And mobility refers to the confidence and the capacity of moving around within that space.
Many patients walk with a cane. Many patients also reject walking with a cane. This is obviously not something that you will teach yourselves. You’ll send people off to have training with someone — whoever practices low vision orientation and mobility in your community. If you don’t have someone like that in your community, then you could easily get training in this area, so you could teach patients this yourself.
Even if you’re not teaching them yourself, you are a vital aspect of them picking this skill up. Obviously, you’re going to probably be the person who refers them. But also, your encouragement is quite vital for them to seek out this skill and this service and this advice. Of also, encouraging them that there’s nothing wrong with using a cane.
01:48:36 I’ve heard so many patients that are really hesitant, because they say… Oh, no, I couldn’t possibly learn that skill. It looks far too hard. Or I don’t want to be identified by other people as being visually impaired, when I’m out. And it really comes down to you convincing them that no, this is actually okay for you to walk around with a cane. It’s quite easy for you to learn. It will take time, but it’s something that I’m confident that you will pick up.
And it’s okay for you to be identified as low vision. It’s safe. People will know — to take care when they’re around you. And so really a lot of encouragement from yourself is vital to them taking this skill on board. It really does provide a lot of confidence and independence. This is something that we’re gonna cover, that you can teach quickly. In your exam room.
You want to make sure — probably most likely the main caregiver will be there, but this is something you want to teach the main caregiver. Often patients will come in with their careers, and you notice they have some type of method similar to this that they’ve sort of informally devised between themselves. As the patient is being helped into the exam room. Take note of this.
How do they do this? And is it efficient? It’s always worth — even if it seems that they have something in place — it’s always worth teaching family members how to guide properly. There’s a few things. It actually gives the person a lot more control, rather than them being dragged along. They have the ability to stop and let go if they’re feeling uncomfortable. When they’re being guided properly.
It also gives them a lot more confidence, because they have a lot more spatial information that they’re getting, rather than just being dragged along. Because they can feel your movements as the guider. Also, they’re free to walk along more naturally. So it seems a little bit more socially appropriate. And it is a lot more respectful. First of all, you’re gonna tell the career that you want them to hold the back of their hand out, and to touch the back of their hand to the back of the patient’s hand. So then the patient can easily find the guide’s elbow. In some cases, they’re gonna hold them to perhaps a finger, if they’re a lot shorter, such as a child. You want to tell the guide that they’ll be about a step or a step and a half ahead of the person. And that the person is holding onto the elbow, making sure that the guide keeps their elbow at 90 degrees, so it’s nice and stable.
And that it’s close to their body, so the person who’s being guided can get some information about where they are, spatially. You want to make sure that they’re maintaining communication constantly. And that they’re using specific language. Like: There’s a small curb in front of you now. It’s time to step up. Or: The door on the left to you is closed. Rather than… Watch out! Or be careful! That’s not really helpful. It’s very stressful in this situation.
So you want to make sure that they use language like “to the right of you”, or “right in front of you”. There’s a curb. There’s a step. It’s small. It’s large. That they’re being quite specific, so the person being guided is empowered. When you’re moving through a doorway, you want to pop your guided arm behind your back, in the small of your back there. And what that allows is the patient — indicates to the patient that you want them to walk directly behind you.
So in a single file. So they’ll do that still holding onto your elbow. When you’re walking through a door, if it’s possible, you want them to be on the hinge side of the door, so you might ask them — give them a moment to swap to your other elbow. So they’re on the other side. And then of course, once you’re through the door, then you’re going to… They’re gonna go back to their original position. If they’re on the hinge side of the door, what they’ll most likely do is they’ll be holding onto your elbow, following single file, and then they’ll reach out to the door and touch the door, and be able to close the door behind them, so you’re not backtracking to close the door. When you’re guiding someone upstairs, you want to make sure that you stop at the first step. That you stand alongside them, as the guide.
And you let the patient know what’s about to happen. For example, the handrail is located to your right. There are seven steps. Either steps going up or down. They want to know if they’re stepping up or down. And you want to know when you’re about to start. And when they get to the last step as well. If you’re guiding someone to a chair, you want to make sure you place their hand on the back of the chair or the handrail of the chair, just so they know, and advise them that I’m about to pop your hand on the chair rest. On your right hand, onto the right chair rest. Also, when you’re walking through a doorway — I think, sorry, I forgot to say — you want to tell them which direction the door is gonna open as well. When you’re teaching these skills, do think about what’s culturally and socially normal. Or what’s culturally inappropriate, such as men and women walking together, or something like that. You want to be a little bit more mindful of those things. Lastly, in the last five minutes, we’re just gonna talk about helping a patient navigate their environment. Obviously they’ll need to scan this environment. This is a very small aspect of vision. I’m gonna throw out a rhetorical question.
Does anyone have any idea what this is? It’s a very small amount of information. So they’re gonna want to scan this environment. But in regular environments, we also want people to get to know the environment. And their caregivers are going to be responsible for helping them explore this environment. And they’re gonna be responsible for helping them visually navigate the environment.
So how about now? It doesn’t really help at all with the blur that’s surrounding it. And scanning this visual field even slowly would be very confronting. So it’s a playground. Now imagine there’s children running around. And lots of noise. You can see that this would be incredibly scary from a patient’s point of view. So you’re gonna teach them just to stop and to break down the information.
So zoom in. Zip it all together. And zoom out. Oh, sorry. So you want to teach the person to use one single section to start off with. So this is the slide. This is how you get on. This is how you go down. This is where it ends. And you keep repeating and teach them about this section until they’re really comfortable. And then you learn about the section next to it. This is the green ladder that goes from the floor.
These are the gray steps that go up and down. When you’re brave enough, the yellow pole to slide down. And with them, really explore that area. Then the patient is able to I guess essentially zip these things together and zoom out. So they’re going to create a visual map, and have a complete understanding of the playground, by having very clear knowledge of each individual section.
