Lecture 2, 3, 4 - LVA assessment + Reg

Question 1

1. LVL Form (Low Vision Leaflet)

Answer 1

• Issued to patient by optometrist
• Self-referral form
• Access to social services
• Supplied by social services departments (SSD)

Question 2

2. RVI Form (Referral of Vision Impaired Patient)

Answer 2

• Issued by ophthalmology department; (e.g. ophthalmic nurses, junior doctors, orthoptists,
  optometrists, dispensing opticians)
• Application for access to social services

Question 3

3. CVI Form (Certificate of Vision Impairment)

Answer 3

• Certifies patient as blind, completed by consultant ophthalmologist
• Certifies patient as blind
• Information to census office
• Access to help is not dependent on registration

Question 4

Paediatric CVI Form

Answer 4

• This is to be completed in addition to the standard form and contains details about the
  disorder(s) resulting in visual impairment of the paediatric patient.

Question 5

What is the registration process?

Answer 5

• Copies of the completed CVI are sent to local social services department, GP & Office of Population Censuses and Surveys for Research
• Social worker visits patient to discuss if they wish to be registered or need a community care assessment
• If there’s a long delay can be back dated
• Children registered blind after 4 years old unless obviously no sight
• Patient can then receive benefits of registration

Question 6

Why should a patient get registered?

Answer 6

To determine funding & resource allocation it is important that accurate statistical information
about the number of blind & PS patients is available nationally & for each local authority area.
Estimates suggest that up to 50% of patients who are eligible are not registered.

Question 7

Whats the benefits a registered patient can receive?

Answer 7

• Financial help (extra benefits and concessions e.g. income tax relief & VAT exemptions)
  
  • 50% off TV license for blind, not PS!
  • Free BT-directory enquiries service
• Free GOS sight test (England)
• Transport (free in some areas, disabled car badge)
• RNIB- talking books & many other very useful services
• British wireless for the Blind Fund- radios

Question 8

Registration – Disadvantages and problems with the process*

Answer 8

• Health care & other professionals may not tell patients about registration and it is often done as a last resort by ophthalmologist
• Poor communication between professionals involved- ophthalmologists, social workers, optometrists etc.
• Long waiting times
• Not enough social workers - may not be trained in dealing with LV patients
• Budget cuts & lack of funding

Question 9

Low Vision Aid Assessment: Difference between normal eye exam

Answer 9

• There is not one unique outcome or solution fot the Px (e.g. VA of 6/6)

Question 10

Points to consider before you start low vision assessment:

Answer 10

• What does the patient want you to do (and is this possible)?
   Px expectations may be too high or very low
   Px may be distressed, disillusioned & tire easily
   Poor motivation
• The patient must agree with what you want them to do - they make the final choices!

Question 11

What points can make LVA’s time consuming?

Answer 11

• Adjust your speed to the patient (e.g. Elderly, children) and avoid unnecessary tests/procedures
• Keep talking to the patient. Don’t use gestures which they might not see!
• Get all their current/past spectacles and magnifiers if possible
• Encourage carers/family to be present unless patient objects
• Px may have other disabilities e.g be prepared to cope with hearing loss as well

Question 12

What general observations can be done from first contact with the Px?

Answer 12

• Are they bothered by bright light?
• Any physical infirmities, which restrict range of activities they need to undertake and limit
  their visual requirements, but also restrict the ability to handle LVAs.
• Do they look straight at you when talking, or use eccentric viewing?
• Can they navigate independently, or need to be guided? If guidance is required offer your arm and use the correct sighted guide technique.

Question 13

How to correctly guide a VIP?

