1

Introduction to low vision •

The partially sighted comprise that group of individuals •
whose vision is not sufficient for ordinary reading or
ambulation despite correction with conventional
.glasses
Normally, individuals are not incapacitated until the •
vision in the best eye has deteriorated to at least 6/15
.or worse in the best corrected eye
Included in the classification of the partially sighted •
are persons deemed legally blind that have a visual
acuity of 6/60 or worse in the better eye, and persons
.with a field restricting of 20 degrees or less
Not usually included in this classification are persons •
whose near vision remains normal or near normal
although their distant vision may have worsened, this
is often the case with nuclear sclerosis , and early
.myopic retinal degeneration
2
Most individuals with subnormal vision can be •
.assisted by properly selected optical aids
The assistance does not mean restoration of •
vision, but utilization of the available vision to
restore the individual to a position of self-
.sufficiency
To an adult this may mean opportunity for •
employment. In industry, their work out-put has
been as good as that of their fellow workers or
often better, and their safety record is usually
.superior

3
Children can be afforded the opportunity to •
obtain an education, instead of becoming wards
.of the state
For the elderly individual, visual assistance may •
provide a new lease on life, preventing the
insidious decline to a state of mental lethargy
because inability to read, write, or maintain
.hobbies

4
The rehabilitation of the partially sighted is •
extremely gratifying since patients have been
told that their vision cannot be improved, and
have felt the implication that their hobbies or
.work will probably require abandonment
Witnessing a partially sighted individual reading •
for the first time in years is a more dramatic
event than seeing a post-operative cataract
patient read the 6/6 line, since the former is
often in despair, and expects nothing, whereas
the latter is usually confident that vision will be
.restored
5
 :Factor of age •
Management of the partially sighted persons •
.varies with age of the patient
Children affected form a small but important •
group, because if they are not assisted with
their disability, they may fall behind their
peers, and eventually fail to achieve a level of
education that will allow them to live an
.independent and satisfying life

6
They have the longest period to live with their •
disability, and have so little knowledge to
.depend on
Yet it is in this group that motivation, a •
necessary factor in learning to use an optical
aid, is likely to be high, whereas it may be
.lacking in the elderly
Also children are assisted by possessing an •
excellent range of accommodation, which
enables them to perform visual feats at near
.despite poor distance vision

7
Many children with distance vision of 6/60 have •
.excellent reading vision
In this group are children who have congenital •
nystagmus , high myopia, albinism, or
.congenital chorio-retinitis
In the early grades, children often require no •
special optical aids, since they either have
normal reading acuity, or can compensate for
.the disability by holding the print quite close

8
Also the children's books are printed in rather •
.large type
For children aged 7 to 8 years, the size of the •
print is conventionally about 18 points (requiring
6/30 vision), whereas for ages 9-12 years it is
.12 points (requiring 6/24 vision)

9
As the child progresses into the higher grades, •
the print in the text-books invariably becomes
smaller. It is usually at about the seventh
grade level that the child, who has been able to
get along previously in a school for sighted,
finds that he cannot keep up and must obtain
special assistance from visual aids and from
.the teaching staff
At this point optical aids become important •
because they may enable many of these
children to continue with their sighted
.classmates
10
Young adults actually constitute the smallest •
group of those becoming partially sighted, since
the adult usually experiences the onset of the
.loss of vision because of injury or disease
The young adult's situation is often difficult •
because his livelihood depends on successful
rehabilitation. Although motivation should be
high, young adults tend to experience
depression, apathy, despair, and even
bitterness concerning their recently acquired
visual disability, and this reaction, of course,
.retards effective visual retraining
11
Elderly individuals, constitute the largest •
group of the visually handicapped, principally
because they often suffer from the diseases of
.aging
The group is often difficult to assist because of other •
physical infirmities, which may include senility,
tremors, defective hearing, and diminished vigor.
Although a proportion of patients in this age group are
slow to accept the changes they must employ in
learning to cope with their new disability ( and in fact,
some of them never adjust ), there is a large
proportion that are, or can be motivated to make the
.adjustment necessary to achieve some useful vision
12
Assistance for patients with subnormal •
:vision is provided through
.A careful eye examination -1 •
A good history from the patient, including an -2 •
assessment of the patients reaction to his loss
of vision, and of the degree of adjustment
made, and a survey of the patient's interests,
.education, and visual needs
.The provision of optical and non-optical aids -3 •

13
It is important in the eye examination to test •
.visual acuity for distance accurately
The partially sighted patient should therefore •
.be tested at 3 meters rather than 6 meters
Most projectors or charts have no test print •
beyond 6/60, and if a patient is tested at 3
.meters, this deficiency is remedied

14
To convert to standard notations, the results •
.are multiplied by 2, for example 3/21 = 6/42
To test vision less than 3/60, the patient is •
instructed to walk closer to the chart, and the
visual acuity is recorded in terms of the
distance the patient can stand before the chart
and read 6/60 letter, for example, 2.5/60,
.1/60..etc
It is also important to obtain a careful •
refraction since correction of the basic
refraction error may sometimes be all that is
.necessary
15
A good history provides many essential details. If the •
patient has not accepted his visual loss, he is not a
good candidate for optical aids, nor is the individual
.who has recently experienced visual loss
Many patients have discovered some sort of visual •
aid, and they are good candidates for more
.sophisticated aids
Some individuals are content to be able to read hokey •
scores, and manage their shopping, and personal
mail, whereas with others, reading may play a much
larger part in their daily life, whether for personal
.pleasure or in earning a living
Many young people need the assistance of visual aids •
.to finish school
16
Low vision, partial sight, visual impairment, •
and legally blind, are synonymous for the
same state, which is reduced visual acuity
which even with the best optical correction
provided by regular lenses still result in visual
performance on standardized clinical test which
.is less than expected for a patient of that age
Other terms, which are often used inter- •
changeably with those above, such as visual
disability and visual handicap, are not
synonymous and they illustrate different
.aspects of the problem
17
 Examples Definitions Level

Age m. degeneration - Ophtjalmological

.- Cataract
Disorder
diagnosis
( Disease )

A) Anatomicai structure :
A change in the structure or
.- Photoreceptor degeneration
function of the eye or visual
Impairment
Lens opacity. -
( Consequence at level of
B) Physiological structure : .pathway
1- Central scotoma : Central vision organ
patchy, and distorted poor contrast
.sensitivity
.Inability to detect low contrast edges -2

- A problem in the
Inability to read.
- Inability to recognize faces. performance of daily
Disability consequence
.- Falling on steps or kerbs .at level of patient
activities
-

Fear of rejection by friends not Social disadvantage- the inability

acknowledged in the street. or need for exceptional effort to Handicap
.- Unable to go out alone fulfill role in society considered ( Consequence in the wider
18 .appropriate for that individual social environment )
In all these cases, the aim of rehabilitation is to minimize the •
.handicap produced by a given disorder
Visual impairment, is minimized by proper medical and •
.surgical eye care
.Visual disability, is reduced by aids and training •
And the visually induced handicap, is reduced with timely •
.interventions by vision rehabilitation professionals
 :Low vision definition •
Is a bilateral impairment of vision that significantly •
impairs the functioning of the patient, and cannot be
corrected by medicine, surgery, therapy or eye
.glasses, or contact lenses
It is often a loss of sharpness ofacuity and loss of •
.visual field
: There are two parts of this definition •
•
The amount of vision in the better eye with best -1 •
.correction
The task ( function ), what it is that person want to -2 •
,do but cannot
.For example, reading, playing cards or driving •
• 20
:Visual impairment may present as •
Reduced visual acuity is the most frequently •
occurring low vision symptom, it so greatly
interferes with a person's( quality of life ), that
early relief is sought so the affected person can
continue reading, working, and sometimes
.driving
Other visual symptoms are blind spots •
( scotomas ), tunnel vision, night blindness,
color blindness,.. Etc. Many exist with or
.without reduced visual acuity
21
Low vision is not blindness, which is the •
.absence of useful vision or light perception
Persons with low vision may see light, color, •
movement, shape, and size of objects however,
things can appear blurred, faded, distorted, or
.(not all there ), or ( not there at all )

22
: Most states and federal lows define •
Legal blind : For various official purposes, is •
an acuity rating in which the best ophthalmic
correction achieves no more than 6/60 for
distance vision in the better eye, or a defect in
the visual field in which the widest diameter of
vision subtends an angle no greater than 20
.degrees

23
For educational purposes : The partially •
seeing child is considered to be one who has a
distance visual acuity between 6/21 and 6/60 in
the better eye with the best ophthalmic
correction, and who can use vision as the
.primary mode of learning
For travel purpose vision : Is defined as •
vision of 1/60 or better in which the peripheral
field of vision is at least 50 degrees in the
.widest diameter

24
25
These definitions fail to consider near or •
.reading vision
Also fail to evaluate defects within the •
peripheral visual field that do not result in
contraction in the field itself but that block out
.certain areas
Fail also to give a time indication of the •
individual's visual efficiency from the behavioral
.and functional point of view

26
Mehr and Freid ( low vision, Chicago, •
:professional press 1975)
defined partial sight (low vision ) as reduced •
central acuity or visual field loss that even with
the best optical correction, result in visual
.impairment that hinders performance

27
From a functional view point ,the patient with •
low vision is one whose visual problem
interferes with the performance of routine visual
.tasks related to a daily pattern of living
Low vision can then be measured either in •
terms of the visual impairment which is created,
or the visual disability, and both are used
.according to the particular situation

28
As far as the patients are concerned , however, •
they are more likely to identify their visual
difficulties in functional or disability terms,
complaining of an inability to perform every day
tasks, such as reading, recognizing faces, or
.even driving
The problem here is that it is extremely difficult •
to quantify such problems, or to relate them to a
particular level of visual acuity (particular
.degree of impairment )

29
It is common in a low-vision clinic to encounter •
a patient with, for ex., very constricted visual
field who navigates easily, whilst another
patient with more moderate loss needs to use
touch instead of vision to get around. The
reasons for these differences are unique for the
individual patient, and often complex, in the first
patient the condition may have slowly
progressed over 20 years allowing gradual
adaptation, whilst the second patient may have
an insurance claim pending relating to the
.accident which caused the vision loss
30
Evaluation of a patient with low vision for •
: rehabilitation : Includes
.Distance and near central visual acuity -1 •
.Visual field -2 •
.Ocular motility-3 •
.Color vision -4 •
.Binocular function -5 •

31
There is a constant search for a simple clinical •
test of impairment which can be easily and
quickly performed in the consulting room, and
gives an accurate prediction about how
disabled a patient will be when carrying out a
particular task such as reading or navigation in
an unfamiliar place, as suggested before, such
.a correlation may not exist

32
It is certainly true that distance visual acuity has •
been found to be a poor predictor of mobility,
.face recognition and reading
Other tests, such as contrast sensitivity and •
visual field measurement, have been found to
increase the accuracy of predictions, but often
the only solution is to test the patient on the
actual task, this is of course done routinely for
reading, where samples of print paragraphs of
.various sizes are used

