LOW VISION AIDS

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 Outline
Revision
Introduction
Optical LV aids
Non optical LV aids
Mobility and orientation
Sensory substitution
Training patients with low vision

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 Assignment
1. Basis to classify LV aids as optical or non optical & their difference?
2. What are the advantages and disadvantages of hyper ocular & clip
on spectacle magnifiers?
3. Can telescopes be used for near vision? If so, how?
4. How can we record VA using Log MAR at different distances for a
low vision patient?
5. Discus about the revised visual impairment and blindness
categories (from grade 0-9).
6. How can you differentiate hand magnifiers from stand magnifiers?

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 Revision
• Definitions
– Disease
– Impairment
– Disability ICIDH
– Handicap
– Low vision
– Blindness ICD 10th, WHO, revised def (ICO &WHO)
– Legal blindness
– Typical low vision patient
• Impacts of VI
• Low vision assessment:- Hx taking, VA, CS, refraction
• Magnification: types, determination, ways
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 Introduction

 Low vision management

Major component of comprehensive vision rehabilitation

 Low vision aids

Do not restore sight but make it easier for people with
vision loss to take advantage of their remaining abilities
Can be optical or non-optical aids

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 For any low vision device to be effective and comfortable,
– The Px must be motivated to use the device for specific task

– Have confidence that the device has been appropriately given

– Know how to maximize the use of the device

– Know its potentials and limitations

– Supplement the use of the device with appropriate lighting

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Management Goals
 Improving distance, intermediate or near vision

 Improving print reading ability

 Reducing photophobia

 Improving the ability to travel independently

 Improving the ability to perform activities of daily living

 Maintaining independence

 Promoting independence and improving the quality of life

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Optical low vision aids for near
 Spectacle magnifiers
– High reading adds

– Hyper oculars
– Clip on magnifiers

 Hand magnifiers
 Stand magnifiers
 Electronic (CCTV)

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 Spectacle magnifiers
High reading adds
• High plus reading glasses also called "microscopes"
• Given as an add to the best distance refraction
• Amount of add needed depends on the accommodation
and the reading distance

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• If the patient is monocular, the poorer eye may be occluded
if it improves visual functioning

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Advantages
– Hands free
– Good field of view (Can read several

words at one time)

– Binocular viewing possible
– Cosmetically acceptable

– Can incorporate cyl

– Can read for longer periods of time than with hand-held and
stand magnifiers
– Bifocals possible, up to +16.00 add
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Disadvantages
– Short working distance for high powers

– Need additional illumination

– Often not tolerated by elderly people

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Hyper oculars
– Very high plus aspheric lenses
– bi convex, lenticular forms
– x4 to x12

– Monocular usually

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Clip on magnifiers
– binocular up to x3
– monocular up to x7

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Hand magnifiers
 Used for spot reading
 Available from + 4.0 to + 68.0Ds
 Most patients accept up to x6 magnification

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Advantages
 Wide range of powers
 Socially acceptable
 Inexpensive
 Portable
 The eye to lens distance can be varied
 Patient can maintain normal reading distance
 Work well with patients having eccentric viewing
 Illuminated hand held's available

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Disadvantages
• Need good dexterity and occupies both hands
 Patients with tremors, arthritis etc have difficulty holding the
magnifier

– Maintaining focus is a problem especially for elderly

– Field of vision is limited
• Higher power magnifiers allow the patient to read only a few
letters at a time & reading speed can be affected.

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Stand magnifiers
• Simplest device for reading
• The patient needs to place the stand magnifier on the
reading material and move across the page to read
• Has a fixed focus
• Up to x22
• Commonly prescribed x3 to x7

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Advantages
• Fixed accurate working distance
– Useful if hand tremor/weakness

• Good range of powers

• Can use hands free in lower powers

• Binocular viewing for lower powers

• Inexpensive
• Can be used in combination with spectacles

• Illuminated stand magnifiers available (battery or electrical)

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Disadvantages
• Short working distance can reduce illumination

• Can be bulky / heavier/not portable

• Field of vision is reduced

• Too close reading posture is uncomfortable for the
patient

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•Bright field/ flat field magnifier
•Up to x 2.2
•Gathers light

