THE ISSUE Is
Do Occupational Therapists Have a Prin1ary Role
in Low Vision Rehabilitation?
T he patient with low vision is de-
fined as a person with an eye
disorder whose visual perfor-
mance is decreased as a consequence of
reduced acuity, abnormal visual field, re-
duced contraSt sensitivity, or other ocu-
lar dysfunctions that prevent perfor-
mance to full capacity. It may be
hereditary, congenital, or acquired
(Faye, 1984). Low vision describes a se-
rious visual loss that cannot be corren-
ed by medical or surgical intervention
or by speCtacles. It is a rersistent, irre-
versible deficit that interferes with daily
living bur rarely leads to to[al blindness
(Weinrab, Freeman, & Selezinka, 1990).
The majority of persons with low vision
are left with visual problems that cannot
be cured and must handle the prospect
of living with permanent, if nor progres-
sive, vision loss (Fletcher, Shindell,
Hindman, & Schaffrath, 1991).
Many of the limitations in inde-
pendent living exrerienced by persons
with low vision can be imrroved
through vision enhancement, training in
the efficient use of remaining vision,
task and environmental modification,
appropriate substitution of O[her
senses, and management of emotional
issues. However, persons with visual
dysfunction continue to be underserved
by vision-related rehabilitation programs
in general as well as by occupational
therapists in particular. There are a
number of reasons that visual disabil-
ities are underserved, ranging from the
lack of identification of visual problems
in patients to the lack of specialized
vision-related rehabilitation rrograms
for all who need such services (Bailey,
1992; Marx, Werner, Cohen-Mansfield,
& Feldman, 1992; SilverStone, 1993).
Even though every state has a num-
ber of programs and trained service
prOViders with services targeted for per-
Tbe American .Journal of Occupational Tberapy
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Judy McGinty Bachelder,
Don Harkins, Jr,
judy McGinty Bachelder, PhD, om F/\OTA,
is Assistant Professor. Occupational
Therapy Prop,ram, Washinp,ton Uniuer-
sity School o/Medicine, 4444 Forest
Park Auenue, 51 Louis, Missouri 63108
Don Harkins, jr., MA. is Director a/Vo-
cational SenJices Department, The Re-
habilitation Institute, Kansas City,
Missouri.
Thi, article was accepted for publication July
10. 199').
sons who are blind or visually impaired,
there are at least four imrortant reasons
why occupational therapists should be-
come involved in providing vision-related
services and rehabilitation. First, elderly
rersons comprise the majority of the
population with low vision, yet they
continue to be the mOSt underserved by
exiSting state, charitable, and private
programs (DiStefano & Aston, 1986;
Gieser, 1992). According to the Ameri-
can Association of Retired Persons
(AARP) (1992), elderly persons tYrically
wait an estimated 5 to 7 years between
the time they lose their vision and the
time they receive assistance such as re-
habilitation. As a result, many older per-
sons with visual imrairments are social-
ly isolated, depressed, dependent. and
institutionalized, even though functional
visual training would allow them to live
independently (AARP, 1992). Among
those who are in nursing homes, jt has
been estimated that as many as 48%
have a visual impairment (Havlik, 1986).
Vision loss can severely impair a
rerson's ability to interact with the envi-
ronmenr, including the use of social and
health services, and can hamper per-
formance of even the simplest everyday
tasks (Branch, Horowitz, & Carr, 1989).
According to the clinical literature
(Branch et aI., 1989), older persons who
confront visual impairment experience a
range of rsychological reaCtions, includ-
ing grief, confusion, anger, fear, anxiety,
depression, loss of control. loss of self-
esteem, diminished social comfort, and
low levels of visual interaction. In addi-
tion to the emotional and psychological
consequences, vision loss has been
cited as a major cause of aCtivity limita-
tion among older persons, a finding
supported by the most recent data from
the National Center for Health Statistics
(Havlik, 1986). Visual impairment has
been found to be strongly associated
with greater difficulty in performing dai-
ly actiVities, such as walking, getting
outside, and transferring to and from a
bed or chair (Branch et aI., 1989). Often
their narrow world becomes smalJer
with the addition of chronic health
problems (DiStefano & Aston, 1986)
The rresence of concurrent disabilities
underscores the importance of estab-
lishing a consolidated rehabilitation pro-
gram that addresses the multiple health
concerns of older persons with visual
impairments that is readily accessible to
all older persons.
