April 2018

Low vision in the 21st century
BY NAOMI MELTZER*
Last century, low vision services were regarded
as a last resort and an admission of failure.
Generally, when patients enquired as to
whether there was anything available to help
them see, the answer was either a tentative, ‘you
could buy a magnifier’ or a more defensive, ‘you’re
not bad enough for that yet’.
When medical and surgical options ran out,
the patient was dismissed with ‘there is nothing
more that can be done, sorry’. This was effective
at getting the patient out the door, but left them
emotionally and physically stranded, unable to
comprehend how to function visually when they
were neither blind nor seeing. More patients were
rendered functionally “blind” by this statement
than by any other documented pathology and,
sadly, many continue to exist in this state today,
convinced this statement remains true as it was
given by those they trusted.
For some, this attitude has continued into this
century, despite huge changes in medical, optical
and electronic technology, and the current view
of low vision as a spectrum of functional changes
that occur along the pathway between normal
vision and no light perception. A few weeks after I
started my low vision practice in 2011, I ran into an
ophthalmological colleague who told me, ‘I hope
you never get to see any of my patients!’ But for
many, there has been a shift in thinking towards
understanding that visual function cannot be
defined by the size of letter read on a high-contrast
distance chart or a monocular electronic visual field
analysis; and visual rehabilitation does not mean
restoring vision to normal, but the rehabilitation
of a person with visual loss to function within their
family, whanau, community or workplace.
Much of this change has been driven by the
realisation that even with the amazing advances
in medical science in the management of
ongoing problems such as glaucoma, macular
degeneration or other retinopathies, it is just that
– management of the condition – not restoration
of normal visual function. Thus, the best outcomes
are obtained when patients are given as much
information as possible on the range and type of
additional services available to them sooner rather
than later when all else has failed.
Times are changing for low vision patients, and about time too
Today, the modern low vision consultation reviews
how a patient with low or declining vision functions
in their everyday environment and how we can help
them use the vision they have more efficiently to
manage their day-to-day activities. This involves
taking a holistic view incorporating their general
health, and the impact of perhaps other health
problems such as stroke, Parkinson’s or diabetes
on their visual functioning; and their physical
environment – are they confined to one, poorly-lit
room in a rest home or actively participating in
sport or looking after other family members? Does
their visual problem extend to passive reading or
do they have other needs such as mobility or glare
control? Is there a history of amblyopia, binocular
vision instability or balance problems that has been
forgotten along the way or considered irrelevant due
to the patient’s poor distance acuity? Has the need
for prescription glasses to focus at near range been
overlooked as their vision deteriorated? Or do they
perhaps simply need reassurance there are options
available to help them if and when they need it?
A functional, low vision consultation helps assess
each patient on an individual, case-by-case basis,
going way beyond the ‘let’s see if a magnifier will
help’ approach.
Recently, a request for assistance from a resource
teacher brought home to me how much a bit of
lateral thinking and a good stock of low vision
aids can change an
otherwise ordinary
day. A 12-year-old
boy with low vision
due to retinopathy
of prematurity, copes
well in the classroom
with just his spectacle
prescription correcting
his hypermetropia and
high cyls plus a closeworking
distance to
use his accommodation
for extra magnification.
However, given he was
starting woodwork
and sewing and would
have to use sewing
machines, fretsaws and
grinding machines and the like, the resource teacher
was on the hunt for some additional magnification
for him.
She had found a magnifier attached to a
goose neck stand, but this got in the way of the
student and couldn’t be moved easily from one
piece of equipment to another. The boy was also
required to wear safety glasses for the woodwork
equipment so an initial idea to use a head loupe
was a non-starter, while a large magnifier on a
tilting wire frame, ‘just got in the way’. We settled
on a hands-free “embroidery” magnifier, which
sits against his chest with a cord around his neck
and is LED-illuminated. While only providing 2x
magnification (he needs 3.5x to read a mm ruler)
it was sufficient to help him see the needle or the
blade of the saw at a normal working distance.
What was exciting however, was watching the
student. He was like a kid in a candy store trying out
all my high-tech and low-tech electronic stuff. In his
lifetime, he will no doubt use way more high-tech
aids than are available today, but this exercise at
least showed both of us, how a simple low-tech, lowcost
magnifier and a good dollop of lateral thinking
can triumph. A very satisfying outcome all round. ▀
*After 30 years in general optometry,
Naomi Meltzer realised her passion
lay in visual rehabilitation and now
runs an independent, low vision
consultancy service in Auckland. She is
a MDNZ founding trustee, a qualified
CentraSight and eSight assessor and
OrCam trainer. For more, see the Low
Vision Services classified on p26.