They have a little bit better map of the whole playground. So when they’re approaching the playground and there are lots of children running around them, they’re feeling a little bit more confident about what they’re walking towards, when they’re scanning, they know what they’re scanning for. So that’s all for me today. Thanks so much for joining me. I would just like to finish off by saying that really no activity is prohibited.
If you are fit enough to complete the activity, then your vision shouldn’t stand in the way of you doing that. A really great question is: How can I continue my sport? So it’s good to ask patients: What were you doing before, for exercise? And they might say… I used to love skiing. You can see they’re still fit enough to really enjoy that. And so you can connect them with a club that has a guide, and knows how to help visually impaired or partially sighted people ski.
You can see this is a person who is rowing. They’re rowing with someone who is a guide, and making sure that they’re going in the correct way. You’ve got a partially sighted rugby team here. And a lot of people still run and they still run marathons, and they do this with their guides. So really the biggest obstacle standing in the way of your patient’s independence and getting back to the regular activities prior to their visual impairment is their confidence.
And building their confidence and giving them some ideas and referring them off to people who can help… But also you being one of the people that helps them, it really does start with you. It starts with you, because you are their primary eyecare practitioner. So I hope you enjoyed today’s lecture. I think we’re gonna… I think we do have time for some questions. I’m going to stop sharing here.
Okay. Let’s see what we have here. So I’m not gonna talk about low vision devices. And the advancement in low vision devices. But that is a good question. We had a lot of questions like that come in this morning. I’m gonna have a chat to our team at Cybersight and see if we can address something like that in another webinar. But please do sign up, and ask questions like this on our community page.
So we can answer them for you. I love this, actually. Someone said: Are there any examples of Alexa or Google or Siri helping low vision patients? Absolutely! Yeah, that’s a fantastic idea. That’s a really good thing to advise patients to get. Someone’s asking about central vision loss here. And what is one of the issues in terms of daily living. Have a little bit of a think about this person with central vision.
Even just thinking about filling up a cup. They’re gonna be watching this cup directly. And so you’re gonna want to teach them eccentric fixation and things like that. But also, helping them incorporate devices. Be mindful that obviously your peripheral vision isn’t as clear as your central vision. And so you want to make sure that, for example, you’re putting tape on the edges of walls here and things like that, so people aren’t knocking their head.
They do have that peripheral vision that’s intact, but it’s maybe not as clear, so they won’t identify subtle changes in contrast. So you want to make sure that they’re taking advantage of all the things that we discussed today, these really, really simple things to make navigating their environment a lot easier.
Those are all the ones that I’m gonna answer today. There are a few questions in there that we’ll answer privately, that are a little bit more specific to new devices and magnifiers. Like I said, please, please, please get online. Join our community. Join the discussion. Particularly if you have difficult patient cases. Often you and I might work through a case and then I’ll say: Look, I think this is a really interesting case,
something that a lot of people have probably experienced with their patients. Could we make it public? And if you agree, and the patient agrees, then we’ll make the case public, so other people can learn from it. Making sure when you’re posting things up, that you do deidentify patient information so you’re not breaking any HIPAA rules or anything like that. So if that is all of our questions for today,
that’s me all done for today. I’m gonna pass you back over to our Cybersight guru.
Too often I see a patient who is all set up with a visual aid that they could need. They’ve got their best visual acuity and the best visual field they can get. But they’re still walking out of the clinic no better off functionally and no more confidently than when they arrived. As clinicians, we get super excited and carried away with the diagnosis of disease and the mapping of visual space and the prescribing of telescopes, magnifiers, and prisms.
But we really fail to guide our patients, sometimes, on how to adapt their environment to suit their vision. We may have improved visual acuity, and we may have improved the extent of the visual field, but we really failed to provide the patient with functional vision, which I think a lot of the time the patient is disappointed — but is a little bit concerned, a bit worried to face. So that’s what we’re gonna look at today.
Before I start today’s lecture, I received a lot of really interesting questions, fantastic ones, actually. Today’s lecture won’t address some of those questions. However, we will be working to answer them either privately — so either myself or some of my colleagues will answer them privately. Or we’ll also work with the Cybersight team to perhaps present some lectures that more specifically address some of these questions, such as prescribing prisms. I also had a few questions about setting up your own low vision clinic, which I think is a fantastic webinar to present. So I’ll have a chat to some colleagues and a chat to the team, and see if we can set up something like that in webinars to come. I also received a lot of questions that were specific for patient cases that you’re seeing. And I want to encourage those who have questions like that,
either ones that you sent or you have questions that you’re thinking — I would really like to ask someone for some more advice on this — anyone who had specific patient cases, I’d really like you to join our online learning community. So I know you all signed up to the live webinar, most likely going through this website. This is www.cybersight.org. You’ll see on the top corner here it says: Join us. And if you click that, this screen here will come up. You can pop in your name, your details, and make sure you click online courses and expert advice. Once we set you up, you’ll log in through here, like this, and your screen will look something like this. This is me logging in this morning. You can click start a new case. You can see that there are several cases that were started only a few minutes ago, or a few hours ago. People responding to private cases, to general questions. You can click start a new case here. Or down at the bottom. And you’ll see you can click select a subspecialty, so low vision, optometry, pediatrics, you can put in your patient information, age, their visual acuity. Really, when you’re creating new patient cases, the more information you can give the clinician that you want to speak to, the better.
So jam pack this with information. And either if it’s a general patient case, open to the public — someone might generally answer it. Or if you specifically ask for someone, then they will answer you back. They might ask for more information, before they answer the case. And then you can have a little bit of a dialogue about that particular patient. You can also create a general question.