Second, because occupational
therapists work with elderly persons,
we are constamly confronted with prob-
lems created by their visual impair-
ments, and we need to know how to ad-
dress low vision so that we can more
effectively meet their needs. Two thirds
of older persons with visual impair-
ments have at least one other chronic
condition that limits their mobility or
independent functioning (AARP, 1992),
Vision loss in elderly persons is also re-
927
 Jared ro orher healrh conditions and dis-
abilities. There is srrong evidence thar,
among aged persons, poor vision in-
creases rhe likelihood of falling (Branch
t:( ai, 1986). In addition, visual impair-
ments have been found ro impede res-
rorarive programs for orher parhological
conditions (Weinrah et ai, 1990).
The number of associared proh-
lems is exacerbared hy rhe facr rhat
many providers and elderly persons
rhemselves fail ro disringuish between
rypical age-relared visual changes and
changes relared ro eye disease or pri-
mary condirions (Branch er a1., 1986).
Consequently, visual loss is somerimes
overlooked. I helieve rhar ir is impera-
rive rhar occupational rherapists rou-
rinely address rhe visual aspect of older
patients' performance regardless of
rheir primary condition or reasons for
referral ro occuparional rherapy.
A rhird reason for rhe need for
grearer involvemenr of occuparional
rherapisrs in vision-relared services is
rhar many of rhe specialisrs who provide
vision rraining, such as rehahiliration
teachers or orientarion and mobility
specialisrs, are nor available in less pop-
ulared or rural areas (Branch er ai,
1986; Gieser, 1992). A large popularion
in need of low vision rehahiliration are
rhose persons who receive only primary
eye care because low vision or vision-
relared rehabilirarion services are un-
available or are unknown (0 vision spe-
cialisrs (Branch et ai, 1986; Faye, 1984;
Gieser, 1992). Even rho ugh a number of
privare and srare-supported sysrems ex-
ist for persons who are hlind or visually
impaired, many older persons are
underserved because they do nor fir
wirhin rhe rypical parient caregories.
Tradirional services are provided hy
nonprofir, charitable insriturions rhar
rely on private donarions and rax sup-
pon or by stare agencies and contracted
nonprofir agencies rhar rely on dwin-
elling government funding. Because
rhese agencies exclusively serve persons
wirh visual impairments, rhey are mosr
prevalent in areas wirh a large
popularion.
Heimerdinger (1995), president
and chief execurive officer of rhe Jewish
Guild for rhe Blinel, has made a srrong
case for occuparional rherapisrs ro ac-
quire rhe expertise ro provide vision-
related rehahilitarion services. In a lener
ro tradirional providers of hlindness and
low vision service~, he rointed our rhat
928
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in rhe furure: (a) rehabiliration services
will be provided through rhe healrh
care system in a managed care mode,
(b) there will he an increasing demand
for vision-relared rehahilirarion as rhe
aging popularion lives longer and in-
creases in numbers, (c) access to ser-
vices will be an issue, especially in non-
urban areas, (d) even wirh growrh,
visual disahiliry will nor provide a suffi-
cient marker ro support a large cadre of
specialisrs, especially in nonurban areas,
(e) irinerant services are not ourcome
or cost effective, (f) the mosr prevalent
healrh care delivery locarions will he
communiry hospirals and ourparient
clinics, and (g) rhe mosr universally
prevalent rehahilirarion specialisrs will
he physical and occuparional rherapisrs.
Heimerdinger has advocared for major
effons by rhe vision anc! hlindness
organizarions and professionals to "pro-
vide specialized rraining and resource
marerials for rhe licensed occuparional
and physical rherapisrs who will he
availahle in rhe local communiry" (Hei-
merdinger, 1995, p. 24).
A founh reason for occuparional
rherapisrs ro provide vision-relared re-
hahilirarion is rhar rhe applicarion of re-
hahiliration rechniques and approaches
has heen found to be effecrive. A num-
ber of srudies have documented thar
rhe proper use of devices, rechniques,
and rraining methods can successfully
maximize rhe use of remaining vision in
persons wirh low vision. Training in rhe
use of magnificarion, illuminarion, and
conrrasr, along wirh environmental
modificarions, has heen found ro be ef-
fecrive (Goodrich & Mehr, 1986) Wirh
individualized rraining in rechniques ro
maximize rhe use of residual vision and
rhe use of oprical and nonoprical de-
vices, persons wirh low vision are ahle
(0 grearly improve their ahility to read
and perform self-care and work-related
aerivities (Nilsson & Nilsson, 1986). The
mosr drama ric improvements in visual
performance are seen when interven-
rions include hmh individualized train-
ing and environmental modifications.
