A survey of Alabama eye care providers in 2010-2011.

BACKGROUND: State level information regarding eye care resources can provide policy makers with valuable information about availability of eye care services. The current study surveyed ophthalmologists, optometrists and vision rehabilitation providers practicing in Alabama. METHODS: Three mutually exclusive provider groups were identified, i.e., all ophthalmologists, optometrists, and vision rehabilitation providers working in Alabama in 2010. Eligible providers were contacted in 2010 and 2011 and information was requested regarding provider demographics and training, practice type and service characteristics, and patient characteristics. Descriptive statistics (e.g., means, proportions) were used to characterize provider groups by their demographic and training characteristics, practice characteristics, services provided and patients or clients served. In addition, county level figures demonstrate the numbers and per capita ophthalmologists and optometrists. RESULTS: Ophthalmologists were located in 24 of Alabama's 67 counties, optometrists in 56, and 10 counties had neither an ophthalmologist nor an optometrist. Overall, 1,033 vision care professionals were identified as eligible to participate in the survey: 217 ophthalmologists, 638 optometrists, and 178 visual rehabilitation providers. Of those, 111 (51.2%) ophthalmologists, 246 (38.6%) optometrists, and 81 (45.5%) rehabilitation providers participated. Most participating ophthalmologists, optometrists, and vision rehabilitation providers identified themselves as non-Hispanic White. Ophthalmologists and optometrists estimated that 27% and 22%, respectively, of their patients had diabetes but that the proportion that adhered to eye care guidelines was 61% among ophthalmology patients and 53% among optometry patients. CONCLUSIONS: A large number of Alabama communities are isolated from eye care services. Increased future demand for eye care is anticipated nationally given the aging of the population and decreasing numbers of providers; however, Alabama also has a high and growing prevalence of diabetes which will result in greater numbers at risk for diabetic retinopathy, glaucoma, and cataracts.

Supports and barriers as experienced by individuals with vision loss from diabetes.

PURPOSE: The purpose of this study was to explore the perceived environmental supports and barriers to daily functioning for people with low vision due to diabetic retinopathy and the adaptive strategies used by these individuals to improve person-environment fit. METHOD: The researchers used a qualitative descriptive approach with eight participants with low vision as a result of diabetic retinopathy. Data collection methods included semi-structured interviews, observation of participants' home environments and focus group discussions. RESULTS: Participants described aspects of the physical environment, the social environment and psychological adjustment as important in adapting to vision loss and diabetes. Four themes emerged from the data analysis: "It's a Complicated Life", "The World Isn't Accessible", "Making it Work" and "Learning to be Blind". CONCLUSIONS: Physical and social environmental influences on functioning are complex. Adaptation to vision loss is an ongoing process that may be aided by peer interactions and more community-based rehabilitation. To best rehabilitate people with low vision due to diabetic retinopathy, the influence of both the physical and social environment along with psychological adaptation need to be considered. Periodic rehabilitation, interventions taking place in community settings and the formal inclusion of peers in the rehabilitation process may be indicated. Implications for Rehabilitation Consideration of the social as well as the physical environment is essential in the rehabilitation of people with low vision due to diabetic retinopathy. Adaptation to vision loss by those with diabetic retinopathy is complicated by the fact that diabetes is a systemic disease that affects multiple body systems. Psychological adaptation to vision loss is characterized by cycles of grieving and acceptance, which affects readiness for rehabilitation. Alternative approaches to rehabilitation may be indicated for people with low vision due to diabetic retinopathy, including periodic intervention over time and the inclusion of peers in the rehabilitation process.

[The results of the application of the pre-formed physical factors and neuroprotective therapy for the rehabilitative treatment of the patients with diabetic retinopathy].

To evaluate the effectiveness of the neuroprotective agent used to treat the patients presenting with non-proliferative diabetic retinopathy. The study included 114 patients (228 eyes) at the age varying from 42 to 70 who presented with diabetes mellitus and non-proliferative diabetic retinopathy. Three groups were formed depending on the mode of treatment. The patients in main group underwent endonasal electrophoresis of 0.1% semax preparation. Patients of the comparison group were treated with intranasal instillations of semax and those of the control group received only standard hypoglycemic therapy and treatment with Doxy-Hem. The patients of the first two groups showed positive dynamics of the studied functional characteristics (visual, perimetric, and electrophysiological ones). The most pronounced and long-standing (up to 12 months) positive effect on the visual function was documented in the main group. The results of the present study give reason to recommend the inclusion of endonasal electrophoresis in the combined rehabilitation treatment of the patients presenting with diabetes mellitus and non-proliferative diabetic retinopathy.