Answer 13

– VIP follows half a pace behind
– VIP takes guide’s arm slightly above elbow
– Change to holding wrist if space narrow (or guiding child)
– Crowds: in single file

Question 14

How steps, doors and chairs are handled with a VIP:

Answer 14

Steps
– keep up a running commentary
– say if they go up or down

Doors
– VIP on same side as hinge
– Guide opens door and “hands it” to VIP

Chairs
– approach from behind and put VIPs hand in centre of back-rest, or
– approach from in front, and put their hand on arm-rest, or seat
– VIP stands with back of knees touching edge of seat before sitting
– Guide should say if there are any obstructions round the chair

Question 15

Visual status questions during H&S:

Answer 15

• Distance and Near Vision (ability to read newspaper, watch TV etc)
• Mobility
• Everyday tasks (e.g. kitchen)
• Hobbies or interests
• Different lighting conditions

Some practitioners use questionnaires to assess visual status

Question 16

Whats important about patients saying they cant see/read anything?

Answer 16

What they actually mean is they don’t enjoy reading, because it is difficult, but it is important to find out what size print they would be able to manage, as this is useful when calculating their magnification requirements

Question 17

Ocular and General health history:

Answer 17

• Onset of impairment, duration and circumstances
  − Stability of vision, difference between the eyes
• Ocular condition if known
  − Cause, duration & onset (sudden onset patient may be too upset for assessment)
  − Stability & prognosis (deteriorating, improving or stable)
  − Current, past & future treatment
• General health and medication
• Physical infirmities (e.g. Arthritis or Parkinson’s - can’t hold hand magnifier.)
• Registration of vision impairment

Question 18

Previous & Current Low Vision Aids history:

Answer 18

• Previous LVA assessments and previous LVAs used?
• Important: Have they previously tried LVAs that they didn’t find useful and Why?
• Current LVAs & spectacles used?
  − Record VAs and details of currently used LVAs (e.g. power /magnification,
  how old?, condition etc. )

This is important because if a px used to be able to read with a magnifier, but now can’t, their eye condition has deteriorated

Question 19

Occupation & Education:

Answer 19

For patients of working age this is relevant as it will help you establish target VAs, required
working distances and magnification needs.

Question 20

Patients Motivation & Expectations during history:

Answer 20

• What does the patient hope you can do for them?
• Is their expectation realistic?
• If their expectation is unrealistic try to let them down gently, but do not promise things
  you can’t deliver!!

Patient motivation has major outcome, if a px is more positive and willing to try new things, they are more likely to succeed using them

Question 21

Social Circumstances & Family history:

Answer 21

You may sometimes need to initiate a referral to social services/voluntary organisations:
* Live alone?
* Family & friends?
* Attitude of patient (angry, denial, confident, unconfident, depressed or accepting)
* Attitude of family (caring & supportive, over-helpful or uncaring)

Question 22

Requirements & Priorities:

Answer 22

• Important to prioritise, unlikely solution for all problems
• Different LVAs will be required for different tasks, px may have many LVAs

Question 23

Psychological Aspects

Answer 23

• patients must be willing to accept help
• Beware of patients that don’t want help because they dont want to be a burden
• Loss of vision is a form of bereavement, and the adaptation to loss is known as the Loss model

Question 24

What are the 5 stages to the Loss Model

Answer 24

The Loss Model is probably most appropriate to sudden visual loss. The five stages are:
1) Denial & shock “It can’t be happening.”
2) Grief “I used to do such a lot, now I can’t do anything.”
3) Anger “Why ME? It’s not fair!”
4) Depression & apathy “I’m so sad, why bother? I’m sure you will not be able to help me”
5) Acceptance “It’s going to be OK.”

Question 25

Describe “Shock” in the Loss Model

Answer 25

• Sudden loss, eg wet AMD or stroke
• Disbelief,
• Patient doesn’t appear to comprehend and doesn’t appear to be listening

Question 26

Describe “Grief” in the Loss Model

Answer 26

• Not the same as disbelief
• Refuses to admit that they have a problem (good example is driving with reduced VA
  against the advice of eye care professionals); Most of the public think that ‘blind’ =
  complete darkness
• May refuse LVA’s (“I just need stronger glasses”)

Question 27

Describe “Anger” in the Loss Model

Answer 27

• May feel that there is lack of or improper treatment
• Px may stop taking prescribed medication

Question 28

Describe “Depression & apathy “ in the Loss Model

Answer 28

• Hopeless situation, Going to get worse
• Nothing can be done and LVA assessment is a waste of time
• May need counselling or psychotherapy

Question 29

Describe “Acceptance” in the Loss Model

Answer 29

• Final stage
• Understands and accepts the condition
• Makes effective use of remaining VA
• Uses LVA’s, eccentric viewing, white stick etc.
• Happy to use aids in public

Question 30

What did Dodds (1989) model describe?