•Bar magnifier
•Up to x2 in 1 direction
•Gathers light

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Closed circuit television system(CCTV)
• Consists monitor, camera and platform to place the reading text

• It has control for brightness and contrast

• Magnification varies from x3 to x70

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Advantage
• Very high powers up to X70

• Can adjust brightness and contrast

• Have choice of color displaying

• Normal posture
• Better field of view

• Binocular viewing

• longer working distance

• Psychologically acceptable
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Disadvantages
• Not portable
• Expensive
• Difficult to use
• Not available /provided to patient by employer or
education services /

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Types
 TV screen mounted over X-Y table
 Portable
 Head mounted

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 Problems using low vision aids
• Case scenario
– You dispensed a 3x hand magnifier to your patient, who read N5
easily at the low vision assessment. The patient returns
complaining that he cannot see anything with it at home.

• How can you explain this?

• What can you do to help?

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 What factors affect reading performance?

• Near VA
• Size/position of scotoma
• Contrast sensitivity
• Binocular stability
• Acuity reserve
• Posture, dexterity
• Contrast reserve
• Cognitive function
• Reading speed
• Poor understanding of LV aid
use

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 Acuity reserve
• If you want to read comfortably for a sustained period of time e.g. a
book then you will need an acuity reserve.

• This means that the text should be around 3x larger for fluent reading
than your threshold acuity otherwise your reading speed will be too
slow and you may feel like giving up.

• However for spot or survival reading e.g. instructions on packet,

threshold acuity is sufficient (even if it is hard work).
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 Contrast reserve

• For fluent reading you need a contrast reserve of 10x your

contrast threshold i.e. the print needs to be bold.
• For spot or survival reading you only need 3x your contrast
threshold
• When the text is both small and of poor contrast it’s very
difficult to read.

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 Acuity reserve and contrast reserve

In practice, may help explain why?

• Good near VA but c/o difficulty of reading

• More magnification needed than expected

• Illumination helps such a lot

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Low vision optical devices for
Distance

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 Telescopes
• Afocal systems- parallel rays of light enter the telescope
from an infinitely distant object, and parallel rays leaving
the telescope form a final image at infinity
• Usually x2 to x10 are prescribed
• Field of view decreases with magnification

• Only possible device to enhance distant vision

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 How does a telescope work?

• In a essence
– System of 2 lenses; objective and eyepiece

– High powered lenses

– Angular magnification

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 How does a telescope work?
• Galilean
– Positive objective
– Negative eyepiece

• Keplerian (astronomical or terrestrian)

– Positive objective

– Positive eyepiece

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 Galilean telescope

FO FE
M = b/a

a b

fo
fe
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 Keplerian telescope

FO FE
M = b/a

a b

fo fe

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 Magnification = - dioptric power of eyepiece
dioptric power of objective

i.e. M = - FE
FO

e.g. Galilean telescope e.g. Keplerian telescope

FE = -40D FO = +20D FE = +40D FO = +20D

M = - (-40) M = - (40)
20 20
M = x2 M = - x2
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 Telescopes: comparison
• Galilean
– smaller, lighter, cheaper

– image upright and virtual

– poorer image quality, lower magnification up to x4

• Keplerian
– longer, heavier, more expensive

– image real & inverted, needs roof prism

– better image quality, higher magnification up to x12

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 Is this telescope Galilean or Keplerian?

• Educated guess based on size/ weight / magnification/

• Exit pupil method

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 What’s the exit pupil?

• Exit pupil = image of objective lens formed by eyepiece

• All light emerges through exit pupil

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 Where’s the exit pupil?

exit
pupil

Galilean: virtual exit pupil within telescope

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 Where’s the exit pupil?

exit
pupil

Keplerian: real exit pupil outside telescope

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 Looking for the exit pupil
• Hold telescope 20cm from the eye, eyepiece towards you
• Exit pupil is small bright circle of light
• Move head side to side
• Observe movement of exit pupil
– With movement: Galilean
– Against movement: Keplerian
• Keplerian exit pupil much easier to see
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 Why’s the exit pupil important?
• When eye placed at exit pupil,
– eye receives all light entering telescope

– maximum light
– maximum field of view

• Keplerian:
– exit pupil outside telescope
– eye at /close to exit pupil

– better image quality and FOV than Galilean

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 Telescopes: field of view

Depends on
• Magnification
• Vertex distance
• Diameter of objective
• Tube length
 FOV better with Keplerian than Galilean

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 What do the numbers on the telescope mean?