Targets for rehabilitation: an evidence base for adaptive coping with visual disability.

PURPOSE: This study examined the role of assimilative and accommodative coping dimensions for the mental health of people with visual impairment, with the aim of informing rehabilitation planning. RESEARCH METHOD: Telephone interviews were conducted with 216 middle-aged adults with vision loss. Assimilative and accommodative coping were assessed both in terms of general coping tendencies and goal-specific coping. RESULTS: Assimilation was used more than accommodation in goal-specific coping. In contrast, endorsement levels of general coping tendencies were higher for accommodative compared with assimilative coping. The strongest beneficial effects on mental health emerged for accommodative coping as a general coping tendency and assimilative coping as a goal-specific strategy. CONCLUSIONS: Results suggest that vision rehabilitation programs should encourage accommodative coping as a general life approach. However, for specific goals, rehabilitation should help individuals determine their feasibility, and focus on developing assimilative strategies for feasible goals, while reevaluating and letting go of unfeasible goals.

Causes of visual impairment in Thai diabetic patients in the visual rehabilitation clinic.

BACKGROUND: Visual disability from diabetic retinopathy is one of many public health problems. Knowing the causes of blindness and low vision in diabetic patients will help in policy planning in order to reduce diabetic complications and prevent blindness. OBJECTIVE: To study the causes of visual impairment, blindness and related factors in diabetic patients who registered at the visual rehabilitation clinic, Siriraj Hospital, Mahidol University, Bangkok. MATERIAL AND METHOD: A retrospective study of 133 diabetic patients who registered at the visual rehabilitation clinic between January 2007 and December 2010 was conducted. The patients were divided into 2 groups: a low vision group (VA in the better eye < 6/18-3/60) and a blindness group (VA in the better eye < 3/60--No light perception). The history of diabetic mellitus, associated systemic diseases, laboratory investigations, ocular changes and treatment were recorded. The causes of visual impairment and blindness were collected and analyzed. RESULTS: Of a total of 133 diabetic patients, 93 cases (69.9%) were in a low vision group and 40 cases (30.1%) were in a blindness group. The causes of visual impairment were proliferative diabetic retinopathy (84.6%), retinal detachment (37.2%), macular edema and scar (25.9%), optic atrophy (143%), neovascular glaucoma (11.7%) and vitreous hemorrhage (4.9%). Tractional retinal detachment (p-value < 0.001) and optic atrophy (p-value = 0.021) were the associated factors causing blindness in visual disability patients with statistical significance. Optic atrophy (38 eyes) occurred post vitrectomy in 19 eyes. CONCLUSION: Visual disability in diabetic patients is caused by the complications of diabetic retinopathy and its management. The prevention of disease progression, especially macular edema and proliferative diabetic retinopathy, will decrease the rate of visual impairment and blindness.

The effect of low vision rehabilitation in diabetic eye disease: a randomised controlled trial protocol.

