Losing some or all of one’s vision is a traumatic experience. Even day-to-day activities like reading the newspaper, watching television, paying the bills, or cooking dinner can be a challenge. Unfortunately, visual impairment is a condition that nearly seven million Americans live with -- and as the baby boomer population ages, that number is expected to double.

The good news is that with the right adaptive tools, technology, proper ongoing training, and support, most people with vision loss can do virtually all of the things they need to do.

Recognizing the need for comprehensive services for people dealing with permanent irreversible vision loss, the Duke Eye Center has established the Duke Vision Rehabilitation Program. The program gives patients access to a complete array of services -- from recommendations and training on assistive devices, to psychological counseling for patients and their families, to site visits by an occupational therapist to help set up their home or office efficiently -- virtually everything they need to maximize their quality of life.

The Duke Vision Rehabilitation Program, located on the lobby entrance floor of the main Eye Center clinic, is directed by Diane Beasley Whitaker, OD, an experienced optometrist and low vision specialist who came to Duke from UNC Hospitals in 2006 to start the program.

“Adjusting to partial or total vision loss is an all-encompassing life process,” Whitaker, an assistant professor of ophthalmology, explains. “To address all the different aspects of vision rehabilitation, we’ve created a comprehensive, multidisciplinary program that offers patients a full range of services, all in one convenient place, to navigate them through the process of vision rehabilitation.”

The program serves patients who have experienced permanent, irreversible vision loss that cannot be corrected by traditional glasses or lenses. Vision loss can be a result of a variety of diseases and conditions, including age-related macular degeneration, glaucoma, corneal disease, diabetic retinopathy, trauma, and systemic diseases like hypertension, stroke, or brain tumor. Most of the program’s patients are adults.
Because children dealing with vision loss have unique needs that require specialized expertise, the Eye Center has also established the Duke Pediatric Low Vision Program (see article on page 7).

The Vision Rehabilitation Program brings together optometrists, ophthalmologists, opticians, assistive technology instructors, social workers, clinical psychologists, geriatric specialists, and occupational therapists at Duke and throughout the community -- and the team is still growing. Using this team approach means patients enjoy the convenience of coming to one place to meet all of their needs without duplicating the efforts of the professionals involved in their care.

Comprehensive Care to Meet Personal Goals

Patients are generally referred to the program by their eye care provider or another health care provider such as a neurologist or geriatrician. The first step in the process is measuring the patient’s visual function and limitations, including the ability to read written words (which better emulates real-world settings than an eye chart), field of vision, ability to see differences in contrast and depth, and hand-eye coordination. After evaluating the patient’s visual function, Whitaker meets with each patient to discuss his/her personal visual goals. Does the patient want to read the newspaper? Work on the computer? Cook dinner? Do needlework? Drive?

Taking into account the exam results and the patient’s own goals, Whitaker recommends appropriate strategies and assistive technology, from electronic or conventional magnification devices to computer aids and non-optical aids like needle threaders, writing guides, as well as any appropriate training techniques to maximize visual function.

Once the recommendations for adaptive technology have been made, patients meet with Jerry Mansell, LDO, an optician with nearly 30 years of experience working with visually-impaired patients. Mansell and the patient work together to customize the recommended aids and try alternatives until an optimal solution is found. Mansell then teaches the patient to use the technology correctly and successfully.

“Almost Nothing They Cannot Do”

Mansell, who was recruited to Duke from the Bascom Palmer Eye Institute in Miami to work as the coordinator for the Vision Rehabilitation Program, calls working with patients to help them achieve a
good quality of life “my life’s calling.”

“We will leave no stone unturned to help someone be able to do what they want to do,” he says. “Once people accept their vision loss and understand all of their options, they can choose between the realities. If someone is willing to put in the work to become proficient in using this technology, there’s almost nothing they cannot do.”

Mansell draws from a range of available devices, strategies, and tools, from special lighting and glare control to magnifiers and electronic devices. Solutions also include large-print address books, large-button phones, and talking watches. Each patient is unique in his/her visual abilities as well as interests, finances, and lifestyle, Mansell notes. One person might want to be able to cook and another might want to be able to sew or watch television. That’s why the service of the program is highly individualized.

“With someone who has age-related macular degeneration who wants to be able to read, for instance, the first thing we do is determine what level of vision we can achieve by using full-spectrum lighting and filters to reduce glare, which is a big issue with this disease. Then we determine the best way to deliver the magnification they need, whether through a magnifying glass, special eyeglasses, a hand-held device, or one that’s hands-free and with or without illumination. We can also use electronic devices to enlarge reading, writing, and other material onto a user-friendly display. For patients who have no remaining usable vision, an optical character recognition reader (OCR) device can be employed to read mail or the newspaper aloud.”

Mansell offers other examples. “For someone who wants to see in the distance, we would use a telescopic lens, telescopic glasses, or electronic devices of different types. For someone who wants to be able to do needlepoint, we’ll work with hands-free magnifiers and lighting, as well as teaching the individual to use contrast, like using a black background to see the white thread more easily. For another person who wants to continue to play the cello, we’ll need to work on helping him/her read music.”

Mansell generally directs patients to stores where they can buy these devices at a reasonable price. However, he also stocks some of the highly specialized items and works closely with the vendors from the companies that provide them.

Ongoing Training Is Essential

The process doesn’t stop at finding the right assistive tools. Training patients to use these tools correctly is critical -- although unfortunately, it’s the step that is often overlooked in the traditional low vision field, Whitaker notes.

After Mansell teaches patients to use the devices they’ve selected, arrangements are made for ongoing training. Patients can work with an occupational therapist at the Eye Center clinic or in the home or
Office, where therapists teach patients to use the device in their own environment. During these visits, the occupational therapist can also evaluate the patients’ environments and make recommendations for enhancing efficiency and safety, based not only on the visual challenges but other limiting conditions. The therapist can also provide techniques for patients to maximize their remaining vision.

The Duke Vision Rehabilitation Program also works in conjunction with the North Carolina Department of Health and Human Services through its Division of Services for the Blind and provides referrals to the division’s many professionals who provide care for people throughout the entire state.

Care for the Whole Person

During the initial exam, patients are also screened for depression or other mental conditions that may accompany vision loss so they can be referred to appropriate health professionals if deemed helpful.

“Many patients can benefi t from disability adjustment counseling, not only for themselves but often for their families as well,” Whitaker explains. “Family members often experience adjustment issues when a relative loses vision, and counseling can help them deal with the stress and the changes.”

Duke’s program is an evolution from a traditional low vision program, which often leaves patients to learn how to use the devices on their own, Whitaker notes. “Vision rehabilitation is a process, not a product. We are creating a comprehensive program that covers every aspect of the process, from counseling and education to assistive technology and vocational training. There is already a great need for this type of service, and that need will continue to grow as the baby boomers age.”