Low Vision and Older Adults

Glaucoma: Angle Closure Glaucoma

*acute emergency* aqueous fluid becomes *blocked*, quickly raising intraocular pressure

Diabetic Retinopathy: Typical Manifestations

*fluctuate* and include blurry vision - reduced contrast sensitivity - decreased night driving - reduction of color discrimination - *patchy spots* on visual field - *TOTAL BLINDNESS* see spots or floaters in the field of vision, have blurred vision, and have a dark or empty spot in the center of the visual field.

Glaucoma: Primary Open-Angle

*fluid passes too slowly through spongy meshwork.* pressure damages *optic nerve*

*Dry* AMD

*most common form of AMD* causes deposits of *yellow-colored extracellular material within the macula of the eye* causes possible *atrophy of the retina* and gradual loss of *central vision*

*Wet* AMD

*proliferation of abnormal blood vessels that leak blood and fluid into the macula* *central vision loss* progresses *quicker than dry AMD*

Functional impairments related to aging changes

- can't see close objects - can't coordinate eyes - images become blurrier - night sight decreased - eyes adapt slower to lighting changes - decreased contrast sensitivity or the ability to distinguish various shades of gray or shades of color - color differentiation diminishes - narrowed visual fields

Contrast Sensitivity Deficit: Clinical Signs

- cannot distinguish faint features of objects i.e. white rice on white plate

Visual Acuity Deficit: Clinical Signs

- cannot see small visual details i.e. nutrition info on food labels

Low Vision: Contrast interventions

- coffee in light mug - milk in dark mug - tape on steps - Bold-lined paper and bold-tipped pens Using colors that contrast or are opposite of each other.

The *central or focal vision system* analyzes a visual target in terms of its __________, ________, _______, and _______

- details - color - shape - texture

The *peripheral or ambient visual system* provides background information about one's _____________ in relation to the ____________ and is quick to detect ___________.

- position - environment - motion

Visual Field Deficit: Clinical Signs

- reduced search pattern - change in head position when viewing people on lost field - bumping into objects on lost field - misplaces things on affected field

Oculomotor Deficit: Clinical Signs

- reduced speed - reduced control - reduced coordination - diplopia

Low Vision: Central Vision - Interventions

- rotate head or trunk to use *peripheral vision* - *ECCENTRIC VIEWING*

Low Vision: Peripheral Vision - Interventions

- tactile markers - writing guides that use tactile skills to help write on lines - auditory or talking items

Primary visual aging changes: Lens become _______, _______, and _________

- thicker - inflexible - opaque

Low Vision: OVERALL HINTS FOR TX

- use lots of lighting *without glare* - organize and *declutter* - improve *contrast sensitivity* - increase *font* - *adaptive equipment* and proper usage

Visual foundation skills

- visual acuity - oculomotor control - visual pursuits - saccades - visual fields

Evaluation: ADLs & IADLs Assessments

1. Melbourne Low Vision and ADL Index: *impact of a person's visual impairment on ADLs & IADLs* 2. COPM - semi structured interview to ID person's perception of their performance in the areas of self-care, productivity, and leisure. Rates importance of the activity to the person and hw a person's perception of performance changes over time.

Evaluation: Visual Acuity - *Far*

1. Snellen E Chart 2. Tumbling E chart - fpr illiterate or with aphasia

AMD: typical manifestations

1. impaired mobility skills 2. reduced ADL & IADL performance 3. decreased ability to recognize faces and perform detailed work *4. possible difficulty with social participation* Results in a gradual loss of ability to see objects clearly. Objects appear distorted in shape and straight lines look wavy or crooked, creating difficulty with reading.

Eccentric Viewing: The first step in eccentric viewing techniques is?

1. increasing the client's awareness of the central scotoma, or blind spot. 2. Head positioning for optimal viewing 3. practiced using optical devices such as magnifiers 4. Scanning exercises across the full field of vision

Glaucoma: *2 Types*

1. primary open-angle glaucoma 2. angle closure glaucoma

Cataracts: Typical manifestations

1. reduced visual acuity 2. blurry vision 3. decreased ability to distinguish color 4. reduced night driving 5. distortion of images 6. increased glare sensitivity 7. reduced contrast sensitivity most frequently report blurred or hazy vision and reduced intensity of colors

An older adult client with age-related macular degeneration presents for evaluation and demonstrates difficulty reading and signing consent forms. What visual function should the OTR® evaluate first? A. Visual acuity B. Tolerance to glare C. Visual field D. Visual scanning

A Age-related macular degeneration causes loss of central visual acuity, resulting in difficulty discriminating small visual details required for reading and writing.

