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The role of occupational therapy in visual impairment in Aotearoa/New Zealand.

Abstract

This paper acknowledges that most occupational therapists encounter low vision as a complication in clients with other functional impairments and medical conditions and few have the opportunity to become specialists in low vision. It therefore offers a brief outline of how occupational therapists can do vision rehabilitation for low vision, including an overview of conditions, assessments, interventions and models. There is a real need for occupational therapists to become effective advocates for the development of low vision services, no matter what service they are currently working in, and so visual impairment is situated in current political and policy context of Aotearoa/New Zealand.

Key words

Vision rehabilitation, low vision, visual deficits.

Reference

Butler, M. (2016). The role of occupational therapy in visual impairment. New Zealand Journal of Occupational Therapy, 63(1), 31-33.

In this paper I aim to provide a brief overview of practice and policy around low vision in Aotearoa/New Zealand, in order to raise awareness among occupational therapists and to increase our efficacy as advocates for the development of low vision services throughout New Zealand. Most occupational therapists encounter low vision as a complication in clients with other functional impairments and medical conditions and few have the opportunity to become specialists in low vision. The consideration for occupational therapists is therefore one of discriminating the extent to which low vision contributes to, or complicates, a primary diagnosis. Low vision can be implicated in almost any condition: hip fractures or depression; fatigue or walking difficulties; occupational alienation or headaches; stroke or brain injury. It impacts on people's ability to carry out important activities including obtaining an education, living and traveling independently, being employed, and enjoying and seeing visual images. It is caused by visual deficits that cannot be corrected with medical treatments, ordinary glasses or contact lenses (Oslo, 2004).

At one time there were ten low vision clinics in Aotearoa/New Zealand, but now all but two of these have disappeared. Meanwhile, the number of people with visual impairment has steadily increased and Statistics New Zealand's 2013 post-census Disability Survey (2014) found that self-reported visual impairment among adults increased an astonishing 100 percent between 2001 and 2013 (from 81,500 to 163,000), which is equivalent to 4% of the population. There are a few consumer groups (Retina, VICTA, Albinism NZ and Macular Degeneration NZ), but these largely voluntary groups cannot begin to provide a service to the numbers of people who need it. The Blind Foundation is funded to provide services to people who are severely impaired, which means that only 7% of people with visual impairment meet the criteria for the Blind Foundation, while 93% of people with visual impairment have nowhere to go for support. They are usually told that nothing can be done, and this is a real cause for concern.

Conditions causing low vision

When I started to read and learn about about vision, I found it helpful to divide the various conditions into the places where I could expect to find them.

1. the front of the eye,

2. the back of the eye

3. the optic chiasm to the occipital lobe.

I then arrived at a 'stunning glimpse of the obvious': optometrists deal with conditions that go as far as the back of the eye; opthalmologists tend not to look beyond the optic chiasm; while occupational therapists deal with the whole spectrum, from the front of the eye to the back of the brain. This seemed significant to me and I found it highly motivating as I worked towards arriving at a very basic working knowledge of the various elements of visual impairment that an occupational therapist is likely to encounter in daily practice. My aim was to be able to explain clearly to the family what it means when my mother is diagnosed with macular degeneration and glaucoma, or any other visual impairment.

Cataracts are an example of a condition that affect the front of the eye, caused by clouding of the eye's natural lens. This is the most common cause of vision loss in people over the age of 40. To understand what it is like put a piece of sellotape over your glasses and try to make out the hazy outlines. Glaucoma is an example of a condition that affects the back of the eye resulting in damage to the optic nerve. To understand glaucoma, make a tunnel of your fist and look through it and you can see how peripheral vision is affected. The onset of glaucoma tends to be slow and insidious, and for this reason it is sometimes called 'the silent thief'. You sometimes notice this condition when an individual starts to walk into branches, or the sides of doors. Macular degeneration affects the back of the eye, but this time the damage is done at the tiny spot known as the macula (about 5.5mm in diameter). To understand the effects of macular degeneration, put a fist in front of your face and there will be a blind spot (scotoma) in the centre of your visual field. This blind spot gradually increases, but it is possible to learn to see using just peripheral vision.

Given that the brain devotes 30-40% of capacity to serve the need for vision (Cavanagh, 2011), it is not so surprising that acquired brain injury carries a substantial burden in terms of visual impairment. The most common categories of neuro-related vision dysfunction encountered by occupational therapists tend to be vision field deficits, ocular motor dysfunction and unilateral neglect. However, the range of conditions created by neurological visual impairment is so varied and baffling that I am not going to attempt to give a simple simulation of the condition. In any case, neurological visual impairment is covered in almost all undergraduate OT curricula and Warren's (1993) hierarchy of visual perception provides a structure for understanding how higher level skills are built on foundations of visual acuity, visual fields and oculomotor control. It is useful to note that this is stil the seminal piece of work in the field of brain injury and neurological visual impairment.

