Visual Impairment from Uncorrected Refractive Error among Participants in a Novel Program to Improve Eye Care Access among Low-Income Adults in Michigan.

PURPOSE: To assess the rate of visual impairment (VI) from uncorrected refractive error (URE) and associations with demographic and socioeconomic factors among low-income patients presenting to the Michigan Screening and Intervention for Glaucoma and Eye Health through Telemedicine (MI-SIGHT) program. DESIGN: Cross-sectional study. PARTICIPANTS: Adults ≥ 18 years without acute ocular symptoms. METHODS: MI-SIGHT program participants received a telemedicine-based eye disease screening and ordered glasses through an online optical store. Participants were categorized based on refractive error (RE) status: VI from URE (presenting visual acuity [PVA], ≤ 20/50; best-corrected visual acuity [BCVA], ≥ 20/40), URE without VI (PVA, ≥ 20/40; ≥ 2-line improvement to BCVA), and no or adequately corrected RE (PVA, ≥ 20/40; < 2-line improvement to BCVA). Patient demographics, self-reported visual function, and satisfaction with glasses obtained through the program were compared among groups using analysis of variance, Kruskal-Wallis, chi-square, and Fisher exact testing. MAIN OUTCOME MEASURES: PVA, BCVA, and presence of VI (defined as PVA ≤ 20/50). RESULTS: Of 1171 participants enrolled in the MI-SIGHT program during the first year, average age was 55.1 years (SD = 14.5), 37.7% were male, 54.1% identified as Black, and 1166 (99.6%) had both PVA and BCVA measured. VI was observed in 120 participants (10.3%); 96 had VI from URE (8.2%), 168 participants (14.4%) had URE without VI, and 878 (75.3%) had no or adequately corrected RE. A smaller percentage of participants with VI resulting from URE reported having a college degree, and a larger percentage reported income < $10 000 compared with participants with no or adequately corrected RE (3.2% vs. 14.2% [P = 0.02]; 45.5% vs. 21.6% [P < 0.0001], respectively). Visual function was lowest among participants with VI from URE, followed by those with URE without VI, and then those with no or adequately corrected RE (9-item National Eye Institute Visual Function Questionnaire composite score, 67.3 ± 19.6 vs. 77.0 ± 14.4 vs. 82.2 ± 13.3, respectively; P < 0.0001). In total, 71.2% (n = 830) ordered glasses for an average cost of $36.80 ± $32.60; 97.7% were satisfied with their glasses. CONCLUSIONS: URE was the main cause of VI at 2 clinics serving low-income communities and was associated with reduced vision-related quality of life. An online optical store with lower prices made eyeglasses accessible to low-income patients. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

[Application progress of quality of life assessment scales and psychological assessment tools for evaluating overall quality of life in patients with uveitis].

Uveitis is a common sight-threatening ocular disease that has multiple heterogeneous clinical entities, complicated pathogenesis, and a high complication rate. The visual impairment caused by uveitis, the side effects of long-term systemic therapy, and the economic burden due to the high cost of treatment have a significant impact on the patient's physical, psychological, and social functions, resulting in a decrease in the quality of life of uveitis sufferers. Accurate assessment of patients' quality of life is helpful to guild treatment, enhance compliance and improve patients' overall quality of life. This article reviews the current progress on the quality of life assessment scales and psychological assessment tools to evaluate overall quality of life in patients with uveitis, thereby to provide reference and theoretical basis for selecting and developing the quality of life assessment tools for uveitis patients.

Protocol for the development of versions of the Montreal Cognitive Assessment (MoCA) for people with hearing or vision impairment.