PURPOSE: Current research highlights a rising incidence of diabetes and its complications. Diabetic retinopathy is the leading cause of blindness within the working-age population of the United Kingdom. Increasing severity of retinopathy is associated with reduced visual function and participation in daily living. Only 8% of those referred to Moorfields Eye Hospital's low vision clinic have diabetic eye disease, a value less than prevalence figures for diabetes would predict. The lack of evidence for effectiveness of low vision intervention in this patient group could be responsible. Therefore, in line with CONSORT guidance, we present the methodology of the first randomised controlled trial to quantify the effect of low vision rehabilitation on people with diabetic eye disease. METHODS: One hundred participants were recruited into four retinopathy severity groups based on their diagnosis according to the English National Screening Programme Grading Protocol. Participants were randomised to either immediate intervention (1-2 weeks after enrollment) or delayed (control) intervention (3 months after enrollment). Intervention was a standard low vision assessment performed in a hospital clinic. The Activity Inventory (AI), was administered to all participants by telephone within 1 week of enrollment (before any intervention) and repeated at 3 and 6 months. RESULTS: One hundred participants (Type 1: 28, Type 2: 72; male: 62, female 38) have been recruited. Median habitual distance acuity was 0.19 logMAR (6/9, 20/30), with an interquartile range of 0.06-0.30 logMAR (6/7.5-6/12, 20/25-20/40). AI responses were scored by Rasch analysis, providing a measure of visual ability. Median baseline visual ability was 1.64 logits, with an interquartile range of 0.60-3.75 logits. Difference in mean change in visual ability between intervention groups will be assessed 3 months (primary outcome) and 6 months (secondary outcome) after enrollment. CONCLUSIONS: This is the first randomised controlled trial investigating the effectiveness of low vision rehabilitation for people with diabetic eye disease. With recruitment already complete, it is hoped this work will be the first step in guiding referral criteria for those with diabetic eye disease into the low vision service.

Impact of a guide dog on glycemia regulation in blind/visually impaired persons due to diabetes mellitus.

The aim was to assess glycemia regulation in a blind diabetic patient after getting a guide dog. Glycosylated hemoglobin (HbA1c) results of a blind patient before and after getting the guide dog were retrospectively collected. The paired t-test results yielded a two-tailed P value of 0.0925, a difference considered not statistically significant; the 95% confidence interval of this difference varied from -0.2494 to 1.889. An improvement of glycemia regulation was observed with the guide dog compared to previous glycemia regulation, however, the difference was not statistically significant. The moderate improvement could probably be attributed to the mobility of the blind person having a guide dog. Standard quality of life tests should be included in the evaluation of diabetic blind persons, especially the impact of a guide dog on glycemic control or other chronic complications of diabetes.

Impact of visual impairment on service and device use by individuals with diabetic retinopathy.

PURPOSE: This study was performed to assess the use of devices and caregiving among individuals with diabetic retinopathy and to evaluate the impact of visual acuity on use. METHODS: Data were collected using a questionnaire that included items on demographic and clinical characteristics and on the use of services, assistive devices, and caregiving. The study was approved by an institutional review board. Two ophthalmologists identified and invited patients with diabetic retinopathy and provided best corrected visual acuity (BCVA). Patients provided informed consent. De-identified data were analysed in SAS(R). RESULTS: Of the 806 respondents, 55% were women; mean age was 65 years. Respondents were classified into five categories based on BCVA. Few respondents used services such as transportation and counseling, but there was wide use of assistive devices. More than 20% of respondents used a cane, a hand-held magnifier, and/or special glasses. The mean number of devices used increased significantly as BCVA deteriorated, as did hours of caregiving. Annual costs for services, devices, and caregiving increased as BCVA deteriorated. CONCLUSIONS: There are substantial differences in the use and costs of assistive devices and caregiving among individuals with diabetic retinopathy with varying BCVA.

Second eye cataract surgery in the diabetes patient? Quality of life gains and speed of visual and functional rehabilitation.

PURPOSE: To assess gains in quality of life (QOL) and visual acuity (VA), and to evaluate speed of visual and functional rehabilitation in diabetes patients with different stages of retinopathy (DR) after phacoemulsification in either one or both eyes. METHODS: This prospective longitudinal study comprised 102 patients having either (1) first eye, or (2) first and subsequent second eye cataract surgery. One surgeon performed all surgeries. In both groups, the following subset of patients was compared: those with no apparent retinopathy (no DR), those with mild nonproliferative DR (NPDR), those with severe NPDR, and those with proliferative DR. VA and questionnaire (VF-14) responses were recorded prior to and 1, 3, 6, 8 and 12 months after surgery. RESULTS: Patients with no DR and mild NPDR showed a significantly more rapid speed of visual and functional rehabilitation compared to patients with severe NPDR and proliferative DR. Maximum visual and functional results for these patients were observed 1 month after surgery, and values were significantly higher in comparison to other patients (p values <0.0001). Patients with no DR and mild NPDR who had second eye surgery demonstrated significant improvements (VA, QOL) and sustainment of the improved functional status achieved after first eye surgery (p<0.001). CONCLUSIONS: Patients with no DR and mild NPDR show greater significant improvements in QOL and VA, and a more rapid speed of visual and functional rehabilitation in comparison to patients with more advanced DR. Functional gains are sustained at 1 year after surgery, if second eye surgery is performed.