33
The international classification of the diseases •
of the WHO ( World Health Organization )
1977, broadly defines Blindness as having no
.vision or no significant usable vision
And, Low vision as having significant usable •
.residual vision

34
The major trends today are toward integrating •
blind and visually impaired people with society
rather than separating them from it, and toward
developing as a primary goal, the maximum
use of residual vision of the visually impaired
.child
Rehabilitation services teach vocational and •
: daily living skills and provide mobility training
.Trained guide dogs are commonly provided - •
Library services, offer Braille books, talking - •
.books….etc

35
Legal blind : (WHO) : Vision less than 3/60 •
. and /or a field of vision of 10 degrees or less
Legal blind : (United states ) : Remaining •
vision in the better eye after best correction is
. 6/60 or less
Or contraction of the peripheral field in the •
better eye to 10 degrees or less from the point
.of fixation
Or the widest visual field diameter subtends an •
. angle less than 20 degrees

36
It is difficult to apply these definitions to young •
children because of the difficulty of testing
acuity using snellen`s chart . So they registered
as partially sighted until age four , unless
. obviously totally blind
•

37
Causes of blindness and partial sight •

Causes and disorders leading to low vision are •

numerous, not only including congenital and
acquired ocular conditions, but also including
systemic diseases with ocular manifestations or
neurological insults, as well as trauma with it's
.all sequences

38
 : Systemic conditions ) 1 •
- . Diabetes mellitus which lead to diabetic retinopathy •
Hypertension which leads to hypertensive- •
.retinopathy
Cerebro vascular disease or stroke ( brain blood - •
.vessels )
.Atherosclerotic disease affecting vessels of the eye - •
-: Human immune-deficiency virus ( HIV) •
Usually do to cytomegalovirus infection, a virus that •
.affects the eye
.Vitamin A deficiency- •
-.Infections involving the eye •
39
- •
: Ocular conditions ) 2 •
: According to the time of onset •
: a- Inherited •
Cornea Corneal opacities •
A/C Congenital glaucoma •
Lens Congenital cataract •
Retina Inherited retinal •
-: dystrophy like
Retinitis pigmentosa - •
Juvenile macular - •
. degeneration
. Optic nerve
40
Inherited optic atrophy •
b- Intra –uterine (exposure to infection or •
. toxin via mother )
Lens rubella cataract •
Retina toxoplasmosis •
Optic nerve alcohol and other •
toxins

41
c- Perinatal ( events occurring at birth or •
. immediately after )
Cornea Ophthalmia •
. neonatorum
Retina Retinopathy of •
. prematurity
.Optic nerve Cerebral hypoxia •

42
d-Childhood : ( events occurring during early •
.life )
Cornea Xerophthalmia •
.Retina Retinal detachment •
Optic nerve -Meningitis, •
. -neoplasms
.Others Trauma •

43
: e- Elderly people •
Chronic simple glaucoma - •
.Cataract - •
.Eye injuries - •
Age related macular - •
. degeneration
Tumors involving eye or - •
. surrounding structures

44
: Risk factors •
•
The factors that place a patient at risk for visual •
impairment are numerous and are related not only to
ocular disease and abnormalities but also to trauma
: and systemic health conditions
.Parents consanguinity •
.High risk pregnancy •
.Poor prenatal care •
.Premature birth •
.Alcohol, smoking, or drug ingestion •
.Exposure to UV rays •
.Age and age related macular degeneration •
Trauma •
45
•
 Types of low vision •
: Over all blur with no field defects ) 1 •
This condition typically occurs when the •
refractive media ( cornea-lens- vitreous )
.become cloudy
In many cases of cloudy media, the individual's •
complaint often seems out of proportion to their
measured distance V A , this is usually due to a
.significant change in their contrast sensitivity

46
Causes : Cataract, Albinism, Nystagmus, •
Diabetic retinopathy ( macular edema ),
Macular problems ( aplasia- edema, and
.amblyopia )
: Symptoms •
.Blurred or hazy distance and reading vision - •
.Decreased contrast - •
,Glare sensitivity - •
.Fading of colors - •
Little effect on peripheral vision, and travel- •
.abilities
47
: Central field defect ) 2 •
The loss of central vision creates a blur or blind •
spot, but peripheral vision remains intact, this
makes it difficult to read, recognize faces, and
distinguish most details in the distances.
Mobility, however, is usually unaffected
because peripheral ( side ) vision remains
.intact

48
: Causes •
Macular degeneration, macular cyst, macular - •
hole, cystoid macular edema, diabetic macular
…edema
.Toxoplasmosis, Histoplasmosis - •
.Optic nerve disease - •
.Central photocoagulation- •
Trauma, drugs - •
.Retinal vascular disease - •

49
: Symptoms •
.Blurry and hazy vision- •
.Central distortion- •
.Reading problems - •
.Difficulty recognizing faces - •
.reduced detail, and contrast loss - •
.Color vision changes - •

50
: Peripheral field constriction ) 3 •
Loss of peripheral vision is typified by an •
inability to distinguish any thing to one side or
both sides, or any thing directly above and or
.blow eye level
Central vision remains, however, making it •
.possible to see directly ahead
Typically loss of peripheral vision may affect •
mobility and if severe, can slow reading speed
as a result of seeing only a few words at a time,
.this is sometimes referred to as tunnel vision

51
: Causes - •
.Retinitis pigmentosa •
.Glaucoma - •
.Optic nerve disease - •
.Stroke ( vascular disease ) - •
.Traumatic brain injury- •
,Brain tumor - •
Diabetic retinopathy or photocoagulation - •
Multiple sclerosis - •
Retinopathy of prematurity - •
Retinal
52
detachment - •
: Symptoms •
. .Difficulty with visual orientation in space - •
.Reduced night or dim light vision - •
.Limited response to magnification- •
.Reduced contrast sensitivity •

53
: Generalizes haze ) 4 •
Causing the sensation of a film or glare that •
.may extend over the entire viewing field
: Extreme light sensitivity ) 5 •
Exists when standard levels of illumination •
overwhelm the visual system, producing a
.washed out image and /or glare disability
People with extreme light sensitivity may •
actually suffer pain or discomfort from relatively
.normal levels of illumination

54
: Night blindness ) 6 •
Result in inability to see out at night under star •
light or moon light, or in dimly lighted interior
.areas such as movie theaters or restaurants •
Causes : Retinitis pegmentosa , and Vit.A •
.deficiency
N:B Some diseases like cataract, corneal opacities can cause •
temporary low vision, but these diseases can be surgically
.removed
Distortion : Objects appear crooked, wavy, or ) 7 •
.doubled
retinopathy, and Causes include, macular degeneration, •
.diabetic retinal detachment
55
 Low vision examination •
Techniques and procedures •
Although the principles and techniques for •
examination the visually impaired patient
involve modifications and adaptations of those
used in more routine visual examination,
flexibility and readiness to modify standard
procedures are often necessary to secure the
.most accurate and reliable findings

56
The visual examination cannot follow a rigid •
pattern but must be adapted to the special
.needs and requirements of the patient
However, it's details may vary, the low vision •
examination must consider at least four major
: factors
.Case history -1 •
.Examination procedures -2 •
.Evaluation of the findings -3 •
.Visual training and follow up -4 •

57
:Case history -1 •
A thorough case history discloses information •
that determines what direction the examination
should follow and whether or not the patient
.can be helped
Specific inquiry by the examiner should be - •
directed toward the diagnosis, prognosis, and
.duration of ocular pathology

58
The type of ocular pathology ( congenital or - •
acquired )
.The present visual status - •
The patient's ability to travel in various - •
environments and at different light levels ( as in
.day-light or in twilight )
the patient's need for and expectations from a - •
.low vision aid
•
Psychological factors related to a patient's - •
reaction to his or her handicap as well as
.readiness
59
for visual correction
Age and educational history and type of low - •
.vision aids formerly prescribed or now in use
If the ocular pathology is inactive, or showed - •
rapid deterioration, in the first case the
prognosis is more favorable, and in the second
case a low vision aid may be of limited
.usefulness
The duration of ocular pathology is important - •
because a patient whose visual loss of long-
standing may have fallen into a pattern of
acting like a blind person who depends on
family and friends in the pattern of daily living,
such adaptation may have lost all motivation to
.learn
60
to read again
If the patient prefers day light or twilight, if he - •
has more difficulty at night or dim illumination,
there is peripheral constriction in the visual
field, the patient with poor central vision and no
peripheral vision, is difficult to help, because
.low vision aids depend on peripheral vision
Sort of the job : Some patients desire to view - •
television or to read , others wish to sew or
.write
Still others are concerned with improved •
.distance vision

61
 - •
Faye and weiss in 1965 pose the following
:questions for three age groups
: The older patient ) 1
How long has the patient been visually -
?handicapped
Has the patient tried to use visual aids -
?independently
What are the diagnosis, prognosis, and duration -
?of ocular pathology
? What are the patient's goals -
Did reading play a large part in patient's earlier -
? life
? How is the patient's general health -
62
: The young adult ) 2 •
Is the patient going to college or into - •
? vocational training
? Has the patient reading print successfully - •
Does the patient need visual aids other than - •
? for reading

63
: Children ) 3 •
? Is the disease congenital or acquired - •
Does the patient play well with his siblings or - •
? other children
Does the pre-school child hold books or toys - •
? close to his or her eyes
Is the child placed in regular classroom or - •
sight-saving, sight- conservation, or Braille
?class

64
 : Evaluation of visual performance •
The low vision examination focuses on determining •
: residual visual ability, so it include
A) Refraction : - Objective, subjective, and •
assessment of present spectacles, and low vision
.devices
.B) Visual acuity : For distance , and near •
C) Ocular motility, and binocular vision assessment •
: like ocular alignment, sensory-motor testing,and
contrast sensitivity testing
.)monocular and binocular ( •
D) Ocular health assessment, like external •
examination, biomicroscopy, tonometry, and central
.and peripheral fundus exam
65
E) Visual field assessment, by
confrontation method, Amsler grid
assessment ( monocular and binocular ),
Tangent screen testing, Goldman perimetry(
kinetic perimetry ), and static automated
.perimetry
F) Supplemental testing, like contrast
sensitivity, glare testing, color vision, and
.electroretinogram

66
 Examination procedures •
Carefully taken visual acuities for far and near •
distances should be determined with and
.without currently worn correction if available
It is frequently desirable to carry out definitive •
acuity ratings after retinoscopy or subjective
.testing has been completed

67
: Retinoscopy •
When difficulties arise in retinoscopy because - •
of small pupils, opacities of the media, or
irregular corneal surfaces, keratometry provides
important details by establishing the presence
.of keratoconus or an irregular corneal surface

68
If the media are involved, the examiner must - •
determine whether some reflex can be secured,
even if not in the visual axis, in such instances
the patient is asked to fixate at the most
comfortable position that will provide best
.vision

