Professional Documents
Culture Documents
Low Vision ICO
Low Vision ICO
Range of
(Near-)Normal Vision
Normal
Vision V I S U A L STANDARDS
Mild
Vision
Loss
ASSESSMENT
and
Moderate
Vision
Loss
REHABILITATION
Low Vision
Severe
Vision
Loss
of
VISION-RELATED
Profound
Vision
Loss
Near- FUNCTIONING
Blindness
(Near-)
Blindness
Blindness
This report is part of a series prepared for the International Council of Ophthalmology.
All reports are available at www.icoph.org/standards ; they include:
VISUAL STANDARDS –
ASPECTS and RANGES of VISION LOSS
with Emphasis on Population Surveys
VISUAL STANDARDS –
VISION REQUIREMENTS for DRIVING SAFETY
with Emphasis on Individual Assessment
2
ASSESSMENT and REHABILITATION of VISION-RELATED FUNCTIONING
VISUAL STANDARDS –
ASSESSMENT and REHABILITATION
of FUNCTIONAL VISION
3
Acta Ophthalmologica 2010
Editorial
doi: 10.1111/j.1755-3768.2010.01885.x
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Acta Ophthalmologica 2010
For example, uniform criteria for elective cataract surgery but whose References
access to elective surgical care were VF-14 score is low. These patients
introduced in Finland in March 2005 most likely are more in need of sur- Colenbrander A (2010): Assessment of func-
tional vision and its rehabilitation. Acta
as part of a national health care gery than the former group of patients
Ophthalmol 88: 163–173.
reform. The primary criteria defining who fulfill the national criteria. International Council of Ophthalmology
access to cataract surgery were set to It is unlikely that cataract surgery is (2008): ICO report and statement on func-
20 ⁄ 40 vision or less in the better eye an exception in which assessment of tional vision; http://www.icoph.org/stan
or 20 ⁄ 60 vision or less in the worse functional vision likely would help to dards/index.html.
eye. These criteria are clear cut and allocate health care resources Kivelä T, Sarikkola A-U, Ess S-L, Helstedt
easy to apply, but are they truly the more rationally. Recognizing the T, Leivo T & Uusitalo RJ (2006): Helsinki
best available for defining who will importance of functional vision, the Simultaneous Bilateral Cataract Surgery
Study: prospective, randomized comparison
benefit from swift surgery and whose International Council of Ophthal-
of patient–rated outcomes of same day vs.
treatment can be deferred? mology (2008) has adopted the state- separate day cataract surgery. Invest Oph-
Let us draw from a trial which ment: thalmol Vis Sci 47: E-Abstract 660; http://
enrolled 507 consecutive patients ‘Ophthalmic care extends beyond abstracts.iovs.org/cgi/content/abstract/47/5/
scheduled for bilateral cataract sur- the treatment of eye disease to pro- 660.
gery (Kivelä et al. 2006). All patients moting the well being of the patient. Koestler FA (1976): The unseen minority. A
completed one widespread measure of Treatment decisions should consider social history of blindness in the United
functional vision, the Visual Function patient needs and ascertain that the States. New York: AFB Press 312.
Kuhn F, Morris R, Witherspoon CD, Hei-
Index VF-14 (Steinberg et al. 1994) in clinician’s expectations match those
mann K, Jeffers JB & Treister G (1996): A
its original and in a shortened form of the patient. Studies of ophthalmic standardized classification of ocular
(Uusitalo et al. 1999). The question- outcomes should likewise include trauma. Ophthalmology 103: 240–243.
naire was designed and thoroughly appropriate tools to evaluate visual Kuhn F, Morris R & Witherspoon CD
validated for assessing functional functioning. These principles should (2002): Birmingham Eye Trauma Terminol-
vision of patients with cataract (Stein- feature prominently in ophthalmic ogy (BETT): terminology and classification
berg et al. 1994). It consists of 14 training, ophthalmic practice and in of mechanical eye injuries. Ophthalmol
Clin North Am 15: 139–143.
items which address everyday visual health care policy decisions’.
Massof RW (2008): Moving toward scientific
tasks. The respondent chooses an How should this resolution influ- measurements of quality of life. Ophthal-
answer that corresponds to the level ence your practice and the organiza- mic Epidemiol 15: 209–211.
of difficulty he or she has in perform- tion that you work for or are Massof RW & Ahmadian L (2007): What do
ing each task, ranging from no diffi- responsible of? A rational starting different visual function questionnaires mea-
culty to being unable to perform the point for formulating your answer is sure? Ophthalmic Epidemiol 14: 198–204.
task. Of the 507 patients who all ful- to read and digest Dr Colenbrander’s Ritter CG (1957): Questions and answers on
filled the visual acuity criteria for review. You do not need to accept low vision. New Outlook Blind 51: 446–453.