• e.g. 8 x 20 6.5o
– magnification = x8
– diameter of objective = 20mm
– field of view = 6.5o

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Types
– Hand held telescopes
– Clip on design
– Spectacle mounted telescope
– Bioptic design: mounted on a pair of eyeglasses
– Telemicroscope design

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A. Hand-Held Telescopes
• The most common type of distance optical device

Advantages
– Inexpensive, small and portable
– Available in a range of magnification powers

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Disadvantages
– Restriction of the FOV (Depth perception is distorted)
• Walking or moving about while looking through the telescope is
not recommended

– They require steady hands and good motor control in order

to focus the lens
• Even slight hand movements or tremors can affect the clearness of
the image

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B. Clip-on telescopes
• Monocular telescopes also come in clip-on versions that
attach to eyeglass frames and leave both hands free.

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C. Spectacle-Mounted Telescopes
• Spectacle-mounted telescopes are permanently attached
to the lens of an eyeglass
Advantage
• They can be monocular or binocular

• They leave both hands free and are more stable than
hand-held telescopes
• They are available in a range of magnification powers
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Disadvantage
• They are the least "normal" looking of any low vision
device
• Walking or moving about while looking through the
telescope(s) is not recommended because depth
perception is distorted and balance is affected

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D. Bioptic telescopes
• are mounted on the upper part of each eyeglass lens

• This placement allows the user to look through the

bottom half of the lens while walking and then stop
and look through the telescopes to read a sign or
identify a person.
• Bioptic telescopes can be used while driving.
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E. Telemicroscope
• have an extra removable lens cap that fits over the end of
the telescope and allows the user to focus closer for
reading or other near tasks
• helpful when playing card games, knitting, or using the
computer.

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 Field expanding devices

• Three methods of increasing the field

Compressing the existing image to include more of
available area with minus lens
Provide prisms that relocates the image from a non
seeing to a seeing area
Use a mirror to reflect an image from a non seeing area.

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 Non optical low vision aids

– Items designed to promote independent living

– Used to help a Px to use his or her vision more efficiently

– Can be used to enhance reading, writing, orientation and mobility
– Cheaper than optical devices usually
– Easily available for use

– They alter environmental perception through enhancing

 illumination
 colour, shape, size

 contrast and position

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 Designed to make everyday tasks simpler
 Can be used with or without optical devices
 Available in
– specialty companies e.g. liquid level indicators and talking
thermometers
– general retail stores e.g. large button phones, high contrast large-
print books

 A slogan used is making things ‘Bigger, Bolder & Brighter’.

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 Making things Bigger (RSM)

– Large print texts

– Watches and clocks with large dials and hands or displays

– Telephones with bigger numbers

– Large dice and playing cards & bingo cards

– Rulers and tape measures with large scales

– Large dial blood glucose monitors

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 Making things Bolder
 By increasing the contrast
 To aid vision but did not affect the vergence system
 Did not increase size or improve the focus of retinal image
 Can be using
Luminance contrast
Chromatic( color) contrast

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 Using color contrast
o using different colors for the object and background
• Patient specific
• Should be tried against d/t backgrounds provided by coloured
sheets of paper
E.g.
o Colored electrical sockets

o Unmatched kitchen utensils

o Food ordering with d/t colour and place on contrastile plate

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 Making things Brighter
 Increasing the illumination
 Lighting preference varies
 Be aware of glare
Increase in lighting = increases glare

 Use directional light, with shade from the side

 Evaluate current lighting
 Demonstrate various types of light
Day light, incandescent light, tungsten halogen lamp, pen torch
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 Positioning
• Light source should be to the side of better eye

• Moving light closer will yield higher illumination

 Higher levels of illumination is needed in patients with

• Lost cone functions (macular degeneration)

