n estimated 3 million Americans live with partial

Providing Low Vision
Rehabilitation Services A or total vision impairment, including 600,000 to
900,000 classified as legally blind and another
100,000 who experience light perception only or tOtal

With Occupational blindness (Kirchner, 1985). Two thirds of the low vision
population are more than 65 years of age with women

Therapy and substantially outnumbering men (Fletcher, Shindell,
Hindman, & Schaffrath, 1991). According to projections

Ophthalmology: A made in 1979, the estimated number of elderly persons
with marked visual impairment will increase from 990,000

Program Description to 1.7 million by the year 2000 (Kirchner, 1985). Most of
these persons experience vision loss secondary to chron-
ic age-related conditions such as macular degeneration,
diabetic retinopathy, and glaucoma (DeSylvia, 1990). AJ-
Mary Warren though techniques exist that control the rate of deteriora-
tion, medical science has been unable to establish effec-
tive cures for these conditions, which leaves persons
Key Words: low vision. rehabilitation affected by them with permanent and irreversible vision
loss.
Persons with low vision Jive in a kind of gray area
between normal correctable vision and complete blind-
This article describes a low vision rehabilitation pro- ness (Orr, 1992). They are not totally blind, yet they do
gram operating within a hospital-based outpatient re- not have sufficient vision to read food and medication
habilitation clinic. The program uses a team ap- labels, write a check, balance a checkbook, drive a car,
proach combining ophthalmology and occupational operate a computer, prepare a meal, or complete other
therapy services. Patients are reJerred to the program functional activities needed to maintain an independent
by their primary care physician Jor a low vision eval- life-style (Warren & Lampert, 1994). For a considerable
uation completed joint~y by the ophthalmologist and number of older persons, low vision is their primary phys-
occupational therapist. The ophthalmology portion of
ical impairment. However, because of the impact of low
the evaluation includes assessment of visual acuity,
vision on the performance of activities of daily living
contrast sensitivi~y jimction, and macular perimelly
with a scanning laser ophthalmoscope. The occupa- (ADL) , many older adults with low vision find they must
tional therapy evaluation Jocuses on assessing the enter retirement and residential care facilities or reside
functional limitations experienced by the patient due with their children (Orr, 1992).
to the vision loss and determining how the patient is Traditionally, low vision rehabilitation services for
best able to use remaining vision to complete daily ac- adults have been administered through community-
tivities. Occupational therapy treatment emphasizes based organizations such as Lighthouses for the Blind
training the patient to use remaining vision as effi- or through state vocational rehabilitation services. Gen-
ciently and effectively as possible to complete daily ac- erally, these rrograms use an educational model with
tivities and includes training in use oloptical devices. rehabilitation teachers, counselors, and orientation and
Because oj the specialized nature oj the service pro-
mobility specialists for service delivery. AJthough occupa-
vided, additional postgraduate preparation is needed
tional therapists have been included in these rehabilita-
to enable occupational therapists to provide effective
low vision rehabilitation. tion teams, the number of occupational therapists pro-
viding low vision rehabilitation services through the
blindness system has been quite limited. The reason for
this limitation is largely because occupational thera-
pists traditionally practice within the health care system,
which has had only minimal involvement in low vision
rehabilitation.
In 1990, The Health Care Financing Administration
(HCFA) approved low vision as a physical impairment
Mary Warren, MS. O'IR. is Director of Occupational Therapy, appropriate for rehabilitation (Code oj Federal Regula-
Visual Independence Program, The Eye Foundation of Kansas
tions, 1994) This inclusion enabled Medicare to cover
City, Department of Ophthalmology, University of Missouri
rehabilitation services delivered through recognized
Kansas City School of Medicine, 2300 Holmes, Kansas City,
health care providers including occupational and physical
Missouri 64108.
therapists, licensed psychologists, and social workers
This article was accepted for publication April 26, 1995 through physician referral and direCtion Consistent with

The American jOU/71.al of Occupational Tberap.l' 877

Downloaded From: http://ajot.aota.org/ on 08/28/2014 Terms of Use: http://AOTA.org/terms

treatment must be medica/(v necessar)!. Herndon & therapists. which is the teaching hospital affiliated with the School of Medicine.:nl Sessions Per lm- The goal of the program is to provide rehabilitation Classification % I. vision evaluation.:ver<. The program is staffed by an ophthalmologist and five occupational therapists who are Table 1 Percentage of Patients in Each Diagnostic Classification employed by the medical center. & Peterson. Primary rehabilitation services are provided by the Patients Referred for Occupational Therapy Services in occupational therapy staff members.cvel % pairmenr Level services to persons with low vision to enable them to Macul. and complete dis- not-for-profit foundation that serves the educational and charge planning. DiabetiC r<. area school systems.n degenerarion 37 Pmfound 20 9 continue to live productive and satisfying lives as inde. program (see Table 1). Frey. Number of women 794. During the initial visit.:ars. 199'5). state rehabilitation services with low vision. the medical director writes an order for occupational sion rehabilitation with ophthalmology and occupational therapy.:rage age 68 ycat·s. health services or both that could expand to include low The program uses a team approach that combines vision rehabilitation in the services they provide. After completion of the evaluation. Therapy services are then initiated and carried therapy services. The program operates as an outpatient rehabilitation clinic as pan of the ambulatory care services of Truman Medical Center. because most hospitals already have es. few therapist. Number 9 Downloaded From: http://ajot. and physical therapy are available through the medical center as Average Numb<. it is deter- programs exist in the health care system that provide this mined whether the patient is appropriate for and would service. which includes approximately 157 physicians. 878 October /995. meaning prevalent condition is age-related macular degeneration that the patient's ability to complete necessary ADL has (36%). This inclusion has the program. limited number of referrals are received from optom- spread and comprehensive service delivery to persons etrists. The purpose of this article is to describe a hospital.:r dary to congenital and hereditary conditions. home. benefit from rehabilitation services. who constitute the largest proportion of the program and provides physician referral and direction for low vision population but generally receive only limited the rehabilitation services provided by the occupational services (Crews. or community. or tablished outpatient therapy departments or home the patients themselves. Retinal and glaucoma spe- services to be broadly incorporated into the health care cialists make up the primary referral base for the delivery system for the first time.org/terms .:rinoparhy 9 S<. a private ual patients. A immediate positive effect of making possible more wide. Numb<. One of the occupational and Visual Impairment Level and Average Number of therapists has a master's degree in orientation and mobil.:t-ate 39 q pendently as possible. Patients are referred to the program for a low Landry. The program is not limited to spe- Neurological 3 Unqualified 17 4 cific conditions or age ranges. Treatment Sessions Provided Per Impairment Level of ity. Since the inception of the pro- able. the median ratient age is 77 years. Diagnosric Impairm<. update treatment plans. The effect would be most dramatic in meeting the needs of ophthalmologist serves as the medical director of the older adults.:r Visual of Tt'eall1lenl needed.:n 4')2. No/e. which makes gerontology the primary focus of the been greatly compromised by the vision loss. AV<. and the most 1994). occupational therapy services have been delivered functional ability will improve with therapy. February 1992 to April 1994 services such as social services. nursing.org/ on 08/28/2014 Terms of Use: http://AOTA. to more than 1200 persons. for persons who are blind or have visual impairments. out in consultation with the physician. ed. How- (American Occupational Therapy Association [AOTA]. Patients are seen one to two times weekly depending on their needs and are treated in the clinic. The ophthalmology and occupational therapy services. and reason. in that there is an expectation that the patient's gram. Patients are discharged from the pro- research needs of the Department of Ophthalmology at gram when the goals established on the plan of care are the University of Missouri Kansas City School of Medicine. Referrals are primarily re- The inclusion of low vision as a physical impairment ceived from ophthalmologists within the city and sur- in the HCFA guidelines enables low vision rehabilitation rounding metropolitan area. age-related of m<. N = = 1. 1987. Volume 49. However. the patient is Although it is now possible to provide low vision evaluated by the medical director and an occupational rehabilitation through outpatient therapy services. Median age = 77 y<.aota. Monthly Description of the Visual Independence Program staff meetings are held with the medical director and The Visual Independence Program (VIP) was established occupational therapists to discuss the progress of individ- in 1992 at the Eye Foundation of Kansas City. ancillary the Visual Independence Program.: 24 6 Glaucoma 7 Mod<. and neurological conditions.246. Services are delivered to Miscellaneous 44 both children and adults with visual impairment secon. ever. met or maximum potential has been achieved. established Medicare gUidelines for occupational therapy and systemic diseases. If services are need- based outpatient therapy program that provides low vi.