69
When there is evidence of hazy media and - •
central opacities, the examiner moves to
whatever working distance and to whatever
deviation from the optical axis necessary to
,establish a reflex ( radical retinoscopy)
technique requires short working distance 8- •
.20cm from the patient's eye
Begin the subjective refraction with the net - •
.retinoscopy findings in the trial frame

70
.Start binocularity or with the better eye - •
Provide the largest available letters at a - •
distance of 3 meters and bring them closer if
necessary until the patient can accurately and
.easily identify at least the top line of letters
If retinoscopy cannot be performed, it is •
recommended that the stenopeic slit be used to
.establish a starting point

71
 Visual acuity •
The low vision test is completely different from a •
normal eye exam., by evaluate the amount of
remaining vision using specialized charts which are
closer to the patient, and have more gradation than
.standard charts
Visual acuity is the ability to discriminate the smallest •
.possible letters to highest contrast
In low vision assessment, precise measurement of the •
lower ranges of acuity that are necessary to predict
.function and prescribe devices
. •

72
Contrast sensitivity •
Contrast sensitivity is the visual ability to see •
objects that may be not outlined clearly or that
.they do not stand out from their background
Despite the usefulness of visual acuity as a •
performance measure , it is obviously not a
complete description of visual performance
because it does not deal with the patient's
.ability to detect large objects and low contrast

73
Contrast sensitivity for grating is much more •
fundamental lower- level visual task, involving
simple resolution of the presence of the grating,
compared to the higher level of recognition /
identification task which is required when letters
have to be named in a traditional visual acuity
.test
If the patient is able to detect a grating, then he •
or she can distinguish that the black bars are
separate, so the gap between them ( white
bar ) will subtend 1 min arc at the eye, ( by
analogy with the threshold for 6 / 6 letter
.acuity
74 )
Contrast sensitivity is an element of visual •
ability which represents an array of black letters
.of different size on a white background
Most of what people see every day are objects •
.that do not standout from their background
The ability to detect such objects is the contrast •
sensitivity, which often is limited in cases of low
.vision
Typically, a contrast sensitivity test is performed •
to measure a patient's ability to detect a
number of different grating patterns at different
.spatial frequencies
75
The test determines the patient's contrast •
detection threshold, the lowest contrast at
.which a pattern can be seen
It has often been claimed that the contrast •
sensitivity function shows changes in ocular
pathology at much earlier stage than does
visual acuity. This could make it a useful
screening test , but any changes identified
would not be unique to one particular
.pathology

77
78
Glare and its reduction •
There are occasions when a reduction in •
illumination seems more appropriate , due to
the symptoms of photophobia or glare
.described by the patient
Photophobia is acquired as a result of pathology affecting the •
ophthalmic division of the trigeminal nerve, like keratitis leading
.to miosis and blepharospasm which is alleviated by mydriasis
In contrast, dazzling or glare is a sense of excessive •
brightness within the visual field which can create discomfort
or impair visual performance ,) discomfort glare ( •
.) disability glare ( •

79
80
Discomfort glare : Occurs physiologically and •
transiently in normal vision when a person is suddenly
subjected to much higher level of illumination than he
.adapted
Disability glare : Is distinguished from discomfort •
.glare by reduction in visual acuity
.Cause : - Corneal scar……………. pinhole glasses •
.Cataract…………………..removal - •
: Reflecting light from shining surface - •
Change the .… ) Reflecting glare ( •
direction of light or use sport eye shield, or
typoscopes ( only tow lines appear ) •
•
.Aniridia …………… artificial iris contact lens - •
81
.Albino ………………sun glasses - •
Clinical testing have included simple but •
uncontrolled procedures such as placing the
test chart against a window, or shining a pen-
torch into the eye or comparing outdoor acuity
.facing toward the sun and away from the sun
A careful external examination including slit - •
lamp biomicroscopy, tonometry, and
.ophthalmoscopy should follow

82
Central fields can be assessed by the Amsler - •
grid, by Tangent screen, or by other
.sophisticated central field testing equipments
Study of central field loss can be carried out on- •
1m tangent screen with a fixation target
modified by attaching white ribbons to the
corners to form diagonals . The patient is then
.asked to fixate the center of the diagonal cross

83
The peripheral field of vision can be accurately- •
.determined on arc perimetry
Such visual field studies often provide •
qualitative rather than absolute quantitative
.results
The oculomotor system should be evaluated - •
for the presence of nystagmus, ocular motility
dysfunction, strabismus, substandard
binocularity or diplopia, which could influence
.visual performance or treatment options

84
Color vision anomalies, which can significantly - •
affect educational, vocational , daily living and
mobility needs can be diagnostic of specific
.diseases. ( Ishihara test book )

85
Evaluation of the low vision findings •
The most important aspects of the case history •
: include
.The specific needs or desires of the patient -1 •
Individual's motivation and willingness to -2 •
.learn new visual habits
The patient understanding of the uses and -3 •
.limitations of the low vision aids involve
Additional factors affecting the decision to -4 •
: prescribe aids are
Patient's age, temperament, ability to adapt to new •
.situation
:Duration of visual impairment -5 •
86
The examiner must decide whether the - •
patient's goals are attainable given the nature
of the visual problem, the patient should be
realistic, for example , a patient who seeks to
qualify for a driver's license and can achieve
only 6 / 36 visual acuity when using a
telescopic lens , must be told that such an
expectation is unrealistic

87
Patient motivation is essential to successful - •
.utilization of low vision aids
Without adequate motivation and without •
realistic understanding of the potential and
limitations of the low vision aid, some patients
will not achieve objective data, in such
instances, it is better to postpone prescribing
aids until the patient gains better understanding
.and motivation for weeks or longer

88
Follow up evaluation involving use of loaned - •
low vision aids are sometimes desirable, which
enable the patient to experience directly the
potential and limitation of specific aids and to
.make a final selection that will be satisfactory
A single aid can seldom fulfill multiple needs. •
Multiple aids are frequently used to provide
variations in magnification, viewing distance,
.size of field, and flexibility of use

89
Adaptation, visual training, and follow up •
Once a patient can benefit from a low vision aid •
., proper training in it's use must be given
: There are a number of factors to consider •
Working distance—Field of view—level and •
type of illumination—and the use of auxiliary
supports, such as reading stands to hold the
material in a manner that facilitates smooth
lateral movements of the print at the fixed
distance and in a plane parallel and frontal to
.the face

90
Illumination of increased intensity and proper •
direction , and emanating from correctly
.positioned light source is critical
The examiner begins with low magnification, •
large print , good contrast, widely spaced
letters, short words, optimum illumination, and
.typoscope or reading guide if needed

91
The examiner gradually introduces higher •
magnification, smaller print, poorer contrast,
more closely spaced and longer words, less
control of illumination , and increased
.manipulation
As the patient learns to function, more normal •
.visual conditions can be used
The final phase of adaptive training should •
involve lenses of appropriate power for daily
visual task

92
There are also specific training tasks for-- •
involving adaptation to particular types of low
.vision aids
Telescopic lenses for distance vision - •
require both an explanation and a
demonstration of inherent limitations of both
field of view and parallatic displacement of
.objects viewed
The patient must use fewer eye movements and more •
head movements on the object to be viewed and
judgments are made as to it's distance and position
.from other objects within the field
93
In contrast, efficient use of a telescopic near - •
correction requires the patient to hold the
reading material at a fixed distance, while
maintaining a head position parallel and frontal
to the print and within the limited depth of focus
of the aid, this necessitates movement of the
reading material relative to the head and eyes
.rather than movement of the head alone

94
Training with microscopic lenses or high - •
plus reading correction to cope with limitation
in depth of focus, working distance and field of
.view
When eccentric fixation is present, the patient is •
directed to turn the head into the position that
facilitates maximum utilization of peripheral
.retina

95
To overcome the patient's characteristic - •
resistance to reduced reading or working
distance , begin by having the reading material
to touch the patient's nose and then slowly
moving it away until it comes in focus. If the
print fades, the examiner should remind the
patient to move the material closer to restore
.focus
To maintain a fixed reading position for patients who - •
are unsteady and have difficulty adjusting to a
constant working distance, a neck-tie or cloth-sling
can be used to support their hands as an alternative
.approach
96
To facilitate early adaptation and successful •
use , simpler and less complex aids such as
fixed-focus stand magnifiers might be
prescribed for interim correction, later may
prescribe a more permanent head-borne low
.vision aid
When determining the proper magnification for - •
a school child, by having the child bring a
school book that he or she will be using, proper
.testing material can be obtained

97
In small children,larger print primary grade text- •
books and higher level of accommodation
enable the examiner to use lesser amounts of
magnification to achieve the desired level of
.near vision
A follow-up examination is essential 3 – 6 - •
months after initial visit, and then 6 – 12 months
interval after a low vision aid is dispensed,
since some patients experience a later
reduction in vision that may be the result of
pathololgy or aging, so change in low vision
.aids is frequently needed
98
The child with partial sight •
Recognition of the importance of vision in the •
child's adjustment to school and to society has
led to special educational programs for children
.with partial sight
The aim of such programs is not separation but •
rather integration of such children into regular
.classroom to the fullest possible extent
The basic education philosophy of modern •
programs is that children with partial sight must
.learn to live in a visually oriented society

99
Children were divided in five educational •
: categories
.Category 1: Totally blind children, Braille users •
Category 2 : Children with some useful vision •
.but not enough to read print, then Braille users
Category 3 : Children reading print with optical •
.devices
Category 4 : Children reading print with •
.geometrical magnification
Category 5 : Children with no need of special •
.devices to read print
100
Children with partial sight are defined as those with •
visual acuity between 6 / 21 and 6 / 60 in the better
eye with optimum correction ,or those who require
.special education
A question commonly posed to the ophthalmologist is , •
should child with partial sight be allowed to continue in
? regular grade school
Of great importance are the child's intelligence, •
motivation, and ability to cope emotionally with the
.handicap among regular school children
If a particular child is bright, alert, competitive, and •
capable of maintaining his grades at level
commensurate with his age, attending a regular
.school is to be encouraged
101
There are three major types of educational •
plans in common use for children with partial
: sight
A ) The cooperative plan using a special •
classroom, the child is enrolled in a special
( sight saving ) class, leaving this class
several times a day to join normally sighted
classmates in activities not requiring
.continued use of the eyes

102
B ) The resource room plan, the child is a •
member of regular classroom and has the
opportunity to participate and compete with
normally seeing children and engage in social
activities at his or her own level, so that a sense
.of group belonging can be enjoyed
The resource room is adapted with special •
lighting, colors, and furniture, as well as tapes ,
.large print texts, and other learning resources

103
C ) The itinerant teacher program, is •
designed to provide special educational
.services in suburban and rural areas
An itinerant teacher who is trained in special •
education procedures travels from school to
school in one area, serving as a consultant to
the regular classroom teacher and as a
supplemental teacher to the child with partial
sight using sight conservation method,
.equipment and supplies