• Glaucoma

• Diabetic retinopathy

• Retinitis pigmentosa, Chorioretinitis

 Reduced illumination
• Albinism

• Aniridia 65
 Aspects of optimizing illumination
– Increasing ambient illumination

– Localized task lighting

– Lighting for outside mobility

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 Optimizing the use of magnifiers/improving
reading and writing
 Reading stands
 Maintained required WD without undue effort

 For prolonged reading

 Can be used as office copy holder

 Can be home made or commercially available like Eschenbach and

the RNIB sell reading stands

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 To decide which model to buy,

– Consider the weight of the reading material

– Portability and adjustability
– Free standing on a table top or clamped
– Line marker required or not

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 Double ended clamp
 To convert a hand magnifier into stand magnifier

 One end attached to a table, the other holding a magnifier.

 Useful for doing tasks that require both hands free such as writing
or sewing.
 To hold the magnifier the clips need to be strong and may be
difficult to operate for someone with dexterity problems.

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 Clipboards
– Helpful for anyone using a magnifier

– Provide a firm surface, allows good posture and portability

– Clip-boards with top clips are best to avoid interrupting reading

with stand magnifiers

– The clip needs to be firm but able to be operated by arthritic or

weakened hands

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 Glare reduction – unwanted reflection
Possible approaches
– Changing the environment

– Umbrella, cape
– PH

– Artificial iris CL

– Typoscope
– Visors and shields

– Tints
 For discomfort glare

 For disability glare 71

Absorptive Sunlenses/Sunglasses
 filter out ultraviolet and infrared light
– Helpful for individuals who are sensitive to bright light and glare.
– Reduce glare and increase contrast.

– Inexpensive and easily obtained.

– Can be fitted over regular glasses or tints can be added to Rx
– Available in a variety of colors and tints, in either plastic or glass.

• yellows, green, blues, and brown tints available.

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Mobility and orientation
 assists a person to navigate safely and comfortably from
one position to another in an environment
 Can be
o Obstacle detectors
o Environmental sensors

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 Obstacle detectors
 Sighted guide
 A sighted person guides a person with visual impairment
 Proper training is required
o How to hold the sighted guide
o To stop
o To sit

o To move into the door etc.

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Guide dogs
 Only a very small number of people use guide dogs
 To have a guide dog
– you have to be over 16

– fit and active enough to walk and care for the dog
– Applicants must attend extensive training with the dog
– The owner must be able to direct the dog as to a given route
– the dog assists with crossing roads, avoiding obstructions

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 White sticks and canes
 available from social services and needs some instruction in their use.

 Occupational therapists or physiotherapists usually prescribe them

 Rehabilitation workers give training in the use of these canes.

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Environmental sensors
– To have full information about the environment

– The camera capture a picture and converted into tactile and

auditory information
– Not widely used

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Sight substitution
 To use hearing, touch and smell senses
o Different shaped buttons
o Audio-described videos
o Talking microwaves, clocks, watches, thermometers and scales and
mobiles
o Games with tactile counters, boards and cards

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o Balls that produce sound such as football & cricket
o Bump on can be used
o Talking calculator

o Braille
o Talking books, Computers

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Notex(Money finder)
 It is a rectangular piece of cardboard with steps on top right
corner which helps in identifying the currency of the note

Signature guide

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Training patients with low vision
– To use eccentric fixation
– Steady eye strategy

– To Find the next line

– How to use low vision aids
• Written instruction

– To properly use mobility options

– To use non visual sensory options

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 Quiz 5%
1. How can you differentiate a telescope as Galilean or
astronomical?
2. What are the advantages of stand magnifiers compared
with hand magnifiers?
3. How can you improve the reading performance of the low
vision patient?
4. What factors determine the FOV of a telescope?
5. What do we mean by legal blindness?
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What the low vision practitioner needs to
know about AMD
“I can’t find the macula”

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 Viewing the macular region
• Direct ophthalmoscopy
– macula stop

– get close, not too bright

– ‘look straight into the light please’ (for fovea)

• Indirect ophthalmoscopy
 Using condensing lens and dilators
 Good FOV but lower magnification