So if you have just something like… Does anyone know how to prescribe prisms in a particular disease, you can send that question out, that general question out, and either again a specific mentor, if you assign them, can answer it, or someone from the community might answer it. So yeah. I just really want you to get involved, as much as you possibly can. We love to hear about patient cases that you’re seeing, and the more cases that you send through, really, the better. So I’m gonna start by asking you to avoid the phrase “there’s nothing more I can do”, because there’s actually a lot more we can do, by providing our patients advice on how to use their vision and how to empower them, and empower them in using their vision in their own environment. There’s really… The amount of advice that we can give to them is endless.
01:06:02 These are just a few resources that I think are really helpful in thinking about how patients can navigate their environment, if they have low vision. Additionally, I’d like to just take a moment to especially thank doctors Alexis Malkin and Nicole Ross and Mr. Darick Wright from the New England College of Optometry. The low vision team at the New England College of Optometry is truly remarkable. Okay.
So objectives for the next hour or so, or a little bit less than an hour: First, we want to utilize our patient history to make appropriate recommendations. So listening to the patient, so we’re giving the advice that is specific to their visual needs. Discuss the activities in daily living that become difficult with low vision. Often we take for granted things like drinking out of a cup or filling up the kettle.
Those things seem pretty easy and pretty standard. But we don’t think about actually how difficult they are for someone with low vision. I’d like to equip you with some ideas and helpful hints to help people navigate their visual environment better. This is a huge undertaking, I guess, if you’re gonna sit down and take a patient through all the things that they can do within their home.
Often I’ll give a handout that has all of the things that we’re gonna discuss today written down. And with advice on there. So you can have a small discussion about each thing, and then when they get home with their loved ones and their family and friends and their main careers, they can discuss how they’re gonna adapt their own home. And I just also want to quickly teach you the technique of guiding a low vision person, and also how to teach their caregivers this skill. And also how to help them explore their environment. So first let’s look at utilizing the case history so we can make appropriate recommendations. When we’re treating patients with a reduction in vision, it’s particularly important to ask extra questions on top of our usual case history. And these questions are about how they’re coping with their visual impairment and what daily activities they’d like to do better.
And also how they’re coping with their visual aids. Just because you’ve given them a telescope doesn’t mean that they’re taking it out with them. It doesn’t mean that they’re using it properly. And it doesn’t mean they’re using it to its full potential. Please note in this slide when I’m talking about people with low vision, I’m emphasizing them.
Often people come in, and we’re all guns blazing, we think we know what you want, we think we know what you’re experiencing, and it’s actually really important to listen to what the patient wants and what the patient needs. The number of times I hear from patients “I feel like this is the first time I’ve been listened to” is outstanding. So make sure you’re listening to what they’re asking you.
So during our low vision exam, we’re gonna obtain information about all of these areas. Reading speed, visual acuity, distance and at near. The extent of their visual field, their confidence in using their vision, if they have any contrast restrictions, how well they can move about their environment. With a lot of these things, you can also just observe yourself how confident are they in using their vision, and moving from the waiting room into your exam room, and sitting down in the chair, and how are they managing that, who are they with, and how is that person helping them? If you want more information on how to conduct a low vision examination, there are on the Cybersight website — it’s www.cybersight.org — there are on the Cybersight website a few webinars from a few years back that focus on the low vision exam, and also focuses on low vision devices that you can use, that’s both technology, like our phones and computers, but also looking at magnifiers and telescopes. So now we have all of this information from our exam. We want to know how this applies to the patient’s real life. So first try integrating some of the following questions into your case history. Get to know the patient. What can’t you do anymore, because of your vision?
What are you wanting help with? How has your life changed since you lost your vision? They might say: Well, I was a marathon runner. I did the Boston marathon, the New York marathon, and now I haven’t been running since I lost my vision. Are they living alone? Are they living with family? If they are living at home, have they made changes to their home environment? Or is everything still exactly the same?
So have they made changes to help them get about a little bit easier? Or have they really not altered much at all? When it comes to reading, we want to think about their goals and their needs, but now that they have their visual aids, you’ve already prescribed them, ask how they’re reading at the moment. What are they reading? How difficult is it?
If they could expand their reading, if they could do anything, what would they want to do? Do they want to read books? Letters? Bills? They say… Look, I’m okay with reading, but I’m having trouble really looking at photos of my grandkids. Do they want to go shopping independently? Perhaps at home they’re reading okay, but they would really like to go shopping independently to read the price tag or the packet when they’re at the supermarket.
Also, ask if they have tablets or computers, and if so, if they’re using them with their vision. We’re not gonna really cover this on how they can, although we will very briefly. But how they can use these devices. But if they’re not using them, why. Perhaps they just don’t want them. But perhaps they have one stuck in a drawer or their grandkids have replaced their old one and they’re happy to give Grandma or Grandpa their old tablet.
Teach them how to use that or get their kids to teach them how to use that. You also want to know if they’re experiencing a lot of glare. In our exam, we look at contrast, which is very important, but we want to ask a case history, if they’re experiencing glare. And particularly important if we’re thinking about going from outside to inside or inside to outside. You can imagine if you were going shopping and every time you went from inside the supermarket to outside, you had to stop for a moment. There’s a lot of noise, a lot of people walking around. A lot happening, and all of a sudden you feel blinded by the situation, and you have to just sort of wait until your vision adapts. You can understand that would be incredibly confronting. Ask about TV. TV is often something that people really enjoy. But they’re not really using their TV anymore.
If they do enjoy TV, are they listening to it? Are they watching it? Things as simple as: Is the TV set up so they can use the screen? Is it set up in the right position of the room, compared to their chair? Is the screen too bright for them to really view properly? Or is it perhaps even positioned towards a window, and so they’re getting a lot of glare from the outside light.
And so they can’t really see what’s happening on the TV. You also want to know: Can the patient identify familiar faces? Particularly in crowds. You can imagine that when they’re at home, they can identify somebody who’s just walked into the room that’s familiar, but when they’re outside, and they’re walking with that person, and suddenly they let go, then can they identify that person again?