104
105
 Low vision optics •
Strictly defined, magnification is considered to •
be the ratio of the size of the image to the size
of the object, which in turn equal to the ratio of
.the image distance to the object distance

VA represents the object distance (u)

VA` represents the image distance (v)
AB, the height of the object (O)
A`B` the height of the image ( I )

The magnification ( A`B`/AB = VA`/VA ), or ( I/O = V/U ), is also referred as linear

. magnification
106
The term is applicable to lenses and lens •
systems used in image formation, as in
cameras, projectors, and another instruments
.not used directly in conjunction with the eye

107
When, however , a lens or optical system is •
used in conjunction with the eye, a different
aspect of magnification must be considered,
.namely that of angular magnification
Here the angular size of the image of an object •
seen through an optical instrument is compared
to the angular size of that object seen without
.the instrument

108
In the figure AB represent the height of the •
object(h) seen without the lens, and A`B`(h`)
.represents the image as seen through the lens
The tan of the angle α subtended by the object •
may be presented as h/a, and the tan of the
angle ά, may be presented as h`/b. The a and b
are distances of the object and the image,
respectively, to a given reference point in the
.eye ( the entrance pupil of the eye )
The angular magnification can be expressed •
: as
Tan ά / Tan α •
109
: Hand-held magnifier •
As a basic example of angular magnification, let •
.us consider at first the hand magnifier
Here an object is held at a fixed distance from •
the eye, and a plus lens is held over the object
so that it lies within the focal length of the lens.
This would produce a virtual, erect, and
.enlarged image
Comparing now the angular size of the image •
as seen by the eye (ά ) to the angular size of
the object seen by the eye without the lens (α ),
the angular magnification is again Tan ά / Tan α
110
 Figure (1) Magnification of hand-held •
: magnifier

111
The maximum magnification will be obtained if the
object lies directly at the anterior focal point of the
.lens
If the distance of the lens from the eye is called (Z),
and the power of the lens is (F), the angular
.magnification becomes : 1+ Z F
Figure (1) illustrates the magnification of the hand-
held magnifier. Here the lens ( F ) is Z meters in
front of the eye, and the object at the anterior focal
.plane

112
The object AB subtends an angle α towards •
the eye, the image A`B` subtends an angle ά
.towards the eye
Example : A person views an object 25cm •
from the eye by placing 10.0D lens over the
?object, what is the maximum magnification
As seen in Figure (2), the object must be 10 •
cm in front of the lens ( at the anterior focal
point ), which is 15cm in front of the eye.
Therefore Z becomes 15cm or 0.15m

113
The angular magnification is 1+ ZF, which •
: equals
2.5 x = ) 0.15x 10 ( +1 •
.The angular size of the object is enlarged 2.5x •
If magnification obtainable ( as explained in the •
earlier example ),is not sufficient, the object is
moved closer to the eye, an action which in it's
self produces an increase in angular size

114
The object AB is at first( p) units distance in •
front of the eye, and then it is brought closer to
.the eye, so that now it is (a) units in front
Tan α = AB / p, and Tan ά = A`B` / a •
Since A`B` = AB, Tan ά /Tan α becomes p/a , •
which magnification caused by brought the
.object closer to the eye (M1 )

115
An additional magnification can be obtained by •
placing a plus lens between the object ( brought
.closer ), and the eye
If this second magnification is referred to M2, •
the total magnification M is the product of M1 x
.M2
Since M1 = p/a, and M2 = 1 + ZF •
M = p/a ( 1+ ZF ) •
Remember that value (a) is the sum of the •
value Z and the focal length of the lens ( a = Z
.+ f ), thus Z = a – f (1/F)
•116
The total magnification is therefore calculated •
:as follows
M = p/a ( 1+ ZF ) •
p/a { 1 + ( a – 1/F ) F } = •
p/a { 1 + a F – 1 } = •
p/a x a F = p F = •
As the distance (p) is frequently taken as 25cm •
.or 1/4meter
: Therefore this formula can be expressed as •
M = F/4, and referred to as effective •
angular magnification
117
Example : Find the effective angular •
: magnification of a plus 20 D lens
: Solution •
M = 20/4 = 5x •

118
 The telescope •
The purpose of a telescope is to produce an •
image of a distant object that will subtend a
larger visual angle than that subtended by the
.object

119
The instrument most commonly used in •
conjunction with the eye has a Galilean
construction, with a convergent front lens
(objective ), and divergent lens in the back
.(closure to the eye ) ( eye piece or ocular )
•
The tow lenses are separated by the •
.algebraic sum of their focal lengths
The focal length of the eye piece is shorter •
.than the focal length of the objective lens

120
121
122
The image AB of an object at infinity ( rays •
coming from the upper left in the figure , is
formed by the convex lens at it's posterior focal
point, this image now becomes the virtual
.object for the eye piece
Tan α = AB/ Av1 and Tan ά = AB/Av2 •
The angular magnification is equal to : Tan ά / •
Tan α, which in turn equals F2 / F1 = f1 / - f2
M = F2 / F1 = -f1 / f2 •

123
Where F1 and F2 are the lenses powers, and f1 •
.and f2 are the focal lengths
F1 is the objective lens power , and F2 is the •
.eye piece lens power
Example : Given f1 equals + 12cm, and f2 equals – •
4cm, find the magnification of the telescope, and the
.lens separation
Since the lenses are separated by the algebraic sum of •
the focal lengths , then f1+ f2 = d which equals 12- 4 =
.8cm , where d is the separation between the lenses
The magnification is equal to –f1/ f2 = 12/4 = 3x , the •
image is three times as large as the object. The lenses
.are 8cm apart
124
A telescopic system is by definition an afocal •
system, both the incident and the divergent
.light rays are parallel
It is possible to convert a telescope into a microscope •
by slipping a magnifying lens over the objective lens.
If this is done, the effecting near magnification M E,
will be the product of the telescopic magnification and
.the magnification of the magnifying lens
M E = M1 X M2 = M t X M m •
Where M t is the magnification of the telescope, and •
.M m is the magnification of the microscope

125
Example : An ophthalmic telescope system •
consists of a + 8.0 D, and a – 10.0 D lens. What
is the magnification and separation? If a + 7.0 D
lens is placed over the objective, what is the
?effective magnification of the system
To find the separation, determine the focal •
: lengths as follows
f1 = 100/8 = 12.5 cm , f2 = 100/ -10 = - 10 cm •
Remember that the lenses are separated by the •
sum of the focal lengths, so that f1 + f2 = d ,
.which equals 12.0 – 10 = 2.5 cm separation
: The telescopic magnification equals •
M1 = F2/F1 = 10/8 = 1.25 x •
126
The magnification of the microscope equals M2 •
= F / 4 = 7 /4 = 1.75 x
The effective magnification of the system •
: equals
M E = M1 x M2 = 1,25 x 1.75 = 2.18 x •

127
Magnification can be used to increase the size of the retinal •
: image for the visually impaired patients by
Relative distance magnification, exemplified by the -1 •
.microscope, is useful in near vision
Angular magnification, exemplified by the telescope, is -2 •
.utilized when distant vision required
Simple mechanical forms of magnification can increase the total •
.magnification achieved for an individual patient
:Relative size magnification – 3 •
Is obtained simply by the use of larger objects, for example, •
enlarged photographs, large prints, and large-eyed sewing
.needles
:Projection magnification -4 •
Results when an image is enlarged by projection on a •
.screen
128
The patient vocational and avocational •
interests, as well as the extent of the
individuals useful vision, are important in
determining the type or combination of
.types of magnification to be prescribed

129
 Magnification •
It has been concluded that refractive correction •
alone will not be sufficient to improve the vision
of the low vision patients to the required level
for the tasks they wish to perform, and that
.magnification will be needed
There are four ways of enlarging the retinal •
:image or creating magnification

130
Increase object size : Also called relative ) 1 •
size magnification (RSM)
It means enlarging an object while •
.maintaining the same working distance
The retinal image size is proportional to the •
.angle subtended at the nodal point

131
RSM, is determined by comparing the angle •
subtended by the enlarged object ( ά ) at the
nodal point of the eye to the angle subtended
by the initial object ( α ) that is : Ms = ά / α
)s, is the size ( •
An example for print : If the original size of the •
print was 1M, and the size after magnification
.is 2M , the RSM is 2x
Example : Large print books, larger television •
sets, or computer terminals, and close circuit
. TV ( CCTV ) sets
132
: Decrease viewing distance ) 2 •
Also called relative distance magnification •
.( RDM )
Increasing resolution by reducing distance •
between the object and the eye. As with Ms
(size ), this result in an increase in the angle
subtended of the object at the nodal point of
.the eye

M = ά / α = tan ά / tan α = D1 / D2
133
: Example •
If the original working distance is 40cm and the •
.new working distance is 10cm
The RDM = 40 /10 = 4x •
The disadvantage is that such a viewing •
distance will make too great an accommodation
.demand
With low vision aids, this will normally require a •
.plus lens placed before the eye

134
: Angular magnification ) 3 •
Angular magnification occurs when the object is •
not changed in position or size, but has an
optical system intercepted between it and the
.eye to make it appear larger

135
Thus angular magnification is the ratio of the •
angle subtended by the image formed by the
magnification ( ά ), to the angle subtended by
the object without the magnifier ( α ), that is
.Ma = ά / α •
Examples of devices that produce angular •
magnification are telescopes, and hand
.magnifiers

136
: Electronic magnification ) 4 •
Also termed projection magnification, is the •
enlargement of the object by projecting it onto a
.screen
The most familiar low vision aid that uses this •
.principle is the closed circuit television( CCTV )

137
To see the details of an object, we move it closer •
to the eye so that the details now subtend a
larger angle on the retina. This process of
increasing the visual angle is termed angular
.magnification

138
Moving an object from position I to position II in •
the figure introduces a magnification that is
.defined by the ratio of angles
Magnification = Tanά / Tanα . This is •
directly related to the vergence of light rays
from position II / position I , and inversely
related to distance of position II / position I
. distance
Moving an object closer to the eye cannot be •
continued indefinitely because accommodation
.sets a boundary on it
139
It is arbitrarily assumed that 25cm from the eye •
is the limit for long comfortable viewing, and
thus any object located at this point subtends
.one unit of angular magnification at the retina
To increase the visual angle still further, an •
.optical device is necessary
One such instrument is a plus lens of a focal •
length smaller than 25cm that is located at the
.anterior focal point of the lens

140
The refracted rays from the object tip seen in •
the figure, will leave the lens as parallel rays,
and all must cross the axis at the same angular
inclination ( ά ) as the ray that goes through the
.lens nodal point ( N`)
The angular retinal image size will be ( ά ) also •

141
In addition, because parallel rays of light are •
incident at the eye, no accommodation effort is
required to see the object. The angular size on
the retina depends solely on the focal length of
the lens, the smaller the focal lens, the larger
.the angle
The magnification that is obtained in this •
manner, when compared to the arbitrary
situation of the unaided eye ( object at 25cm ),
: is
M = 25cm / f lens = D lens / 4

