8 months ago

April 2018

Low vision in the 21st

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

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