Steinberg EP, Tielsch JM, Schein OD et al.
being admitted to cataract surgery, all of his viewpoints, but you should
(1994): The VF-14. An index of functional
14% got a score 90 or better, indicat- definitely be aware of them. Func- impairment in patients with cataract. Arch
ing negligible difficulty in performing tional vision has come of age and Ophthalmol 112: 630–638.
their everyday visual tasks. portends to become one megatrend Uusitalo RJ, Brans T, Pessi T & Tarkkanen A
A population of patients also exist of the beginning decade of eye care. (1999): Evaluating cataract surgery gains by
whose visual acuity exceeds the cur- assessing patients’ quality of life using the
rent national criteria for access to Tero Kivelä VF-7. J Cataract Refract Surg 25: 989–994.
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Review Article
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Acta Ophthalmologica 2010
This article explores the basic con- manager may worry whether the It is useful to draw a line in the mid-
cepts and methods for the assessment insurance will pay. The daughter wor- dle of Fig. 1. On the left side we speak
of functional vision. It is based on a ries whether her mother can still drive. of visual functions, which describe how
report prepared for the International These are all very different aspects of the eyes function; on the right side we
Council of Ophthalmology (ICO) and a single clinical case. Each of these speak of functional vision, which
the International Society for Low aspects tells us something about the describes how the person functions.
Vision Research and Rehabilitation patient, but also gives us insight in the When organ functions are reduced, we
(ISLRR), presented at their respective point of view of the beholder. speak of impairments. Ocular visual
conferences [the World Ophthalmol- Similarly, when considering visual impairments caused by ocular disor-
ogy Congress (WOC-June 2008) in functioning, we can perceive many dif- ders are most common; the resulting
Hong Kong and Vision-July 2008 in ferent aspects of vision loss depending reduction in visual functioning consti-
Montreal]. This article also builds on on our point of view (Fig. 1). tutes the traditional domain of vision
previous reports for the ICO (ICO First we may consider how various rehabilitation. More recently, increased
2002, 2006) and ISLRR (ISLRR causes, such as scarring, atrophy or attention is being asked for cerebral
1999), on the Guides of the American loss, may result in structural changes. disorders, which may cause cerebral
Medical Association (AMA 2001, Here the focus is on the tissue and we visual impairment. In infants and chil-
2007), on a WHO consultation (WHO need the pathologist to examine these dren the cause is often perinatal cere-
2003) and on resolutions of the World changes. bral ischaemia; in adults it may be
Health Assembly emphasizing the Yet, the structural changes do not traumatic brain injury; in older
importance of rehabilitation in general tell us how well the eye actually func- patients it may be the result of a stroke.
(WHO 2005) eye care in particular tions. We need to widen our view to Cerebral visual impairments may cause
(WHO 2006) and the prevention of the organ as a whole. We need a clini- abnormal visual functioning, which
visual impairment (WHO 2009). Prior cian to measure aspects of organ func- can be captured under the term visual
reports emphasized population-based tion, such as visual acuity, visual field, dysfunction. This is an important new
studies, where statistical averaging contrast sensitivity, etc. area of vision rehabilitation, but will
obscures individual differences. The However, knowing how the eye not be covered in this article.
current review considers how to evalu- functions does not tell us how the per-
ate and document the effectiveness of son functions. So we need to widen
rehabilitation aimed at improving our perspective again, this time to the
Terminology
individual performance for a wide person level. We need to consider Distinguishing these aspects is impor-
range of activities. tasks, such as reading, mobility and tant because each aspect requires dif-
face recognition. Here we need vari- ferent methods of assessment.
ous low-vision professionals to work Unfortunately, traditional terminology
Aspects of Vision Loss with the patient. often ignores these differences by
Vision loss can be observed from Beyond that, we need to look at the using terminology that is not aspect-
many different points of view, each of person in a societal context. Do these specific. Questionnaires may ask about
which reveals a different aspect. Con- changes impact on the person’s partic- night vision (a visual function) as well
sider a patient with AMD who comes ipation in society, causing job loss or as about night driving (a functional
to make an appointment. The front a reduced quality of life? How can we ability) and blur the distinction by
desk will think about when to sche- be sure that the patient is satisfied, speaking about vision function for
dule her. The doctor will think about which should be the end goal of all both aspects. Separating visual func-
which treatment to select. The office our interventions? tions from functional vision makes the
distinctions clearer.