142
If the power of a lens is 10.0 D, it's •
.magnification is 2.5 x
since the refracting apparatus of the human •
eye can be thought of as a 60.0D lens it acts as
15 x magnifier with respect to an object located
.at the retinal plane ( M = 60 / 4 = 15 x )

143
Although there is no difference in •
magnification , moving the magnifier closer to
.the observer's eye increases the field of view
•
Entire object can be seen if the lens is held •
.close to the eye

144
Only part of the object can be seen if lens held •
.far from the eye

145
 Types of Low vision aids •
Low vision aids are divided into optical and •
: non-optical devices
Optical aids: Are divided into •
: Conventual's lenses-1 •
.Strong minus lenses for high myope- •
Rigid Gas permeable contact lenses for those- •
with corneal scars, keratoconus, high myope,
.and so forth

146
: Magnifying lenses-2 •
The patient often can see details only if they •
.are magnified
Magnification devices are available for both •
.distance and near vision
The degree of magnification required will , of •
course, depend on the patient's visual acuity
and age, and the work for which the optical aid
.is designed

147
In terms of visual acuity alone the Kestenbaun •
rule is commonly helpful ( the denominator of
the patient's distal visual acuity is divided into
the nominator ), the result should approximately
equal the magnification required for seeing
Jaegar ( J 5 ) on the near vision chart. Multiply
this figure by 2 to achieve (J 1 )
: For example •
D for J 5, + 10.0 D 5.0 + = ) 100 / 20 ( 30 / 6 •
for J1
D for J5, + 20.0 D 10.0 + = ) 200 / 20 ( 60 / 6 •
for J1
148
With trial and error methods carried on from this •
.point for further refinement
A young person , specially child would need •
less because of accommodation and usually
the addition to the ordinary spectacle would be
the weakest lens that would enable reading J 5
.on the near vision chart
For viewing distance objects, telescopes •
monocular or binocular can be sometimes
useful, and Kestenbaun rule is helpful, the
patient will often have to try two or three aids
.before deciding which is the best
149
Plus lens magnifier •
: Optical principle •
The plus lens used as magnifying aid allows the •
patient to obtain an increased image size by
holding an object close to the eye without
requiring the accommodative effort that would
usually be expected from viewing at this
.distance
This is achieved by placing the object at the anterior •
focal point of the positive convex lens, so that parallel
light leaves the lens , the virtual image is at infinity and
.the patient's accommodation can be relaxed
150
151
Although the magnifier to the object distance •
must be held constant and equal to the focal
length of the plus lens, the magnifier to the eye
distance can be increased without affection of
the angle of incidence ( as rays emerge from
the lens are parallel ) , and so the magnification
. remains the same
In this way it is possible to use a plus lens •
.magnifier close to the eye or remote from it

152
: Plus lens magnifier can be •
Spectacle mounted plus lens ( simple- •
. microscope or loupe )
.Hand held - •
.Stand mounted - •
: Practical considerations •
Working distance : Is the magnifier to the ) 1 •
eye distance, and can be varied without
.affecting the magnification and can be large

153
Working space : Is the magnifier to the ) 2 •
object distance, and this can not be varied and
remain limited ( is the focal length of the
magnifier ) , and determine the magnification
.achieved
Here lies one of the major limitations of all plus- •
lens magnifiers, they range in power up to +
80.0 D ( 20 x ), with working space as low as
12.5 mm. This is psychologically difficult and
tiring to maintain the working space, and
difficult to illuminate the task area ( it is
.impossible for writing, playing music….etc
154
Depth of focus : It is the range of magnifier- ) 3 •
to- object separation over which the object ( or
the magnifier ) can be moved without the
patient noticing any change in image clarity.
Depth of focus is usually small in plus lens
magnifiers. This changes from one patient to
another because the size of blur on the retina
.depends upon the size of the patient's pupil

155
Field of view : The field of view of the ) 4 •
magnifying lens is defined as the angle
subtended by the lens periphery at the image of
.the eye's entrance pupil
The field of view which the patient obtain with a •
: magnifier depends on
The magnifier to eye distance, halving this --1 •
will double the field of view
The patient should encouraged to hold the ( •
.) magnifier close to the eye
. •
156
The lens diameter : When the patient --2 •
complains of limited field of view ( only a few
letters are visible ), the lens diameter should be
.changed to a larger one
The power of the lens : As the power increases, --3 •
the field of view decreases ( the powerful lenses are
usually small in size ) , the patient must be given the
minimum magnification which allow him to perform the
.task
To maximize the field of view , the patient must be •
encouraged to hold the magnifier as close to the eye
.as possible

157
:High plus reading lenses •
They can be made either in single vision or in •
bifocal form ( doublet ), or triplet design, and
they range in power from approximately + 4.0 D
. to + 20.0 D
When total near power exceeds + 10.0 D, •
meniscus lenses exhibit spherical and
.chromatic aberrations

158
For powers exceeding 10.0 D , lenses are best •
ground with a flat ocular surface or in biconvex
form, preferably aspheric, plastic aspheric,
single vision lenses are available and are
frequently prescribed as a monocular reading
correction with a distance prescription in plastic
.over the other eye
Binocular corrections are prescribed •
infrequently since most patients with low vision
have one eye that is more amenable to visual
.correction

159
A marked difference in attainable acuity •
between the two eyes and a considerably
reduced working distance render binocularity
.impossible or impractical
Bifocal lenses may be designed as one piece, •
.fused bifocal , or with cemented segment
In most cases that do involve binocular •
correction , the bifocal segment requires
decentration or the incorporation of base-in
.prism or both

160
If no distance prescription is required , half eye •
glasses are advisable, because the lenses are
smaller, thinner , lighter in weight, and
.adaptable to base-in power effects
The use of thin membrane ( Fresnel principle ) •
prism, which can be pressed onto the bifocal
segment allows the addition of base-in prism
.without decentration

161
High plus reading additions have several •
:advantages over low vision aids
.They are less complex in design -- •
.More conventional in appearance -- •
.Provide larger field of view -- •
.Can provide greater depth of focus -- •
They are the most commonly prescribed •
form of low vision aids and achieve a high
.degree of success with their use

162
: Spectacle- mounted magnifiers •
A magnifying lens is mounted in spectacle •
.( simple microscope ), or special head band
These lenses of short focal length are designed •
for use in near viewing ,they provide flat field for
view that is comparatively free from aberrations
but their short focal length impose limitations on
the field of view, on the working or reading
.distance, and on light control
Microscopic lenses extend the magnification range •
beyond that obtained with telescopes, adopted for
.near vision and are available in powers 2 x to 20 x
163
 : The purpose of microscopic lens is two fold

To collimate the light from a near object to obtain relative ) 1

.distance magnification
To enlarge the ocular image by means of the angular ) 2
.magnification of the lens

164
A compound microscope spectacle, sometimes •
referred to as a tele-microscope, may be
obtained by placing an additional convex lens (
.(reading cap ) over the telescopic unit
The great challenge faced by patients using •
microscopes is adaptation to the close working
.distance required

165
:Advantages •
.Frees the hands for manipulative tasks-1 •
Provides widest field of equivalently powered-2 •
.optical options
Allows greater reading speed of equivalent-3 •
.reading option
Makes binocular vision possible up to-4 •
.approximately + 10.0 D add equivalent
More cosmetically acceptability to some-5 •
.individuals than other options
.Portable and relatively inexpensive-6 •
166
: Disadvantages •
Requires closer working distance and may-1 •
.obstruct the illumination
May be inconvenient for spot reading tasks-2 •
in which information is gained from single
.words or short phrases ( e.g. price tags )
Fixed optical center may reduce-3 •
.effectiveness when using eccentric fixation
Makes writing difficult if lens add is stronger-4 •
. than 10.0 D
•
167
Hand held magnifier •
Designed as simple double-convex and plano- •
convex reading lenses, are available in all most
. sizes and powers from + 4.0 to + 20.0D
The distance between the eye and the lens can •
be varied quickly depending upon reading
.distance and the magnification needed

168
In the lower magnifying powers that is 1.5 x •
(+6.0 D ) or 2 x ( + 8.0 D ) , these magnifying
units are considered satisfactory from an optical
.point
In the higher powers, such as 8 x ( + 32 D ) or •
10 x ( + 40 D ) , optical aberrations, particularly
astigmatism caused by oblique incidence,
become so severe that the usable field of view
has an angular diameter of only approximately
30 degree, which severely restricts the
.functional field of view for reading

169
A major limitation of the hand magnifier, •
especially one of a glass design is the difficulty
of maintaining constant focus , also as
magnification increases, the lens diameter is
reduced. One way of over-coming this problem
.is to use Fresnel lens

170
The surface of the Fresnel lens consists of a •
series of concentric simple lens sectiones, or
zones, of the same power, which together have
the optics of a simple lens, of large diameter
and short focal length, without the thickness of
.such a lens
The hand held magnifier is specially useful for •
shorter term readings such as looking up words
in a dictionary or telephone book or reading
.bills or recipes
Some hand magnifiers have a built in light source that •
.provides increased contrast for reading
171
: Advantages of hand-held magnifiers •
It is usually inexpensive, portable, and-1 •
.readily available
Convenient for spot reading task in which-2 •
information is gained from single words or short
.phrases (price tags)
Hand magnifiers have the most normal-3 •
.appearance of any low vision device
User can read at a more longer working distance -4 •
.than comparable powered reading spectacle
.Some magnifiers come with built in lights-5 •

172
:Disadvantages of hand-held magnifiers •
.It requires steady hands and good control-1 •
Strong magnifiers allow users to read only-2 •
.few letters at a time
.Reading speed will probably decrease-3 •
Magnifiers without built-in lights require-4 •
.supplemental lighting for best vision
.Extended use cause hand and arm fatigue-5 •
Finding and maintaining the correct focus is-6 •
.sometimes difficult

173
Stand mounted magnifiers •
: Stand mounted magnifiers are divided into •
.Fixed focus magnifiers-1 •
Variable focus magnifiers : a )Low-2 •
powered( < + 10.0 D , large diameter)
b) High powered ( > +40.0 D, small diameter)

174
Magnifiers that have a fixed object to lens •
distance are used with the eye close to the
lens to provide a large field and little
.aberrations
The plastic aspheric lens offers lighter weight , fewer •
aberrations and an increased field of view. The amount of
accommodation needed varies with the distance from eye to
.lens
For some patients single binocular vision can be achieved if the •
.reading material is held at a convenient distance