and duration of therapy. in. ocular mo- tility. although not at the same level of acuity as or she will have difficulty completing activities at near. hensive evaluation of the patient's ADL skills is complet- In addition to these visual function tests. the physician ed. frequency reduced contrast presentation (such as curbs. etc). nosis (such as macular degeneration). or automated perimetry. & Depending on the nature of the patient's vision loss. Table 2. refraction.Weal Preparation Home Ylanagemertt Applying make-up Setting appliance dials Cleaning Applying toothpa. laser directly onto the patient's retina to image the retina while a HeNe laser presents stimuli to precisely map out The Occupational Therapy Evaluation the boundaries of the macular scotoma in relation to the fovea and characterize fixation. Fletcher.org/ on 08/28/2014 Terms of Use: http://AOTA. The device provides sub.tructions Minor household repail's Eating neatly Identif

ing foods Telephone usage Seasoning foods Pouring liqUids Spreading topping.org/terms . Examples of common daily living tasks that are difficult for persons with low vision to accurately and safely complete. 1994). evaluation to write the medical prescription for occupa- tional visual capacity of the patient to provide the thera.aota. the diag- oped for low vision evaluation (Colen brander & Fletcher. tation.ocating corrcCl aisle and item Complcting check or money order Recognizing acquaintenances Reading prices Maintaining financial ledger !v\aintaining orientation in unfamiliar places Making change Addressing ~lI1d mailing bills Locating public rest["()oms Making grocely list Eating in reSlaurams NegOlialing curbs and steps Avoiding collisions Figure 1. some aspect of the completion of almost all ADL. The PRL essen. needed to enable the therapist to establish and cany out tion. priate optical devices that the therapist may use in phisticated imaging device that scans an invisible infrared treatment. For patients with retinal macular involvement. the initial stantial information for rehabilitation because it deter. chopping.Wanagemenl Communitt' Activities Accessing transportal ion Reading hills and financial statements Accessing transportation I. 1994). Consistent with Medicare Part B gUidelines. patient to resolve visual detail (Schuchard. tional therapy services. A precise el of visual impairment (from profound to moderate) (see acuity measurement is obtained with techniques devel. The During the initial visit to the program. services to be provided by the therapist. The prescription includes the lev- pist with information needed for treatment. or far visual distances. Evaluation examines the anterior and posterior segments of the eye The Ophthalmology Evaluation and may evaluate clarity of the optic media. Because the patient is referred with a diagnosis. Colenbrander & Fletcher. evaluation completed by the occupational therapist is mines where the patient has relocated the preferred ret. steps. used to determine whether there is medical necessity for inal locus for fIXation (PRL) when the fovea is no longer therapy intervention It must be established that the pa- functioning (Schuchard & Fletcher. patient's psychological status and functional limitations ceives joint ophthalmology and occupational therapy are informally assessed by the physician through observa- evaluations to establish the medical necessity for rehabili. TiJe American Iournal of Occupational Thera/Jr 879 Downloaded From: http://ajot. slicing Cal' maintenance Managing medications Reading recipes. the actual fovea. tient'S vision loss has resulted in a functional limitation in tially functions as "new" fovea and can be used by the ADL or unsafe performance of ADL or both (AOTA. medical precautions. Contrast sensitivity function is measured to deter. 1994). and other parameters if indicated. tion and interview. he Maino. compre- tient must make to use the PRL and resolve visual detail. The physician provides the therapist with sug- Patients with suspected macular scotomas (blind gestions on the strength of magnification needed on the Spots) are evaluated with macular perimetty by using a basis of the acuity measurement and a range of appro- scanning laser ophthalmoscope (SLO). in this issue).V/onev . a description of 1992). the patient's mine the patient's ability to see accurately objects with rehabilitation potentia!. The SLO is a so. resolu- Selfcare . the patient re. The therapist will use the information middle.te i'vleasunng ingredients Washing clOthes Completing nailcare Timing foocl cooking Ironing SeleCling c!mhing Determining when food b clone Yard maintenance Mending c]mhing Cutting. and any additional information Visual field testing is completed with either confronta. treatment. Shopping . The physician uses the information gained from the the ophthalmologist concentrates on evaluating the func. tangent screen. Because vision is used in from the SLO to determine what eye movement the pa.

