Rehabilitation of the Visually Impaired: Diplomate Emeritus in Low Vision

By Frank W. DiChiara O.D. F.A.A.O.

This book is about the visually impaired. It describes the usual elements of low vision—the low-vision examination, the corrective devices, microscopes, telescopes, hand and stand magnifiers, and nonoptical aids. There is so much more, and the book can be a great reference for the social worker, the physical therapist, the occupational therapist, the optometrist and ophthalmologist, and anyone who works with visually impaired individuals. There is a wealth of information that our authors have made available to the reader. The optics are simple to understand. Anyone who works with visually impaired will comprehend the pathology as most will have been exposed to them.

Contributions have been made by prominent men and women such as Dr. Paul Ajamian, Dr. Wayne Hoeft, Dr. Lawrence Kline, Dr. William Padula, Dr. Bruce Rosenthal, Dr. Tracy Williams, and Dr. Norman Weiss. They are some icons in the field of low vision.

• Language: English
• Publisher: Page Publishing, Inc.
• Release date: Jun 16, 2021
• ISBN: 9781662424472

Book preview

Chapter One

Vision Rehabilitation

Christopher A. Butler, BA,

Executive Director of In-Sight

What is Vision Rehabilitation?

Low-vision evaluations provide a critical bridge to independence for people living with vision loss. Teaching patients the proper use of directed lighting, magnification, glare control, lenses, and other devices helps people to use their remaining vision more effectively and efficiently.

For adults living with vision loss, however, the low-vision evaluation may only be the first step on the road to independence. Vision rehabilitation programs are a logical next step for people with visual impairments as they provide the tools, techniques, and peer support needed to increase confidence and independence at home, school, work, and in the community.

Vision rehabilitation programs can comprise a number of different specialties, including independent living skills training, assistive technology, orientation and mobility, peer support groups, reading services, and recreational programs.

Vision rehabilitation programs are offered in every state through nonprofit agencies that specialize in working with people who are blind and visually impaired, state government agencies, the veteran’s administration, as well as some for-profit companies that employ professionals such as occupational therapists.

Vision rehabilitation, when offered through a nonprofit VA hospital or state agency, is typically provided at low or no cost to the patient. Many of these agencies offer center-based programs as well as training that can be provided in a patient’s home or in the community. Some agencies also offer residential programs that house people for the duration of their training, which provides the opportunity to practice skills without the distractions and obstacles that they may encounter at home.

Different agencies have their own admission standards and may require a patient to be below a certain income level, have a certain level of acuities or fields, or live within a particular geographic area in order to qualify for some services.

Vision rehabilitation programs are typically staffed by certified vision rehabilitation teachers (CVRT), certified orientation and mobility specialists (COMS), certified low-vision therapists (CLVT), social workers, and other specially trained professionals who are skilled at helping people living with visual impairments to achieve their independent living goals.

The VisionServe Alliance (https://visionservealliance.org/) has a comprehensive list of nonprofit agencies that provide services for people who are blind and visually impaired.

Independent Living Skills Training

When someone is living with a visual impairment, especially when its onset is later in life, even the most basic tasks can seem like an insurmountable challenge. Everything from putting toothpaste on a toothbrush to eating out in a restaurant suddenly becomes a source of anxiety and frustration.

The fear of being embarrassed, lost, or unable to successfully complete a task may lead the person to exhibit feelings of isolation, depression, and anger.

The important thing to understand is that people who are blind and visually impaired can do almost anything that fully sighted people can do. With advances in technology, combined with common sense adaptations, people with visual impairments live full, active, and happy lives.

Independent living skills training, often provided by a vision rehabilitation teacher, can help people develop a set of simple adaptive techniques to reclaim their independence.

These adaptive techniques may focus on training the brain to pay more attention to information that comes from our other senses: hearing, taste, touch, and smell. It also may include using simple tools, such as bump dots, to help make everyday tasks easier.

The first step in the independent living training process is generally an assessment, which helps to determine what the person’s specific goals are. The assessment will include a conversation with the person about what things they are struggling with. They may also be asked to complete a series of activities designed to evaluate their current skills, and the vision rehabilitation teacher may make a visit to the person’s home to assess simple changes that could be made to increase safety and independence. As a part of the process, the vision rehabilitation teacher may also reach out to family members, friends, and caregivers about their perceptions of the person’s strengths and needs.

Some of the suggestions a vision rehabilitation teacher may make while visiting a person’s home are fairly simple and straightforward. Eliminating scatter rugs to avoid tripping over them, moving furniture closer to the television to make it easier to see, installing fluorescent tape on stair treads to decrease the chance of falls, and increasing lighting under kitchen cabinets are easy and inexpensive things that people can do to improve their safety and independence.