175
Focusable stand mounted magnifiers with •
variable object to lens distance , permit
variation in magnification and correction for
.moderate degree of ametropia
Plano convex or ( paper weight ) magnifiers •
have a one piece glass construction consisted
of an upper convex curve and a lower flat
surface that rests on the printed page. The
focus of these magnifiers is fixed, and their
design increases and distributes the light
.evenly on the page
Such aids can be used in conjunction with spectacles •
or non-spectacle magnifiers to increase the
.magnification and brightness of an object
176
 : Indications for stand mounted magnifiers •
When the visual field is constricted to 10-1 •
. degrees or less
When an auxiliary lens or reading small type-2 •
.is needed
When the decision to prescribe spectacles-3 •
for certain patients is difficult and interim
.correction is desired
When prescribing for patients with hand or-4 •
.head tremors
When visual loss is extensive and the-5 •
.potential
177
for correction is limited
: Advantages of stand mounted magnifiers •
.Inexpensive, light weight , and readily available-1 •
The focusing distance is set by simply placing the magnifier-2 •
.on the page
.Helpful for individuals with poor motor control-3 •
. Available in very strong power ( up to 88 D )-4 •
.Magnification is constant for a given add power-5 •
.Usable at normal reading distances-6 •
.Available with built-in light source to enhance contrast-7 •

178
Disadavantages of stand mounted magnifiers •
.Less convenient to carry due to size -1 •
.Requires one or both hands -2 •
.More bulky than hand magnifiers -3 •
.Cannot be use on non-flat surfaces -4 . •
Field of vision is smaller than equivalent powered -5 •
spectacle lenses
Causes excessive shading and reduces lightening -6 •
.onto surface ( unless self illuminated )
.Impossible to write under most designs -7 •

179
.Prolonged use may result in poor posture -8 •
The individual's bifocal strength may not -9 •
.match the image plane of the stand magnifier
Illuminated versions require batteries or -10 •
.direct current
Telescopic lenses •
The simplest form of telescopic lenses is the •
Galilean type, which consists of two lenses, a
minus ocular lens, and a plus objective lens,
mounted coaxially and separated by a distance
equal to the sum of their focal lengths. This
form is advantageous for securing a moderately
.flat field tolerably free of astigmatism
The anterior focus of the plus lens coincides •
with the posterior focus of the minus lens. As a
consequence, the rays are parallel upon
.entering and leaving the telescope
181
There is no focus and the unit is termed afocal •
Although the system is afocal for distant •
objects, it is not for near objects, and a reading
addition must be added for near viewing
.distances
The power or magnification of the telescopic •
lenses in the spectacle form ranges from 1.5 x
.to 8 x

182
The magnification for near vision is determined •
by dividing the dioptric power of the reading
addition by ( 4 ), and then multiplying this by
the magnification of the telescopic unit which
.is ( 2.5 x )
If the spectacle ( reading ) addition is + 8.0 D , •
the magnification for near vision is = 2.5 X 8 /
. 4 = 5.0 x

183
Telescopic spectacles are preferred when •
attaining the maximum reading distance is
essential. ( For example, a 2.2 x magnification
in the telescopic spectacle with + 8.0 D
addition, equals 4.4 x for near vision, this lens
is used at a working distance of 12.5cm ( 100 /
8 ), in contrast a + 18.0 D sphere achieves 4.5
x and provides a working distance of 5.5 cm
.) 18 / 100 ( •

184
Low vision reading caps also provide •
intermediate near vision in approximately a 25
.– 40 cm range
Good results using a 3.5 x reading binocular •
telescope in bifocal form for binocular vision at
40 cm working distance were reported by
.Feinbloom

185
Small, compact telescopes, designed in powers •
from 2.5 x to 4.0 x and mounted in the upper
portion of the carrier lens. By tilting the head
slightly upward at periodic intervals, the patient
is able to use the telescopic lens for improved
.distance vision
Certain patients with low vision can drive a car •
.successfully by using ( bioptic ) telescopic aid

186
Telescopes can be used for distance , •
.intermediate, or near vision enhancement
Spectacle- mounted telescopes are known as •
(full – diameter ) when they are center
mounted, or as ( “bioptic” – superior- ), or
(“reading”- inferior- ) when they have off-center
.mounting

187
A bioptic is a special pair of glasses with a •
telescope permanently mounted in the glasses'
lens. While looking straight ahead, a bioptic
user sees a normal, unmagnified image through
the glasses. Then by dipping one's head slightly, the
bioptic user instantly sees a magnified image through
the telescope. This "bi-optical" system allows the user
to rapidly switch between a normal view and a
magnified view without ever using his or her hands. In
some areas, some people with low vision can use
.bioptics to drive
Telescopes for distance •
: Afocal telescope •
Is an optical system that provides angular •
magnification without changing the vergence of
.light
: A ) Galilean telescope ( terrestrial ) •
Have a plus power objective lens and a minus •
.power eye-piece lens
.They form an erect image •
: B ) Keplerian telescope ( astronomical ) •
Have a plus power objective lens and a plus power •
. eye- piece lens
.They form an inverted image •
189
The equivalent power of afocal telescopes •
.equals zero
= The amount of magnification •
power of eye-piece lens / power of objective •
.lens

190
: C ) Adjustable telescope •
Some telescopes can be adjustable , with such •
telescopes it is possible to correct spherical
refractive error by varying the distance between
.the objective and the eye-piece lens
If the wearer is hyperopic with respect to •
distance object, the separation between the
.lenses increased
If the wearer is myopic with respect to a •
distance object , the separation between the
.lenses decreased

191
: Advantages of telescopes •
Useful for magnification from near to-1 •
.distance
Useful for specific tasks requiring-2 •
.magnification at variable distances
Portable monocular units are useful for spot-3 •
.distance vision ( like signs )
They can be mounted in a spectacle to leave-4 •
.hands free if necessary

192
: Disadvantages of telescopes •
.Field of view is restricted-1 •
The higher the power of the telescope , the smaller -2 •
.the field of view
Luminance is reduced because there is a 4 % loss -3 •
of light due to reflection at every lens surface; this is
reduced to some degree by the use of anti-reflecting
.coating
Depth of field is more narrowed compared to -4 •
. spectacle or hand- held magnifiers for near use
Contrast is reduced when looking through telescope. This can-5 •
be a problem for individuals who have experienced problems in
.their contrast sensitivity
.Often relatively expensive if spectacle mounted-6 •
193
Telescopes for near ( Tele-microscope ) •
These telescopic systems are designed or •
modified with reading caps or close- focus.
.They can be hand-held or spectacle-mounted

194
Spectacle-mounted reading telescopes can be •
in full-diameter ( center-mounting ) or bioptic
.configuration
They are available in Galilean or Keplerian •
.designs
When afocal telescope used for near, a •
divergent rays will incident on the objective
lens, this can be solved by placing a plus lens
of appropriate power either in front of , or
behind the telescope, this lens called ( reading
.cap )
The working distance of telemicroscope is •
.determined by the power of reading cap
195
: Advantages of telemicroscopes •
The main advantage of the tele-microscope-1 •
lens is that it provides the same magnification
as a high addition with an increased working
.distance
Patients are able to see at an intermediate -2 •
distance because they provide a good level of
.magnification at arm's length

196
: Disadvantages of telemicroscope •
There is proportionate reduction in field of vision and depth of-1 •
.focus
.They can feel heavy on the face-2 •
.They are the least normal looking of any low vision device-3 •
It can sometimes be difficult to find and maintain the correct -4 •
.focus
The depth perception and the balance can be affected-5 •
.because objects appear closer than they really are
Patient cannot walk or move about when using tele--6 •
.microscope, because he can easily trip and fall if he do so

197
Real- image magnification •
)Electronic devices( •
Optical magnifying systems are limited •
practically to a maximum magnification of 20 x ,
and if using a plus lens to achieve this, it would
require a + 80.0 D lens , with a working space
of 1.25cm ( equal to the anterior focal length of
the lens ), such a high powered system would
also have considerable aberrations and be
severely restricted in field of view

198
By contrast, real image magnification is •
available up to extremely high levels without
loss of image quality, and it does not require a
change in the working space from the patient's
.preferred or habitual position
The most efficient way to provide real-image •
magnification is electronically , using a TV
camera to create a magnified image on a
.monitor screen
So electronic magnifiers are preferable to optical •
magnifiers because they can provide higher
magnification, greeter freedom of eye position, and
.reverse- contrast text ( white on black )
199
: Types of electronic devices •
.A ) Video magnifier or CCTV •
.B ) Computer access •

200
: Video magnifier ) 1 •
A video magnifier is an electronic device that •
produces enlarged images of text and objects
.on a monitor or screen
Video magnifiers can be used to read printed •
material, look of photographs, and illustrations,
read prescription bottles and product labels,
write checks, complete forms, and perform
.close work such as sewing
An image of the material to be magnified is •
captured by a digital video camera, sometimes
.called charge-coupled device ( CCD ) camera
201
The digital video camera is connected to a •
monitor or screen on which magnified images
.are displayed
Some video-magnifiers have their own monitor •
or screen, while others are connected to a
.separate computer or television
Video-magnifiers are often called Close Circuit •
Television ( CCTV ), because early models
used conventional television screens to display
.images
The camera and television screen were directly •
connected in a close circuit, leading to the term
.(CCTV )

203
CCTVs enable the vision-impaired to read •
newspapers, medicine bottles, telephone
books, handwritten letters and much more. A
CCTV system consists of a video camera that
projects a magnified image of printed text,
handwriting and photographs onto a video
.monitor PC or TV screen
Magnification = linear size of image on screen / •
.linear size of original object
.It is up to 70 x or more is possible •
Video magnifiers are divided into tow •
categories ( desktop, and portable )
: A ) Desktop video magnifiers •
Desktop video magnifiers feature a camera •
mounted over a tray on which the material to be
.magnified is placed
Some have a built-in monitor and are known as •
.stand- alone magnifiers
Other are designed to connect to a television or •
.personal computer

206
Most desktop video magnifiers have a ( reading •
tray ), that holds the material to be magnified.
This tray can be moved from side to side , or
forwards and backwards, in order to position
the desired part of the material directly under
.the camera
Desktop video magnifiers usually take about as •
much desk space as a personal computer, and
perhaps a little more because of the need for
.free space in which to move the reading tray

207
There are many types of desktop video •
: magnifiers like
: Stand-alone desktop models-1 •
These are video magnifiers that have their own •
monitor or display, they typically consist of a
single unit with a monitor, a moveable tray, and
.a camera focused on the tray
,Usually the monitor is on top of the unit •
In what is known as the ( in-line ) configuration •

208
although some stand -Alone models allow the •
user to place the monitor on the side
,There is also a built-in light source •
,Such as a miniature fluorescent tube •
.to illuminate the tray •
Stand-alone desktop models typically have monitors •
measuring from 35-62.5cm diagonally. Larger
monitors allow more magnified material to appear on
.screen at a given level of magnification
Desktop models are also available with flat screens ( flatron ), •
which are lighter in weight and easier to reposition for a more
.comfortable viewing angle

209
: Computer-linked and TV-linked desktop models-2 •
Desktop video magnifiers that connect to a computer •
or to a standard TV monitor via a connector cable are
.also available
The magnified image is displayed on the computer or •
TV screen. Like stand alone models, computer-
linked ,and TV linked desktop models typically have
movable trays and a frame to hold the camera above
.the tray, but most do not have their own monitors
Computer connected models are often helpful for •
people who work with computers on the job or at
school

