Living Well with Vision Problems

1. Living Well with Vision Problems Brenda Wendling, MSW, LCSW Director of Adult Services St. Louis Society for the Blind and Visually Impaired

2. What Do We Know About Vision and Aging • There are physical changes to the eye as one gets older • Some eye diseases and conditions affect older people more than younger people • Some environments and places we regularly go are not always the best for seeing things easily

3. Vision, the Eyes and Aging • In our 40’s, it gets harder to focus for near (reading, sewing) and intermediate tasks (computer, reading recipes while cooking) • In our 40’s our eyes also get drier, especially while doing tasks for prolonged periods of time. • Many people are getting their first eye exam because of what they are experiencing.

4. In Our 50’s • Medical conditions such as hypertension and diabetes are developing at an increasing rate. • In our 50’s , eye dryness continues, especially with women and with people taking more medications. • Annual routine eye exams are important as well as routine physicals.

5. In Our 60’s • Our health may continue to change and there is an greater increase in risk for age-related eye diseases and medical conditions. • One may notices that they are having more difficulty while reading with dimmer lighting ( in the evening, at a restaurant) • A healthy 60 year old retina requires 3 x’s as much light as a healthy 20 year old retina • It may take more time to adjust visually when going from light to dark or vice versa • Routine eye exams and physicals • Task lighting is very beneficial

6. Common Problems • Blurred Vision – Blurred vision makes this appear to be out of focus at distance and near even with best spectacle correction. • Generalized Haze – This causes the sensation of film or glare that may extend over the entire field of vision. • Photophobia – Extreme light sensitivity exists when standard levels of illumination creates discomfort and blur. It can produce a washed out image and/or glare. • Night Blindness – The inability to see outside or inside at night when illumination is decreased slightly or significantly.

7. Acuity Alone Is Not The Best Predictor • Visual acuity alone cannot be used as a good predictor of the degree of problems a person may have. • Someone with relatively good acuity (20/40) can have difficulty functioning, while someone with worse acuity (20/200) might not have any major problems functioning.

8. Main Eye Conditions Affecting Older Adults • Macular Degeneration-macula • Glaucoma-optic nerve • Cataracts-lens • Diabetic retinopathy-lens, retina, optic nerve, vitreous, macula, and blood vessels • Hypertensive Retinopathy-blood vessels and optic nerve • Traumatic or Congenital Eye Diseases

9. Macular Degeneration • Macular degeneration- deterioration of the macula which allows us to see smaller details and centrally. • The macula is what an eagle uses to spot a small rodent from hundreds of feet away. • We use the macula to read, write, see facial features, thread a needle, for cooking, driving, walking, dialing a phone, and etc. • Straight lines may appear wavy and/or door frames may look crooked • Letters or numbers may be overlooked or obscured • Faces can look distorted or features may look blurry and missing

10. What Does Someone with Macular Degeneration See

11. Glaucoma • Glaucoma is a disease that affects the optic nerve. • It is one of the leading causes of vision impairment when untreated. • It is usually silent and painless until it progresses to a more severe stage. • Glaucoma is usually manageable, but is not curable and vision loss cannot be regained. • Overall vision may be reduced, things may look dimmer • One may not notice things that are in the periphery ( up, down, left, right) • Driving may not be an option anymore, peripheral vision needed for driving • One may bump into things beside them or not notice what is out in the distance.

12. What Does A Person with Glaucoma See

13. Cataracts • Lens cloudiness creates blurriness, glare, and difficulty identifying similar colors. • The cloudiness can be removed when it interferes with vision to a certain level of vision. • An ophthalmologist will perform a cataract extraction and will insert an intraocular lens which has a particular power to focus one’s vision. • There are several types of intraocular lenses • Many are designed to correct for distance vision • Some are designed as a bifocal • Some patients receive monovision correction-one eye focuses for distance vision and the other eye focuses for near vision.

14. What Does A Person with Cataracts See

15. Diabetic Retinopathy • Diabetes can affect one’s heart, blood vessels, eyes, kidneys, fingers and toes, etc • Retina damage happens slowly. This may or may not interfere with vision, so one may not be able to notice this change. • Blood can be in the retina and/or fill up in the vitreous of the eye and obstruct vision. • Sometimes the blood will clear out by itself. Sometimes laser treatment and/or surgery is needed. • Over time, the network of thin, delicate, weak vessels can form scar tissue and pull the retina from the back of the eye. This can cause a retinal detachment. • This retinal detachment can cause permanent partial or total vision loss.

16. What Does A Person with Diabetic Retinopathy See

17. Strokes Can Affect VisionCausing Hemianopsia

18. Charles Bonnet Syndrome Charles Bonnet Syndrome is a common condition among people who have lost their vision. It causes people who have lost vision to see things that aren’t really there, known as visual hallucinations. Two broad types of hallucinations: Simple repeated patterns Complex hallucinations of people, objects and/or landscapes. No medical cure for CBS. Usually improves with time. No proven drug available to stop it, but drugs for other problems have been successful in helping some people.