Evaluation: Visual Fields - Central

Amsler Grid

An older adult client with a history of falls and glaucoma is referred to occupational therapy for evaluation and intervention. Which strategy should the OTR® teach the client to compensate for impaired vision due to glaucoma? A. Use a colorful, patterned tablecloth. B. Place dinner plate to the left of midline. C. Rotate head to choose clothing from a closet. D. Pour coffee into a dark colored mug.

C Rotating the head would help the client use the remaining vision to compensate for peripheral vision loss

Evaluation: Environmental

Assessment at the client's work, home, or both, recommendations to improve safety and functioning - *lighting* in home/yard - contrast of items in the environment - glare - *adaptive aids currently used: how used*

A client with visual field deficit secondary to glaucoma reports difficulty locating grocery items when shopping. Which intervention using a remediation approach would be MOST appropriate? A. Solicit assistance from employees in the store B. Use wider head turns in an organized search pattern C. Initiate slower head turning to promote accuracy D. Position head to one side to increase the visual field

B Using a remediation approach, the focus of the intervention is on increasing the speed, width, and organization of the visual search pattern so the client can completely search the visual fields.

An older adult client complains that objects appear distorted—for example, straight lines look wavy. The client has difficulty reading and makes frequent mistakes when reading but is able to navigate busy and crowded environments using peripheral vision. Which visual deficit would the OTR® suspect? A.Glaucoma B.Macular degeneration C.Cataract D.Diabetic retinopathy

B. Macular degeneration results in a gradual loss of ability to see objects clearly. Objects appear distorted in shape and straight lines look wavy or crooked, creating difficulty with reading. A: Clients with glaucoma experience loss of peripheral vision and often report difficulty with mobility. C: Clients with cataract most frequently report blurred or hazy vision and reduced intensity of colors. D: Clients with diabetic retinopathy see spots or floaters in the field of vision, have blurred vision, and have a dark or empty spot in the center of the visual field.

Low Vision

Best-corrected visual acuity less than 6/12 = <20/40 in the better-seeing eye

The OTR®'s next client has macular degeneration in both eyes. To prepare the treatment environment for this client, which course of action should the OTR® take? A. Close the blinds and the curtains. B. Sit directly in front of the client. C. Increase lighting and avoid glare. D. Place dark objects on a black table.

C This client will see more clearly if the room lighting is adequate. However, glare should be avoided because the eye condition may make the person more sensitive to glare.

Evaluation: Visual Fields - Peripheral

Confrontation testing: provides gross measurement of visual fields *client fixes on a central target and acknowledges the appearance of stimuli*

An OTR® is screening an older adult who has had a stroke. The physician's referral notes that the client eats food on only half of the plate and completes grooming tasks swiftly, making many mistakes. Which scanning pattern would be MOST likely to prompt the OTR to recommend additional testing for unilateral neglect? A. Organized, symmetrical scanning B. Rescanning with an organized scanning C. Abbreviated or shortened scanning D. Disorganized, random scanning

D A disorganized, random scanning pattern is characteristic of unilateral neglect, which can be further assessed using a cancellation, drawing, or reading task. A: An organized and symmetrical scanning pattern, rescanning with an organized scanning pattern, and an abbreviated or shortened scanning pattern are all characteristic of visual field deficit, not unilateral neglect.

Accommodative Facility

the speed of focus adjustment and ability to maintain focus over time

T or F?: Providing occlusion for a client with double vision can be prescribed without an optometrist/ophthalmologist approval

FALSE *occlusion must be prescribed with supervision from an optometrist*

Eccentric Viewing

If central vision loss, rotate head or turn trunk to use peripheral vision

Evaluation: Visual Acuity - *Near*

Lighthouse *Near* Visual Acuity Test

Best-corrected vision

Sharpest, clearest vision attainable by the client, under the best circumstances, using vision out of the best eye, with standard corrective lenses

stronger the magnification does what?