When functional abilities are
The organ The person restrained, many speak about ‘disabil-
Structure Function Abilities Consequences ity’. The term disability can also mean
Focus: Tissue Organ Person Society different things to different people. It
can refer to the impairment aspect, as
Examples: Scar Acuity Reading Participation
atrophy field mobility it does in the Americans with Disabili-
quality of life
loss contrast ADLs ties Act. It can refer to a loss of abil-
ity, as in disabled veterans and as
used in ICIDH. Finally, in being on
disability it refers to a socioeconomic
consequence. When these differences
are not acknowledged, the result may
be confusion and misleading questions
Visual functions Functional vision
(how the eye functions) (how the Person functions) may be asked, such as why disability-
Ocular disorders Visual impairment Reduced functional vision as-an-impairment cannot be trans-
Cerebral disorders Cerebral vis. imp. Abnormal functional vision (visual dysfunction) lated simply and unequivocally into
disability-as-a-socioeconomic-condition
Fig. 1. Different points of view reveal different aspects of visual functioning. ADL, activities of (Lenny & Van Hemel 2002). Because
daily living. of this, we prefer to avoid the term
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Acta Ophthalmologica 2010
Fig. 2. The primary outcomes for rehabilitation are different from those for medical interventions, although the ultimate goal (improved quality
of life) is the same for both.
disability by speaking about ability naire (NEI-VFQ) (Mangione et al. Under the aspect of visual functions
loss, which refers strictly to the ability 1998), are useful. (Fig. 3, left), we measure parameters
aspect. Various activities may cover The traditional medical focus is on that define how the eye functions;
more than one aspect. When we con- the organ of vision, its structure and these include visual acuity, visual field,
sider reading, the measurement of its functioning. Rehabilitation requires contrast sensitivity, etc. We do this by
threshold print size refers to organ a shift in focus to the functioning of varying one parameter at a time in a
function. Measures like critical (or the person and particularly to how we simplified, artificial environment. Con-
optimal) print size (the minimal print can improve that functioning. It also sider that the visibility of a test object
size needed for an optimal reading requires a shift in the doctor–patient depends on its size, contrast and illu-
rate) (Mansfield & Legge 2007), relationship. Under the medical mination. If we vary the size, while
reading speed (words per minute) and model, the doctor acts and makes keeping contrast and illumination con-
reading endurance (hours per day) decisions; on the patient side, we ask stant, we create a letter chart to mea-
describe the abilities of the person. only for compliance. In rehabilitation, sure visual acuity. If we vary the
Reading enjoyment, finally, is an there is nothing the doctor can do contrast, while keeping size and
aspect of quality of life. ‘for’ the patient; there are only things illumination constant, we create a
Awareness of these aspects can help patients can do for themselves. We contrast sensitivity test, like the Pelli–
us when assessing the outcomes of can give a patient crutches; the patient Robson or Mars cards. If we vary the
various interventions (Fig. 2). has to do the walking. We can give a illumination, while keeping size and
Medical and surgical interventions patient a magnifier; the patient has to contrast constant, we perform a dark
affect mainly the link between organ do the reading. The doctor’s role is adaptation test. Each of these tests
structure and organ function; their not less important, but it shifts from provides us with a threshold measure-
primary outcome measure is an doing to guidance and instruction. ment for that stimulus parameter; the
improvement of organ function. Most response level is fixed at 50% above
clinical trials use visual acuity as the guessing. Threshold measurements are
primary outcome measure, but other Measurement Methods used because they enable more pre-
visual functions should be considered cise psychophysical calculations, not
also. A secondary outcome is
for Various Aspects because threshold performance is the
improved visual abilities, while The measurement methods used for the most relevant performance level for
improved quality of life – our ultimate different aspects differ considerably. activities of daily living.
goal – is a tertiary outcome.
When we move from medical to
rehabilitative interventions, the func-
tional status of the eye is a given
and the outcome arrow moves to
improved abilities (functional vision).
To assess and document specific reha-
bilitation outcomes, we must ask
specific questions, comparing the out-
comes to preset goals. Asking global,
generic questions about quality of life
is not sensitive enough.
Improved quality of life, of course,
remains the ultimate goal. Here, gen-
eric tools that cover more than one
domain, such as the National Eye Fig. 3. The various aspects require the assessment of different qualities and different criteria.
Institute Visual Function Question- Their assessments should not be comingled.
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Acta Ophthalmologica 2010
Under the aspect of functional Rehabilitation for an activity such The medical model (ICIDH) sees
vision (Fig. 3, centre), we must assess as reading can be approached from disability as a challenge for individual
how the person functions. To do this, different points of view. When we rehabilitation; it emphasizes the
we must focus our attention on visual contrast reading print with reading assessment and enhancement of the
skills and abilities such as reading, Braille, we differentiate based on the individually available resources and is
orientation and mobility (O+M) and resources used. When we contrast thus relevant for individual healthcare.