Because you can imagine that would be incredibly confronting. You also want to ask about how they’re getting around. Are they dependent on someone else in order to get from one place to another? Do they venture outside the house very often? And if they do, do they do it by themselves? Or do they do it with assistance? Can they use a cane? Do they have a guide dog?
Do they use a guide, a family member, or a loved one, to help them guide them as they’re walking outside? And if they’re not using these things, why not? Why are they feeling that they can’t use these things, they don’t want to use these things? And would they like to travel more independently outside, if they could? A lot of people are quite happy not to. But a lot of people would say… Oh, you know what? I wouldn’t mind just going down to the corner store by myself.
I think that would be okay, except how I’m set up right now, I can’t manage it. We also want to ask about the tasks that they’re having trouble with every day. And it’s always good to be specific, to give them ideas about what might be difficult. Often patients have just accepted “I just can’t do that anymore.” So you say: Are you having any troubles with the things you do on a daily basis? They go oh, no.
You might say… Do you cook anymore? And they might say… Oh, no, I absolutely don’t cook. Can you fill a cup by yourself? Oh, absolutely not. So they are having difficulties doing those daily tasks. So give them some ideas and ask them specific questions. So you can get a better idea of what they are doing independently, and what they require someone else to help them out with.
Think about all the things that we do on a daily basis, even. We really do take those things for granted. Like drinking. Eating from a plate. Rather than a bowl. Filling a cup up. With water from the kettle or from the tap, without spilling it everywhere, without overflowing. Putting on makeup or shaving in the morning. Cooking is an obvious one that a lot of patients do give up.
Taking the correct medications. If you take multiple medications, each morning, we really do take for granted that I can read the back of the bottle and I know which one to take and which one not to. Getting dressed in the morning, and also choosing your own clothes to get dressed. We really do sort of take that for granted.
When you’re washing, and bathing, picking up the shampoo rather than the soap or the conditioner, to wash your hair. Cleaning the house. Being able to see the dust and the dirt, vacuuming, being able to vacuum. If you wanted to. I hate vacuuming, so I’m not sure why anyone would want to vacuum, but… Doing the vacuuming. Also putting on the dishwasher or washing the dishes, when everyone is in the kitchen helping out.
Can you wash the dishes anymore? Can you help dry? Can you put things away? These are all really — they’re activities that really with just a small amount of advice, and maybe a small number of adaptations in the house, that patients can really do these things independently, in a lot of cases. Listen to what your patient is saying. So we’re already saying… Listen to what their needs and what their wants are, rather than imposing our own onto them. But also, listen about what they’re saying. Do these complaints correspond with their visual field restrictions? Because they usually — or they should — they should do. So if someone says: I can take stairs going up, but not stairs going down, this suggests a variety of visual field defects. So we can anticipate things they might be having trouble with with an inferior visual field defect.
I bump into doors on my right. Does this correspond to a right visual field defect that they’re having? So think about what they’re saying and how that relates. During this consultation, you will hear a lot of unrealistic requests, like I want to restore my vision to what it was before the accident, before the macular degeneration. What surgery can bring my vision back. It’s only natural that patients will want to ask these questions.
It’s important to be honest. But it’s also important to be kind in your response. And understand that this is really what the patient would like to do, is to go back to what it was like beforehand. But it’s really your job to help them realize that even though their vision won’t be restored fully to what it was, that you can help them get back to the things that they were doing before they lost their vision.
We may not be able to achieve all their goals. There are just some goals that just aren’t possible with the vision that they have. And so let your patient know you will try to help them achieve their goals and to make them as independent as possible. But try and work with sort of one goal at a time. Be clear that things may not be performed the way they were prior to losing their vision.
I’m gonna introduce a lot of ways here to get around, for example, filling up a cup without it overflowing. There are gonna be some things that are involved or some tricks that are involved to help them do that activity, and so the activity itself won’t be performed exactly the same. So there will be a lot of adaptation. It’s also really important to manage their expectations of their main caregiver and their family and friends.
But particularly the main caregiver. Be really respectful when approaching this kind of discussion. Often people have been caring for their loved one with low vision for a really long time. So be mindful that this is most likely the caregiver’s full-time job. And often they’re gonna feel redundant and possibly resistant to change. Even though from your point of view, you’re thinking… But this would be great.
It would make them more independent and thus you more independent. But if you’re involving the main caregiver in the changes that are being made, you might get a little bit of resistance from them. So just be really respectful and mindful that this is affecting their lives too and these changes will be affecting their lives too. And you’ll be relying on the main caregiver to give a lot of — to implement a lot of this advice.
Lastly, it’s always really good to ask your patient and their family if they have any thoughts on what might make their vision worse. Because often you can debunk any untrue old wives’ tales or concerns, such as… I don’t like to go outside, because I know the sun will make my vision worse. Which obviously is not the case. So you can talk them through, about how culturally that’s just an old wives’ tale and it’s not true, or why it’s not true, or why it feels that way, but it’s not true. Often something I hear is: If I wear my glasses too often, my vision will get worse. So you want them to really open up and tell you about the concerns that they’re having. Try not to laugh at them or make fun of them. Be really, really caring and kind. They’re in a really vulnerable position, and they’re being really honest with you. So try not to say… No! You’re wrong! Or that’s not correct!
But just to talk them through and show that this is actually not the case. Also, just very quickly, whilst we’re getting to know our patients, I just want to touch on identifying psychological needs. It’s very important to be aware that both the caregiver and the patient are grieving their independence and the patient is grieving their vision. These are some signs to look for. Denial, guilt, anger, depression, sadness, acceptance, adjustment to vision. How they’re coping.
I’m gonna let you read over this slide yourselves. The slides will be posted up online. After our webinar today. But in many cases, I want you to be aware, because you are the primary practitioner. They’ve seen you, they’ve come to see you for their vision problem, and they may not see someone else for a little while, regarding their vision. You’re really in this perfect position to refer them, if you think they might need counseling. That’s both the caregiver and the patient.