Tackling trachoma and
other NTDs
BY ELLA EWENS
In December 2017, Dr Martin Kollmann, a
consultant ophthalmologist and associate
professor at the University of Nairobi, travelled
to New Zealand to address delegates from the
partnerships, humanitarian and multilateral
division of the New Zealand aid programme at the
Ministry of Foreign Affairs and Trade (MFAT). The
main aim of the visit was to build awareness of the
link between neglected tropical diseases (NTDs)
and poverty and demonstrate how tackling NTDs
is key to a region’s socio-economic development.
Dr Kollman, a senior advisor on NTDs for the
international charity CBM (formerly the Christian
Blind Mission), was accompanied by CBM NZ
chief executive, Stephen Hunt, and international
programmes manager, Linabel Hadlee.
NTDs are a diverse group of tropical infections,
especially prevalent in low-income populations in
developing regions. They are caused by a variety
of pathogens such as viruses, bacteria, protozoa
and helminths. The disabling and debilitating
effects of NTDs include blindness, mobility
impairment, preventing children’s growth and
development, malnutrition and extreme pain.
They are labelled ‘neglected’ because they affect
communities in extreme poverty. In some cases,
the uncontrolled spread of NTDs has resulted
in pastoral communities abandoning their land
to escape the transmitting pathogen but, as a
result of NTD control programmes, in more recent
times 25 million hectares of arable land has been
regained, feeding 17 million people annually.
Two of the most common blinding NTDs are
onchocerciasis (river blindness), found in Africa
and some parts of the Americas, and trachoma,
the leading cause of infectious blindness in
humans, caused by infection with the bacterium
Chlamydia trachomatis, which is still found in
Africa, the Americas, Asia, the Middle East and
the Pacific. Ethiopia carries 39% of the global
trachoma burden, with an estimated 74 million
people at risk and 40% of children aged 1-9
infected. Women are highly susceptible due to
greater exposure to young children, who typically
spread the disease. Trachoma is active in the
Pacific, particularly Papua New Guinea and
Australia in remote communities.
A doctor treats a trachoma sufferer in Ethiopia
Blindness from trachoma is irreversible. Infection
is spread through personal contact and by flies
that have been in contact with facial discharges
from an infected person. With repeated episodes of
infection over many years, a sufferer’s eyelashes may
be drawn in so they rub on the surface of the eye,
causing pain and permanent damage to the cornea.
CBM supports NTD control and elimination
programmes in 12 countries promoting the
SAFE (surgery, antibiotics, facial cleanliness
and environmental educational) strategy at
a community level. Over the last 12 years,
CBM has funded nearly 16 million mass drug
administration projects and almost 900,000
trachoma surgeries. CBM has also supported the
training and education of more than 83 million
health and community workers.
At his meeting with MFAT, Dr Kollmann
showcased a CBM-funded programme in
Amhara, Ethiopia which received an award for
its innovative approach embracing community
engagement and ownership. International aid will
not achieve its sustainable development goals
with an economic focus only, he said, but must
also focus on preventing and eliminating NTDs to
be successful.
Although NTD interventions have proved to
be very cost-effective, globally only 0.6% of
health expenditure targets NTDs, hence CBM’s
government awareness programme, which wants
aid givers to target more aid towards health to
support more NTD elimination programmes. This
will represent a tangible benefit for children,
women and adults; solidly contributing to poverty
eradication and sustainable development goals,
explained Dr Kollman.
Dr Martin Kollmann
Dr Martin Kollmann, a consultant ophthalmologist and associate professor at
the University Nairobi, is a senior CBM advisor, coordinating global activities
in the fight against diseases of poverty and inequity. He studied human
medicine in Germany and worked for three years with the German volunteer
service, DED, in rural hospitals in Ethiopia before completing his training in
ophthalmology at Munich University. He holds a degree in tropical medicine
and medical parasitology and an MBA in healthcare management. Today,
at the University of Nairobi Institute of Tropical and Infectious Diseases,
Dr Kollmann trains postgraduates, undergraduates and mid-level eye care
Dr Martin Kollmann, raising
awareness of trachoma and other
NTDs
professionals and is heavily involved in research. He has also developed an innovative sponsorship
programme, which supports training for young Africans at recognised institutions in the region.
8 NEW ZEALAND OPTICS April 2018