Makes the field of view smaller and the magnifier is held closer to the eye

Primary visual aging changes: Corneas become (thicker/thinner)

thicker

___________specialists teach mobility skills, including use of a white cane or guide dogs to clients with vision impairments to promote safe and independent travel

Orientation and mobility specialists

Evaluation: Contrast Sensitivity

Pelli-Robson Contrast Sensitivity Chart

Glaucoma results in what type of vision loss?

Peripheral Experience loss of peripheral vision and often report difficulty with mobility.

Low Vision: General Interventions

Recommend and train the client in use of non optical devices to improve I and safety for ADLs and IADLs. - large-print books/magazines - talking clocks - computer adaptations - electronic magnification - screen readers - sound to text *remove clutter, improve organization* **HOW TO USE PRESCRIBED OPTICAL DEVICES**

A client with low vision was prescribed a handheld magnifier to promote reading. The client reports to the OTR® that the handheld magnifier does not make text clear enough to read. Which recommendation is BEST for the OTR to make?

The handheld magnifier should be held at a predetermined distance from what is being read. Handheld magnifiers, which are prescribed by an optometrist or ophthalmologist, must be held at a predetermined distance from what is being read.

Cataracts

The lens of the eye *becomes more opaque*, and reduction of light going to the retina occurs

An older adult client with age-related macular degeneration presents for evaluation and demonstrates difficulty reading and signing consent forms. What visual function should the OTR® evaluate first? A.Visual acuity B.Tolerance to glare C.Visual field D.Visual scanning

The right answer is A Age-related macular degeneration causes loss of central visual acuity, resulting in difficulty discriminating small visual details required for reading and writing. B, C, D: Tolerance to glare and visual field and visual scanning are not characteristic of age-related macular degeneration.

Which symptom may be attributed to typical visual aging changes? A.Slowing ability to adapt to light and dark B.Difficulty recognizing and reading facial expressions C.Increasing color blindness D.Improving ability to see objects at a close distance

The right answer is A As people get older, they find it more difficult to adapt to light and dark conditions B: This symptom is more typical in someone with macular degeneration. C: Color blindness remains and is not a typical aging change. D: As people age, the ability to see close objects diminishes rather than improves.

A client reports visual stress, fatigue, and frequent double vision. On evaluation, the client demonstrates asymmetrical eye movement and difficulty moving the eyes together. The client would like to return to continuous reading tasks. Which intervention would be MOST appropriate for the OTR® to recommend? A. Occlusion under the supervision of a physician B. Eye exercises to improve eye coordination C. Additional task lighting when reading D. Visual search and scanning tasks with mobility

The right answer is A Double vision is eliminated by occlusion, which removes the image presented on one eye; occupational therapy practitioners can implement this intervention only under the direction of a physician. B: Eye exercises are recommended and directed by an optometrist or ophthalmologist. C, D: Additional task lighting and visual search and scanning tasks are not recommended interventions for oculomotor dysfunction.

An older adult client who lives independently and has age-related macular degeneration reports difficulty reading small print. The OTR® completes acuity testing and determines that the client has visual acuity of 20/200. What recommendation should the OTR make? A. Increase illumination and enlarge print B. Reduce background contrast when reading C. See an eye care specialist for visual field testing D. Use occlusion to facilitate reading

The right answer is A For clients with visual acuity loss, increased illumination and enlarged print facilitate reading. B: Background contrast should be increased, not reduced, to promote visibility. C, D: Age-related macular degeneration does not result in changes in visual field or oculomotor function, so visual field testing and occlusion would not be recommended.

An OTR® provides consultation to a senior activity center, where many clients engage in tabletop games. Which recommendation would be MOST beneficial to promote clients' engagement in this activity? A.Increase general lighting and provide task lighting B.Increase clients' visual search and scanning C.Provide eye exercises for those with low vision D.Provide rulers or cards for clients to use to underline print when reading

The right answer is A More than 2.4 million adults age 40 or older in the United States have low vision, and age is the single best predictor of low vision and blindness. Increasing the intensity and amount of available light enables objects and environmental features to be seen more readily, reducing the need for high contrast between objects. B: Visual search and scanning patterns are used by people with visual field deficits and would not be appropriate for all senior center clients. C: Eye exercises promote oculomotor function and would not be appropriate for all senior center clients; in addition, they must be prescribed by an eye care provider. D: Rulers and cards are used to underline print for people with visual field loss and difficulty staying on the line. They would not be appropriate for all senior center clients.