activities of daily living (ADL). Such reading poetry with reading manuals The social model (ICF) sees disability
tasks always involve multiple parame- or maps, we make a distinction based as a social challenge in defining public
ters, which can vary independently on the goal that is served. policy and in fighting discrimination;
and cannot be separated. Therefore, Therefore, when considering func- its emphasis is on modifying the phys-
measuring functional vision is more tional vision, we must consider two ical and also the social environment
complex than measuring visual func- further aspects. What are the tasks so that people with an ability loss
tions. We also notice that we are no that must be accomplished, so that experience fewer obstacles when com-
longer interested in threshold perfor- societal participation is enhanced? pleting tasks. It is relevant for public
mance but in sustainable, supra- And what resources are available for health and for healthcare policy.
threshold performance. When reading accomplishing these tasks? Combining The focus of the ICF on tasks and
a book, print size, contrast and illumi- these two aspects, we end up with a participation is important, but for
nation all need to be well above large matrix of factors. rehabilitation it is not sufficient by
threshold to provide a comfortable The resources include visual itself. For instance, the ICF considers
performance reserve (Whittaker & resources (Fig. 3, left), which are the reading as a subcategory of applying
Lovie-Kitchin 1993). traditional focus of low vision care. knowledge and groups it with other
Finally, we must consider the socie- However, they should also include activities, such as thinking and prob-
tal context. We describe this aspect as non-visual resources such as touch lem-solving. When planning vision
quality of life (Fig. 3, right). Here we (cane, Braille), hearing (talking books) rehabilitation, we also need to know
must consider elements such as mak- and memory. Beyond that we need to which resources are to be used, be it
ing and keeping friendships, social strengthen, where possible, the per- visual (using magnification), non-
skills, self-confidence, etc. In this last son’s attitudinal and coping skills. visual (Braille) or instrumental (talk-
domain the concept of measurement is Under the task aspect (Fig. 3, right) ing books). Similarly, when discussing
even more difficult, because quality of we may consider changes in the envi- products and technology, the ICF
life involves highly subjective judg- ronment that serve to modify the task specifies the purpose of the technology
ments. When we move a cosmopolitan requirements. (for mobility, for education, for ADL,
city dweller to a small rural commu- In ICIDH (WHO 1980), the etc.). When providing individual
nity, and a rural farmer to a metropo- ability aspect was described as vision rehabilitation, we also need to
lis, both may complain that their dis-ability (= ability loss). In ICF specify the means used, which may be
quality of life has deteriorated. The (WHO 2001), the descriptor was task-dependent. The same person may
ultimate goal can best be described changed to activities. Abilities and use a magnifier to read bills or price
with the word ‘satisfaction’ – that is activities are two sides of the same tags and talking books for recrea-
the subjective balance between indi- coin; one cannot be described without tional reading.
vidual achievements and individual the other. Abilities relate to the
expectations. It should be noted that resources that are available; activities
many so-called quality of life ques- relate to the tasks that need to be
Resource Inventory
tionnaires are not limited to the strict accomplished. To list the available resources, the tra-
quality of life aspect; they blur the ICIDH was said to use the medical ditional eye exam offers a starting
distinctions between the aspects by model of disability; ICF adopted the point for visual resources. But the list
combining items from all three social model. The difference may be has to be expanded to include other
domains. When analysing such instru- explained by the following compari- visual skills, such as visual search
ments, the responses should not be son. The medical model may say: strategies and higher cerebral func-
lumped into a single score as if they these wheelchair users are handi- tions and the distinction between
all assessed the same aspect. capped because they are paraplegic. hemianopia and hemi-neglect. Too
The social model may say: these often these other aspects of vision
wheelchair users are handicapped receive little attention.
Assessment of because there are not enough kerb Furthermore, we need to list non-
cuts or ramps. We sometimes hear visual resources (Braille, long cane,
Functional Vision that the social model has replaced the guide dog, etc.). A person with retini-
Among these three aspects, the focus medical model. This is a misconcep- tis pigmentosa (RP) may travel ade-
in this article is on functional vision tion. The two models are not exclu- quately during the daytime, but may
and its assessment because this is the sive, but rather complementary and need cane travel skills after dark.
aspect that must be used to measure serve different purposes. Providing Here, seemingly subtle variations in
vision rehabilitation outcomes. When wheelchairs is the responsibility of the the questions asked may be important.
looking more closely, we will note healthcare system; providing kerb cuts When the RP patient is asked whether
that within this broad aspect there are is the responsibility of the public his night vision has improved, the
other sub-aspects. works department. answer is ‘no’. When asked whether
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night travel has improved, the answer visual functions, such as visual acuity, Therefore, it is not surprising that it
is ‘yes’. Psychological support and visual field and contrast sensitivity. has been said that ‘more people are
coping skills are also important: it is We are so familiar with these mea- blinded by definition than by any
known that vision loss often leads to surements that we often think that other cause’ (attributed to Lloyd
depression, and depression may hinder they are sufficient to characterize Greenwood, 1949). How can we bring
successful adaptation. visual functioning. However, when we order to this confusing terminology?