But your role doesn’t just stop there, because your positivity and your encouragement is really vital in empowering the patient. And by providing them tools and tricks, like we’re gonna discuss in a moment, you really empower the patient. And this plays a huge aspect in promoting positive mental health. So I just want you to be aware of the role that you do play in addressing the psychological needs of your low vision patients.
Okay. So we’ve gotten to know our patient. Let’s see how we might help them achieve independence in their daily living. This is a summary of things that we’re gonna look at today in making an environment workable for your patient. So I’ll leave this with you, just to read over, when you have a look at the slides. They’re usually pretty simple, and they’re usually actually pretty inexpensive tricks and tools.
These adaptations not only allow the patient more independence, but it also helps the patient to be a lot safer. For example, the ability to dial a telephone for help. Also a lot of patients — they’re not leaving the home alone. But they do need to be able to evacuate the home in an emergency, without assistance. So by allowing them to have a little bit more independence, you’re also giving them a little bit…
You’re also giving them tools to be a little bit safer when things don’t go as planned. For example, the patient with the inferior field defect, they also need to be able to safely walk around their home without falling over low objects. And so you need to have a chat to them about — you want to make sure that those objects are removed. You want to make sure that people aren’t placing objects where they don’t belong.
Just to prevent them from falling. It’s important to keep them independent as it is to keep them safe. So a good way to start is advising a patient to fix up any hazards in their house, like loose carpeting. If there’s a rug, maybe tacking it down, so the person doesn’t get their foot caught under the lip of the rug and fall over. If there are broken handrails on staircases, make sure they’re fixed.
For example, the patient who has that inferior field defect may be installing a handrail on the staircase in the home, if there is one. So they can hold onto it, as they’re going down the stairs. Non-slip flooring, also really important. They’re not gonna see the spills or anything that are on the kitchen floor or the bathroom floor. And so making sure there’s non-slip flooring is really important.
I did have one question, actually, that came through this morning, about asking like: Where do you start with parents and what advice do you give parents who have children with low vision? And a lot of parents do say… Well, I don’t even know where to start. How do I even do this? And I think my main advice is not to be too quick to help the child when they’re having difficulty.
And to let them sort of explore their visual environment. And to do things independently. To allow them to be a little bit braver and do things independently. Even though it may seem from your point of view a little bit scary to let them go ahead and give that task a shot themselves. Also, I’d like to remind my parents — the parents — just because the child experiences the world differently doesn’t mean that there’s limitations to what they can do.
It just means that they experience the activity slightly differently to what the parent would experience the activity. To start off with, I like to talk to them about helping their child explore their visual environment, and the very last slides of our presentation today will quickly go over that. But also, being consistent in the order of motions, in the surfaces that you use, for example, dressing a child on the same surface.
So the child feels safe and they know what’s coming next. They know what to expect. So let’s start with improving contrast. You want to advise your patients to use contrasting colors in pretty much all activities. It makes life a lot easier. Even activities as simple as eating. As you can see here. We want patients to avoid using patterned backgrounds such as a flowery or checkered tablecloth.
And we want them to serve food on plates that are contrasting, compared to the food. So the patient can find the food on their plate. Again, this is advice that you’re gonna be giving both the caregiver, their family and friends, in addition to the patient. So can you imagine you’re someone with low vision, and you’re confronted with this. Eating off that white plate is gonna be almost impossible, because you can’t see the rice on it. So finding that rice is gonna be incredibly impossible. Whereas eating from the red plate or the green plate is gonna be a little bit easier. How to think about your own homes. We love to color coordinate at home with our floors and benches and tables and walls. And we particularly like functional things to blend in.
Or to match. And this is really unhelpful for a person with low vision. So if you do need to install a safety rail, making sure that safety rail is a different color to the wall that it’s attached to. If patients are being served meals, try not to match the tablecloth or the placemats with the color of the crockery. Your toothbrush. Can they find their toothbrush really easily, against the background of the white bathroom?
Or is the bathroom and what it’s sitting in also white? So you want your patients and your caregivers to start thinking about these things and how they can make these changes. Advise patients to outline changes in their environment, such as stairs, such as going into different rooms. You can — by using tape, you can highlight — okay. Now I’m stepping into the bathroom. I’m now stepping into the kitchen.
You can see going up those stairs is a lot safer with those little orange marks. Sloping walls such as the one that I have here behind me — putting a mark on the wall with tape really helps the patient from hitting their head. Because it doesn’t blend in with the background. But it really stands out a lot easier. This is for safety, and also direction.
If you do have a kid with low vision, enhancing your toys with colored tape or markers, to provide more contrast, and these things — I just traced around the puzzles there. So doing something like that is easy with a Sharpie or a marker. This doesn’t just apply to kids’ toys. Ask your patient what their favorite games are to play at home with family and friends. Do they like playing solitaire or cards with their family?
Do they play games where they’ve got dice? You can get a lot of games that are high contrast. For vision impaired adults. Also, you can see you can trace around a puzzle in a similar sort of way that you would for a child. Obviously using color to highlight ceilings and stairs for safety is really important. But also thinking about advising your patients to get the doorways painted a different color to the walls, so they can identify the doorways as they’re approaching them.
So they can find the light switches. Getting tape around that edge of the light fixture, so they know where to go, to turn the light on and off. Also making sure that things that blend in, like a squatting toilet is a really fantastic example of you accidentally popping your foot into the toilet, rather than to the side where you need to rest your foot. So you want to make sure that they have clear edges.
And so they know where to pop their foot. Also talking about color. Separating things that look very similar, like keys. Using color — you can see we’ve got a pill bottle here. Also some different colored caps. Perhaps some things that they’re using. They’re using color in a way to identify things that look quite similar. Okay. So that’s color and contrast. There are some examples. Again, I like to write these kinds of things down on a handout,
so the patient can go home and have a think with their loved ones about what changes they can make and what changes they want to make. Let’s have a bit of a chat about lighting. You want to advise your patients to have curtains or blinds on their windows, if they’re suffering from a lot of glare, so they can control the level of light in the house during the daytime.