• Slit lamp with Volk lens

 Dilate
 better field of view (stereoscopic view)
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What does AMD look like?
• Dry AMD
look for yellowish, whitish or
pigmented patches
i.e. drusen, RPE changes,
geographic atrophy (late)

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• Wet AMD
It depends
– early or late
– may not see anything much

– Look for any CNV

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How do we know which type of AMD?
1. Patient may know
2. Vision loss: gradual or sudden
3. Distortion
4. Visual acuity (caution)
• 6/18 or better: dry or early wet
• 6/60 or worse: wet or advanced dry (GA)
5. Funduscopy
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Wet AMD: visual symptoms

• “When I look at my cigarette, instead of being straight, it looks bent”

• “Straight lines seem wavy”

• “Last week the vision in my left eye suddenly went and I can’t see at
all”

• “I noticed a black patch in the middle of my vision a few weeks ago

and it’s got worse”

• If patient notices recent onset distortion and / or Recent vision loss

(days or weeks) Refer urgently
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Amsler chart
• Can confirm distortion if suspicious symptoms
• Can be given to Px for self monitoring at home

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Management of AMD
1. Risk reduction

2. Treatment of choroidal neovascularisation

3. Rehabilitation

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 Risk factor Is it modifiable?
• Age no
• Family history no
• Smoking yes
• Hypertension yes
• Sunlight exposure yes
• Diet yes

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 Stop smoking
Thornton, J. et al. Smoking and age-related macular degeneration: a
review of association. Eye (2005) 19, 935−944.

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 Do statins help?
• Smeeth et al. A case control study of age related macular
degeneration and use of statins. Br J Ophthalmol. (2005) 89: 1171-

1175.
• Not sure yet

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 Dietary advice
• There is evidence that eating a healthy balanced diet with fresh
fruit and vegetables can help prevent AMD (i.e. prevent
progression to wet)
• Sweet corn and yellow peppers

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 “Is there any treatment?” wet

Need fluorescein angiography to decide.

• Majority: no treatment

• Macular translocation surgery

• Laser:
– Some people with wet AMD eligible for PDT (newer cold ‘gentle’ laser)

– Very few treatable with conventional laser (hot, destroys retina

• Anti VEGF treatments

• We must refer any suspected wet AMD urgently for fluorescein
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angiography
• Rehabilitation
 Low vision devices (optical/non optical)
 Visual field expanders

 Sight detectors

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Summary: be positive!
• “You’ll always keep your peripheral vision”
• Low vision assessment to preserve most of the remaining
vision
• Regular eye examinations to detect new problems
• Wear sunglasses
• Eat a healthy diet
• Stop smoking
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Management strategies for various
ocular conditions
 Nystagmus
• Involuntary oscillation of the eyes

• Congenital
– Idiopathic
– Associated with aniridia, albinism, ROP, congenital cataracts

• Amblyopia develops
• VA related to the extent of movement & other pathology

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Management
• Correct the refractive error

• Options for distance

– Monoc or binoc telescope
– Sit close to the board
– Sit with board on Px’s right side to use null position
• ask during case history

• encourage its use

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Options for near
– Enlarged print/handouts
– Simple magnifiers e.g. bright field, low plus

Other considerations
– Often high astigmatism > 3.00 DC, with the rule

– Contact lenses

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 Albinism

Some people with oculocutaneous albinism

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• Pigment absent or reduced in RPE and choroid

– excess light enters the eye through the iris,

& pupil
– discomfort and disability glare
– associated with reduced VA, nystagmus,
squint
– high refractive error
Fundus hypo pigmentation
e.g. R&L +5.00/-3.00x180

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Management
• Correct refractive error

• Manage nystagmus
• Manage glare

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Glare management options
• Modify the environment
– school, home, window blinds

• Wide brimmed hat, visor,

• Typoscope
• Tinted contact lens
• Sunglasses
– May still need additional task lighting
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Sunglasses e.g.
• wrap around
• over shields

• Rx sunglasses

• fixed tint

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 Aniridia

• Absence of iris

• Associated with cataract, nystagmus,

glaucoma, high refractive errors

• Can be from trauma

Management
• Control glare

• Cosmetic contact lens

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 Congenital cataracts
Polar cataract Sutural cataract