that require vi- reading is the primary activity affected Although reading sion for successful completion. 1990) and the Minneso. maintain. an address book. tial are resolved. This information is used formation on how the vision loss has affected accuracy to determine the patient's potential to use his or her and speed of reading. in. the thermostat. clock and to perform when treatment is initiated. leisure activities that involve seeing at near. evaluation is completed through clinical observation.(independent or no problem) point scale is used. and reading a food label. aisle markings. MNread is designed to provide a tests is correlated with information obtained from the quick. the watch faces. Baldasare. and com. advertisements. initial evaluation is followed by evaluation of performance coming mail. able to fully participate in therapy. bills. documents the: patient's limitations in ADL resulting from 880 Octoher 1995. reliable estimate of ma. a treatment program is initiated by the occu- view with the therapist. print distortion created by poor ability to effectively use other sensory systems to com- quality or script lettering. acuity measurement. pleted hy the ophthalmologist. observation is made as to whether the patient is lished. & Miller-Shaffer. menus.'(imum reading speed in the macular perimetly testing. established. and use an eccentric viewing posi- to assess the visual component of the reading process by tion (the PRL) is evaluated through clinical observations measuring the patient's visual word recognition skills combined with analysis of the patient's performance on (Baldasare. A plan of care is established with the patient that to 5. Although vision is not needed for the emotional support system. store signs. threshold sensitivity. the VSRT and MNread tests. If the patient does not have: contrast presentation (for example. tivities such as filling a glass with water. the telephone directory. The initial evalua- and so forth tion additionally includes assessment of the patient's re- Two standardized tests are used to measure reading habilitation potentiaL ability. 1989) (see the Appendix)..aota. tactile tation (such as that in a dark restaurant). For example. stan. because: it is believed that the patient would not be able to write legibly. & Whittaker.(unahle or dependent on others) clinic. Number 9 Downloaded From: http://ajot. patient's apparent adjustment to disability. including family support and physical act of writing. on his or her ability to efficiently and effectively use re- ta Low Vision Reading Test (MNread) (Legge. The VSRT is designed ty to locate. and contrast senSitivity testing com- Legge et aI. the community. and whether any serious medical con- application of writing to ensure legibility. Because there ditions exist that may limit participation in therapy. recipes. Although these tests give precise in. green letters on a sufficient remaining vision to use for ADL. his or her yellow background). Performance on these two Watson et aL. kinesthesia. 1986. and The questionnaire focuses on those ADI. identifying coins. therapy is not recom- ture. buttering a piece of bread. 1990). the patient'S performance on different types of printed Other issues that may affect the patient's ability to materials under different levels of illumination. patient is asked to prepare a typical meal or complete a street signs. price tags. The patient is asked to fill out a blank check. Treatment Self-care and homemaking performance are ad- dressed through completion of a self-performance rating If medical necessity and good rehabilitation potential are questionnaire completed by the patient through an inter. a are described in Figure 1. The patient is asked to rate his Ot" pational therapist. and which may include the home. & Luebker. One must be able to read food and medication labels. his or her ular vision loss. participate in and benefit from therapy are informally The functional application of writing to a variety of evaluated through interview. the telephone touch pad. or reduced illumination presen. In some instances. appJiance dials.org/ on 08/28/2014 Terms of Use: http://AOTA. Some of these activities is often thought of as something done for pleasure. PRL patient with low vision (Ahn. tion of visual detail is the major visual impairment. The patient's abili- Luebker. naire. Legge. 1993. If are no standardized low vision assessments for handwrit.org/terms . Watson. stay on line when writing. make an then therapy is postponed until the issues limiting poten- entry into a financial ledger. plete the writing task within a reasonable amount of time and with a reasonable amount of effort. Ross. and complete: a dictated sentence. expiration dates. the patient is asked to perform several simple ac- pleted each day to maintain an independent life-style. they do not provide information on remaining vision to see visual detail and to determine the whether the patient is able to read materials with reduced treatment strate:gies needed. Whittaker. Volume 49. & maining vision for functional activities. financial state. sewing task during a treatment session. complete his or her signa. middle. Therapy sessions are provided in the her difficulty in performing a variety of ADL including most contextually relevant environment for the patient. in specific areas identified by the patient as being difficult ments. medical neceSSity fOt" treatment intervention can be estab- ing. lished but rehabilitation potential is deemed to be poor. discrimination. the Pepper Visual Skills for Reading Test (VSRT) The patient's success in therapy will depend in part (Watson. it is needed for the functional financial resources. 1989). This instructions. A 1. Therefore. During these mended even though medical necessity has heen estab- tasks. and proprioception) is dardized testing is augmented by clinical observations of evaluated. In addition to the question- major amount of reading for information must be com. or the far visual distances. These issues include the activities is another activity affected in persons with mac. pensate for the vision Joss (including hearing.

had more than one secondary condition.g. and pat. 1. For example. the patient team to ensure that the goals achieved at discharge have is trained to use it to efficiently and safdv complete specif. A chan review of 249 to use their remaining vision as efficiently as possible. clothing. background contrast. the telephone directory. phys. 1986) The patient is taught sons with low vision have at least one other physical how to eccentrically view an object by making the neces. outlines the procedure by evaluation of the patient's work and home environment is which the goals will be achieved. supplies. ability to complete financial transactions and tation services are elderly. Once conditions often limit the options for optical devices avail- eccentric viewing is established. director and is scheduled once a month over a period of 5 In addition to training in the use of optical devices. ability to engage in leisure and community weakness or paralysis secondaly to stroke. tern to maximize the use of remaining vision. patients and their insulin for diabetes management. To patients admitted to the VIP program showed that 67% achieve this with a patient who has a macular scotoma.org/ on 08/28/2014 Terms of Use: http://AOTA. hearing loss. dialing the telephone. middle. Many older tivities with optimum efficiency. and techniques. the need for illumination. the vision loss. The limitations imposed by these secondary sary eye movements to focus the object on the PRL. had at least one secondary medical condition. and establishes a time completed. The as presence of astigmatism).. such as residual 5. the person's loss of vision may coincide fovea. commu- Tbe Americ({l'ljourllal or Occupatiollal Therapy 881 Downloaded From: http://ajot. utensils. and age-related tremor. presence of tremor. the patient's performance in therapy are completed on a ical limitations of the patient (e. and modifying arrange- ment offurniture. and psychosocial needs of 4. tools. A thorough liorating those limitations. months. Written materials are provided to reinforce 2.aota. and with low vision. measuring In addition to therapy services. These findings tablish awareness and consistent use of the PRL for identi. monthly basis and are reviewed with the medical director joint deformity in the hanel. etc). Another consideration III working with older meal preparation and the use of magniflcation to resolve persons is that the initiation of therapy often occurs si- visual detail is introduced. the patient is taught to able to the patient or require modification of devices and apply it during specific ADL such as reading. cognitive. Once an optical device is sel<:cted. progress notes on hands need to be free /). refractive needs (such who recertifies the need for continuing treatment. do the dressed (see Table 1). joint deformi- activities. heightening the contrast of addressed in the treatment plan: critical environmental features. independence. food. mending. impairment. writing. and 21% the therapist initially works on scanning exercises to es.g. cosmesis. and acceptability therapy program is concluded when the patient achieves to the patient. and events and be prepared to address those adjustment is- other activities. awareness of the nature of his or her condition. writing. efficient and effective use of optical devices to and so forth to facilitate safety and more independent read materials needed for daily liVing functioning. Because the PRL "viII not have multaneollsly with other major tranSitions in their lives the equivalent capability to resolve visual detail as the For example..org/terms . ability to complete self-care and homemaking ac- older persons to ensure program success. and reading specific families may participate in a surpon group for persons materials (such as menus. ty and pain secondary to arthritis. The format is a combination of patient education the patient is taught how to manipulate envirunmental and group sharing aimed at increasing the patient's features such as lighting. After discharge. ability to write legibly to complete communica- learning. checkbook. The therapist must be sensitive to these other life magnifier to effectively use it for reading. and recommendations are made for increas- frame for treatment. The patient spouse or a move from home into a residential care facili- is taught how to match the PRL to the focal width of the ty. the magnifier for reading and half-eye magni~!ing spectacles patient is scheduled for a brief follow-up visit with the for writing. Patients are encouraged to schedule ic tasks such as check writing and management of the adc. are comparabJe to those reporteu by Kirchner anu Peter- fication of visual uetail at near. The group is conducted by the medical instructions on food packages). magnification is necessary for the patient to use the with a traumatic or stressful event such as the loss of a PRL to see print and other small visual details. In general. Determination of which optical device affords the The treatment program typically extends over a peri- best magnification will depend on several factors These od of several sessions as rehabilitation goals are ad- include the specific demands of the task (e. sets achievable functional goals for ame. During therapy. cardiac Performance of ADL is addressed by training patients limitations.litional annual follow-up visits with the physician. persons have other disabilities and limitations that may and safety substantially complicate rehabilitation. tions needed for daily living Because most persons requiring low vision rehabili- 3. sues as well. the therapy program must manage financial affairs independently address the physical. five primarv ADL are ing or changing illumination. been maintained. Often more than one optical device is the established goals and a discharge summary docu- needed. the patient may require a Stand menting goal achievement is written. and far visual son (1980) that approximately two thirds of elderly per- distances (Goodrich & Mehr.

