While age-related macular degeneration, an incurable eye disease, is the leading cause of vision impairment in those 55 and older, it doesn’t have to signify the end of a patient’s independence and quality of life. Occupational therapists who work in low-vision rehab programs across the country are helping those with low vision learn new strategies, regain their confidence and effectively use their remaining sight.

At the nonprofit Chicago Lighthouse, Hillary Napier-Gondek, OTR/L, MS, associate director of occupational therapy services, works with clients who have a visual impairment that can’t be corrected by contact lenses, glasses or surgery. In addition to seeing patients with age-related macular degeneration, she sees patients who have glaucoma, cataracts, diabetic retinopathy, or have suffered a stroke or head trauma.

Because many patients, and ophthalmologists, aren’t aware of low-vision rehab services and the potential benefits offered, Napier-Gondek and her staff, including Laura Hayes, OTR/L, MS, say marketing needs to be an integral part of any program.

"We work to build relationships with local doctors and let them know about our services. We also ask our patients to help us spread the word," Napier-Gondek said. "Our goal is for low-vision rehab to be seen as part of a patient’s continuum of care."

After evaluating patients, Napier-Gondek and Hayes discuss functional goals with patients and often prescribe assistive devices such as magnifiers or closed-circuit televisions, to help with daily activities, such as reading, taking prescriptions and cooking meals at home.

Hayes stressed rehab goes beyond providing patients with a few low-vision devices. "We also look at ways to improve lighting and contrast in the patient’s home so they can continue to live safely in their own home," she said. "In addition, we can introduce them to adaptive cooking tools which they can use to prepare their favorite meals, or checkbooks with bolder lines to help them make bill-paying easier."

Growing area for OTs

With the aging baby boomer generation, the field of low-vision rehab is an emerging specialty area for OTs. According to statistics from the National Eye Institute, National Institutes of Health, by the year 2030, 6.3 million Americans are expected to have age-related macular degeneration.

"The majority of OTs who work with adults can benefit from having low-vision training," said Jennifer Kaldenberg, OTR/L, MSA, SCLV, CLVT, FAOTA, assistant professor of vision rehabilitation, New England College of Optometry in Boston. "While they don’t need a specialized practice, OTs should have some knowledge of how to assess patients with low vision and train them in the use of adaptive equipment and techniques."

While many OTs are introduced to low-vision rehab techniques through CE courses and on-the-job-training, there are some formal education programs. Monica Perlmutter, OTR/L, MA, OTD, SCLV, an instructor in occupational therapy, ophthalmology and visual sciences at the Washington University School of Medicine in St. Louis, is a graduate of the University of Alabama-Birmingham’s graduate certification in low-vision rehabilitation program. The eight-semester program was launched in 2001 and can be completed online with the exception of several campus visits.

At her facility, Perlmutter and her colleagues work with optometrists and ophthalmologists as part of a multidisciplinary team that provides low-vision rehab in an academic-based clinical practice.

"Our OTs travel to patient homes within a 35-mile radius of the OT program and typically meet with patients three to five times, depending on their goals and needs, to help them make adaptions to achieve their vision-related goals," Perlmutter said. "The treatment will vary from one individual to the next based on their vision-loss pattern, cognitive status and other factors that affect their performance."

In some cases, that means training the patient to use eccentric viewing and steady eye techniques that can help them to use their residual vision more effectively. "With eccentric viewing, clients with central vision loss learn to shift their gaze in order to use a healthier portion of the macula to look at objects," Perlmutter said. "This takes practice to master the technique, but can be applied to viewing appliance controls, reading and seeing faces."

In their low-vision rehab work, Perlmutter and her colleagues use the Canadian Occupational Performance Measure, an individualized, client-centered outcome measure for identifying and evaluating self-perceived occupational performance issues. "Goals may include being able to live independently, to be able to venture into the community safely and participate in events such as dining out and attending church, as well as to pursue specific hobbies and activities," she said.

Looking to the future

Statistics released by Lighthouse International indicate that our country may be on the verge of a low-vision epidemic. In addition to the growing number of baby boomers affected by age-related macular degeneration, 5.3 million adults suffer impaired vision caused by diabetic retinopathy — approximately one quarter of diagnosed diabetics — and the obesity epidemic promises to boost that showing.

The solution, experts claim, is vision-loss rehab programs, which not only allow people to live safely and independently but also offer patients a better quality of life.

A study in the May 2008 issue of the Archives of Ophthalmology showed that low-vision rehab programs significantly improved vision in veterans who suffered from macular degeneration.

"In addition to affecting daily function, low vision increases the risk of depression, injury and an overall decline in health," said Audrey Smith, PhD, associate professor and dean of the College of Education and Rehabilitation at Salus University, Elkins Park, Pa. A low vision therapist, orientation and mobility specialist, and teacher of the visually impaired, she also serves on the technical advisory board of Technical Vision Inc., a company that specializes in the design and manufacture of electronic mobility aids. The company is working on a product called StreetLight canes to help those with low vision move around their houses and in low-lighting independently.

Smith said one of the biggest fears people with vision loss have is of falling and gravely injuring themselves. "Devices like these not only increase a patient’s independence, they also give them the confidence of being able to navigate on their own," she said.

Smith points toward significant advances in vision-loss assistive devices during the past decade, and said she sees the field continuing to expand as aging consumers demand more programs and services.

While Medicare and Medicaid cover most vision-loss rehabilitation, they do not cover assistive devices, which can force OTs to become creative when working with clients on a limited budget.

"Often it can be something as simple as putting black tape around the edges of white light switches rather than replace all of the light switches," Kaldenberg said. "Or using tactile bump dots to identify the different settings on a clothes dryer, or placing them on an oven at 350 and 400 degrees, the most commonly used settings. There are a wide range of ways that OTs can help their clients with vision loss to improve safety, function and performance." •

Linda Childers is a freelance writer.