INTRODUCTION: Hearing and vision impairments are highly prevalent among older adults and impact commonly used cognitive assessment tools for the identification of dementia. Adaptations of such tests for people with hearing or vision impairment have not been adequately validated among populations with such sensory impairment. METHODS AND ANALYSIS: We will develop two versions of the Montreal Cognitive Assessment (MoCA) for people with acquired hearing impairment (MoCA-H) or vision impairment (MoCA-V). The MoCA-H and MoCA-V will exclude the existing MoCA items that are presented in spoken or visual format, respectively, and include new suitably adapted items. Participants (n=792) with combinations of hearing, vision and cognitive impairment will complete standard or adapted versions of the MoCA across three language sites (English, French and Greek). Development of the MoCA-H and the MoCA-V will be based on analysis of adapted and standard MoCA items following model-based development to select the combination of items for the MoCA-H and MoCA-V that provide optimal sensitivity and specificity for detection of dementia. ETHICS AND DISSEMINATION: The study has received ethical approval from respective centres in the UK, France, Greece and Cyprus. The results of the study will be disseminated through peer-reviewed publication, conference presentations, the study website (https://www.sense-cog.eu/), the SENSE-Cog Twitter account (@sense_cog) and the MoCA test website (https://www.mocatest.org/). The main outputs of the study will be versions of the MoCA that are appropriate for use with adults with acquired hearing or vision impairment and will contribute significantly to the clinical care of older people.

[Vision-related Quality of Life with Low Vision - Assessment and Instruments]. / Visuelle Lebensqualität bei starker Sehbehinderung ­ Messung und Messinstrumente.

Patient-reported outcome measures have been met with increasing interest, particularly in clinical research. They are used to capture the patient-relevant impact of an intervention or a loss of function. In patients with loss of vision, vision-related quality of life is assessed in order to quantify the impact of visual impairment in everyday life. When using quality of life instruments, psychometric characteristics - such as reliability, validity and responsiveness - are of great importance to ensure that the collected data are robust. There are various questionnaires to assess health-related quality of life, vision-related quality of life or visual function, but not all of these are suitable for patients with very low vision. The IVI and NEI VFQ questionnaires are available in German and can be used to assess vision-related quality of life. However, additional studies to evaluate these instruments and refinement or development of novel tools are needed to better meet the growing interest in using patient-reported outcomes as clinical study endpoints.

Screening, Education, and Rehabilitation Services for Hearing Loss Provided to Clients with Low Vision: Measured and Perceived Value Among Participants of the Vision-Hearing Project.

OBJECTIVES: Combined vision and hearing impairment, termed dual sensory impairment (DSI), is associated with poorer health outcomes compared with a single sensory loss alone. Separate systems of care exist for visual and hearing impairment which potentially limit the effectiveness of managing DSI. To address this, a Hearing Screening Education Model (HSEM) was offered to older adults attending a low-vision clinic in Australia within this pilot study. The present study aimed to evaluate the benefits of seeking help on hearing handicap, self-perceived health, and use of community services among those identified with unmet hearing needs after participation in the HSEM. DESIGN: Of 210 older adults (>55 years of age) who completed the HSEM and were referred for follow-up, 169 returned for a follow-up interview at least 12 months later. Of these, 68 (40.2%) sought help, and the majority were seen by a hearing healthcare provider (89.7%). Changes in hearing handicap, quality of life, and reliance on community services between the baseline and 12-month follow-up were compared between those who sought help and those who did not. In addition, the perceived value of the HSEM was assessed. RESULTS: Results showed that there was no significant difference in hearing handicap between those who sought help (mean change -1.02 SD = 7.97, p = 0.3) and those who did not (mean change 0.94 SD = 7.68, p = 0.3), p = 0.18. The mental component of the SF-36 worsened significantly between baseline and follow-up measures across the whole group (mean change -2.49 SD = 9.98, p = 0.002). This was largely driven by those not seeking help, rather than those seeking help, but was not significantly different between the two groups. Those who sought help showed a significant reduction in the use of community services compared with those who did not. Further, all participants positively viewed the HSEM's underlying principle of greater integration between vision and hearing services. CONCLUSIONS: These findings suggest a need to further develop and evaluate integrated models of healthcare for older adults with DSI. It also highlights the importance of using broader measures of benefit, other than use of hearing aids to evaluate outcomes of hearing healthcare programs.

Depression in Visual Impairment Trial (DEPVIT): A Randomized Clinical Trial of Depression Treatments in People With Low Vision.