shift to functional vision and to the Recognizing two ranges – ‘sighted’
abilities of the person, we must con- versus ‘blind’ – is simple for adminis-
Task Inventory sider quite different categories such as trative use, but it denies the value of
ICF provides a broad classification of face recognition, ADL and orientation residual vision and the continuum of
tasks and environmental factors. For and mobility (O&M). ranges of vision loss.
a more detailed analysis of vision- While we have well-standardized Common sense demands that the
related tasks, the Activity Inventory methods to measure the function of term blindness not be used for persons
(Massof et al. 2007a) should be men- the eye, the terminology we use to with useable residual vision. In 2002
tioned. This is a list of over 500 tasks, relate our numerical measurements to the ICO adopted a resolution calling
grouped under 50 goals and three attributes of the person is often con- for replacement of the visual-acuity-
objectives (daily living, social interac- fusing. The Social Security Adminis- based definitions by definitions based
tions, recreation). It has been tested tration (SSA) in the USA considers a on functioning (ICO 2002):
and validated on over 1800 patients at person ‘statutorily blind’ when visual
(1) The term blindness should be used
Johns Hopkins University. acuity is less than 20 ⁄ 100 (< 0.2);
only for those with little or no residual
Because asking all questions of all other US agencies consider a person
vision, who have to rely predominantly
patients is impractical, the strategy is ‘legally blind’ at 20 ⁄ 200 or less
on vision substitution skills, such as
to first ask whether a particular task (£ 0.1). Yet in Australia, ‘legal blind-
Braille, a long cane or talking books,
or goal is needed and ⁄ or difficult. ness’ is defined as less than 6 ⁄ 60
to perform activities of daily living.
Tasks and goals that are not difficult (< 20 ⁄ 200, < 0.1); meanwhile, the
(2) The term low vision is appropri-
or not needed are skipped. Thus, this WHO applies the term ‘blindness’ to
ate for the much larger group that
tool provides a comprehensive, stan- visual acuity less than 3 ⁄ 60
has residual vision, so that vision
dardized yet individualized analysis of (< 20 ⁄ 400, < 0.05). All of these crite-
enhancement tools can be used to
each patient’s problems. ria leave the person with a significant
improve the performance of daily liv-
level of residual vision (Fig. 4). Note
ing skills.
that the changes in letter-chart legibil-
Ranges of Vision Loss ity in Fig. 4 are far more pronounced
(3) For finer distinctions, the ICO rec-
ommends the general term vision loss,
For the medical aspect we have good than the visibility changes in the
which can be used with modifiers,
standardized methods to measure room.
Fig. 4. The presence of the letter chart in the image allows the determination of the visual acuity level, represented by successive degradation of
the image. Note that the ability to read the chart decreases far more than the ability to recognize people or objects in the room.
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Fig. 5. The visual acuity ranges recognized in International Classification of Diseases, 9th revision (ICD-9), clinical modification of ICD-9 for use
in the USA (ICD-9-CM) and International Classification of Diseases, 10th revision (ICD-10) provide convenient reference points on a continuous
scale. They do not represent stepwise increments in ability.
ranging from mild to moderate, loss’, as used in the clinical modifica- on tradition, because there is no sci-
severe, profound and total loss tion of ICD-9 for use in the USA entific evidence of any breakpoint in
(Fig. 5). Note that the term blindness (ICD-9-CM; US Public Health Service the ability scale that would justify
cannot be used with modifiers. 1978), has exactly the same definition their placement at any particular
as ‘low vision’ (WHO); the term point (compare Fig. 4). Because the
Because two ranges do not acknowl-
‘severe vision loss’ (ICD-9-CM) has transitions are gradual, any func-
edge the continuum, the WHO intro-
the same definition as ‘legal blindness’ tional classification should not to be
duced the low vision category in the
(USA); the term ‘profound vision loss’ based on rigid transitions. Note that
International Classification of Diseases,
(ICD-9-CM) is equivalent to ‘blind- the horizontal lines in the left part
9th revision (ICD-9; WHO 1977)
ness’ (WHO). Nevertheless, these of Fig. 5 are not extended to the
30 years ago. The word ‘low’ indicates
terms have a very different psycho- right-hand part. The ICO recommen-
that vision in this range is not normal.
logical impact. In WHO publications dations state that blind persons rely
The word ‘vision’ indicates that it is
(ICD-9, ICD-10), the same ranges are predominantly on vision substitution.
not blindness.
identified with numbers [moder- Even for a patient with only light
This is more than just a play on
ate = 1, severe = 2, profound = 3, perception, that light perception may
words. The terminology used has
less = 4, no light perception help in determining where the win-
important psychological effects. We
(NLP) = 5], because numbers are eas- dow is, and thus in remembering
say ‘you are blind’, but ‘you have low
ier to translate into various languages. where other objects are in the room.