210
A computer-linked video magnifier does not •
magnify the computer screen, for this purpose a
screen magnifier or screen magnification
.software is required
Typically computer-linked models have a split •
screen option that shows computer output on
part of the computer screen and images
magnified by the video magnifier on the other
part of the screen

211
: B ) Portable video magnifier •
•
The first portable video magnifiers were hand- •
held camera units that resembled a computer
mouse, which could be connected to any
.television

212
TV-linked mouse-camera are portable in the •
sense that they can be moved from one
location with a television to another location
with a television, but they cannot be used any
.where that lacks a television
It would be difficult to take one to a store, to •
read labels, or to a business meeting to look at
.the agenda
Today , there are a verities of truly portable •
video magnifiers available with camera units or
color television, and displays that can be
.moved together to any location
213
 TV-linked camera-mouse -1
: models

Camera-mouse models feature a camera mounted in a device that

resembles a large computer mouse. The camera-mouse unit is
connected to a television or other display unit via a control box , and a
.connector cable
To scan a document or other item, the camera-mouse is moved over
.it
A light emitting diode (LED ) in the camera device illuminate the
.material
Rollers on the bottom of the unit aid scanning of text and other flat
.material
The camera unit is a mouse style magnifier that can also be held over
.round surfaces such as cans and medicine bottles
214
 : Dual system ( desk-top / camera-mouse models ) -2
A dual system combines desktop and hand-held camera-mouse features ,
these dual systems have a desktop frame with a movable tray and a cradle
for holding a camera unit. When the camera is setting in it's cradle, the frame
and camera form a desktop video magnifier, but the camera unit can also be
.removed from it's cardle and used as a hand-held camera unit
Single-unit hand-held models -3
Some hand-held models have a small viewing
screen ( a flat panel display or LCD )in the same unit as the camera, with power from a
.rechargeable battery
These models can be used in any
Location, they are recommended for ( spot ) use ,
such as looking at labels, checking addresses on envelopes , looking at bus schedules
., …etc

215
: Video telescopes -4 •
Another type of hand-held models is the video •
Telescope, which has a camera at one end and •
,A built-in display at the other end •
The display measures about one •
. inc( 2.5cm )diagonally

216
To view an object, the display end is held •
Up to one eye or watch it through the screen , •
while the camera end is aimed
.At the object •
Video telescopes are the only video magnifiers •
That can be used by pedestrian with low vision •
As a travel aid. For example, they can be used •
to read street signs or signs on buildings , and
to tell whether a pedestrian signals reads
.or ( Don't walk) ) Walk ( •

217
: Head-mounted systems -5 •
•
Systems that combine display goggles with •
cameras mounted in front of the goggle eye
pieces are called (head mounted video
.magnifiers)

218
Several head-mounted systems are now •
available. Unfortunately, head-mounted
systems cannot be used for walking, because
the magnification provided by the goggles
greatly narrows the user's field of vision,
. making it unsafe to walk with the goggles on
However head-mounted systems can be used •
for stationary viewing tasks, such as reading or
watching TV, and since the systems are light
weight and portable, they can be taken to
school to watch the blackboard or to a museum
.to look at paintings
219
:Common features of video magnifiers •
•
There is a number of design features found in •
.all the main video magnifier types
Understanding these features can help •
consumers to compare different types, brands,
.and models
Some of these features are listed below, with •
: brief explanations

220
 : Monitor size ) 1 •
In general, larger monitors show a larger •
portion of the material under view at any level
.of magnification
A disadvantage of larger monitors is that they •
.take more space
In desktop models, flat screen display take up •
less space in relation to the size of the display
.area

221
: Magnification range ) 2 •
Each model has it's own magnification range that •
defines what levels of magnification are available to
.users of that model
Depending on model, the maximum magnification may •
be less than ten times or more than 100 times of the
.original size
As magnification increases , less of the magnified •
material can be seen on the display, and some people
may find this makes it difficult to read materials at full
.magnification
To deal with this problem, some models have an over- •
view mode with lower magnification levels, which
allows users to orient themselves on a page before
.increasing magnification to read
222
: Display color ) 3 •
Some models provide only black and white •
displays, which may be sufficient for those
who plan to use the magnifier solely for
reading news-papers, and other texts. Other
.models have a full color displays
Most color models offer a black and white •
viewing mode, and some offer other display
options, such as a full color, medium contrast
.photo mode suitable for viewing photographs

223
: Reverse video ) 4 •
Many models include a reverse video feature, •
in which black letters on white paper as well as
white letters on a black background. This
feature is helpful to individuals who are prone to
experience glare when looking at a bright
.image
: Alternate color combination ) 5 •
Many models can display text in other color •
combinations in addition to black and white,
such as green on black , light blue on black,…
etc, for those individuals who find other color
.combination easier to view
224
:Magnification controls ) 6 •
In some models, the magnification level can be •
changed by raising and lowering the camera above
the material being viewed, in other models, a lever or
.knob controls the magnification level
: Manual or automatic focus ) 7 •
In manual focus models, the camera must be •
refocused by hand each time the magnification level is
changed. For those who find it difficult or tiresome to
focus a lens manually by turning a knob, many models
offer automatic focus capability, or a zoom feature that
provides extra magnification as needed without
.refocusing
225
: Windowing and line markers ) 8 •
Windowing allows person to narrow the viewing window •
vertically or horizontally to focus on a selected part of the text
.that he or she wishes to read
A similar purpose is served by the line marker feature, which •
puts lines into the display to underline or over line rows or
vertically defines columns without masking text outside the
.marker-defined area
: Power source ) 9 •
Desktop magnifiers are compatible with standard house-hold •
.alternating current ( AC ) power outlets
Most hand-held camera-mouse models also have a power cord •
.attached to the control box that comes with the camera unit

226
 : B ) Computer access •
For low vision patient who use a computer, the •
standard display may be of sufficient clarity, especially
if display color and size can be selected within the
programme and the viewing distance can reduced. If
this insufficient, there are a number of software
.programs which will enhance the display
The software used provides access to the system by •
magnifying the screen contents, and in some versions,
.speaking or reading what is displayed
Zoom text magnifier enlarges and enhances every •
thing on computer screen, making all of the
.applications easy to seen and used
227
NON-OPTICAL DEVICES •
Large print devices such as books, playing -1 •
.cards, and telephone dials
Reading stands that support posture and -2 •
.comfort
.Illumination devices -3 •
.Typoscopes for writing and reading -4 •
.Bold tipped pens and bold rule paper -5 •
Sensory substitution, such as talking books-6 •
and clocks

228
:Large print devices -1 •
•
Large print is over size type that enables •
people who cannot comfortably read regular
size print to enjoy all the pleasure and
.conveniences of reading, technically speaking
Large print is 14-point type, about twice the size •
of type you find printed in most books,
magazines, and newspapers

229
Large type visual aids include, telephone dials with •
large numbers, playing cards with large figures, and
.school text books
The use of large print is some what limited since the •
patient's reading activity is restricted to material
.available in large form
Most patients are far better off with some optical •
device to provide the magnifications so that the range
.of reading, both for pleasure and work is unrestricted
However, convention typewriters (speech writers ), •
which use large capital letters may be helpful for
.some

230
: Reading stands -2 •
Can be helpful for maintaining proper •
.placement of reading material
•
Use of these devices can reduce postural •
fatigue and facilitate placement of adequate
.light on reading materials

231
: Illumination devices -3 •
Illumination is probably the single most important •
.factor in enhancing visual functioning

Proper illumination is a crucial factor in •

maximizing the useful vision of the patient with low
.vision

232
Light must be direct and of sufficient intensity, and it •
must be introduced at such an angle that glare and
.spectral reflexions are avoided
Lighting increases contrast between print and •
.background, thereby making details more legible
Valuable improvement in lighting can often be •
achieved by having the patient simply alter the
position of existing lamps or their shades, or even by
altering the strength of the bulbs used. The patient will
soon realize the benefits, and even those who may
have mild photophobia can usually obtain some
.benefit

233
: Reading slit or typoscope -4 •
•

Typoscope consists very simply of a rectangle •

of black card with a small central slit, it is
designed to be placed over a page of text, so
that only one or more lines of print can be seen
.within the slit area
234
 :The aim of the typoscope •
It helps the patient to read along lines of the text -1 •
.without straying up or down
When reaching the end of the line, the patient can first •
track back along the line which has been read, and
.can then move the typoscope down to the next line
Increase contrast by preventing scattering from the -2 •
background, which can produce improvement in the
vision of patients with incipient cataract or corneal
.opacities
The reading slit serves to direct eccentric viewing, -3 •
which is important to improve reading in patients with
.macular disease
The feature is particularly helpful with high •
.magnification aids
235
: Marking pens--5 •
•
Marking pens are nylon-tipped or felt-tipped •
pens that write or print in different widths, so
that a partially sighted persons can read their
.own writing or printing with greater ease
The partially sighted person chooses a pen with •
the width of mark most easily recognized, and
then writes or prints as large as is needed to be
able to read the writing. These pens are readily
.available in all stationary stores

236
: Sensory substitution devices -6 •
The most effective intervention for the visually •
impaired patient is the optimum use of residual
vision, including telescopes, typoscopes, color
.contrast, and improved illumination
An alternative, though usually limited approach •
is ( sensory substitution ), that is the use of
non- visual alternative like hearing or touch, as
a means of obtaining information from the
environment , ( like talking books or talking
.clock )

237
Of course, for an individual patient, it is not an •
all or nothing choice, use may be of both visual
and non-visual strategies, depending on the
.circumstances
For example, the patient may use a magnifier •
for reading mail, but for leisure reading prefer to
.listen to books recorded on a tape

238
 Prescribing magnification •
Determine whether binocular or monocular ) 1 •
correction would be preferable if it is possible
and if the acuities of the two eyes are similar,
then it is usually visually beneficial to use
binocular viewing, unless the design of
magnifying device or the limitation on viewing
conditions which it imposes may mean that
.viewing must be monocular

239
Identifying the specific task to be performed ) 2 •
.and predict the magnification
If the patient sees 6 / 60 and wants to see 6 / •
30, it must be magnified and the details within it
must be made to subtend a larger angle at the
patient's eye. ( in fact an angle of double the
size ). This will require 2 x magnification, and
less than this will be insufficient to see the
letter, whereas any greater magnification than
this will be unnecessary and has smaller field of
.view and increased aberrations

240
Select an appropriate low vision aid, if -3 •
.required
Trial of predicted magnification and aid, and -4 •
.modify if necessary
.Determine the required spectacle correction -5 •
Loan aid for trial after instruction or training -6 •
.in it's use
.Plan the follow up visits -7 •

241
: A ) Distance magnification •
For distance task, one must try to estimate •
what acuity some one would require to perform
: the task adequately
For example, 6 / 18 might be needed to watch •
T or 6 /6 to read bus numbers
.Magnification = required V.A. / present V.A •

