February 27, 2016

Low Vision Rehabilitation Needs More Emphasis on Communication and Social Skills


Low Vision Rehabilitation Needs More Emphasis on Communication and Social Skills

Lea Hyvärinen, MD, PhD (Honorary Professor, Rehabilitation Sciences at Rehabilitation and Education in Blindness or Impairment of Vision in Dortmund, Germany) has described social difficulties caused by types of blindness and visual impairment. In her paper, “Effect of Vision Loss on Communication and Social Skills” she writes that “many problems in communication and social skills are due to misunderstandings among sighted individuals unaccustomed to . . . contact with vision impaired individuals in gatherings and public places.”
Dr. Hyvärinen emphasizes the need for better education of the sighted public and inclusion of  training in social participation in the standard vision rehabilitation program. She briefly discusses eight typical conditions of adults that necessitate better understanding.
Large angle nystagmus that requires head turn to find a null zone (smallest angle of nystagmus and thus best visual acuity) looks strange when seen for the first time. Training does not help and often it is not possible to operate the eye muscles, so a partial solution is darker lenses with a near correction lens close to the frame where the person looks through in the ‘null zone’. The person should be able to say shortly “in this position I see you best”. A sighted person should be polite and ask “where should I stand/sit so that you see me best?”
Aniridia, lack of irises (the colored ring surrounding the pupil) causes too much light entering the eyes. Filter lenses with a Polaroid surface that looks like typical sunglasses can be used to prevent “dazzle” from the light. Aniridia can be effectively hidden behind contact lenses with the iris hand painted on them. There is a small clear area in the middle functioning like a pupil. With the iris painted on the contact lens, a normal amount of light enters the eye and the person functions like a typically sighted individual.
Light sensitive, photophobic eyes, may require very dark lenses outside and lighter lenses inside or phototropic lenses that change the filter effect. Some sighted people react negatively if the poorly sighted photophobic (light sensitive) eyes require very dark glasses so the eyes cannot be seen. In most cases, filter contact lenses may be enough to decrease glare sensitivity and at the same time give the irises an interesting colour when seen through lightly tinted lenses in the spectacles. The photophobic person is no more bothered by the light and looks normal through the lightly tinted glasses. A visually impaired person may not be able to use contact lenses. These persons should have a shady corner table with no extra lights or candles.
Losses in motion perception may be a part of otherwise mild changes in visual processing functions. It may affect only some frequencies. Therefore vision needs to be assessed for safety in traffic, body movements, facial expressions and lip reading, and speech reading.  The results of this assessment should be discussed in detail with the individual, his family, and people involved in arranging activities.
Facial expressions are fast moving, faint shadows on faces. They convey important visual information in communication. They give added emotional value to spoken words. If a vision impaired person has low contrast sensitivity and poor motion perception, facial expressions are not perceived. A vision impaired person must learn to listen carefully and watch body language to be aware of the emotional content of spoken words.
Poor motion perception may make the lip movements blurred and prevents lip reading, speech reading. A vision impaired person with problems seeing lip movements often looks like a normally sighted person, so the vision problem is not easily seen by others- much like a hearing impairment.  Hearing impairments are not as frightening a loss as vision impairment to normally sighted individuals, thus it is convenient to hide vision loss pretending not to hear well. The visually impaired person may ask they are speaking with “It is difficult to hear you because of the background noise. Can you please talk more slowly and clearly?” allowing for more opportunity to read the lips of the person they are talking to. .
Central scotoma means loss of vision in the center of visual field, the area we normally use to look at details. A vision impaired person with change in the macula has to look past an object or person he wants to see. Depending on where at the edge of the non-seeing central area he has “an island of best vision”, he pushes the central scotoma aside so that the best available vision can be used. Often it is easiest to push the scotoma upwards; i.e. the VI person in front of you seems to look at your hairline when he is looking at your eyes. He will notice that you are surprised by his gaze position and may dare to explain why he looks so strangely. You should say to the vision impaired individual- “Do you have problems with your vision here? Would it be better for me to stand closer or further away from the windows?” This would be a gentle way of saying that you are willing to adjust the communication situation to fit the needs of the vision impaired person. He will tell you where he will prefer to be.
Retinitis pigmentosa (RP) causes loss of sight in the area around the central vision; first on the sides and later also above and below central vision. Therefore this kind of scotoma is called ringscotoma. It is largest at twilight, thus in daylight it may be so narrow that the person him- or herself cannot notice it. Constant variation in the width of the ring scotoma is a significant problem when a person [with] this condition moves in an unknown place where some areas are poorly lit. When he enters a dark room, visual field may suddenly shrink and the image loses its clarity. These individuals should have a foldable long cane in their pocket and be trained to use it whenever vision functions poorly. If he does not have the cane, he must remain standing at the door until his retina slowly adapts to the low luminance level. It is polite to offer to be a personal guide (if you are trained in how to guide a person with visual impairment) or offer to move back to a well-lit area.
If a person waiting at a door of a dark room is unable to walk farther, remember that the person may be in danger of falling. If possible, turn on lights or use a flashlight to improve the individual’s visual function. If not possible, guide the person through the dark area or turn back to the area where you came from. Visual functioning of many persons with retinal degenerations varies widely as a function of luminance. Their retinal cone cells adapt slowly to lower luminance levels. When they come into bright sunlight, they will need time to find their darker glasses and a cap. These sudden changes in an individual’s vision related functions should be known when you have a vision impaired guest visiting.
Dr. Hyvärinen’s paper is a good introduction to social difficulties that can be eased by a better understanding of the needs of visually impaired individuals. Prevent Blindness and MD Support join her in encouraging the inclusion of effective socialization strategies in low vision rehabilitation programs, along with increased efforts in public education.

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