vision’. The verbs to be and to have
One caveat. When drawing neat A person with lesser vision loss may
have different implications. Compare
dividing lines between ranges (Fig. 5), use a magnifier to read price tags,
the statement that you are a problem
one should not think that those lines but may prefer talking books for
to the statement that you have a
represent stepwise increments in abil- recreational reading. Thus the transi-
problem. The first statement sounds
ity. Rather, the dividing lines may be tion from occasional use of vision
irreversible; there is nothing we can
compared to milestones along a road. substitution to predominant use is a
do about it. The second statement
They are useful reference points, but very gradual one. Note that the
leaves room for hope, and naturally
the landscape does not change sud- range of profound low vision, which
leads to the question: what can we do
denly when we pass a milestone. The clearly is a part of that transitional
to alleviate your problem?
landscape changes gradually in the range, is part of the low vision cate-
Therefore, we should avoid the term
area between the milestones. gory in ICD-9-CM yet the WHO
‘blindness’, legal or otherwise, when
Thus, the lines in Fig. 5 are drawn (ICD-9, ICD-10) considers it part of
referring to persons with residual
based on statistical convenience and its blindness category.
vision. The term ‘moderate vision
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Acta Ophthalmologica 2010
Performance Ranges Recognizing more than three QoL Group 1990) has five questions,
ranges is also important as we discuss the NEI-VFQ Mangione et al. 1998)
The visual acuity scale in Fig. 5 fol- the consequences of vision loss, has 25, the Activity Inventory (Massof
lows a logarithmic progression of let- known as the burden of vision loss, et al. 2007a), mentioned earlier, has
ter sizes. This progression, consistent at both the individual and the societal hundreds. To make administration
with Weber–Fechner’s law (Weber level. Collapsing the six ranges to manageable, the latter skips questions
1834), was first proposed by Green three (normal ⁄ low vision ⁄ blindness) about tasks that are not difficult or
(1868) and is part of the Early Treat- may be useful for broad initial not necessary. Others have reviewed
ment of Diabetic Retinopathy Study screening and for simplified tabula- the many available instruments (Mas-
(ETDRS) protocol (Ferris et al. 1982), tions, but is too coarse for many clin- sof & Rubin 2001; de Boer et al.
which is now generally accepted as the ical applications. 2004).
de facto international standard. The When rating questionnaire or sur-
question of how many subdivisions vey responses from different respon-
the scale should have is a legitimate dents, other subjective factors come Likert Versus Rasch
one. Having a scale with too many into play. Statistical analysis has
subdivisions results in a spurious sense shown that in most instances respon-
Scores
of accuracy; having too few subdivi- dents cannot distinguish consistently Deriving a score from the patients’
sions discards valuable information. between more than four categories of responses is not as easy as it may
For visual acuity the listed line difficulty and three categories of seem, because there are two unknown
increments have proven to be clini- importance (Massof et al. 2005a, variables: tasks may be more or less
cally convenient and useful. On an 2005b). Some researchers collapse demanding and patients may have
ETDRS chart where each line has five study results to binary or dichoto- greater or lesser abilities. On top of
letters, the line increments are of the mous variables (yes ⁄ no, true ⁄ false, that, there are many unknown factors
same order of magnitude as the aver- greater than ⁄ less than). It has been that add statistical noise to the
age accuracy of clinical measurement, shown that this approach often responses. A common approach is to
which has a 95% confidence interval achieves simplicity at the expense of simply add the number of positive
of five or six letters (Raasch et al. accuracy (Beck et al. 2007). It should responses for each patient. This is
1998; Bailey et al. 2007). be noted that while distinctions such called a Likert score. This type of
When rating reading ability, we as between mild and moderate diffi- scoring is simple, but not very reli-
shift our criterion from threshold culty may not be reliable when com- able. If two patients each answer three
measurement to sustainable perfor- paring different respondents, they may of five questions, but not the same
mance. Factors other than visual acu- be relevant when prioritizing rehabili- ones, are their abilities the same?
ity also play a role; in retinal disease tation goals for a specific patient. Also, consider a group of patients
reading fluency can be influenced sig- who are asked a set of questions of
nificantly by scotoma interference, varying difficulty. Adding some diffi-
which is less important for single let- Performance Scales cult questions will not change their
ter recognition. Under these condi- How can we develop reliable scales abilities, but it will depress their aver-
tions a coarser scale is indicated. The upon which we can base the definition age score; adding some easy questions
six ranges in Fig. 5, comprising four of various ranges? Earlier, we dis- will do the opposite.