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• One or both eyes can be affected
• Surgery depends on severity of VA reduction

• Associated with nystagmus, squint, amblyopia

• Px with congenital cataract may be
– phakic

– pseudophakia
– aphakic

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 Management
– treatment of amblyopia
– IOL
– aphakic contact lens (1 or both eyes)
– aphakic spectacles

Adults and children

– bifocals/reading add
– glare management, UV protection
– low vision aids as needed
– squint correction
– strategies for nystagmus 113
 Retinitis pigmentosa
• Group of hereditary retinal disorders
• Affects rod photoreceptors
• Ring scotoma, spreads out and
inwards
• Advanced cases- small central
island of field left
mid peripheral bone
spicule pigmentation
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 RP: peripheral field loss

Normal view

Constricted field

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 RP: night blindness
normal night blindness normal

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 RP: glare

Images courtesy of http://www.retina-international.org/vision.htm 117

 RP: management
• Case history- extra questions
– problems with night vision?

– bumping into things?

– any difficulties at school, work?

– mobility, travel- how does Px manage?

• Providing help- advice

– Education and employment services

– Rehab worker: white cane, guide dog

– Constant light levels in home, manage glare

• Low vision aids and tints if needed

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 Glaucoma
• Symptoms?
– Early or late stage of disease

• Other eye conditions? Referral needed?

– e.g. cataract, AMD, DR

• Glaucoma getting worse?

– refer/upgrade registration

• Eyedrops
– can Px comply?
– stress compliance

– may need district nurse to instil drops 119

 Glaucoma
• Low vision aids if needed
• Manage:
– glare

– poor near VA,

– field loss (advanced)

• Encourage close relatives to have eye exam

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 Diabetic retinopathy
• Other eye conditions? Referral needed?
– e.g. cataract, AMD, glaucoma

• DR getting worse?
– refer/upgrade registration

• Blood glucose monitoring, treatment?

– can Px comply?

– stress the importance of control of blood glucose, blood pressure and cholesterol

– regular attendance diabetic clinics (eye, foot..)

• Low vision aids as needed- ?binocular

• Px may be very unwell

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 Hemianopia

L eye’s R eye’s field

field

e.g. Px with right homonymous hemianopia from stroke

– near VA N5
– complains difficulty of reading
– advice?

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 Hemianopia: management
• Typoscope
• Training: head and eye scanning (younger Pxs)

it might be easier
Read text vertically as
Or

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 Hemianopia: management

• Prism to shift image from non seeing seeing non

seeing
field to seeing field
• Prism base towards field defect
• Binocular to avoid diplopia
• Rarely prescribed

e.g. R sided field loss

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Constricted fields: management

e.g. RP, advanced glaucoma

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 Constricted fields: management
• Often gradual constriction therefore Px adapts
• Training
– head and eye scanning (younger Pxs)
– Hold print further away, sit further back from TV, board at school
– Field expander

• Mobility aids: cane, guide dog, rehab worker

• VA will reduce ++ with attempts to expand field
• May want to do perimetry
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 Management strategies: summary
• No ‘disease specific’ low vision aid
– patient chooses according to need

• Younger Pxs may derive more benefit than older Pxs from
– spec mounted aids, telescopes, CCTV, eccentric viewing training
and mobility training

• Consider referral to social services for employment and

education support

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In general our treatment option depends on:
• Degree of visual impairment, disability, or handicap

• Underlying cause of visual impairment and prognosis

• Patient's age and developmental level

• Overall health status of the patient

• Other physical impairments which may affect the ability to

participate in vision rehabilitation.

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• Patient's adjustment to vision loss
• Patient's expectations and motivation
• Patient’s cognitive ability to participate in the
rehabilitation process
• Visual requirements, goals, and objectives
• Lens systems or technology available
• Support systems available

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SIGHT IS NEXT TO LIFE
– Protect it

– Save it

– Restore it

– Let us work together

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‫״‬HELP WHEN THERE IS NO CURE‫״‬.
THANK YOU!

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