You want to perhaps have non-reflective surfaces, such as your benches or your work surfaces. Or you want to cover them with a non-reflective material, so you can eliminate the glare coming from overhead lighting. Coming back up at the patient. If you have a patient who’s a student, you want to ask about: Well, where are you studying? Where are you working?
If they’re facing a window, you want to advise them to move that desk so their back is to the window, to avoid the amount of glare that they’re getting from that light. You will also probably be advising your patients to use individual lighting to focus on a specific task. Also, when you’re prescribing magnifiers, have a think if a magnifier with an inbuilt light will help or will hinder the patient in their task.
Often, we want to prescribe the magnifier with the inbuilt light, because we know that will help quite a lot. But show them with and without. And you might actually find that they get a lot more vision out of the magnifier without that light. So you just want to see what best suits the patient. Encourage your patients and their family to be really, really organized, both in their homes and in their workspaces and their learning environments.
You want to return things to the same place, once you’ve used them. You want to make sure that you’re eliminating clutter and unnecessary items. You want to reduce the amount of visual clutter, so you can see here on this open shelf — that’s a lot of information for someone with low vision to take in. And perhaps not something that they need to see. So, by covering their shelf unit with a solid cloth, it really reduces the amount of visual clutter for the patient. Family members will want to help the school team organize the classroom. And one way of doing this — also at home — is by dividing it according to subject areas. Such as music, table work, coloring, snack areas. You want to use rugs and furniture that are brightly colored, and usually very solid colors, rather than being a bit of everything.
To help divide these areas up so the patient can identify where they need to go next. You want to make sure that they can arrange the furniture in a way that it’s easy and safe for the patient to move around the classroom. Also you want to make sure that they’re not regularly moving furniture, particularly without the patient knowing, because they’re likely to have a visual map of what the classroom looks like, and you don’t want them running into things that they’re not expecting. And you want to have designated places for toys and for objects and for things that they’re about to use, so they know exactly where to go to get them. Separating activities into groups is a really fantastic way to make a patient feel a lot safer and a lot more confident in their environment. This even applies to eating, where a patient can easily identify which food they want to eat next.
By having it separated. Always in the same way. You’re gonna want to pass on a lot of this advice to teachers. Particularly teachers who are teaching kids in a mainstream school environment. Kids spend a lot of time in this environment, and it’s really important for them to thrive at school, just because they’ve got low vision doesn’t mean they can’t thrive academically. And you want them to feel comfortable during these learning tasks and to get the most out of them.
So you might want to arrange a sit-down with the teach and the parents as well, or you can write a letter or you can send that same sort of list but maybe tailor it to classroom learning, that the patients’ parents can give to the teaches. Sounds are a really great way of helping a patient navigate their environment. We can use sound to indicate where things are in the environment.
Or if we want to read things, some examples of this is when the cup is full. So you can see over to the left of the screen there, there is a small device that’s placed on the cup, and as the water comes up the side, when it hits the device, then it makes a beeping sound. When it hits the sensor. And so the patient knows to turn the tap off or to stop pouring into the cup. Otherwise it’s gonna overflow.
We have talking clocks. You can press the clock and it says it is currently 4:17. We have talking tape measures that will tell you what the exact measurement is, so you don’t have to read it. We also have these talking readers, where you can scan something that it identifies. For example, this is scanning the yellow marker. And it will say that it’s the yellow marker. Or it might say if you programmed it… Some of them, you can program them, and it can say… It is whatever medication. And it will help patients identify things within their homes that they’ve labeled. Balls. I think they’re very cool. You can buy tennis balls, cricket balls, basketballs, with ball bearings or something inside them, that when they’re moving, they’re making noise. And this helps the patient catch a ball, because they can hear where the ball is within the environment and they can hear it coming towards them.
Advise your patients to make every day items in large print. That’s homework, recipes, calendars, measuring cups. You want to be able to magnify specifically the writing on the medication bottles. You’ve got timers, kitchen timers, here. You’ve got large print games, such as Sudoku, word puzzles, you’ve got super large Boggle here. Super large high contrast cards. These are bingo cards at the top.
You’ve got large mah jongg tiles. So if your patient — ask your patient what games or what things, activities, they like to play with their family. If they say — look, I used to really enjoy mah jongg, then say you can actually get large mah jongg tiles for you to continue playing that. Or you can continue playing Scrabble or Monopoly with your family. Also keyboards and phones.
All of these can be sourced pretty easily in large print and high contrast. So you’ve got some things that just go over the top of your laptop keyboard. And you’ve got other things that you specifically buy the phone or the keyboard to attach to your main computer. That has larger print on the keyboards.
Labeling. Ask your patient’s caregiver to label all the useful items. This can be done in high contrast, large print labeling. It can also be done in Braille, if your patient is going to learn Braille. This is particularly useful if they’re young. You can see on the top left hand corner that’s a labelmaker for Braille, which is very cool. You can see it’s labeling here… Possibly something that looks like the dishwasher, the on and off button.
Also, these things don’t have to be particularly expensive. Even just by tying a rubber band or a ribbon around something can help your patients easily identify that it’s theirs. Advise caregivers to label clothing and clothing drawers. So the patient can independently dress themselves. And they’re gonna match. Texture. You may not actually be aware of this. And I wasn’t, until I became an optometrist.
But often the sidewalks — there’s a lot of textured markings on the sidewalks, to help those with low vision navigate their way around the sidewalks. And they know when to stop and they know which way is straight and which way is forward. So advise your patients and their loved ones to walk the patient’s route to school, to the shops, to work, and see what cues are available. What tactile symbols and signs are available on their way to that place.