lines each, seem to provide an appro- cussed how visual functions are More appropriate, but statistically
priate scale. Note that the estimates of assessed by varying the stimulus until more complicated, is the method of
reading performance in Fig. 5 refer to a defined (threshold) level of perfor- Rasch analysis (Rasch 1960; Bond &
statistical averages. The performance mance is reached. For functional Fox 2001). This is a statistical method
of individual patients may be consid- vision, on the other hand, the ques- aimed at deriving simultaneously the
erably better or considerably worse tions or tasks are standardized while best estimates of the patients’ abilities
than the statistical average. The role the performance level is the variable. and the difficulty of the tasks. The
of rehabilitation is to improve visual Timing the performance provides application of this method for low-
functioning, even if visual functions an objective assessment (Owsley et al. vision patients has been advocated and
remain the same. 2001) and an easy numerical score, employed by Massof et al. (2005a,
Epidemiological studies have found but it is only possible for a limited 2005b). Applications for refractive sur-
that uncorrected or under-corrected number of tasks. An example of a gery have been explored by Pesudovs
refractive errors are the most frequent simple set of timed ADLs is given in et al. (2007). A common way of repre-
cause of visual impairment. They cause the Appendix. senting the results is in a diagram with
mostly mild or moderate vision loss. Asking the patient to rate the diffi- patients (ranked by ability) on the left,
The traditional ‘blinding’ eye diseases culty of each task allows exploring a tasks or questions (ranked by diffi-
are less frequent, but cause much more much wider variety of tasks. However, culty) on the right and a common scale
significant levels of vision loss. Deci- the responses are subjective; some in the centre. The diagrams in Fig. 6
sions about the allocation of scarce patients aggravate their problems, follow that convention.
health resources need to consider both others deny them. Nevertheless, the Figure 6A shows three patients
the frequency and the severity of each questionnaire approach is widely used. responding to a standardized task.
condition. Using the six listed ranges The number of questions varies They will find the task easy, possible
can capture these differences. widely. The EuroQol (EQ-5D) (Euro- or hard, depending on their level of
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Acta Ophthalmologica 2010
Fig. 6. It is important to match the difficulty of tasks to the abilities to be evaluated. A mismatch can lead to erroneous judgments.
ability relative to the demands of the difficult before surgery and easy after The opposite effect may occur if we
task. surgery (Fig. 6D), we get a different use questions designed for cataract
Different patient groups have differ- result. The revised test will lead us to surgery on the first eye for cataract
ent abilities. Figure 6B shows that cat- conclude that cataract surgery is surgery on the second eye. Second-eye
aract patients will have better abilities indeed effective. surgery will indeed improve perfor-
after surgery than before. The same is Many questionnaires have been mance, but not by as much as surgery
true of AMD patients after rehabilita- designed for cataract surgery (Massof on the first eye. If we use question-
tion. But the abilities of an AMD & Rubin 2001), although the psycho- naires designed for the first eye, we
patient after successful rehabilitation metric validity of several has been might conclude that second-eye sur-
will still be less than those of a cata- questioned (de Boer et al. 2004). gery is not very effective.
ract patient after successful surgery. Could we use those for AMD? Selecting questions that are spaced
This means that we need a variety of When we present the cataract ques- evenly along the difficulty axis and
tasks that are spread evenly over the tions to AMD patients before reha- that are matched to the ability range
difficulty scale. bilitation, they will find them hard of the population to be tested is essen-
What happens if we have too nar- (Fig. 6E). After rehabilitation, they tial for these measurements. Rasch
row a range of difficulties (Fig. 6C)? will still find them hard, and we analysis provides a means for doing
Before surgery, cataract patients will may conclude that rehabilitation has this.
rate the tasks as easy; after surgery had little effect. Again, we need to
the tasks will be very easy. This may adjust the level of difficulty. If we
lead us to conclude that cataract sur- do that, we will find that tasks that
Different Settings
gery has only a very limited effect. were hard have become easier, and The considerations described earlier
However, if we test these patients that rehabilitation is indeed effective point to the fact that different ques-
on more demanding tasks that are (Fig. 6F). tion sets may be needed for different
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Fig. 7. The well-designed Low Vision Intervention Trial (LOVIT) (a randomized clinical trial)
showed effect sizes that were much larger than those in other studies that were designed less References
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In Summary tiveness of vision rehabilitation [see
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International Council of Ophthalmology
In an age of evidence-based medicine the Low Vision Intervention Trial (ICO) (2002): Visual standards, aspects
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for a sample of low-vision patients. Arch Ware JE Jr & Sherbourne CD (1992): The Accepted on May 9th, 2009.