19. Terms to know: • Acuity – the sharpness or clarity of vision. Acuity is typically measured in terms of what can be read standing 20 feet away from the eye chart. • Field – is the width of the area seen without moving the eyes or turning the head. Normal vision is a field of 180o • Legal blindness – best corrected visual acuity is 20/200 in the better eye and/or if visual field is 20o or less. • Totally Blind – unable to see anything out of either eye. • Low Vision – with best correction, unable to read regular newspaper print. • Vision Impairment – broad term used to refer to any degree of vision loss that affects a person’s ability to perform the usual activities of daily life and cannot be corrected with glasses or contact lenses.

20. Driving • Most individuals report giving up driving in the most difficult part of vision loss. • Not driving is a life altering change. • Many individuals do not know of the transportation resources available. • Many individuals with vision loss are fearful of going out of the house alone. Criteria for having a drivers license in Missouri: Acuity: • For non-restricted - 20/40 with or without correction. If blind one eye, other eye must be 20/50. • Absolute minimum 20/160 – will have restrictions. Field: • 55o or better in each eye • 85o in one eye only with restrictions.

21. Vision Rehabilitation Vision Rehabilitation is specialized training and services to help an individual learn new adaptive techniques to regain or maintain independence in daily living. These services are provided by specially trained professionals. The services include: • Low Vision Clinic - evaluation by an Optometrist for devices that could enhancing reading and distance vision • Vision Rehabilitation Therapist/Occupational Therapy – daily living tasks • Orientation and Mobility – getting around safely • Assistive Technology – using technology (computers, tablets, cell phones) • Social Work – counseling, support groups, family education • Recreation – leisure activities and socialization

22. Tip # 1Use Task Lighting for Better Light Good Task Lighting Example

23. Characteristics of a “Good” Task Light • Flexible arm or gooseneck • Many people now use “daylight” or LED bulbs & lights • CFL Bulb of 15 watt or incandescent bulb 60 watt or more • Light directs down on material • Shade does not block light • For general lighting, CFL bulb of 20 watt or more and incandescent bulb of 75 watt or more • Use of “light app” on smart phones

24. Poor Lighting Example Lamps with heavy, ornate shades Stationary light source (overhead lights)

25. Tip # 2Contrast is an Eyes Best Friend Color Contrast helps highlight and makes some tasks easier to do • Black on White typically best, some reverse of white on black also can help • Colors that are similar make things more difficult, such as black letters on blue background • Can be incorporated into everyday living • Pour coffee into white lined mug, or milk into black lined mug • Use of placemat for dinner plate, with placemat opposite color of plate/dishes • Rug (or tape) at foot of stairs/outside step and before 1st step down, contrast color to floor/carpet • Bathroom towels contrast with wall color • Dark trash can with white liner • Reversible cutting board (white onion on black, hamburger on white)

26. Adding Contrast to Everyday Living

27. Tip #3Use Quality Magnification Tools • Hand Held Magnifiers, Non-Lighted • Lighted Hand Held Magnifiers • Stand Magnifiers • Hands Free Magnification • Distance Magnification • Electronic Magnification Tools

28. Hand Held Magnifiers • Cons • Needs additional lighting • Scratches easily • Pros • Portability & most common style • Low cost

29. Lighted Hand Held Magnifiers Pros • portable with light • medium price range • Cons • replacement of batteries • may not be enough light

30. Stand Magnifiers • Pros • Holds right focal distance • Holds page flat • If lighted, has own source • Cons • Not able to write under • Reflection from light if not a • lighted magnifier • Higher cost

31. Hands Free Magnification • Pros • Hands are free • Easier to use when writing • Cons • Close focal distance when increasing magnification

32. Distance Magnification • Pros • See things at a distance without moving closer • Cons • Small visual field • Hard to hold steady or heavy if mounted on glasses

33. Electronic Magnification Devices CCTV’S Pros • Easy to use • Lighting not an issue • Various magnifications • New hand held units • Cons • Cost • Space needed

34. Computer Screen Magnification Pros Software options to enlarge text Increase font size Contrast options Cons Larger size print makes harder to see entire screen

35. New and Emerging Technologies • Smart Phone Based Applications • Picture to voice, Extra Lighting, Money & Other Identifying • Head Mounted Magnification • Devices worn on the head and magnifies to screen on device • “Star Wars” type look • Expensive as most are over $5,000 • Eyeglass Camera to Voice Devices, Not Magnification Based • Use of “Artificial Intelligence” to make “Artificial Vision” • Takes Picture of Printed Material and converts to speech • Programmable for facial recognition and other objects • Price range from $2,500 - $4,500