Sight for seniors: a summary of findings and challenges to providing community-based eye care to low-income seniors.

PURPOSE: The Sight for Seniors (SFS) program was developed to provide eye care and eyeglasses to low-income seniors. METHODS: Residents from a Chicago Housing Authority senior development participated in SFS. A community liaison promoted SFS and enrolled residents. Patients received transportation, eye care that took place at the Illinois Eye Institute, and spectacles at no out-of-pocket cost. RESULTS: Eighty-nine patients were seen. The mean age was 71.8 years (standard deviation, 7.2). Fifty-six (62.9%) patients were women, and 73 (82.0%) were black. The last eye examination was reported within a year by 16 (18.0%), and 44 reported that their last medical examination was within 1 year. All patients required and received eyeglasses. Seventy-four (83.1%) improved Snellen distance visual acuity by 1 line or more and 26 (29.2%) by 3 lines or more. Twenty (22.5%) had glaucoma, and 9 had diabetic retinopathy. Sixty-three (70.8%) reported a history of hypertension (HTN) and 33 (37.1%) type 2 diabetes mellitus (DM). HTN was controlled in 4 (15%) of those with HTN and DM and 12 (34.3%) of those with HTN but not DM. CONCLUSIONS: Last reported eye examination, medical history, and examination findings support the need for eye care in this population. These findings are applicable to similar populations.

[Spectrum of ophthalmologic and social rehabilitation at the Tübinger Low-Vision Clinic : a retrospective analysis for 1999-2005]. / Ophthalmologische und soziale Rehabilitation sehbehinderter Patienten : Eine retrospektive Analyse an der Tübinger Sehbehindertenambulanz von 1999-2005.

BACKGROUND: In addition to medical care, the visual and social rehabilitation of low-vision patients is of increasing importance. The aim of our study was to evaluate the actual spectrum of patients concerning diagnoses and appropriate low-vision aids at a low-vision clinic. METHODS: In a retrospective study, the medical records of 4,711 patients treated at our low-vision clinic from January 1999 to December 2005 were reviewed and analyzed. The main outcome measurements were age, ophthalmologic diagnoses, magnification requirement, and prescribed low-vision aids, as well as social and professional rehabilitation measures. To evaluate the efficiency of visual rehabilitation, reading speed was measured in a subgroup of 930 patients before and after administration of low-vision aids. RESULTS: Age-related macular degeneration was, at 40%, the most frequent diagnosis. Other main diagnoses were tapetoretinal dystrophies, optic atrophy, and diabetic retinopathy. The median magnification need was 4x. A highly significant correlation existed between the measured magnification power and the magnification factor of the prescribed low-vision aids. Visual rehabilitation was frequently sufficient with simple optical low-vision aids such as high-plus reading additions and magnifiers. Closed-circuit television systems were necessary in 26%; however, 85% of these patients had a high magnification need of more than 6 x. For distance vision, a monocular telescope was the low-vision aid prescribed most often. A high proportion of patients needed more than two low-vision aids for different application areas. Forty percent of patients needed special social and professional rehabilitation measures. In a subgroup of 930 patients, the mean reading speed was 35+/-50 words/min before the use of low-vision aids, which increased significantly to 81+/-46 words/min with the use of such aids. Therefore, the reading speed essentially doubled following the use of low-vision aids. CONCLUSION: Our results provide actual, quantitative data about the need for and success of rehabilitation for visually impaired patients. A large number of patients suffer from age-related macular degeneration. Independent from the causal ophthalmologic diagnoses, most patients benefited greatly from the rehabilitation measures provided by the low-vision service and were thus able to improve their quality of life. In the face of the increasing number of visually impaired elderly patients, rehabilitation should start as early as possible.

Eye on diabetes: a multidisciplinary patient education intervention.