Assessment and interventions

There is much to learn about visual impairment, but the basic philosophy of occupational therapy remains the same. The model of model of visual functioning (Silviera, 2014) describes visual abilities, individual capacity and environmental cues. This model helps to tease out the relationship between assessments of visual function (the integrity of the visual system) with functional vision (how the person operates as an occupational being). It should be noted that this model is based on the early work of Corn (1996), a vision therapist who clearly understood the world and visual impairment in the same holistic way as occupational therapists.

Assessments of visual function include screening for: refractive errors, visual acuity, contrast sensitivity, visual fields (including peripheral, hemianopic and central fields), occulomotor functions and binocular vision (Weisser-Pike, 2014). This can feel a bit formidable to the busy clinican, so I have put together a list of apps for basic vision screening. For example "Sightbook includes a Snellen visual acuity test, an amsler grid (for macular degeneration) and contrast sensitivity among other tests, while Visual Fields Easy is good for peripheral vision loss. The focus is on iOS apps, as Apple devices are highly rated by those who are living with visual impairment.

There are a number of interventions to assist with low vision issues that are perfectly within the scope of occupational therapy. For example environmental adaptations can include a number of different types of magnification, several of which are covered in my blog about the apps and accessability features of ipad. Increasing contrast between objects and their backgrounds is a simple and effective way to improve visual function, such as using different coloured chopping boards. Filters can be used for glare control, contrast enhancement, retinal adaptation and eye protection, and these are provided in the form of 'sunglasses' in a variety of colours and levels of light filtration. There are a number of different skills that can be taught, such as eccentric viewing, visual tracking and visual scanning. Other techniques include sensory substitution, which can help people learn to use their remaining vision more effectively, for example by putting bump dots onto appliances. Neurological visual impairment can be helped using a range of simple interventions including lenses and prisms, occlusion (generally done in consultation with an eye care professional), attention training and scanning.

Where to from here for occupational therapy and low vision services?

In 2014 there was a petition made to the House of Representatives and Health Committee. The petition, supported by a submission from Occupational Therapy New Zealand - Whakaora Ngangahau Aotearoa (OTNZ-WNA), requested an inquiry into the need for accessible, comprehensive low vision services for the growing number of New Zealanders disabled by irreversible vision loss who do not qualify for membership of the Blind Foundation. Following that a report was developed for the Ministry of Health (2015) and stakeholders who were interviewed identified that "a good low vision service must be provided by a core team consisting of an optometrist(s) and an occupational therapist/low vision therapist". In October 2015, OTNZ-WNA was invited to put forward a candidate for the Ministry of Health Low Vision Rehabilitation Service Reference Group. Shirley Milligan and I shared a position. This group aimed to develop guidelines for the development of visual impairment services in Aotearoa New Zealand.

As occupational therapists, we already do a significant amount to help people with visual impairment by taking it into account when we are doing functional assessments. Occupational therapy is a good friend to people with visual impairment and to the professions (like optometry and ophthalmology) that serve them. It is my strong belief that occupational therapy is in a good position to be a key part of any service development in this area. We need to educate ourselves to understand and better serve the needs of people with visual impairment at multiple levels in the near future. I hope that this paper demonstrates part of our increasing capacity and commitment in this area.

Note:

The material for this paper has become the kernel for my blog (www.visionmattersot.com) and facebook page (visionmattersot). Both are regularly updated.

References

Cavanagh, P. (2011). Visual cognition. Vision Research, 51(13), 1538-51. Retrieved from doi.org/10.1016/j.visres.2011.01.015

Corn, A., & Koenig, A., (1996). Foundations of low vision: Clinical and functional perspectives. New York: AFB Press.

Duckworth, S, (2015). Stocktake and needs analysis of low vision services in New Zealand. Wellington: Ministry of Health. Retrieved from www.health.govt.nz/publication/stocktake-and-needs-analysis-low-vision-services-new-zealand

Silveria, S. (2014). 'Reframing Visual impairment for the Australian National Disability Insurance Scheme'. Australian Orthoptic Journal, 46 (1): 17-22.

The International Society for Low-vision Research and Rehabilitation (2005), Towards a reduction in the global impact of low vision. New York, USA. Retrieved from www.isvrr.org/_media/oslo_workshop_04.pdf

Weisser-Pike, O., (2014) Assessing abilities and capacities: vision and visual processing in Occupational Therapy for Physical Dysfunction, Radomski, M.V. and Trombly Latham, C.A. (ed), Lippincott Williams & Wilkins, New York, USA.

Warren, M. (1993). A hierarchical model for evaluation and treatment of visual perceptual dysfunction in adult acquired brain injury, Part 1. American Journal of Occupational Therapy, 47, 42-54. doi: 10.5014/ajot.47.1.42

Mary Butler

Corresponding author:

Mary Butler (PhD., RNZOT) Principal Lecturer, School of Occupational Therapy Otago Polytechnic

Email: mary.butler@op.ac.nz
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Title Annotation:Viewpoint
Author:Butler, Mary
Publication:New Zealand Journal of Occupational Therapy
Geographic Code:8NEWZ
Date:Apr 1, 2016
Words:1908
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