Other recommendations from the vision rehabilitation teacher might require the person to invest a bit more time and effort in training and practice, but the results are well worth it.

For instance, many people with visual impairments struggle with using kitchen appliances such as microwaves, stoves, and ovens because they can no longer clearly see the buttons or dials used to set the proper time or temperature. While the person might be able to use a hand magnifier for this task, many people say that they find it cumbersome to carry a magnifier with them everywhere they go in their home. A vision rehabilitation teacher may suggest the use of bump-ons, which are small peel and stick silicone dots, to create a tactile marker. A bump-on placed on the five and start buttons of the microwave, for instance, will help people to find the most critical parts of the keypad. Once a person can find the five with some practice, they can easily locate all the other numbers.

Independent living training can encompass a large array of topics, but most programs offer comprehensive training in the following topics:

Organization and labeling which provides the foundation for many other skills—creating an organizational and labeling system helps people more easily find items in their kitchen, bathroom, closets, and office spaces, as well as prescription medications and other important items.

Communication skills include learning about adaptations for writing such as using low-vision pens, bold-lined pads, and signature guides—using phones that are specially designed for people living with vision loss, and for some people, it may also include lessons in braille.

Home management covers all the daily living skills needed to be independent in our own homes, including learning adaptive skills for cooking, cleaning, washing clothes, and basic home repairs.

Personal self-care, including shaving, brushing teeth, and applying makeup.

Financial management helps people learn how to pay their bills using large print checks or check guides, identify currency, and maintain their financial records.

Mealtime skills help people learn adaptive techniques for identifying what is on their plate, finding and applying the right amount of seasonings, cutting food, pouring without spilling, and other tasks that can become a challenge with low or no vision.

Not everyone will engage in training in all these areas. In most programs, a training plan is developed that is tailored to a person’s specific needs and interests.

The people who are the most successful in these programs are those who commit to consistently practicing and implementing the skills they learn in all aspects of their lives.

A great example of successful independent living training is Harold, a man in his mid-seventies who came to In-Sight for vision rehabilitation training. Throughout the training process, he was resistant, always pointing out that his wife did all the cooking, cleaning, laundry, household finances, and other activities of daily living. So in his mind, there was no reason for him to learn these skills for himself. He would often remind us that he was here simply because his family made him come.

About six months after Harold finished his training with us, his wife unexpectedly passed away. Suddenly, Harold was on his own. Thanks to the initial training as well as the follow-up support he received once he was on his own, he was able to live independently in his own home for several more years.

Assistive Technology

Advances in technology have helped to make people living with vision loss more independent than ever. Computers, video magnifiers, and smart devices have made it easier for people with visual impairments to access information, connect, and communicate.

Just like fully sighted people, those living with low and no vision can successfully use computers and tablets to access information, communicate via e-mail, play games, interact on social media, shop, and much more. Most computer platforms now come with basic screen magnification and screen readers built into them, which makes it possible for people with low or no vision to access them easily. Depending on their needs, some people may also invest in specialized software that provides more powerful tools for accessing the computer, such as screen magnifiers and text to speech capabilities.

Most smartphones now come equipped with a wide range of accessibility features that can be toggled on, including the ability to enlarge text, change the color and contrast of the background and text, magnify items on the screen, a voice-over feature that reads text to the user, and a smart assistant, such as SIRI on Apple products, that can retrieve information and open and close applications. These features make it possible for people with low and no vision to fully access their phones to communicate, find information, play games, and participate in social media.

There are also a growing number of smartphone applications that people with visual impairments can use to increase their independence. There are apps that can read text, identify currency, provide walking directions, and utilize artificial intelligence to describe a scene using the device’s camera. Like all apps, however, some are better than others, and prices can vary from free to quite expensive.

Another burgeoning area of technology is smart devices, which allow a person to access the features of the device or appliance with just their voice as opposed to having to press buttons or type in text. Smart speakers, such as the Amazon Alexa, can play music, tell you the time, maintain your calendar, find information, read audiobooks, and play games simply by the user-speaking commands. Similarly, smart televisions can change channels, find specific programs, and adjust the volume using just your voice as opposed to trying to navigate the small buttons on a remote control.

There are also some assistive technology devices that have been created specifically for people with low or no vision. Some of these are inexpensive and simple to use, including a full range of talking products, such as watches, scales, and clocks, while others are more expensive and may take some training in order for a person to use them successfully.

Many people with low vision, for instance, find video magnifiers to be a useful tool for reading, writing, and other tasks. A video magnifier is simply a camera that is mounted above a tray on which the user can put items that they want to see. The camera sends the image to a video monitor that is typically mounted above the tray. By using the controls on the machine, the user is able to make the image on the screen larger or smaller as well as change the color and contrast to make it easier to see. People use video magnifiers to read their mail, newspapers, magazines, books, food packaging labels, medicine bottles, and much more.