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Appendix was constructed by Fletcher (Gills can be compared before and after the
et al. 2007; Hester et al. 2009). The provision of aids and training, and
The following examples are meant as test consists of six common tasks: (i) ranges from 48 to 639 seconds with a
illustrations of different approaches; reading a bill; (ii) writing a cheque for median of 4 min. This is not a prohib-
the list is far from exhaustive. the amount; (iii) paying the amount in itive time in a low vision clinic. If the
cash; (iv) finding a telephone number patient takes more than 2 min for a
Timed instrumental activities of daily in the phone book; (v) dialling that task, that task is skipped. Thus, the
living number; and (vi) finding all four of maximum time is 12 min. In addition
the kings, queens or jacks from the 12 to timing the performance, observing
There is a need for simple tests of royal playing cards. Patients generally the patient can provide valuable
visual functioning that can be imple- experience these tasks as relevant; they insights into their problem-solving
mented easily and inexpensively in are allowed to use any tools or aids skills and motivation; it quickly sepa-
any low vision service. One such test, that they have available. rates those who aggravate their com-
a simple set of timed instrumental The tasks offer a range from easy plaints from those who deny their
activities of daily living (TIADLs), to difficult. The total completion time problems.
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Questionnaires The LOVIT (Stelmack et al. 2008) domain that has least in common with
of the Veterans Affairs Department in reading. This comparison demon-
There are dozens of visual function
the USA was such a study. In it, strates how important it is to focus
questionnaires, designed to evaluate
patients were assigned randomly to a the outcome measures on the goals of
functional vision (Massof & Rubin
vision rehabilitation programme or to the rehabilitation plan. If the study
2001; de Boer et al. 2004). Massof &
a 4-month waiting period (which was had used a global assessment tool that
Ahmadian (2007b) used four com-
the usual waiting period for patients averaged over all domains, the effect
monly used ones [Activities of Daily
who were not in the study). The size would have been smaller.
Vision Scale (ADVS) (Mangione et al.
6-week protocol was well defined and It is hoped that this study will not
1994), Visual Activities Questionnaire
documented and was implemented in remain the only randomized control
(VAQ) (Sloane et al. 1992), Visual
the same way in the various partici- study of vision rehabilitation out-
Function questionnaire (VF-14)
pating centres. Evaluation was per- comes.
(Steinberg et al. 2001) and National
formed by telephone by interviewers
Eye Institute - Visual Function Ques-
who did not know whether they were
tionnaire (NEI-VFQ) (Mangione et al.
talking to a treated or a control
1998)] on 407 low vision patients. Clinical Low Vision Rehabilitation
patient. The evaluation took place at
Extensive statistical analysis showed Network
4 months, to avoid the immediate
that all four measured essentially the
post-treatment effects. A total of 126 Not all rehabilitation programmes can
same visual ability variable, although
patients participated. Each participant muster the resources for a study as
there were differences in the validity
was seen for about 10 hr in the clinic, cited earlier. Also, in many services or
and accuracy of their scales. It was
did about 17 hr of homework and agencies the number of patients is rel-
found that the visual ability variable
received one home visit. atively small, hampering statistical
is different from and independent of
Figure 7 presents the results for dif- evaluation. One way to overcome
the physical and mental health param-
ferent domains. The grey arrows to these problems and to avoid duplica-
eters measured with the SF-36 (Ware
the left indicate a slight deterioration tion of efforts and overhead expense
& Sherbourne 1992).
in the control group. The larger, black is the creation of clinical research net-
The same findings will probably be
arrows to the right indicate the effect works. For vision rehabilitation the
true for all other, similar question-
sizes for the treated group. Low Vision Center at Johns Hopkins
naires. Given the large number of
For studies of this type an effect University has initiated a Clinical
questionnaires that exist already, it is
size of 0.8 is often considered a large Low Vision Rehabilitation Network
not advisable to generate additional
effect. By this measure the effect for (CLOVRNET) (Goldstein 2008)
ones unless their development is prop-
visual reading tasks was exceptionally through which various smaller entities
erly evaluated along the lines dis-
large and larger than that of any of can cooperate on joint studies. At the
cussed in this article.
the other domains. This is consistent time of writing, the Low Vision Reha-
with the fact that the protocol was bilitation Outcome Study (LVROS) is
aimed at improving reading perfor- collecting pilot data from 16 centres
LOVIT
mance. The effect sizes were also while the Low Vision Rehabilitation
Aside from the need for simple tests, substantially larger than those Devices and Services Study (LVRDS)
there is also a need for well-designed reported in other studies (Goldstein is in the planning stages.
studies of rehabilitation outcomes that 2008). This probably reflects the more This is a promising development that
meet the requirements for randomized rigorous design of this study. There also responds to the mandate that clini-
control studies (Cochrane 1972). were significant spill-over effects to cal research should extend beyond the
Unfortunately, such studies are still other domains. Not surprisingly, the larger institutions into private practice
rare in vision rehabilitation. smallest effect was seen for mobility, a and community-based settings.
173