Answer 30

• self-efficacy is regarded as the primary factor in adjustment to vision loss.
• He argued that early skill-oriented intervention can prevent loss of competence and foster a sense of personal control essential to successful rehabilitation.

Question 31

What is the Self-Efficacy Model?

Answer 31

Self-Efficacy Model
* Loss of sight reduces ability to do simple tasks
* Loss of control & self esteem (personal & social)
* Depression

Treatment
* Prevent loss of competence- start rehabilitation as soon as possible
* Goal is to get them performing old tasks at a very early stage
* Simple techniques with positive feedback
* Tasks which show rapid progress
* Attribute failure to external influence and success to their own efforts

Question 32

What environmental factors can affect the process of adjustment to the ability?

Answer 32

• Death of partner, relative or close friend
• Patient is carer for someone else
• Financial problems
• Reaction of relatives eg over helpful or don’t care

Question 33

Vision Assessment: Aim and steps

Answer 33

The aim is to establish the patient’s magnification requirements for specific tasks. A reliable, consistent VA measurement is essential, although it can be tricky to obtain this.

1. Measure current distance best corrected VA (BVA) & Near BVA with aids & specs. It is
   often not useful to measure vision (abnormal relationship between vision and VA).
2. Refract if indicated
3. Establish distance magnification requirement
4. Near magnification requirement

Question 34

1. Measure current distance best corrected VA (BVA) & Near BVA with aids & specs.

Answer 34

• use current correction if apparently correct
• give the patient impression they are doing well – cooperation is key!
• start close, work back (0.5m then 1m etc)
• increase or decrease illumination if necessary
• recording:
• monocular & binoc VA, type of chart and distance, light level, head turn/eccentric viewing etc

Question 35

2. Refract if indicated

Answer 35

Objective – important because subjective often very difficult/variable.
Subjective
* Think about ‘Just Noticeable Difference’, DO USE LARGE STEPS!!!!!
* Direct the patient to single letters or lines and use comparisons e.g.: “Clearer with or
without?”
* DO NOT ask open ended questions like: “How is it with this lens?” or “What can you read
with this lens?”
* Reduce testing distance if required (adjust Rx for distance!)
− Px should be able to see about 4 lines of the test chart

Question 36

3. Establish distance magnification requirement

Answer 36

• Identify the visual task & estimate the VA that is required for the task (target VA [TVA])
• Calculate magnification requirement based on BVA and TVA
• Check if px achieves this with LVA
• Often more important for younger patients or children (ability to see board etc.)

Question 37

4. Near magnification requirement

Answer 37

• Idenntify visual task and estimate TVA
• Measure BVA, and estimate magnification required
• Assess central fields - if a defect is suspected, before prescribing magnifiers, as may need to assess eccentric fixation
• Try predict magnification - check VA with magnifier, modify as requried
• Start with simple magnifiers, high add, hand or stand magnifier
• Always prescribe LVA with clear instructions

Question 38

Other tests

Answer 38

• Establish binocularity (e.g. Cover test) and eye dominancy (many LVAs are monocular)
• Contrast sensitivity if indicated
• Fields (Amsler may be most useful in LVA assessment)
  − Ophthalmoscopy/fundus photography, OCT, IOPs etc
• Spend your time wisely and do not do unnecessary tests

Question 39

Advice & follow up

Answer 39

Important- patients often forget what the aid was intended for or how to use it
* Ideally review patient in 2-4 weeks
* may need to change LVAs

Question 40

Communication

Answer 40

• Speak slowly & clearly
  o May have hearing loss - speak to best ear
• Be encouraging & positive
• Don’t rush the patient, but stay in control

Question 41

Test