242
e.g. If visual acuity is measured in Snellen •
: notation
a) To improve vision from 6 / 60 to 6 / 6 •
= Magnification required = 6/6 ÷ 6/60 •
x 60/6 = 10 x 6/6 •
b) To improve from 2/36 to 6/18 •
= Magnification required = 6/18 ÷ 2/36 •
x 36/2 = 6 x 6/18 •

243
The same method can also be used to asses •
the improvement which might be achieved with
.a particular device
•
Magnification used = Achieved V.A. / Present •
, V.A,, so
Achieved V.A. = Magnification used X Present •
. V.A
E.g. a ) A patient with V.A. of 6 / 36 using •
a x 4.0 telescope, would achieve V.A. of •
X 6 / 36 = 6 / 9 4 •

244
b ) A patient with V.A. of 6 / 18 using a + 2 x •
telescope to view letter chart at 3 meters, the
: acuity achieved would-be
Y = 2 X 6/18 , then 3/Y =6/9/3 •
YX6 = 3X9, then Y = 3X9 /6 = 27/6= 4.5 •
Y = 3/ 4.5 which equals 6/9/3 •
•
So acuity is = 3/4.5 = 3/ 3/5 nearly or 6/9 •

245
If visual acuity measured in Log MAR notation ( using •
Bailey- Lovie or Keeler chart ), then each step
between adjacent lines is 0.1 log unit
) step = 1.25 x ( •
So magnification = ( 1.25 )n, where n is the number of •
.steps
For example , if the patient needs A 10 acuity and •
he has A 16 ( Keeler A notation ), then
Magnification = ( 1.25 )6 = 3.81 x •
If the current acuity is 0,5 , and 0.1 log unit is required •
( Log MAR notation ) , then
Magnification = ( 1,25 ) 4 = 2.44 x •

246
 : B ) Near magnification •
There are several methods of calculating a starting •
.lens power or addition power for near magnification
Kestenbaum,s rule ( based on distance V A ) ) 1 •
Is the reciprocal of Snellen distance V A = the •
reading addition required to read J 5 ( in which letter
subtend 5 min arc at 1.02 m ), which is approximately
.news-paper print
Example : If the distant Snellen V A is 6 / 60 , then the •
reciprocal will be
D, where a patient will require 10 D 10 = 6 / 60 •
.add for near vision

247
: Based on near visual acuity ) 2 •
: A ) Keeler A system •
This is constructed in the same way as the •
Keeler distance charts with each successively
increasing (A) number indicating an increase in
letter size by 1.25 x ( 0.1 log unit )

248
Example : Suppose a patient can see A 14 •
print ( at 25cm with the optimum addition ), and
requires improvement to A 7, then from A 14 to
.A 7 are 7 steps
In each step of the Keeler system, the letter •
.size increases by 1.25 x
Therefore Magnification = ( 1.25 )n ( where n •
is the number of steps of improvement
. required , M = ( 1.25 )7 = 4.75 x

249
:B ) Sloan M system •
These charts were originally designed to be •
used at a standard distance of 40cm, but the
relationships between the letter sizes are the
.same no matter what viewing distance is used
Each letter size bears the notation " x M " •
where x equal the distance in meters at which
the overall height of the lower-case letter
.subtends 5 min arc
.Magnification = present V A / required V A •

250
Measure near visual acuity using M system, •
and record as a fraction
. ) testing distance over M letter read ( •
When the goal is 1 M , a simple ratio gives the •
focal distance of the addition required to read
.M 1 •
: Example •
If 4 M is read at 40 cm , it is recorded as •
.4M / 40 •
4M ÷ X / 1 M then x = 10 cm which / 40 •
. needs + 10 D add
251
: C ) N- point notation •
This is the most common system in use, and is •
employed in a variety of different charts. It uses
printing terminology rather than precise angular
subtence to label print size, but if the overall
height of a lower-case letter measured , it can
be shown that this is approximately proportional
to the point notation. That is , a letter of size
labeled " 10-point " or ( N 10 ) , is approximately
.twice the size of ( N 5 ) letter

252
= Magnification required •
present V A / required V A •
•
Thus if the patient could read N 48, for •
example, at a standard distance of 25cm
and , ) equivalent to magnification = 1x ( •
,wanted to read N 6 print, then
. Magnification = 48 / 6 = 8 x •

253
An alternative method for determining near •
: magnification
This method is described by Bailey and Lovie, •
and the required equivalent power is
.determined rather than the magnification
The base line acuity can be taken at any •
.working distance and with any reading addition
The method then uses the algorithmic scale to •
plot changes in reading acuity, working
.distance, and equivalent power
. The scale allows calculating of these changes •
254
: Bailey-lovie logarithmic scale •
Lens power print size •
8 0.8 •
10 1.0 •
12 1.2 •
16 1.6 •
20 2.0 •
25 2.5 •
32 3.2 •
40 4.0 •
48 5.0 •
64 6.0 •
80 8.0 •
10.0 100
The present reading acuity is measured in -1 •
point notation, this number is then located on
.the scale
The " required acuity " is then decided, and -2 •
.this number also located on the scale
The number of steps ( in the direction of -3 •
descending numbers ) between these two
.acuity values is then counted
So the working distance of the patient will -4 •
then need to decrease by the same number of
.steps

256
In the case of presbyope with no available •
accommodation , the required reading addition
will need to increase by the same number of
steps in order to see clearly at that required
.reading distance

257
: Examples •
A young adult sees N 32 print at 25 cm. At what reading -1 •
distance will be able to read N 8 print
?) newspaper ( •
Locating 32 and 8 on the scale, you can see that there are 6 •
steps between them, the reading distance, therefore, have to
.decrease by 6 steps as well
32to 25, 25to 20, 20 to 16, 16 to 12, 12 to 10, 10 to 8, and 8 to ( •
.)6
.As it is present at 25 cm, this will need to become at 8 cm •
Note that if the available accommodation is insufficient, the •
patient may need some reading addition to maintain clear vision
.at this distance

258
A total presbyope reads N 40 at 40 cm with + 2.5 -2 •
reading add. What reading add will be needed to read
? N 12 print
Locating 40 and 12 on the scale, you can see that •
there are 5 steps between them. The reading addition
.will therefore have to increase by the same 5 steps
As it is presently at + 2.5 , this will need to change to •
. o.8 + •
this gives a ,) to 3.2, 3.2 to 4, 4 to 5, 5 to 6, 6 to 8 2.5 ( •
working distance which has decreased by 5 steps
from 40cm to 12 cm, and this is of course the focal
.length of + 8.0 reading addition

259
Management strategy for visual field defects •
: Central field defects -1 •
Most patients with a central scotoma develop a •
preferred retinal locus ( PRL)
which equals Eccentric fixation below or to the •
.right of the scotoma
Most of those patients will benefit from an •
eccentric viewing using a preferred retinal
.locus, with a viable healthy retinal tissue

260
Prismospheres are suitable low vision device, •
which shifts the macular scotoma.
Prismospheres are available in the range of
.and + 8.0, base-in prisms 5.0 + •
Increased direct illumination should be •
recommended for all near tasks, non-optical
systems, filters, tints, and sun glasses for
improved contrast glare and photophobia
.should be evaluated
•

261
: Peripheral field defects -2 •
For orientation and mobility, the peripheral field is •
most important . This is the most challenging field in
.low vision management
A ) Prisms : Place with the base toward the field •
defect, so that when the patient looks into the prism,
.the image is shifted towards the apex
Fresnel press-on prisms can be used or the prism can •
be ground or cemented segmentally into any part of
.the lens
Prisms that ground in or cemented on the lens provide •
.an optically clearer image than Fresnel prisms

262
: Type of segment •
.Gottlieb ( lateral ) - •
Peli ( altitudinal ) - •
.In-wave ( Chadwick optical ) - •

263
 : B ) Mirrors •
Place angle toward the field defect, so that when the •
patient looks into the mirror, objects are visible in the
.non-seeing area, ( the image is reversed )
: C ) Reverse telescope system •
Use to minify the image, so that more information fits •
.inside the usable field
: D ) Minus lens •
Hold away from the eye to minify the image overall, so •
.that more information fits inside the usable visual field
. •

264
For patients with bitemporal hemianopias or right or •
left homonymous hemianopias, it becomes a problem
navigating outdoors, and it is dangerous while driving
.car or two wheeler
For those patients , hemianopic spectacles can be •
used with training, this is a spectacle where a coated
mirror is fixed nasally to the field which is lost , so that
.it is reflected on the seeing side
Stick on Fresnel prisms are used to expand the fields, •
but if the reflecting mirrors are fitted properly they
should solve the problem of patients having bitemporal
.hemianopia

265
The Role of the Optometrist in Low Vision •
: Assessments
: Education
•Optometrists are educated in Low Vision services;
however, many practitioners who choose to specialize
in this area receive additional training.
: The Low Vision Assessment

Patient History
Clinical Evaluation
Recommendations
Instruction
Follow-up

266
Patient History •
The low vision specialist will ask for a complete personal
and family general health and eye health history. A
previous ophthalmologic/optometric report is also
.appreciated
In addition, the optometrist will discuss functional
problems with the patient, including such things as
reading, functioning in the kitchen, glare problems, travel
vision, the workplace, television viewing, school
.requirements, and hobbies and interests
The examiner may then ask if there is some activity (or activities)
.the person would like to perform better
The examiner will eventually demonstrate optical devices that
.might help the person achieve his particular goals
At times, non-visual devices may also be suggested to be used
.alone or in conjunction with visual devices
267
Clinical Evaluation •
Preliminary tests may include assessment of ocular
functions such as depth perception, color vision, contrast
.sensitivity, and curvature of the front of the eye
Measurements will be taken of the person's visual acuity
using special low vision test charts, which include a larger
range of letters to more accurately determine a starting point
for gauging low vision. Lighting levels are carefully
.evaluated as well

Auto-refraction and subjection refraction are performed.

Visual fields are usually assessed, and each eye will be
.examined
Optical devices are used to evaluate distance vision. Reading and other
near vision skills are assessed with high-power spectacle lenses, along
.with hand and stand magnifiers

268
Recommendations •
•The optometrist may prescribe various treatment options, including low vision
devices, as well as assist the person with identifying other resources for vision
and lifestyle rehabilitation.

Low Vision Aids

•Distance Telescopes :

269
Near telescopes or spectacles •

270
: Instruction •
An instructional period focusing upon the •
proper use of low vision devices and/or
techniques is then conducted by a clinician or
another professional. This takes as long as 30
minutes, and may be repeated a few times
before the final prescription is determined.
Patients may usually borrow devices to try them
out. This helps ensure a proper prescription
and gives the patient a chance to indicate her
personal preferences as to which devices are
.prescribed
271
: Follow-up •
Regular follow-up exams are important, because •
the condition that causes the visual impairment,
as well as the individuals own needs and goals
can change. The low vision eye doctor should
determine the length of time between follow-up
services. Generally, a follow-up examination
.should be performed within six months

272