PURPOSE: The purpose of this study is to compare the efficacy of usual care to an intervention emphasizing patient education targeted at a multicultural adult patient population with diabetes seeking eye care in an academic health center. METHODS: Ninety patients were randomized to usual care or to the intervention. All patients received a comprehensive eye health and vision examination and completed a demographic survey, a patient satisfaction survey, and a diabetes eye health pretest and posttest administered by a masked examiner at 1 week and 3 months. A multidisciplinary (optometry, pharmacy, endocrinology) patient education curriculum was developed for patients randomized to the intervention. Because the dependent variable was measured at 3 points on a nominal scale, a binary generalized estimating equation was employed. RESULTS: The assessment of patient knowledge at baseline revealed misconceptions about diabetic eye disease. While most patients recognized that people with diabetes should have regularly scheduled eye examinations through dilated pupils (90.0%), most patients incorrectly reported that diabetic eye disease usually has early warning signs (75.6%). While controlling for age, gender, race, education, and HbA1c level, subjects who participated in the intervention were 2 times more likely to score higher on the posttest (chi(2) = 45.51, P > .00). No differences between pretest and posttest scores were found for patients who did not participate in the intervention (chi(2) = 11.67, P > .11). CONCLUSIONS: Patients who participated in the educational intervention demonstrated an increase in knowledge across time. Patients may benefit from education emphasizing the importance of dilated eye examinations in the absence of ocular symptoms.

Cognitive appraisals, distress and disability among persons in low vision rehabilitation.

OBJECTIVE: Examined cognitive appraisals of interference and tolerance in the prediction of distress and self-reported disability among persons presenting for low vision rehabilitation. DESIGN: Cross-sectional; correlational and path analyses. METHODS: One-hundred and thirteen patients (mean age, 71 years; 52 men and 61 women) presenting for low vision rehabilitation at a university-based centre for low vision rehabilitation participated in an initial clinical vision examination and completed several questionnaires to evaluate cognitive appraisals, emotional distress and self-reported disability. RESULTS: Path analyses indicated that greater tolerance was associated with less interference imposed by vision loss. Greater tolerance was also associated with less emotional distress and symptom severity (visual acuity) was associated with self-reported disability. Cognitive appraisals (tolerance and interference) indirectly influenced self-reported disability through emotional distress. CONCLUSIONS: The data indicate that appraisals of personal ability to tolerate vision loss and the perceived interference of vision loss on goal-directed behaviour and expected activities have greater influence on distress and are subsequently predictive of disability in comparison with objective symptoms (visual acuity). Implications for clinical interventions and further research are discussed.

Vision-related quality of life in patients with diabetic macular oedema.

AIMS: The aim of this study was to determine the impact of diabetic macular oedema (DME) on the quality of life (QOL) in patients with type 2 diabetes mellitus. METHODS: The study was a prospective, consecutive, non-comparative case series. An observational study evaluated the quality of vision and vision-specific QOL using the 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25). Mean VFQ-25 subscale scores in type 2 diabetic study patients were compared with mean VFQ-25 subscale score in groups of patients with type 1 diabetic retinopathy (T1DR) and varying degrees of age-related macular degeneration (ARMD), glaucoma and cataracts and in reference populations. RESULTS: Thirty-three patients completed the NEI VFQ-25. The mean age of the study population was 64 years. When performing a comparison of those patients with DME versus those with isolated T1DR we found that for the general health subscale, the DME versus T1DR group means were 42+/-4.4 versus 61+/-1.0 respectively. The DME versus T1DR quality of vision categorical mean scores were 69+/-4.1 versus 93+/-3.9. The DME versus T1DR VR-QOL categorical mean scores were 62+/-5.0 versus 93+/-1.0. The DME group was significantly worse in each of these three categories compared with the T1DR group (p<0.01). An additional analysis was performed to examine the differences in VR-QOL in the DME group versus varying common ocular diseases, including age-related macular degeneration (ARMD), glaucoma, cataracts and disease-free reference groups. The mean values of VFQ-25 subscale in the DME group were significantly lower then the glaucoma group in ten of 12 subscales, the cataract group in 11 of 12 subscales, and the reference group in 12 of 12 subscales. However, the mean values of VFQ-25 subscale in the DME group were only significantly different from the ARMD group in three of 12 subscales. CONCLUSIONS: Type 2 diabetes patients with macular oedema experience a decreased VR-QOL compared with type 1 diabetic patients with diabetic retinopathy, glaucoma or cataracts. However, VR-QOL in type 2 diabetic patients with macular oedema was similar to those individuals with ARMD.