Training that takes place in rhe person's
own home or a simulared environmenr
rends (0 m~ximize visual skills and im-
prove funerional performance (Good-
rich & Mehr, 1986; Nilsson & Nilsson,
1986: Sekuler & Ball, 1986). The con-
sensus of many ex pens is that compre-
hensive low vision rehabilirarion pro-
grams can have dramaric resulrs on the
independence and producriviry of affeC(-
ed persons (DeSylvia, 1990; DiSrefano &
Asron, 1986; Flercher er aI., 1991: Wein-
rab er aI., 1990). Unfortunarely, whereas
well-organized rehabilirarion programs.
such as musculoskeletal or cardiac pro-
grams, exist ro rrear persons wirh such
condirions, visual rehabi.lirarion pro-
grams have lagged behind rhe need
(Faye, 1990). The needs of many per-
sons, especially elderly persons, for
vision-relared rehabilirarion rhat ad-
dresses rheir biopsychosocial needs are
mosrly unmer (DiStefano & Asron,
1986).
To provide rhe most comprehen-
sive vision-relared rehabilirarion, occu-
parional rherapists will need to under-
srand and have a working relationship
wirh rhe agencies and professionals who
make up rhe vision services nerwork. lr
is also important for occuparional rhera-
pisrs ro be aware of rhe concerns rhar
professionals in rhe hlindness and low
vision rehabilirarion communiry have
about rhe entry of occuparional thera-
pisrs into rhe field.
Vision Services Network
Organized low vision rrearment services
in rhe United Srates hegan in the 1950s
wirh work done by rhe Industrial Home
for rhe Blind in New York. During rhe
late 19')Os and rhroughour rhe 1960s,
developmenrs were occurring rhar led
to rheiniriarion of more programs
(Rosenbloom & Goodrich, 1990). Since
1960, rhe number of journal articles
submined for publicarion on rhe ropic
of low vision has more rhan trirled
(Rosenbloom & Goodrich, 1990). Addi-
tionally, over rhe pasr 30 years. rhere
has heen a growing awareness of rhe
need for multidisciplinary teams among
rhose who work in rhe delivery of low
vision services (Maino, 1993).
Low vision services in rhis counDy
have rradirionally heen offered hyor
closely affiliared wirh srare, federal, and
nonprofir organizarions whose principal
mission has been the delivelY of ser-
vices for persons who are hlind. Hisrori-
cally, many of rhese agencies served
only persons who had gainful employ-
ment as a principal goal. Consequently,
rhere is a general perceprion rhar many
of rhese agencies have a hias against
serving oiller persons or orhers wirhour
vocarional goals. Mosr of rhe exisring
October /995. Volume 49. Number 9
 services are provided at a clinical facility
or at t.he home, school, or work setting
of the client. The Veterans Administra-
tion (VA) offers some inpatient low vi-
sion services to eligible veterans at clin-
ics offered at selected VA medical
centers. Some state and private agen-
cies provide field services such as orien-
tation and mobility training or compen-
satory training in the person's home.
Most of these services are nOt reim-
bursed by third-party payers of medical
or rehabilitation services for elderly per-
sons, such as Medicare.
Among the specialists who work in
the field of vision and low vision reha-
bilitation are ophthalmologists and op-
tometrists who are considered by many
as the gatekeepers of vision services. Al-
though some may criticize these special-
ists for not referring or informing pa-
tients about low vision rehabilitation
programs, it must be understood that
many of them are not specialists in low
vision and therefore do not have the re-
habilitation orientation that is found
among low vision specialists. The vision
services network typically includes the
following professionals and services:
• Ophthalmologists, who diagnose
ocular pathology, recommend
appropriate medical care, and as-
sist in defining corrective
interventions.
• Optometrists, who work with the
patient in achieving best correc-
tion and prescribe low vision de-
vices that allow the patient to
perform essential tasks.
• Technicians, who teach the pa-
tient the application and use of
prescribed low vision devices
• Rehabilitation teachers, who as-
sist the patient in Jeaming to per-
form essential daily living skills,
with or without the use of low vi-
sion aids. Usually, these profes-
sionals have a master's degree
from a program specifically de-
signed to teach daily living skills
to persons with visual
impairments.
• Orientation and mobility spe-
cialists. who instruct the patient
in independent travel skills, with
or without the use of low vision
devices. Typically, these special-
ists have a master's degree from
a program designed to teach ori-
entation and travel skills to per-
sons with visual impairments.