They can acquire this knowledge by they were not satisfied with the service provided. nity resources available to assist in adjustment. organizations such as the American Foundation for sued. ies are necessary to demonstrate the effectiveness of quently given training. project to develop two instruments to measure perfor- ly show that formal training in the use of aids loptical mance in persons with low vision that will be used to devices J and residual vision (e. if occupational therapy is write legibly compared with 0%. and 50% stated that of optical devices. and 20%. Nilsson concluded that "the results clear.8 1-hr sessions in eccentric viewing training and use of bilitation of Persons with Visual Impairment and Blind- the device. at least regarding elderly patients with very poor vision" (1990. The American Occupational Therapy Founda- levels eqUivalent to the trained group on all parameters. is to establish the efficacy of our treatment with increased from 0 to 75. Both groups had These organizations and professionals have a long tradi- similar visual acuities and were given similar devices. which is a major tients to better meet the needs of this fastest growing portion of the occupational therapy intervention pro. sons with low vision and the professionals in these ser- ing in the use of optical devices to that of patients given vices. the literature does nOt contain meriting rehabilitation provides occupational therapy studies demonstrating the efficacy of specific occupation. restoring visual performance in practical situations. These include agencies such as Lighthouses for the only brief instruction in use of a device when it was is.455 and concluded that additional tion courses offered through various facilities and staff members are needed to train patients in how to use organizations. occupational therapists working in low vision rehabilita- veyed 83 patients with low vision who were issued optical tion must have additional specialized knowledge of the devices without training and found that 33% of the re. by studying low vision reha- been wasted on dispensing optical devices out of a tOtal bilitation textbooks. ongoing 882 Octoher 1995. laboration between occupational therapists and these Evaluation at 1 month showed that in the group service providers is necessary to comprehensively meet receiving training. Bell.g.org/terms . Expansion of with low vision. However. to have any lasting impact in the field of low vision reha- tively. Of those surveyed. and Dutton (1991) sur. Col- the screen or newsprint before the initiation of the study. their performance improved to treatment. Although undergraduate course work prepares oc- used their device.. and suc.5 words per minute in the trained this patient population. ocular pathology causing vision loss and the application spondents never used the devices. As a result. A science must be developed that group compared with 0 to 22. reading speed bilitation. Volume 49. and 85% were able to The second requirement. Humphrey and Thompson (1986) surveyed low must be satisfied first if occu pational therapists are to vision patients in a general eye service who were pro. 50% gave the reason that cupational therapists to work with persons with various they thought the device was too difficult to use.6 words per minute in the provides a sound rationale for treatment. with an opportunity to provide low vision rehabilitation al therapy intervention in the rehabilitation of persons services through the health care system. low vision rehabilitation has not been a Inclusion of visual impairment by the HCFAas a condition major focus. low vision devices before they are dispensed. The working directly with optometrists and ophthalmologists authors estimated that approximately $14. When the untrained group was subse. services into this area will enable occupational therapists strate the efficacy of providing training in the use of opti. and of those. 77% stated that they never tion. and professionals such as orien- instruction by an optician when the device was issued and tation and mobility specialists and rehabilitation teachers. Blind. the needs of the patient.000 a year had specializing in low vision. 25%. In addition. However. tion of delivering competent and comprehensive services None of the subjects were able to read television titles on to persons with blindness and visual impairment. The no training group (n = 20) was given ness (see the Appendix). two conditions gram. to provide more comprehensive services to older pa- cal devices to compensate for vision loss. was instructed to practice at home. in the untrained group. studies do exist that demon. similar study. p. 100% were able to read newsprint. 3). The training group (n = 20) received an average of the Blind and the Association for the Education and Reha- 4. respec. training of eccentric study the outcome of service delivery. tion has proVided support in this endeavor by funding a From this study. The first requirement is educa- of devices. Occupational therapists must be knowledgeable Nilsson (1990) compared the reading performance about the rehabilitation services already in place for per- of patients with low vision who had received formal train. viewing) is far more effective than mere instruction in cessful strategies used by others to cope and adapt. vided with optical devices but were not trained in the use appropriate treatment. McIlwaine. 70% were able to read television titles. and by attending continuing educa- annual budget of $49. segment of American society.aota. Efficacy of Low Vision Rehabilitation Services Although occupational therapists have worked with per- Implications for Occupational Therapy sons with low vision and blindness since the inception of the profession. However. In a disabilities to achieve or regain independent functioning.org/ on 08/28/2014 Terms of Use: http://AOTA. Number 9 Downloaded From: http://ajot. Outcome stud- untrained group. enter into this field successfully and provide competent.