While the basic technology of video magnifiers has not changed since they were first developed several decades ago, advancements in technology have created units that now have bigger and wider video monitors and high-definition cameras. Some models also have the ability to read the text on the screen to the user.

Given the vast amount of technology that is available and the speed at which it changes, it is highly recommended that before committing to a particular solution that people engage in an assistive technology assessment to help better define their goals and options so that they ultimately invest in the solution that will be most helpful to them.

An assessment is generally done by a professional with a strong background in assistive technology and generally includes a conversation with the person to determine their goals, their past experience using different types of technology, an evaluation of their current skills, and hands-on demonstrations of various devices. From this assessment, the person with visual impairment should gain a much clearer idea of what types of devices will be the most helpful for them.

Once a person has invested in a piece of assistive technology, it is also recommended that they return for training to ensure that they understand how to make the most of their new device.

Many vision rehabilitation agencies incorporate assistive technology assessments and training either into their low-vision evaluations or as a separate program that works as a piece of the agency’s larger vision rehabilitation program.

While assistive technology is an important and growing part of the vision rehabilitation field, it is important to keep in mind the following:

While prices have come down in the past few years, assistive technology can still be a costly investment that is currently not covered by health insurance. This makes the assistive technology assessment even more important because it helps people to avoid purchasing something that may ultimately not be the right fit for them.

Technology changes very quickly, and so the product you buy today may be completely obsolete in just a few years.

Some technology has other costs associated with it that need to be taken into consideration. Smart technology devices, for instance, are relatively inexpensive but do require a Wi-Fi connection to work, which in most cases means paying a separate monthly fee. Some technology, especially computer software, may require enrolling in a maintenance plan, which comes with a monthly or annual fee to gain access to important updates.

How might someone use assistive technology to be more independent?

Sometimes, it is something that is very basic. Millie, a ninety-year-old woman with very low vision, was frustrated each morning because she could never remember what day it was. Now Millie has an Amazon Echo Dot on her nightstand. Each morning, she wakes up and says, Alexa, what day is it? and the automated voice lets her know. As she has become more comfortable with the device, she has been able to use it to tell her what is on her calendar for the day, what the weather forecast is, and to read the headlines from her favorite newspaper.

Other times, assistive technology can be useful to solve a unique problem. Mike, for instance, has always been a do-it-yourselfer. When the hose on his washing machine needed to be replaced, he was confident that it was something he could do himself instead of having to hire a plumber. Mike, who has very little usable vision, was able to get the old hose off and put the new one on mostly by feel, but when it came time to tighten the clamp on the hose connection, he was having a lot of trouble lining up the screwdriver with the screwhead. The solution he found was to use a free app on his phone to connect with a volunteer who used the camera on Mike’s phone, which he was holding in one hand, to give him directions to successfully guide the screwdriver into the screwhead.

Orientation and Mobility

When vision begins to decline, two main skills are often affected: orientation and mobility.

Orientation is the ability to make a mental map of where you are and where you want to go. Mobility is the act of actually getting there as safely and independently as possible. For most of our lives, we apply these skills unconsciously whenever we have somewhere to go. But people with vision loss must both develop and learn to apply new orientation and mobility skills.

People living with vision loss who have not had orientation and mobility training may report increased instances of trips and falls, collisions with furniture, walls, or other people, and increased anxiety when trying to navigate unfamiliar locations.

These experiences can lead some people to avoid going out of their home for social or recreational activities due to fear and anxiety, which in turn can increase their feelings of isolation and depression.

Orientation and mobility training is generally best provided by a certified orientation and mobility specialist (COMS), who has completed a rigorous masters-level degree program, demonstrated their knowledge and skills as part of the certification process, and continually engaged in professional development activities to hone their skills.

Most vision rehabilitation programs have orientation and mobility training as a component of their overall menu of services, and instruction is generally provided at no or low cost.

As with other vision rehabilitation programs, the first step in orientation and mobility training is usually a comprehensive assessment that includes a conversation with the person about their goals for independent travel and observation of their existing mobility skills. The result of the assessment is often the development of a written training plan that includes a set of goals that the person and the COMS will work on over a period of time.

The structure of an orientation and mobility training plan is very specific to the person receiving the training. A person living in a large city, for instance, would likely have many different needs and access to resources than someone who lives in a very rural area—the same with someone who works full time in a large office building versus someone who is retired and rarely ventures away from home.

In general, orientation and mobility instruction will include route planning, obstacle avoidance skills, the use of protective techniques, and skills for safely navigating stairs, doorways, and perhaps crossing streets. More advanced training may also include instruction on the proper use of various types of public transportation such as buses, subways, and trains.

As part of orientation and mobility training, some people may also receive instruction in the proper use of a