Reported symptoms and quality-of-life impacts in patients having laser treatment for sight-threatening diabetic retinopathy.

AIMS: To explore the patient experience of symptoms of eye disease related to diabetes and its treatment, including increase of symptoms over time and their relation to severity of the condition and the effect of multiple treatments and symptoms on quality of life. METHODS: A qualitative interview study was implemented at four eye clinics in the UK. This study design was intended to yield 240 interviews in patients having their first laser treatment or first follow-up and in multi-treatment patients with a clinically documented loss of visual function in at least one eye (VA

Comparison of low-vision reading with spectacle-mounted magnifiers.

Reading is the most common goal among persons with age-related macular degeneration and other retinal diseases that lead to macular loss, as well as the functional task most affected by the resulting central scotomas. This project determined whether reading ability is different when persons with macular loss read with a new hybrid-diffractive spectacle magnifier versus a refractive-aspheric spectacle magnifier and an aplanatic spectacle magnifier. After subjects completed a low-vision examination, we assigned them to groups that compared different types of spectacle magnifiers and assessed their reading acuity, speed, critical print size (print size large enough to provide a subject's best fluent reading), accuracy, and comprehension. Subjects completed visual analog scales to indicate their perceptions of satisfaction with reading, comfort with reading, and cosmesis (comfort with allowing others to see them read) and were asked which of the compared spectacle magnifiers they preferred for prescription. We subjected the data to paired t-tests to ascertain whether differences existed in subjects' reading ability and perceptions between the types of reading devices. Subjects' reading comprehension, perception of satisfaction, and perception of cosmesis were significantly better with the hybrid-diffractive lens than with the refractive-aspheric lens. Although subjects' critical print size was significantly better with the aplanatic lens than with the hybrid-diffractive lens, functional reading ability was not significantly different. More subjects preferred the hybrid-diffractive lenses for prescription. The hybrid-diffractive spectacle magnifiers are an important addition to the optical-device armamentarium for reading with low vision.

Resolución temprana con tratamiento médico en el estrabismo parético en pacientes con diabetes mellitus / Early resolution with medical treatment in the paretic strabismus in patients with diabetes mellitus

Objetivo: reconocer el mejor tratamiento para la pronto recuperación del nervio parético. Material y método: es un ensayo en comunidad, prospectivo y experimental. Se evaluaron 4 grupos: grupo 1: con tóxina botulínic, grupo 2: con carbamazepina oral, grupo 3: con complejo B oral y grupo 4: control metabólico. A todos los pacientes se les realizó exploración oftalmológica completa y estrabológica con prueba de ducción forzad, puntos de Worth y prismas, así como tiras reactivas para la determinación de glucosa en sangre cada 2 semanas y hemoglobina glucosilada al inicio y final del tratamiento, para su control. Resultados: del total de 80 pacientes estudiados (39 por ciento femeninos y 61 por ciento masculinos) con edad promedio de 60 años; el grupo 1 presentó un tiempo promedio de resolución más rápido (12.2 semanas), en comparación a los otros grupos. Conclusión: la resolución del cuadro parético es más rápida en los grupos tratados con toxina butolínica y carbamazepina (12 semanas), y más tardada en el grupo con complejo B (14 semanas).

Purpose: to recognize the best treatment for recovery of paretic craneal nerve. Material and methods: prospective, experimental and community trial, divided in four groups: group 1: with botulinum toxin, group 2: with oral carbamazepine, group 2: with oral carbamazepine, group 3: with oral vitamin B and group 4: with metabolic control. All pacients were evaluated with complete opthalmological and strabological examination with Worth, prism and force duction text; metabolic control was ascertained with glucosilade hemoglobine and a reactive blood test every two weeks. Results: A total of 80 patients were included (39 percent female and 61 percent male) with a mean age a 60 years old; group 1 showed the shortest mean time of resolution of 12.2 weeks compared to others groups. Conclusions: paretic resolution is faster with botulinum toxin and carbamazepine (12 weeks), and slower with vitamin B (14 weeks).