H. research is needed to ensure that occupational therapy & Physiological Optics. L. for hlind and visually impaired persons in the United States journal of Ophthalmic Nursing & Technology. 7. Optometry and Vision Science. 8. & Whittaker. 80. Ophtbalmologv Clinics of North America Shaffer. E. L. & Thompson. 6. C. part 42. Depanmenl of Psychology Nilsson. (Eds. Ahn. G. D. The Minnesota low vision reading test. Living witb low training and low vision aids: Current practice and implications Ilision: A resource gUideforpeuple lioing witb sl?. (1983).). Low vision reha./rnal olOptometry ton. 243-256) Philadelphia: Saunders. Ross. B J L. Basic concepts Colenbrandel".. Code ol Federal Regulations' Public Health. D. & Lampert. Warren. MA Resources for Rehabilitation. Low and tel-ms for low vision rehabilitation American journal ol vision and vision rehabilitation. & Fletcher. The development and evaluation of a reading (Vol. older people. 26. New York: Philadelphia. (1994). Orr (Ed..) (1992). Crews. U. Rockville. & Dunon.S. 159-165 Humphrey.). Department of Psychology. ity and clinical uses of the Pepper Visual Skills for Reading Test. Luxton. (215) 276-6291 Schuchal·d. R A. M. Ophthalmologl' Clinics ofNorth Occupational Therapl'. A. Shindell. (199'5). & Luebker. 8. C. Minnesota Labo. F. L. Fletcher (Eds. Pf1 187-1(5). Americanjo/. The American jO/l1'11l11 0/ Occupational /hempr 883 Downloaded From: http://ajot.bilitation with and without University of lvlinnesota educational training in the use of optical aides and residual l'vlinneapolis. Philadelphia Saunders. PrefelTed retinal locus: A review with applications in low vision rehabilitation. New York: Author Colenbrander. & Fletcher. Considerations in ad- care guidelines for occupational therapl'. G. 62-69. Ne'\o York: American Foundation for the Blind. Dickman. A. (1983). S. (1985). 119-126 services merit referral and reimbursement by the health Herndon. Primed cards. C.. 785-789. (1987). S. & Greenhlan. S. (1986). Fletcher (Eds. W D . & Mehr.org/terms . journal ol Watson. (1992).. N. & Luebker. D. C. & Schaffrath. journal ol Visual Impairment & Blindness. New De5ylvia.Goodrich. G G. M . A. A..ion Science. Minneapolis.. R (Ed. E. CreCilive re- Fletcher. 105.aota. Statistical brief #7: Visually Impaired Multiple impairments among non-institutionalized blind and 206 North Washington Street visually impaired persons.. (1991). 7. American Foundation for the Blind. 843-853. Aging and blindness: Toward a systems Pennsylvania College of Optometry approach to service delivery. Bell.: A resource manual on characteristics educa- New York. (1994). pp.. D A.). (1989). L (1988). Washington. Uni.. G. S. C (1992). America (Vol.. IVledi. 67. A. 63. I. Data on hlfndness and visual impair- 15 West 16th Street ment in the us. American Foundation ff)[ the Blind. (1994). G L. Low vision Appendix aids: Evaluation in a genel'al eye department. (1988). & Fletcher. Directory o/services bilitation: Visual acuity measurement in the low vision range. Schuchard. M. C. Watson. Colenbrander & D. . M. Orr. scanning laser ophthalmoscope (5LO) low-vision rehabilitation versity of Minnesota. & Landry. 42-44. Author. (1986). The valid- Visual Impa innent & Blindness.. journal ol Visual Impairment & Blfndness. Minnesota Low Vision Reading Test (MN Read) McIlwaine. 119-123.. (1990). D. 6. (1994). 3-32). 305-312 Jose. J A. 296-303 American Foundation for the Blind Kirchner. & Peterson. J A. G. New York: American Foundation for the Blind. G E. and Vision Science. R (1980). . P E. JvlN svstem. DC: U. Western journal of Medicine. New York: (991) Low vision rehabilitation: Finding capable people be. (1995). A rawry for Low-Vision Research. Low vision and aging. D. 7). New York: American (212) 620-2155 Foundation for the Blind. AER Reuiew. (1994). Whinaker. Philadelphia: Saunders. test for low vision individuals with macular loss. Frey.). OptometlJ' York: American Foundation for the Blind. J. c. Low vision and Baldasare.)..). Office of Federal Register National Archives and Records Administration. T. Visual reh~. & Fletcher.0). (1990). adaptations for tbe homes ol blind and visuallv impaired tional view. & Peterson. G. (1986). 154.. R A.). creation for blind and visual/v impaired adults. J. Opbthalmology Clinicsoj'Nm·tb America (Vol. B. C. (23rd ed). 101-107 American Occupational Therapv Association. Transactions of Rehabilitation Resources for Persons With Low Vision the Opbthalmological Society of tbe United Kingdom. 74. A. D. NY 10011 tion employment and service delfvery. In A Colen brander & D. PA 19141 American foundation for the Blind. 3-10 Pepper Visual Skills for Reading Test (VSRT) Orr. lvlakinR hfe more liuable' Simple pendell[ liVing for the handicapped elderly community: A na. A sion. 84. 865-869. MN 55455 vision: A prospective study of patients with advanced age- (612) 625-4516 l'e1ated macular degeneration Clfnical VL. Clinical t)'e and Vision Care. 319-322. Vision and aging Crossroads/or '554-556 service delil'eTi'. Association for Education ane! Rehabilitation of the Blind and Kirchner. Psycho· (703) 548-18R4 physics of reading VUl. VA 22314 Legge. Independent living skills for older Americans: Three-year analysis of service provi- care system.hlloss. Low Minnesota Laboratory for Low Vision Research vision aids -Is our service COSt effective) Eye. Eccentric viewing Weisse. A. hind damaged eyeballs. Low vision and vision References rehabilitation. MD: dressing the daily living needs in older persons with low vision. (1988). joumal ol Visual Impainnent & Suite 320 Blindness. Legge. Hindman. Government Printing Related Reading Office Colenbrander. & Miller. A. R C. L. (1994). G. & Anmore. G E. vision rehabilitation. & Maino. In A. (Ed. 11. Baldasare. 66. (1993). 49. R. Understanding low uision. Alexandria. (1990). Ludwig.' (pp. Fletcher. SJ. C. i'VINread low-vision reading test (version 1. In A L.. I.. Inde. Vision and 1200 West Godfrey Avenue aging Crossroads/or service de!iuer.).. C. Lexing- of peripheral retinal research.org/ on 08/28/2014 Terms of Use: http://AOTA. R. 607-611.

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ing foods Telephone usage Seasoning foods Pouring liqUids Spreading topping.org/terms . Examples of common daily living tasks that are difficult for persons with low vision to accurately and safely complete. 1994). evaluation to write the medical prescription for occupa- tional visual capacity of the patient to provide the thera.aota. the diag- oped for low vision evaluation (Colen brander & Fletcher. tation.ocating corrcCl aisle and item Complcting check or money order Recognizing acquaintenances Reading prices Maintaining financial ledger !v\aintaining orientation in unfamiliar places Making change Addressing ~lI1d mailing bills Locating public rest["()oms Making grocely list Eating in reSlaurams NegOlialing curbs and steps Avoiding collisions Figure 1. some aspect of the completion of almost all ADL. The PRL essen. needed to enable the therapist to establish and cany out tion. priate optical devices that the therapist may use in phisticated imaging device that scans an invisible infrared treatment. For patients with retinal macular involvement. the initial stantial information for rehabilitation because it deter. chopping.Wanagemenl Communitt' Activities Accessing transportal ion Reading hills and financial statements Accessing transportation I. 1994). Consistent with Medicare Part B gUidelines. patient to resolve visual detail (Schuchard. tional therapy services. A precise el of visual impairment (from profound to moderate) (see acuity measurement is obtained with techniques devel. The During the initial visit to the program. services to be provided by the therapist. The prescription includes the lev- pist with information needed for treatment. or far visual distances. Evaluation examines the anterior and posterior segments of the eye The Ophthalmology Evaluation and may evaluate clarity of the optic media. Because the patient is referred with a diagnosis. Colenbrander & Fletcher. evaluation completed by the occupational therapist is mines where the patient has relocated the preferred ret. steps. used to determine whether there is medical necessity for inal locus for fIXation (PRL) when the fovea is no longer therapy intervention It must be established that the pa- functioning (Schuchard & Fletcher. patient's psychological status and functional limitations ceives joint ophthalmology and occupational therapy are informally assessed by the physician through observa- evaluations to establish the medical necessity for rehabili. TiJe American Iournal of Occupational Thera/Jr 879 Downloaded From: http://ajot. slicing Cal' maintenance Managing medications Reading recipes. the actual fovea. tient'S vision loss has resulted in a functional limitation in tially functions as "new" fovea and can be used by the ADL or unsafe performance of ADL or both (AOTA. medical precautions. Contrast sensitivity function is measured to deter. 1994). and other parameters if indicated. tion and interview. he Maino. compre- tient must make to use the PRL and resolve visual detail. The physician provides the therapist with sug- Patients with suspected macular scotomas (blind gestions on the strength of magnification needed on the Spots) are evaluated with macular perimetty by using a basis of the acuity measurement and a range of appro- scanning laser ophthalmoscope (SLO). in this issue).V/onev . a description of 1992). the patient's mine the patient's ability to see accurately objects with rehabilitation potentia!. The SLO is a so. resolu- Selfcare . the patient re. The therapist will use the information middle.te i'vleasunng ingredients Washing clOthes Completing nailcare Timing foocl cooking Ironing SeleCling c!mhing Determining when food b clone Yard maintenance Mending c]mhing Cutting. and any additional information Visual field testing is completed with either confronta. treatment. Shopping . The physician uses the information gained from the the ophthalmologist concentrates on evaluating the func. tangent screen. Because vision is used in from the SLO to determine what eye movement the pa.