36. New and Emerging TechnologiesMagnification & “Artificial Vision” OrCam Iris Vision

37. Tip #4 Use Non-Optical Aids • Writing guides • Large number phone, clock, TV remote, thermostat • Talking clock or watch • Posture Board or Lap Desk • Bold line paper • Dark felt tip pen • Magnifying mirror • Large print or size pill box

38. Tip # 5 Keep Your Home Safe • Use contrast • Put yellow tape or paint on steps • Use different colored plates on electrical outlets • Use plates and cups that contrast to tablecloths or placemats Reduce Clutter: be organized Arrange furniture for clear paths Put handrails by stairs, both sides if possible Use good lighting by stairs Remove or tape down throw rugs

39. Tip # 6 Set Up An Ideal Working Area • Comfortable and adjustable chair • Desk or table, free of clutter • Posture board or lap desk • Good task lighting • Magnification device(s) • Appropriate writing device • Appropriate writing tablet and guides

40. Tip # 7 Slow Down and Pace Yourself Most falls happen when someone is rushing Using magnification requires practice and learning a new way of doing things Read for shorter periods of time

41. TIP # 8 Obtain Large Print Materials Books, checks, menus, playing cards, magazines, utility bills, religious materials or address books are in large print. Inquire at libraries, book store, restaurants or place of subscriptions. Religious resources

42. Tip # 9 Use Your Resources • Access services from state or local agencies • State Library, Minds Eye, Phone Service • Missouri TAP program • Personal shopper or customer service • Order groceries by phone or internet • Large print bills, bank services • Public Transportation • Family and Friends

43. Tip # 10Don’t Be Afraid to Ask for Help or Let People Know • Some try to hide their vision problems, which can make matters worse • If vision loss gets too severe it is not uncommon to get feelings of depression • Many sources of help and/or aids are inexpensive or free • Some use a white cane to let others know they have a vision problem, especially when walking or crossing intersections • Social impact of not recognizing faces and not letting a person know

44. The Drews Low Vison ClinicatSociety for the Blind and Visually Impaired Who Can Be Helped Individuals with Vision Problems that Interfere with Daily Life What Does the Drews Low Vison Clinic Do Assist a Person to Best Use Their Remaining Vision Identify Magnification and Devices Most Helpful Over 250 Different Aids & Devices Transportation Provided to Clinic if Needed What Does it Cost Appointment Covered by Medicare and Most Insurance Plans Aids & Devices begin as low as $10

45. Tips for staff caring for a person with vision impairment Communication: • Introduce yourself and address the patient by name, so they know you are talking to them. • Introduce the patient to others in the room. • Say good bye and tell the patient when leaving the room. • Always explain to the patient what you are about to do. • Ask what the patient is able to see. Few patients are totally blind. • Describe things in detail – food, gift items, rooms, situations.

46. Orienting the Patient to the Room and or Facility • When orienting a patient to a new area or room, walk with them rather than giving verbal directions only. This helps them learn distances and sensory cues. • Don’t assume you know what the patient needs. The person uses their hands more for “seeing” and will explore specific orientation to objects accordingly, such as feeling the chair, sink or other fixtures. • Ask if the patient would like to take your arm for guiding purposes. If so, use sighted guide method, let them hold your arm above the elbow with their thumb to the front. • Keep pathways and corridors clear of obstacles. • Inform patients of any changes to environments.

47. Patients in Bed • Put an “identifier sign” above the patient’s bed/or door station. • Consider adjustable extra lighting for patients with some useful residual vision. • Don’t move patient’s belongings. If must be moved , notify patients of such. • Orient the patient to controls for bed, TV, radio, and call button. Use tactile markings on these items, if needed. • Patient may prefer a corner bed close to door for easier orientation to room. • Knowing the time can help with daily routines. Offer some method for telling time for patient. (talking clock or watch)

48. Mealtimes • Read aloud menus and have patients choose their meal. • Tell patients when trays or meals arrive, and the placement of food on plate using clock method. (Chicken at 6 o’clock, peas at 10 o’clock) • Ask patient if they would like assistance with meal or packaging. • Color contrast can be very helpful for patients with some vision. A light colored plate on dark tray is helpful. Clear drinking glasses may be difficult to find on a tray. • Provide hot drinks in non-spill containers and tell the patient where they are placed.

49. Mealtimes • Read aloud menus and have patients choose their meal. • Tell patients when trays or meals arrive, and the placement of food on plate using clock method. (Chicken at 6 o’clock, peas at 10 o’clock) • Ask patient if they would like assistance with meal or packaging. • Color contrast can be very helpful for patients with some vision. A light colored plate on dark tray is helpful. Clear drinking glasses may be difficult to find on a tray. • Provide hot drinks in non-spill containers and tell the patient where they are placed.

50. Help is as Easy as a Phone Call or E-mail For More Information, Assistance or to Make a Referral Brenda Wendling, Director of Adult Services 314-968-9000 or 314-301-7374 bwendling@slsbvi.org Or Visit us on the Web at: www.slsbvi.org Referrals can be made from the website.