A client reports diplopia, or side-by-side double images, and demonstrates asymmetrical pupil sizes and a droopy eyelid. What would be MOST appropriate for the OTR® to evaluate? A.Oculomotor function B.Visual acuity deficit C.Contrast sensitivity D.Visual field deficit

The right answer is A Oculomotor function is responsible for the symptoms the client is reporting. When images double side by side for near-vision tasks, pupils are asymmetrical, and ptosis (droopiness) of the eyelid occur, cranial nerves may be injured. B: Clients with visual acuity problems most often report blurred vision. C: Clients with decreased contrast sensitivity most often report difficulty going out in the evening because of the challenges associated with maneuvering in low light. D: Clients with visual field deficits most often report bumping into objects, difficulty locating items, and difficulty reading.

A client with visual field deficit after stroke reports running into obstacles on the left side and says that objects seem to appear and then disappear on the left side. The client also reports that vision is unchanged since the stroke. Which phrase BEST explains the client's symptoms? A.Perceptual completion B.Unchanged vision C.Difficulty with contrast D.Onset of presbyopia

The right answer is A Perceptual completion is a process whereby the central nervous system of a person with visual field deficit samples a visual array and internally completes a visual scene on the basis of visual information expected to be found in the array. Perceptual completion allows a client with visual field deficit to be unaware of the absences of vision caused by the deficit.

An older adult client has lost significant vision and reports difficulty with reading, sewing, writing, recognizing faces, and responding to social gestures. Which visual deficit is the client exhibiting? A. Age-related macular degeneration B. Glaucoma C. Myopia D. Presbyopia

The right answer is A Reading, recognizing faces and social gestures, and performing detail work are characteristic functional limitations associated with age-related macular degeneration, which causes loss of central visual acuity and difficulty seeing fine detail. B: Glaucoma alters peripheral vision, not central vision. C: Myopia, where the image of an object is focused at a point in front of the retina and is therefore blurred when it reaches the retina, results in nearsightedness. Myopia can be corrected using a concave lens. D: Presbyopia is a normal age-related change that occurs when the lens of the eye gradually becomes less flexible, thereby reducing the lens' ability to keep images in focus as they come closer. This condition can be corrected using reading glasses.

A client has been diagnosed with age-related macular degeneration. Which is the BEST intervention strategy for the OTR® to use in improving the client's independence in meal preparation? A.Teach the client to use different tactile indicators on a few key microwave buttons. B.Teach the client to use central vision to see the microwave buttons. C.Prescribe an optical device for client to use to see the microwave buttons. D.Instruct the client to lower the general and task lighting in the kitchen and near the microwave.

The right answer is A This strategy would help the client supplement remaining vision with tactile sensation. B: Because central vision tends to be impaired with this condition, this would not be a suitable option. Teaching the client to use sing peripheral vision would be more beneficial. C. Occupational therapy practitioners are unable to prescribe optical devices; however, they can teach clients how to use these devices after they are prescribed by a physician or optometrist. D: Decreasing the lighting would hinder the client from viewing the microwave controls. Increasing the lighting is more appropriate.

A client with reduced visual acuity uses a magnifier to read consent forms but reports that the magnifier is not strong enough. Which response by the OTR® is BEST? A.Provide the client with a stronger magnifier and determine whether the magnifier is appropriate B.Refer the client to an appropriate eye care physician to prescribe an updated magnifier C.Encourage the client to stop using the magnifier until an appropriate magnifier is provided D.Refer the client to an OTR who specializes in low vision practice to issue a updated magnifier

The right answer is B Optical devices are prescribed by an optometrist or ophthalmologist.

A client has been diagnosed with age-related macular degeneration. The client enjoys knitting but is having difficulty seeing the design being knitted. What strategy should the OTR® use to facilitate the client's ability to continue knitting? A. Have the client choose a design with low contrast. B. Have the client rotate the head and trunk to the side. C. Have the client use built-up handles on the knitting needles. D. Have the client use knitting needles the same color as the yarn.