The Amel'ican joun-wl oj' Occupational 7berapl'
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-------, - _._----------- -------------
Occupational therapists are viewed
by many who traditionally work with the
low vision population as providing
expertise about the management of
nonvision-related conditions that affect
functional performance. The participa-
tion of occupational therapists in the re-
habilitation of persons with low vision
resulting from ocular pathology is rela-
tively new to many who provide special-
ized services to persons who are blind
or visually impaired. This situation has
led to some controversy and concern by
"traditional providers" as well as byoc-
cupational therapists who have worked
in low vision rehabilitation. Lambert
(1994) recently discussed the most sa-
lient concerns of the traditional provid-
ers about occupational therapists who
treat persons with low vision as being:
• Unfamiliar with the various disci-
plines in the field, and thereby
not appropriately referring pa-
tients for other needed services
• Inadequate in knowledge or spe-
cialized training in low vision
• Professionals who will introduce
the medical model into a system
based on a patient-centered,
nonmedical model
• Able to bill for thil'd-party l'eim-
bursement for occupational (her-
apy services, whereas traditional
providers have not secul'ed licen-
sure, ancl concern that clinics
may favor occupational therapy
in the delivery of services even
though more disability-specific
pmfessionals may be the most
appropriate provider
In ['aising these concerns, Lambert's in-
tention was to initiate dialogue among
the various disciplines in order to "meet
the needs of each profeSSion and more
importantly, the clients" (pp. 297-298).
Need for Integrated Low Vision
Rehabilitation Services
There is a need for greater attention to
low vision in rehabilita(ion programs as
well as a more integrated approach to
the delivery of low vision services than
currently exists. The population in need
of low vision rehabilitation includes
those persons traditionally treated by
occupational therapists in schools and
in vocarional, hOSpital, and long-term-
care settings as well as persons in the
community who are not being served by
traditional vision or medical rehabilita-
tion programs. Providing low vision ser-
vices will necessitate occupational thera-
pistS' acquisition of specialized
knowledge as well as the development
of a collaborative relationship with
professionals who comprise the tradi-
tional vision services network. Occupa-
tional therapists will need to acquire ad-
ditional knowledge of ocular pathology
ancl optics and receive training in the
functional use of magnification before
providing low vision services. The intro-
duction of more occupational therapy
and new models of service delivery will
not replace but rather will expand the
current vision services network for per-
sons of all ages who have visual impair-
ments ....
References
American Association of Retired Persons.
(1992). Facl sbeet, Amencan Association 0/
Retired Persons Washington, D.C.: Author.
Bail<.:v. K. L (1992) Low vision: The for-
gOllen tr~atmenl..1oumal o/Ophtbalmic
Nursing & Technology. 10. 103-105.
Branch, L., HorowitZ, A., & Can', C.
(1989). The implications for evervday life of
inciuent of self,reported visual decline
among people over age 65 living in the com-
munitv. Gerontologist, 29, 359-365.
DeS"lvia, D (1990). Low vision and ag,
ing. Optometrj' and Ifision Science, 67.
319-322
DiStefano. A.. & Aston, S. (1986). Reha-
biliwion for the blind and Visually impaired
eldedl'. In S. Bradl' & GRuff (Eds), A..qing
and Rehabilitalio~ (pp. 203-216). New
York: Springer
Faye, E. E. (1984). Clinical low uision.
Boston: I.illle, Ilrown.
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phia: Lippincott.
Flelcher, c., Shindell, S, Hindman, T.. &
Scbaffrath, M. (1991). Low vision rehabilita-
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Gieser, D. K (1992). Visual rehabilita-
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Goodrich, G, & Mehr, E. (1986). Eccen-
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Havlik, R. J (1986). Aging in the eight-
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 --------

Heimerdlnger, J. F. (199'5). Letters: billtauon of the visually handicapped with ad-

Health Care Reform. journal of Visual Im-
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23-24
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Weinrab. R.. Freeman. W.. & Selezinka.
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234) Boston' lillie, Brown.
THE ISSUE IS prumdes a forum for debate
and discussion of uccupational therapy is-
sues and related topics The Contributing
Editor of Ibis section. julia Van Deusen,
strives to have buth sides ofem issue ad-
dressed Readers are encouraged to submit
manuscnpts discussing oppusite points oj
uiew or new topiCS. AI! manuSCripts are sub-
Ject to peer z'el'iew Submil three copies to
Hlame Viseltear. cditor
Publzshed articles reflect the opinion
of the authors and are selected on the basis
of interest to the profeSSIOn and qualll)' or
the discussion

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930 October 1995. Vulume 49, Number 9

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