And that’ll help the patient gain a little bit more confidence on the way. Even if they are using a guide to get there. They’ll still feel a lot more comfortable if they know whereabouts they are on that route. By feeling that cue. Back to games and things like that. Texture plays a big role in making games accessible to patients. You can get Uno with Braille. Dice that are textured.
You can get Monopoly, Scrabble pieces, or I think this is Bananagrams pieces, where patients can feel the tiles. Patients can buy watches that have tactile clock faces. Some are quite fancy and some are pretty standard. Depends on what suits the patient best. They can also buy so many things that are adapted for low vision. You can see here this is a map of the United States that perhaps the student is using to learn about the United States.
And it’s raised so they can feel around the areas and where their capital cities are. You have a tape measure here that has little eyelets at the half-inch point. And you have someone who’s measuring here, but they can feel the points at which the centimeters come along. We had a question this morning about writing. And this is… I would say by far the most requested activity after reading.
You want to get your patients to use large clear, clearly lined paper. They can even buy paper like this. Obviously they can make it themselves, if their family and friends are willing. Also, when they’re writing, you want to advise them to use a high contrast pen as well. Because you want them to be able to see clearly what they’re writing.
You can also have writing guides down the bottom here. They can help a patient write a letter. Something that we don’t often think about, but filling out the envelope of the letter. Also filling out and signing a check. If they want to pay by check. So these come in all different shapes and sizes, and they can help patients navigate the things that they’d like to write.
Technology. Using technology as a visual aid has been covered in previous lectures on Cybersight. I think by Nicole or Alexei. But I just want you to be aware of how we can adapt the technology and the visual aids to assist your patient in just everyday activities. Not just reading and writing, which seems to be sort of the main focus. So you can see this lady here is using one of her aids to put her makeup on.
You can see this other lady is using one of her aids to look at a photo of her grandchildren, presumably. So encourage them to explore what they can do with these. There are so many helpful gadgets. You’ve got here an automatic needle threader, which I think is really cool. Also, you have a very cool light box, where you can organize everything that you need in one place, and you can use it either as a light or a light box, depending on the activity that the patient needs to do. Constantly spilling food and water is a very common thing that we hear. It can be extremely embarrassing for patients, getting food and water all over themselves and also all over the table. On the right, we have a spill carrier, for patients to carry water from one room to the other without spilling. And we have a place mate spill guide, that provides a guide for where the edge of the plate is, but also prevents the spilling of food. I just popped down the bottom there where you can buy them. On Amazon and stuff like that. But there’s lots of little things like this. So to end today, we’re gonna quickly talk about orientation and mobility. And we’ve got probably about sort of… 10 to 15 minutes. So orientation refers to how you and other people or other objects are positioned within the space. And mobility refers to the confidence and the capacity of moving around within that space.
Many patients walk with a cane. Many patients also reject walking with a cane. This is obviously not something that you will teach yourselves. You’ll send people off to have training with someone — whoever practices low vision orientation and mobility in your community. If you don’t have someone like that in your community, then you could easily get training in this area, so you could teach patients this yourself.
Even if you’re not teaching them yourself, you are a vital aspect of them picking this skill up. Obviously, you’re going to probably be the person who refers them. But also, your encouragement is quite vital for them to seek out this skill and this service and this advice. Of also, encouraging them that there’s nothing wrong with using a cane.
01:48:36 I’ve heard so many patients that are really hesitant, because they say… Oh, no, I couldn’t possibly learn that skill. It looks far too hard. Or I don’t want to be identified by other people as being visually impaired, when I’m out. And it really comes down to you convincing them that no, this is actually okay for you to walk around with a cane. It’s quite easy for you to learn. It will take time, but it’s something that I’m confident that you will pick up.
And it’s okay for you to be identified as low vision. It’s safe. People will know — to take care when they’re around you. And so really a lot of encouragement from yourself is vital to them taking this skill on board. It really does provide a lot of confidence and independence. This is something that we’re gonna cover, that you can teach quickly. In your exam room.
You want to make sure — probably most likely the main caregiver will be there, but this is something you want to teach the main caregiver. Often patients will come in with their careers, and you notice they have some type of method similar to this that they’ve sort of informally devised between themselves. As the patient is being helped into the exam room. Take note of this.
How do they do this? And is it efficient? It’s always worth — even if it seems that they have something in place — it’s always worth teaching family members how to guide properly. There’s a few things. It actually gives the person a lot more control, rather than them being dragged along. They have the ability to stop and let go if they’re feeling uncomfortable. When they’re being guided properly.
It also gives them a lot more confidence, because they have a lot more spatial information that they’re getting, rather than just being dragged along. Because they can feel your movements as the guider. Also, they’re free to walk along more naturally. So it seems a little bit more socially appropriate. And it is a lot more respectful. First of all, you’re gonna tell the career that you want them to hold the back of their hand out, and to touch the back of their hand to the back of the patient’s hand. So then the patient can easily find the guide’s elbow. In some cases, they’re gonna hold them to perhaps a finger, if they’re a lot shorter, such as a child. You want to tell the guide that they’ll be about a step or a step and a half ahead of the person. And that the person is holding onto the elbow, making sure that the guide keeps their elbow at 90 degrees, so it’s nice and stable.
And that it’s close to their body, so the person who’s being guided can get some information about where they are, spatially. You want to make sure that they’re maintaining communication constantly. And that they’re using specific language. Like: There’s a small curb in front of you now. It’s time to step up. Or: The door on the left to you is closed. Rather than… Watch out! Or be careful! That’s not really helpful. It’s very stressful in this situation.
So you want to make sure that they use language like “to the right of you”, or “right in front of you”. There’s a curb. There’s a step. It’s small. It’s large. That they’re being quite specific, so the person being guided is empowered. When you’re moving through a doorway, you want to pop your guided arm behind your back, in the small of your back there. And what that allows is the patient — indicates to the patient that you want them to walk directly behind you.