PURPOSE: The purpose of this study was to compare two interventions for depression, problem solving treatment (PST) and referral to the patient's physician, with a waiting-list control group in people with sight loss and depressive symptoms. METHODS: This was an assessor-masked, exploratory, multicenter, randomized clinical trial, with concurrent economic analysis. Of 1008 consecutive attendees at 14 low-vision rehabilitation centers in Britain, 43% (n = 430) screened positive for depressive symptoms on the Geriatric Depression Scale and 85 of these attendees participated in the trial. Eligible participants were randomized in the ratio 1:1:1 to PST, referral to their physician, or a waiting-list control arm. PST is a manualized talking intervention delivered by a trained therapist who teaches people over six to eight sessions to implement a seven-step method for solving their problems. Referral to the physician involved sending a referral letter to the person's physician, encouraging him or her to consider treatment according to the stepped care protocol recommended by the U.K.'s National Institute of Health and Care Excellence. The primary outcome was change in depressive symptoms (6 months after baseline) as determined by the Beck Depression Inventory. RESULTS: At 6 months, Beck Depression Inventory scores reduced by 1.05 (SD 8.85), 2.11 (SD 7.60), and 2.68 (SD 7.93) in the waiting-list control, referral, and PST arms, respectively. The cost per patient of the PST intervention was £1176 in Wales and £1296 in London. CONCLUSIONS: Depressive symptoms improved most in the PST group and least in the control group. However, the change was small and the uncertainty of the measurements relatively large.

Improving access to hearing services for people with low vision: piloting a "hearing screening and education model" of intervention.

OBJECTIVES: The aims of this study were to investigate the potential unmet need for hearing services among older people attending low-vision rehabilitation, and pilot a "Hearing Screening and Education Model" (HSEM) of intervention to promote use of hearing services and aids among these individuals. DESIGN: In the Vision-Hearing project, 300 clients attending low-vision clinics in Sydney, Australia, participated in baseline interviews and the HSEM (2010-2011). The HSEM consisted of: (1) standard pure-tone audiometry; (2) discussion of hearing loss and implications of dual sensory impairment; and (3) provision of information on hearing services and facilitated referral. Those with hearing loss who did not own hearing aids, reported low use (<1 hr/day), or used a single aid with bilateral loss were referred for full assessment by an audiologist and to the follow-up arm of the study (n = 210). Follow-up interviews were conducted within 12 months to ascertain actions taken and audiological and other health outcomes. RESULTS: Of 169 participants in the follow-up study, 68 (40.2%) sought help for hearing loss within 12 months. Help-seekers had higher mean hearing handicap scores at baseline compared with non-help-seekers. The majority of help-seekers (85.3%) underwent a complete hearing assessment. Fifty-four percent (n = 37) were recommended hearing aids and the majority of these (n = 27) obtained new hearing aids. Seven participants had existing aids adjusted, and 3 obtained alternate assistive listening devices. Almost half of those receiving new aids or adjustments to hearing aids reported low use (<1 hr/day) at follow-up. Among help-seekers, 40% were unsure or did not believe their audiologist knew of their visual diagnosis. Of concern, 60% of participants did not seek help largely due to perceptions their hearing loss was not bad enough; the presence of competing priorities; concerns over dealing with vision loss and managing hearing aids with poor vision. CONCLUSIONS: Hearing- and vision-rehabilitation services need to better screen for, and take account of, dual sensory impairment among their older clients. If audiologists are made more aware of visual conditions affecting their clients, they may be better placed to facilitate access to appropriate technologies and rehabilitation, which may improve aid retention and benefit.

Comparison of application systems for autologous serum eye drops.

PURPOSE: Autologous serum eye drops are used for therapy of severe ocular surface disorders by patients with visual and manual impairments. Until recently, they were prepared under sterile conditions from open blood sampling systems. Closed blood donation systems simplify production. This study compares handling and costs of a new day dosage vial ("Meise-vial") and a single-dose tube system ("Maco-tube") based on closed production systems with conventional dropper bottles. METHODS: Nonimpaired volunteers and patients with visual or manual impairment (n = 10 each group) single-handedly tested the applicators filled with 1.5 ml sterile isotonic saline solution. Participants rated convenience of opening the containers and applying eye drops on a scale from 1.0 (very good) to 6.0 (very bad). Number of retrievable drops was counted. Participants were asked which system they prefer, both with and without knowledge of the price for the systems. RESULTS: The median for convenience of opening (eye drop application) was 2.0 (1.0) for Meise-vials, 5.0 (4.0) for Maco-tubes, and 2.0 (2.0) for dropper bottles (p < 0.001). Median number of drops retrieved from the systems was 30.5 (vials), 2 (tubes), and 30 (bottles). Ranking did not differ between nonimpaired and impaired participants. Assuming equal prices, 16 participants chose Meise-vials, 14 dropper bottles, and no tubes. With knowledge of pricing, preference changed (p = 0.001), 20 participants (67%) opted for dropper bottles and 5 (17%) preferred the other containers. CONCLUSION: Convenience of opening, applying eye drops, and number of drops retrieved was substantially better for dropper bottles and Meise-vials compared with Maco-tubes. Bottles and vials were equally well received. With regard to price, nonimpaired as well as impaired participants preferred dropper bottles. While closed systems simplify production, patients preferred dropper bottles for daily application of autologous serum eye drops for a number of reasons.