that require vi- reading is the primary activity affected Although reading sion for successful completion. 1990) and the Minneso. maintain. an address book. tial are resolved. This information is used formation on how the vision loss has affected accuracy to determine the patient's potential to use his or her and speed of reading. in. the thermostat. clock and to perform when treatment is initiated. leisure activities that involve seeing at near. evaluation is completed through clinical observation.(independent or no problem) point scale is used. and reading a food label. aisle markings. MNread is designed to provide a tests is correlated with information obtained from the quick. the watch faces. Baldasare. and com. advertisements. initial evaluation is followed by evaluation of performance coming mail. able to fully participate in therapy. bills. documents the: patient's limitations in ADL resulting from 880 Octoher 1995. reliable estimate of ma. a treatment program is initiated by the occu- view with the therapist. print distortion created by poor ability to effectively use other sensory systems to com- quality or script lettering. acuity measurement. pleted hy the ophthalmologist. observation is made as to whether the patient is lished. & Miller-Shaffer. menus.'(imum reading speed in the macular perimetly testing. established. and use an eccentric viewing posi- to assess the visual component of the reading process by tion (the PRL) is evaluated through clinical observations measuring the patient's visual word recognition skills combined with analysis of the patient's performance on (Baldasare. A plan of care is established with the patient that to 5. Although vision is not needed for the emotional support system. store signs. threshold sensitivity. the VSRT and MNread tests. If the patient does not have: contrast presentation (for example. tivities such as filling a glass with water. the telephone directory. The initial evalua- and so forth tion additionally includes assessment of the patient's re- Two standardized tests are used to measure reading habilitation potentiaL ability. 1989) (see the Appendix)..aota. tactile tation (such as that in a dark restaurant). For example. stan. because: it is believed that the patient would not be able to write legibly. & Whittaker.(unahle or dependent on others) clinic. Number 9 Downloaded From: http://ajot. patient's apparent adjustment to disability. including family support and physical act of writing. on his or her ability to efficiently and effectively use re- ta Low Vision Reading Test (MNread) (Legge. The VSRT is designed ty to locate. and contrast senSitivity testing com- Legge et aI. the community. and whether any serious medical con- application of writing to ensure legibility. Because there ditions exist that may limit participation in therapy. recipes. Although these tests give precise in. green letters on a sufficient remaining vision to use for ADL. his or her yellow background). Performance on these two Watson et aL. kinesthesia. 1986. and The questionnaire focuses on those ADI. identifying coins. therapy is not recom- ture. buttering a piece of bread. 1990). the patient'S performance on different types of printed Other issues that may affect the patient's ability to materials under different levels of illumination. patient is asked to prepare a typical meal or complete a street signs. price tags. The patient is asked to fill out a blank check. Treatment Self-care and homemaking performance are ad- dressed through completion of a self-performance rating If medical necessity and good rehabilitation potential are questionnaire completed by the patient through an inter. a are described in Figure 1. The patient is asked to rate his Ot" pational therapist. and which may include the home. & Luebker. One must be able to read food and medication labels. his or her ular vision loss. participate in and benefit from therapy are informally The functional application of writing to a variety of evaluated through interview. the telephone touch pad. or reduced illumination presen. In some instances. appJiance dials.org/ on 08/28/2014 Terms of Use: http://AOTA. Some of these activities is often thought of as something done for pleasure. PRL patient with low vision (Ahn. tion of visual detail is the major visual impairment. The patient's abili- Luebker. naire. Legge. 1993. If are no standardized low vision assessments for handwrit.org/terms . Watson. stay on line when writing. make an then therapy is postponed until the issues limiting poten- entry into a financial ledger. plete the writing task within a reasonable amount of time and with a reasonable amount of effort. Ross. and complete: a dictated sentence. expiration dates. the patient is asked to perform several simple ac- pleted each day to maintain an independent life-style. they do not provide information on remaining vision to see visual detail and to determine the whether the patient is able to read materials with reduced treatment strate:gies needed. Whittaker. Volume 49. & maining vision for functional activities. financial state. sewing task during a treatment session. complete his or her signa. middle. Therapy sessions are provided in the her difficulty in performing a variety of ADL including most contextually relevant environment for the patient. in specific areas identified by the patient as being difficult ments. medical neceSSity fOt" treatment intervention can be estab- ing. lished but rehabilitation potential is deemed to be poor. discrimination. the Pepper Visual Skills for Reading Test (VSRT) The patient's success in therapy will depend in part (Watson. it is needed for the functional financial resources. 1989). This instructions. A 1. Therefore. During these mended even though medical necessity has heen estab- tasks. and proprioception) is dardized testing is augmented by clinical observations of evaluated. In addition to the question- major amount of reading for information must be com. or the far visual distances. These issues include the activities is another activity affected in persons with mac. pensate for the vision Joss (including hearing.