The right answer is B Rotating the head and trunk to the side would allow the client to use the remaining peripheral vision to see the pattern. A and D: These strategies would make it more difficult for client because the client may have difficulty with contrast sensitivity. C: This strategy does not relate to the client's vision condition.

An older adult client with a history of falls and glaucoma is referred to occupational therapy for evaluation and intervention. What strategy should the OTR® use to reduce the client's risk of having a fall? A.Using low-wattage glare free lightbulbs B.Placing contrasting color stripes on each stair edge C.Encouraging client to look forward when ambulating D.Securing a beige throw rug on the beige carpet

The right answer is B The use of contrast would make it easier for the client to see each stair tread. A: This strategy would make it more difficult and unsafe for the client to ambulate because of the inability to see obstacles clearly. C: Because the client has deficits in peripheral vision, the client needs to scan the environment for obstacles when ambulating. D: A beige throw rug on a beige carpet has minimal contrast and would be difficult for the client to see.

An OTR® is selecting intervention activities for a young adult client with a diagnosis of accommodative infacility. Which activity will be MOST difficult for this client? A.Watching sports B.Reading a book C.Driving a car D.Watching a play

The right answer is C Accommodation is the ability of the eye to adjust focus at different distances. Accommodative facility is the speed of focus adjustment and ability to maintain focus over time. Driving a car would be most difficult for this client because looking at the speedometer and then at the road requires adjusting focus at different distances (near distance for the speedometer and farther distance for the road). A, D: Watching sports or a play requires visual tracking or smooth pursuits; accommodative facility would not be challenged. B: Reading a book or other materials requires convergence and ability to focus on an object at near distance; accommodative facility would not be challenged.

During an intervention session in which a client with unilateral neglect reads single letters across several lines, the OTR® uses a vertical line on the left side of the page to cue the client to read the correct line. Which intervention technique is the OTR using? A.Patching B.Attention C.Anchoring D.Prisms

The right answer is C Anchoring, a cue on the impaired side to indicate starting position, brings attention back to the neglected side. Vertical anchoring lines are generally used on the left side. A: Patching increases eye movements to the contralateral side, decreasing neglect. B: Attention training increases attention and general alertness to reduce unilateral neglect. D: Prisms shift the visual field toward the intact side, enabling the client to see things on the involved side.

An older adult client is having difficulty locating curbs, stairs, and objects in low-lit areas within the home environment. Which area is MOST relevant to assess during the evaluation? A.Peripheral vision B.Working distance C.Contrast sensitivity D.Task lighting

The right answer is C Contrast sensitivity can limit a person's ability to locate curbs, stairs, and objects in low light within the home environment. Contrast enhancement makes objects more visible by increasing the contrast between foreground and background. A: Peripheral vision usually is not necessary to locate curbs, stairs, and objects in low light. B: Working distance is closer than the activities for which this client reports difficulty and is considered when working with optics, including the use of bifocals and trifocals. D: Task lighting is used for a specific task and is positioned appropriately. Task lighting may not be beneficial for the tasks of locating curbs, stairs, and objects in low light.

An OTR® notes that a client with a left stroke makes many errors when reading and is required to stop and reread sentences frequently. The OTR suspects left hemianopia. Which action should the OTR take? A.Provide task lighting to promote the client's vision B.Complete acuity testing to determine whether the client needs glasses C.Refer the client to an optometrist or ophthalmologist for automated perimetry testing D.Provide client education materials in large print

The right answer is C Referral of the client to an optometrist or ophthalmologist for perimetry testing is necessary to confirm hemianopia before recommending specific intervention strategies. A, B, D: Hemianopia is a visual field deficit and must be confirmed before making specific recommendations; therefore, recommendations for task lighting, acuity testing, and large-print materials are not appropriate at this time.

An older adult client with a history of falls and glaucoma is referred to occupational therapy for evaluation and intervention. Which strategy should the OTR® teach the client to compensate for impaired vision due to glaucoma? A. Use a colorful, patterned tablecloth. B. Place dinner plate to the left of midline. C. Rotate head to choose clothing from a closet. D. Pour coffee into a dark colored mug.

