Principles of modern low vision rehabilitation

Low vision rehabilitation is a new emerging subspecialty drawing from the traditional fields of ophthalmology, optometry, occupational therapy, and sociology, with an ever-increasing impact on our customary concepts of research, education, and services for the visually impaired patient. A multidisciplinary approach and coordinated effort are necessary to take advantage of new scientific advances and achieve optimal results for the patient. Accordingly, the intent of this paper is to outline the principles and details of a modern low vision rehabilitation service. All rehabilitation attempts must start with a first hand interview (the intake) for assessing functionality and priority tasks for rehabilitation, as well as assessing the patient's all-important cognitive skills. The assessment of residual visual functions follows the intake and offers a unique opportunity to measure, evaluate, and document accurately the extent of functional loss sustained by the patient from disease. An accurate assessment of residual visual functions includes assessment of visual acuity, contrast sensitivity, binocularity, refractive errors, perimetry, oculomotor functions, cortical visual integration, and light characteristics affecting visual functions. Functional vision assessment in low vision rehabilitation measures how well one uses residual visual functions to perform routine tasks, using different items under various conditions, throughout the day. Of the many functional vision skills known, reading skills is an obligatory item for all low vision rehabilitation assessments. Results of assessment guide rehabilitation professionals in developing rehabilitation plans for the individual and recommending appropriate low vision devices. The outcome from assessing residual visual functions is detection of visual functions that can be improved with the use of optical devices. Methods for prescribing devices such as image relocation with prisms to a preferred retinal locus, field displacement to primary gaze position, field expansion, and manipulation of light are practiced today in addition to, or instead of, magnification. Correction of refractive errors, occlusion therapy, enhancement of oculomotor skills, and field restitution are additional methods now available for prescribing devices leading to rehabilitation of visual functions. The outcome from assessing residual functional vision is detection of functional vision that can be improved with the use of vision therapy training. After restoration of optimal residual visual functions is achieved with optical devices, one can follow with training programs for restoration of lost vision-related skills. If an optical dispensary is available where prescribing of low vision devices routinely take place, this will help ensure familiarity and specialization of the dispensary and staff with low vision devices and their special dispensing requirements. The dispensing of low vision devices is an opportunity to introduce the device to the patient, train the patient in the correct use of the device for the task selected, and create a direct and continuous connection with the patient until the next encounter. Following assessment, prescribing, and dispensing of devices, a low vision practitioner, ophthalmologist or optometrist, is responsible for recommending and prescribing vision therapy training to improve residual functional vision. An attempt to present a template for a comprehensive modern low vision rehabilitation practice is made here by summarizing scientific developments in the field and stressing the multidisciplinary involvement required for this kind of practice. It is hoped that this paper and other initiatives from colleagues, the public, and government will promote and raise awareness of modern low vision rehabilitation for the benefit of all.