had more than one secondary condition.g. and pat. 1. For example. the patient team to ensure that the goals achieved at discharge have is trained to use it to efficiently and safdv complete specif. A chan review of 249 to use their remaining vision as efficiently as possible. clothing. background contrast. the telephone directory. phys. 1986) The patient is taught sons with low vision have at least one other physical how to eccentrically view an object by making the neces. outlines the procedure by evaluation of the patient's work and home environment is which the goals will be achieved. supplies. ability to complete financial transactions and tation services are elderly. Once conditions often limit the options for optical devices avail- eccentric viewing is established. director and is scheduled once a month over a period of 5 In addition to training in the use of optical devices. ability to engage in leisure and community weakness or paralysis secondaly to stroke. tern to maximize the use of remaining vision. patients and their insulin for diabetes management. To patients admitted to the VIP program showed that 67% achieve this with a patient who has a macular scotoma.org/ on 08/28/2014 Terms of Use: http://AOTA. hearing loss. dialing the telephone. middle. Many older tivities with optimum efficiency. and techniques. the need for illumination. the vision loss. The limitations imposed by these secondary sary eye movements to focus the object on the PRL. had at least one secondary medical condition. and establishes a time completed. The as presence of astigmatism).. such as residual 5. the person's loss of vision may coincide fovea. commu- Tbe Americ({l'ljourllal or Occupatiollal Therapy 881 Downloaded From: http://ajot. utensils. and age-related tremor. presence of tremor. the patient's performance in therapy are completed on a ical limitations of the patient (e. and modifying arrange- ment offurniture. and psychosocial needs of 4. tools. A thorough liorating those limitations. months. Written materials are provided to reinforce 2.aota. and with low vision. measuring In addition to therapy services. These findings tablish awareness and consistent use of the PRL for identi. monthly basis and are reviewed with the medical director joint deformity in the hanel. etc). Another consideration III working with older meal preparation and the use of magniflcation to resolve persons is that the initiation of therapy often occurs si- visual detail is introduced. the patient is taught to able to the patient or require modification of devices and apply it during specific ADL such as reading. cognitive. Once an optical device is sel<:cted. progress notes on hands need to be free /). refractive needs (such who recertifies the need for continuing treatment. do the dressed (see Table 1). joint deformi- activities. heightening the contrast of addressed in the treatment plan: critical environmental features. independence. food. mending. impairment. writing. and 21% the therapist initially works on scanning exercises to es.g. cosmesis. and acceptability therapy program is concluded when the patient achieves to the patient. and events and be prepared to address those adjustment is- other activities. awareness of the nature of his or her condition. writing. efficient and effective use of optical devices to and so forth to facilitate safety and more independent read materials needed for daily liVing functioning. Because the PRL "viII not have multaneollsly with other major tranSitions in their lives the equivalent capability to resolve visual detail as the For example..org/terms . ability to complete self-care and homemaking ac- older persons to ensure program success. and reading specific families may participate in a surpon group for persons materials (such as menus. ty and pain secondary to arthritis. The format is a combination of patient education the patient is taught how to manipulate envirunmental and group sharing aimed at increasing the patient's features such as lighting. After discharge. ability to write legibly to complete communica- learning. checkbook. The therapist must be sensitive to these other life magnifier to effectively use it for reading. and recommendations are made for increas- frame for treatment. The patient spouse or a move from home into a residential care facili- is taught how to match the PRL to the focal width of the ty. the magnifier for reading and half-eye magni~!ing spectacles patient is scheduled for a brief follow-up visit with the for writing. Patients are encouraged to schedule ic tasks such as check writing and management of the adc. are comparabJe to those reporteu by Kirchner anu Peter- fication of visual uetail at near. The group is conducted by the medical instructions on food packages). magnification is necessary for the patient to use the with a traumatic or stressful event such as the loss of a PRL to see print and other small visual details. In general. Determination of which optical device affords the The treatment program typically extends over a peri- best magnification will depend on several factors These od of several sessions as rehabilitation goals are ad- include the specific demands of the task (e. sets achievable functional goals for ame. During therapy. cardiac Performance of ADL is addressed by training patients limitations.litional annual follow-up visits with the physician. persons have other disabilities and limitations that may and safety substantially complicate rehabilitation. tions needed for daily living Because most persons requiring low vision rehabili- 3. sues as well. the therapy program must manage financial affairs independently address the physical. five primarv ADL are ing or changing illumination. been maintained. Often more than one optical device is the established goals and a discharge summary docu- needed. the patient may require a Stand menting goal achievement is written. and far visual son (1980) that approximately two thirds of elderly per- distances (Goodrich & Mehr.

They can acquire this knowledge by they were not satisfied with the service provided. nity resources available to assist in adjustment. organizations such as the American Foundation for sued. ies are necessary to demonstrate the effectiveness of quently given training. project to develop two instruments to measure perfor- ly show that formal training in the use of aids loptical mance in persons with low vision that will be used to devices J and residual vision (e. if occupational therapy is write legibly compared with 0%. and 50% stated that of optical devices. and 20%. Nilsson concluded that "the results clear.8 1-hr sessions in eccentric viewing training and use of bilitation of Persons with Visual Impairment and Blind- the device. at least regarding elderly patients with very poor vision" (1990. The American Occupational Therapy Founda- levels eqUivalent to the trained group on all parameters. is to establish the efficacy of our treatment with increased from 0 to 75. Both groups had These organizations and professionals have a long tradi- similar visual acuities and were given similar devices. which is a major tients to better meet the needs of this fastest growing portion of the occupational therapy intervention pro. sons with low vision and the professionals in these ser- ing in the use of optical devices to that of patients given vices. the literature does nOt contain meriting rehabilitation provides occupational therapy studies demonstrating the efficacy of specific occupation. restoring visual performance in practical situations. These include agencies such as Lighthouses for the only brief instruction in use of a device when it was is.455 and concluded that additional tion courses offered through various facilities and staff members are needed to train patients in how to use organizations. occupational therapists working in low vision rehabilita- veyed 83 patients with low vision who were issued optical tion must have additional specialized knowledge of the devices without training and found that 33% of the re. by studying low vision reha- been wasted on dispensing optical devices out of a tOtal bilitation textbooks. ongoing 882 Octoher 1995. laboration between occupational therapists and these Evaluation at 1 month showed that in the group service providers is necessary to comprehensively meet receiving training. Bell.g.org/terms . Expansion of with low vision. However. to have any lasting impact in the field of low vision reha- tively. Of those surveyed. and Dutton (1991) sur. Col- the screen or newsprint before the initiation of the study. their performance improved to treatment. Although undergraduate course work prepares oc- used their device.. and suc.5 words per minute in the trained this patient population. ocular pathology causing vision loss and the application spondents never used the devices. As a result. A science must be developed that group compared with 0 to 22. reading speed bilitation. Volume 49. and 85% were able to The second requirement. Humphrey and Thompson (1986) surveyed low must be satisfied first if occu pational therapists are to vision patients in a general eye service who were pro. 50% gave the reason that cupational therapists to work with persons with various they thought the device was too difficult to use.6 words per minute in the provides a sound rationale for treatment. with an opportunity to provide low vision rehabilitation al therapy intervention in the rehabilitation of persons services through the health care system. low vision rehabilitation has not been a Inclusion of visual impairment by the HCFAas a condition major focus. low vision devices before they are dispensed. The working directly with optometrists and ophthalmologists authors estimated that approximately $14. When the untrained group was subse. services into this area will enable occupational therapists strate the efficacy of providing training in the use of opti. and of those. 77% stated that they never tion. and professionals such as orien- instruction by an optician when the device was issued and tation and mobility specialists and rehabilitation teachers. Blind. the needs of the patient.000 a year had specializing in low vision. 25%. In addition. However. tion of delivering competent and comprehensive services None of the subjects were able to read television titles on to persons with blindness and visual impairment. The no training group (n = 20) was given ness (see the Appendix). two conditions gram. to provide more comprehensive services to older pa- cal devices to compensate for vision loss. was instructed to practice at home. in the untrained group. studies do exist that demon. similar study. p. 100% were able to read newsprint. 3). The training group (n = 20) received an average of the Blind and the Association for the Education and Reha- 4. respec. training of eccentric study the outcome of service delivery. tion has proVided support in this endeavor by funding a From this study. The first requirement is educa- of devices. Occupational therapists must be knowledgeable Nilsson (1990) compared the reading performance about the rehabilitation services already in place for per- of patients with low vision who had received formal train. viewing) is far more effective than mere instruction in cessful strategies used by others to cope and adapt. vided with optical devices but were not trained in the use appropriate treatment. McIlwaine. 70% were able to read television titles. and by attending continuing educa- annual budget of $49. segment of American society.aota. Efficacy of Low Vision Rehabilitation Services Although occupational therapists have worked with per- Implications for Occupational Therapy sons with low vision and blindness since the inception of the profession. However. In a disabilities to achieve or regain independent functioning.org/ on 08/28/2014 Terms of Use: http://AOTA. Number 9 Downloaded From: http://ajot. Outcome stud- untrained group. enter into this field successfully and provide competent.