The right answer is C Rotating the head would help the client use the remaining vision to compensate for peripheral vision loss

An OTR® is screening an older adult who has had a stroke. The physician's referral notes that the client eats food on only half of the plate and completes grooming tasks swiftly, making many mistakes. Which scanning pattern would be MOST likely to prompt the OTR to recommend additional testing for unilateral neglect? A.Organized, symmetrical scanning B.Rescanning with an organized scanning C.Abbreviated or shortened scanning D.Disorganized, random scanning

The right answer is D A disorganized, random scanning pattern is characteristic of unilateral neglect, which can be further assessed using a cancellation, drawing, or reading task. A, B, C: An organized and symmetrical scanning pattern, rescanning with an organized scanning pattern, and an abbreviated or shortened scanning pattern are all characteristic of visual field deficit, not unilateral neglect.

Which tool should the OTR® use to assess peripheral visual fields? A.Interview B.Amsler grid C.Snellen chart D.Confrontation testing

The right answer is D Confrontation testing provides a gross assessment of how much peripheral vision the client has. A: Although interview might be helpful in identifying the client's problems, it is not adequate to assess peripheral visual fields. B: The Amsler grid is used to assess central visual fields. C: The Snellen chart is used to assess visual acuity.

An OTR® is evaluating a client with a diagnosis of blindness. The OTR observes the client bumping into objects, people, and the door frame and is worried about the client's potential for injury. What referral should the OTR make FIRST? A.To physical therapy, to address balance, gait, and mobility aids B.To a physician, to determine whether the client's medical condition has changed C.For guide dog services, to promote safety in the community D.To orientation and mobility services, to assess for use of a white cane

The right answer is D Orientation and mobility specialists teach travel (mobility) skills, including use of a white cane, to clients with a vision impairment to promote safe and independent travel. At this time, this client may not be safe for independent mobility; these specialists can provide the techniques and skills to promote safety. A: The client's difficulty navigating results from an inability to see and negotiate the environment, not from difficulty with balance or gait, for which a referral to physical therapy would be appropriate. B: A referral to the physician would be unnecessary because the client has been diagnosed with blindness. C: Orientation and mobility specialists also may provide guide dog services, but such services require more lengthy evaluation and training than use of a white cane.

Visual foundation skills

Visual foundation skills, including visual acuity, oculomotor control, visual pursuits, saccades, and visual fields, should be assessed before completing a visual perception evaluation to screen out visual problems. Underlying problems with visual foundation skills may interfere with the accuracy of visual perception testing.

Age-related macular degeneration (AMD)

a condition in which the *macula* degenerates, gradually causing *central vision loss*

Accommodation

ability of the eye to adjust focus at different distances

Blindness

best corrected visual acuity of *6/60 = 20/200* in the better seeing eye

Low Vision Impairment

best-corrected visual acuity *<20/40* in the better-seeing eye (excluding those who were categorized as being blind)

An OTR® recommends task lighting for a client with age-related macular degeneration. Where should the task light be positioned to promote the client's vision? A. On top of a shiny surface that reflects light B. On a patterned surface or cloth to decrease glare C. Opposite the writing hand or nearest to the best seeing eye D. On top of dull, low-contrast fabric to reduce reflected light

c Lighting should be positioned opposite the writing hand or nearest to the best seeing eye to promote the client's vision.

Cataracts results in what type of vision loss?

central

Diabetic Retinopathy

changes in *blood vessels* of the retina that may *swell and leak* new blood vessels may grow on retina

Primary visual aging changes: strength of muscles, tone, and transparency of corneas (increase/decrease)

decrease

Primary visual aging changes: subcutatneous fat around the eye (increases/decreases)

decreases

Presbyopia

farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age. *difficulty focusing on near objects*

Glaucoma

increased intraocular pressure results in damage to the retina and optic nerve with loss of vision

_______________ results in a gradual loss of ability to see objects clearly. Objects appear *distorted in shape and straight lines look wavy or crooked*, creating difficulty with reading.

macular degeneration

Handheld magnifiers, which are prescribed by an optometrist or ophthalmologist, must be held at a _________________- from what is being read.

predetermined distance

Primary visual aging changes: Pupils becomes (larger/smaller)

smaller

_____________ should be performed BEFORE visual perception evaluations

visual foundation skills this screens out visual problems