So in a single file. So they’ll do that still holding onto your elbow. When you’re walking through a door, if it’s possible, you want them to be on the hinge side of the door, so you might ask them — give them a moment to swap to your other elbow. So they’re on the other side. And then of course, once you’re through the door, then you’re going to… They’re gonna go back to their original position. If they’re on the hinge side of the door, what they’ll most likely do is they’ll be holding onto your elbow, following single file, and then they’ll reach out to the door and touch the door, and be able to close the door behind them, so you’re not backtracking to close the door. When you’re guiding someone upstairs, you want to make sure that you stop at the first step. That you stand alongside them, as the guide.
And you let the patient know what’s about to happen. For example, the handrail is located to your right. There are seven steps. Either steps going up or down. They want to know if they’re stepping up or down. And you want to know when you’re about to start. And when they get to the last step as well. If you’re guiding someone to a chair, you want to make sure you place their hand on the back of the chair or the handrail of the chair, just so they know, and advise them that I’m about to pop your hand on the chair rest. On your right hand, onto the right chair rest. Also, when you’re walking through a doorway — I think, sorry, I forgot to say — you want to tell them which direction the door is gonna open as well. When you’re teaching these skills, do think about what’s culturally and socially normal. Or what’s culturally inappropriate, such as men and women walking together, or something like that. You want to be a little bit more mindful of those things. Lastly, in the last five minutes, we’re just gonna talk about helping a patient navigate their environment. Obviously they’ll need to scan this environment. This is a very small aspect of vision. I’m gonna throw out a rhetorical question.
Does anyone have any idea what this is? It’s a very small amount of information. So they’re gonna want to scan this environment. But in regular environments, we also want people to get to know the environment. And their caregivers are going to be responsible for helping them explore this environment. And they’re gonna be responsible for helping them visually navigate the environment.
So how about now? It doesn’t really help at all with the blur that’s surrounding it. And scanning this visual field even slowly would be very confronting. So it’s a playground. Now imagine there’s children running around. And lots of noise. You can see that this would be incredibly scary from a patient’s point of view. So you’re gonna teach them just to stop and to break down the information.
So zoom in. Zip it all together. And zoom out. Oh, sorry. So you want to teach the person to use one single section to start off with. So this is the slide. This is how you get on. This is how you go down. This is where it ends. And you keep repeating and teach them about this section until they’re really comfortable. And then you learn about the section next to it. This is the green ladder that goes from the floor.
These are the gray steps that go up and down. When you’re brave enough, the yellow pole to slide down. And with them, really explore that area. Then the patient is able to I guess essentially zip these things together and zoom out. So they’re going to create a visual map, and have a complete understanding of the playground, by having very clear knowledge of each individual section.
They have a little bit better map of the whole playground. So when they’re approaching the playground and there are lots of children running around them, they’re feeling a little bit more confident about what they’re walking towards, when they’re scanning, they know what they’re scanning for. So that’s all for me today. Thanks so much for joining me. I would just like to finish off by saying that really no activity is prohibited.
If you are fit enough to complete the activity, then your vision shouldn’t stand in the way of you doing that. A really great question is: How can I continue my sport? So it’s good to ask patients: What were you doing before, for exercise? And they might say… I used to love skiing. You can see they’re still fit enough to really enjoy that. And so you can connect them with a club that has a guide, and knows how to help visually impaired or partially sighted people ski.
You can see this is a person who is rowing. They’re rowing with someone who is a guide, and making sure that they’re going in the correct way. You’ve got a partially sighted rugby team here. And a lot of people still run and they still run marathons, and they do this with their guides. So really the biggest obstacle standing in the way of your patient’s independence and getting back to the regular activities prior to their visual impairment is their confidence.
And building their confidence and giving them some ideas and referring them off to people who can help… But also you being one of the people that helps them, it really does start with you. It starts with you, because you are their primary eyecare practitioner. So I hope you enjoyed today’s lecture. I think we’re gonna… I think we do have time for some questions. I’m going to stop sharing here.
Okay. Let’s see what we have here. So I’m not gonna talk about low vision devices. And the advancement in low vision devices. But that is a good question. We had a lot of questions like that come in this morning. I’m gonna have a chat to our team at Cybersight and see if we can address something like that in another webinar. But please do sign up, and ask questions like this on our community page.
So we can answer them for you. I love this, actually. Someone said: Are there any examples of Alexa or Google or Siri helping low vision patients? Absolutely! Yeah, that’s a fantastic idea. That’s a really good thing to advise patients to get. Someone’s asking about central vision loss here. And what is one of the issues in terms of daily living. Have a little bit of a think about this person with central vision.
Even just thinking about filling up a cup. They’re gonna be watching this cup directly. And so you’re gonna want to teach them eccentric fixation and things like that. But also, helping them incorporate devices. Be mindful that obviously your peripheral vision isn’t as clear as your central vision. And so you want to make sure that, for example, you’re putting tape on the edges of walls here and things like that, so people aren’t knocking their head.
They do have that peripheral vision that’s intact, but it’s maybe not as clear, so they won’t identify subtle changes in contrast. So you want to make sure that they’re taking advantage of all the things that we discussed today, these really, really simple things to make navigating their environment a lot easier.
Those are all the ones that I’m gonna answer today. There are a few questions in there that we’ll answer privately, that are a little bit more specific to new devices and magnifiers. Like I said, please, please, please get online. Join our community. Join the discussion. Particularly if you have difficult patient cases. Often you and I might work through a case and then I’ll say: Look, I think this is a really interesting case,
something that a lot of people have probably experienced with their patients. Could we make it public? And if you agree, and the patient agrees, then we’ll make the case public, so other people can learn from it. Making sure when you’re posting things up, that you do deidentify patient information so you’re not breaking any HIPAA rules or anything like that. So if that is all of our questions for today,
that’s me all done for today. I’m gonna pass you back over to our Cybersight guru.
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January 30, 2020
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