H. research is needed to ensure that occupational therapy & Physiological Optics. L. for hlind and visually impaired persons in the United States journal of Ophthalmic Nursing & Technology. 7. Optometry and Vision Science. 8. & Whittaker. 80. Ophtbalmologv Clinics of North America Shaffer. E. L. & Thompson. 6. C. part 42. Depanmenl of Psychology Nilsson. (Eds. Ahn. G. D. The Minnesota low vision reading test. Living witb low training and low vision aids: Current practice and implications Ilision: A resource gUideforpeuple lioing witb sl?. (1983).). Low vision reha./rnal olOptometry ton. 243-256) Philadelphia: Saunders. Ross. B J L. Basic concepts Colenbrandel".. Code ol Federal Regulations' Public Health. D. & Lampert. Warren. MA Resources for Rehabilitation. Low and tel-ms for low vision rehabilitation American journal ol vision and vision rehabilitation. & Fletcher. The development and evaluation of a reading (Vol. older people. 26. New York: Philadelphia. (1994). Orr (Ed..) (1992). Crews. U. Rockville. & Dunon.S. 159-165 Humphrey.). Department of Psychology. ity and clinical uses of the Pepper Visual Skills for Reading Test. Luxton. (215) 276-6291 Schuchal·d. R A. M. Ophthalmologl' Clinics ofNorth Occupational Therapl'. A. Shindell. (199'5). & Luebker. 8. C. Minnesota Labo. F. L. Fletcher (Eds. Pf1 187-1(5). Americanjo/. The American jO/l1'11l11 0/ Occupational /hempr 883 Downloaded From: http://ajot.bilitation with and without University of lvlinnesota educational training in the use of optical aides and residual l'vlinneapolis. Philadelphia Saunders. PrefelTed retinal locus: A review with applications in low vision rehabilitation. New York: Author Colenbrander. & Fletcher. Considerations in ad- care guidelines for occupational therapl'. G. 62-69. Ne'\o York: American Foundation for the Blind. Dickman. A. (1983). S. (1985). 119-126 services merit referral and reimbursement by the health Herndon. Primed cards. C.. 785-789. (1987). S. & Greenhlan. S. (1986). Fletcher (Eds. W D . & Mehr.org/terms . journal ol Watson. (1992).. N. & Luebker. D. C. & Schaffrath. journal ol Visual Impairment & Blindness. New De5ylvia.Goodrich. G G. M . A. A..ion Science. Minneapolis.. R (Ed. E. CreCilive re- Fletcher. 105.aota. Statistical brief #7: Visually Impaired Multiple impairments among non-institutionalized blind and 206 North Washington Street visually impaired persons.. (1991). 7. American Foundation for the Blind. 843-853. Aging and blindness: Toward a systems Pennsylvania College of Optometry approach to service delivery. Bell.: A resource manual on characteristics educa- New York. (1994). pp.. D A.). (1989). L (1988). Washington. Uni.. G. S. C (1992). America (Vol.. IVledi. 67. A. 63. I. Data on hlfndness and visual impair- 15 West 16th Street ment in the us. American Foundation ff)[ the Blind. (1994). G L. Low vision Appendix aids: Evaluation in a genel'al eye department. (1988). & Fletcher. Directory o/services bilitation: Visual acuity measurement in the low vision range. Schuchard. M. C. Watson. Colenbrander & D. . M. Orr. scanning laser ophthalmoscope (5LO) low-vision rehabilitation versity of Minnesota. & Landry. 42-44. Author. (1986). The valid- Visual Impa innent & Blindness.. journal ol Visual Impairment & Blfndness. Minnesota Low Vision Reading Test (MN Read) McIlwaine. 119-123.. (1990). D. 6. (1994). 3-32). 305-312 Jose. J A. 296-303 American Foundation for the Blind Kirchner. & Peterson. J A. G. New York: American Foundation for the Blind. G E. and Vision Science. R (1980). . P E. JvlN svstem. DC: U. Western journal of Medicine. New York: (991) Low vision rehabilitation: Finding capable people be. (1995). A rawry for Low-Vision Research. Low vision and aging. D. 7). New York: American (212) 620-2155 Foundation for the Blind. AER Reuiew. (1994). Whinaker. Philadelphia: Saunders. test for low vision individuals with macular loss. Frey.). OptometlJ' York: American Foundation for the Blind. J. c. Low vision and Baldasare.)..). Office of Federal Register National Archives and Records Administration. T. Visual reh~. & Fletcher.0). (1990). adaptations for tbe homes ol blind and visuallv impaired tional view. & Peterson. G. (1986). 154.. R A.). creation for blind and visual/v impaired adults. J. Opbthalmology Clinicsoj'Nm·tb America (Vol. B. C. (23rd ed). 101-107 American Occupational Therapv Association. Transactions of Rehabilitation Resources for Persons With Low Vision the Opbthalmological Society of tbe United Kingdom. 74. A. D. NY 10011 tion employment and service delfvery. In A Colen brander & D. PA 19141 American foundation for the Blind. 3-10 Pepper Visual Skills for Reading Test (VSRT) Orr. lvlakinR hfe more liuable' Simple pendell[ liVing for the handicapped elderly community: A na. A sion. 84. 865-869. MN 55455 vision: A prospective study of patients with advanced age- (612) 625-4516 l'e1ated macular degeneration Clfnical VL. Clinical t)'e and Vision Care. 319-322. Vision and aging Crossroads/or '554-556 service delil'eTi'. Association for Education ane! Rehabilitation of the Blind and Kirchner. Psycho· (703) 548-18R4 physics of reading VUl. VA 22314 Legge. Independent living skills for older Americans: Three-year analysis of service provi- care system.hlloss. Low Minnesota Laboratory for Low Vision Research vision aids -Is our service COSt effective) Eye. Eccentric viewing Weisse. A. hind damaged eyeballs. Low vision and vision References rehabilitation. MD: dressing the daily living needs in older persons with low vision. (1988). joumal ol Visual Impainnent & Suite 320 Blindness. Legge. Hindman. Government Printing Related Reading Office Colenbrander. & Miller. A. R C. L. (1994). G. & Anmore. G E. vision rehabilitation. & Maino. In A. (Ed. 11. Baldasare. 66. (1993). 49. R. Understanding low uision. Alexandria. (1990). Ludwig.' (pp. Fletcher. SJ. C. i'VINread low-vision reading test (version 1. In A L.. I.. Inde. Vision and 1200 West Godfrey Avenue aging Crossroads/or service de!iuer.).. C. Lexing- of peripheral retinal research.org/ on 08/28/2014 Terms of Use: http://AOTA. R. 607-611.

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