Lecture 2, 3, 4 - LVA assessment + Reg Flashcards
- LVL Form (Low Vision Leaflet)
- Issued to patient by optometrist
- Self-referral form
- Access to social services
- Supplied by social services departments (SSD)
- RVI Form (Referral of Vision Impaired Patient)
- Issued by ophthalmology department; (e.g. ophthalmic nurses, junior doctors, orthoptists,
optometrists, dispensing opticians) - Application for access to social services
- CVI Form (Certificate of Vision Impairment)
- Certifies patient as blind, completed by consultant ophthalmologist
- Certifies patient as blind
- Information to census office
- Access to help is not dependent on registration
Paediatric CVI Form
- 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.
What is the registration process?
- 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
Why should a patient get registered?
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.
Whats the benefits a registered patient can receive?
- 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
Registration – Disadvantages and problems with the process*
- 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
Low Vision Aid Assessment: Difference between normal eye exam
- There is not one unique outcome or solution fot the Px (e.g. VA of 6/6)
Points to consider before you start low vision assessment:
- 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!
What points can make LVA’s time consuming?
- 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
What general observations can be done from first contact with the Px?
- 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.
How to correctly guide a VIP?
– 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
How steps, doors and chairs are handled with a VIP:
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
Visual status questions during H&S:
- 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
Whats important about patients saying they cant see/read anything?
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
Ocular and General health history:
- 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
Previous & Current Low Vision Aids history:
- 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
Occupation & Education:
For patients of working age this is relevant as it will help you establish target VAs, required
working distances and magnification needs.
Patients Motivation & Expectations during history:
- 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
Social Circumstances & Family history:
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)
Requirements & Priorities:
- Important to prioritise, unlikely solution for all problems
- Different LVAs will be required for different tasks, px may have many LVAs
Psychological Aspects
- 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
What are the 5 stages to the Loss Model
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.”
Describe “Shock” in the Loss Model
- Sudden loss, eg wet AMD or stroke
- Disbelief,
- Patient doesn’t appear to comprehend and doesn’t appear to be listening
Describe “Grief” in the Loss Model
- 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”)
Describe “Anger” in the Loss Model
- May feel that there is lack of or improper treatment
- Px may stop taking prescribed medication
Describe “Depression & apathy “ in the Loss Model
- Hopeless situation, Going to get worse
- Nothing can be done and LVA assessment is a waste of time
- May need counselling or psychotherapy
Describe “Acceptance” in the Loss Model
- 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
What did Dodds (1989) model describe?
- 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.
What is the Self-Efficacy Model?
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
What environmental factors can affect the process of adjustment to the ability?
- 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
Vision Assessment: Aim and steps
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.
- 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). - Refract if indicated
- Establish distance magnification requirement
- Near magnification requirement
- Measure current distance best corrected VA (BVA) & Near BVA with aids & specs.
- 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
- Refract if indicated
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
- Establish distance magnification requirement
- 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.)
- Near magnification requirement
- 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
Other tests
- 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
Advice & follow up
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
Communication
- Speak slowly & clearly
o May have hearing loss - speak to best ear - Be encouraging & positive
- Don’t rush the patient, but stay in control
Test