Rapid assessment of avoidable blindness in two northern provinces of Burundi without eye services.

PURPOSE: To determine the prevalence and causes of blindness, severe visual impairment and visual impairment as well as cataract surgical coverage in two northern provinces of Burundi for the purpose of planning eye services. METHODS: The population-based Rapid Assessment of Avoidable Blindness survey methodology was used. RESULTS: Of 3800 people enrolled, 3684 (97%) were examined. The sample prevalences of blindness, severe visual impairment, and visual impairment were 1.1% (95% confidence interval, CI 0.8-1.4), 0.6% (95% CI 0.4-0.9), and 1.7% (95% CI 1.3-2.1), respectively. The leading causes of blindness were cataract (55%) and posterior segment causes (37%). Severe visual impairment was mainly due to cataract (43%) and refractive error (39%), and visual impairment was mainly due to refractive error (67%) and cataract (18%). Cataract surgical coverage by person at the level of <6/60 was 15%. CONCLUSIONS: The low prevalence of vision loss in this area with no eye services and a low cataract surgical coverage rate is surprising and possibly due to the effects of the previous years of conflict in which those with decreased vision may have been most likely to perish. If this explanation is correct, then Burundi needs to plan to deal with a markedly increasing prevalence of cataract in future.

Rapid assessment of visual impairment (RAVI) in marine fishing communities in South India--study protocol and main findings.

BACKGROUND: Reliable data are a pre-requisite for planning eye care services. Though conventional cross sectional studies provide reliable information, they are resource intensive. A novel rapid assessment method was used to investigate the prevalence and causes of visual impairment and presbyopia in subjects aged 40 years and older. This paper describes the detailed methodology and study procedures of Rapid Assessment of Visual Impairment (RAVI) project. METHODS: A population-based cross-sectional study was conducted using cluster random sampling in the coastal region of Prakasam district of Andhra Pradesh in India, predominantly inhabited by fishing communities. Unaided, aided and pinhole visual acuity (VA) was assessed using a Snellen chart at a distance of 6 meters. The VA was re-assessed using a pinhole, if VA was < 6/12 in either eye. Near vision was assessed using N notation chart binocularly. Visual impairment was defined as presenting VA < 6/18 in the better eye. Presbyopia is defined as binocular near vision worse than N8 in subjects with binocular distance VA of 6/18 or better. RESULTS: The data collection was completed in <12 weeks using two teams each consisting of one paramedical ophthalmic personnel and two community eye health workers. The prevalence of visual impairment was 30% (95% CI, 27.6-32.2). This included 111 (7.1%; 95% CI, 5.8-8.4) individuals with blindness. Cataract was the leading cause of visual impairment followed by uncorrected refractive errors. The prevalence of blindness according to WHO definition (presenting VA < 3/60 in the better eye) was 2.7% (95% CI, 1.9-3.5). CONCLUSION: There is a high prevalence of visual impairment in marine fishing communities in Prakasam district in India. The data from this rapid assessment survey can now be used as a baseline to start eye care services in this region. The rapid assessment methodology (RAVI) reported in this paper is robust, quick and has the potential to be replicated in other areas.

[Analysis of multi-variate recurrent fall risk factors in elderly people using Residential Assessment Instrument-Home Care: comparisons between single and recurrent fallers].

PURPOSE: This study was done to determine the risk factors for recurrent fallers (2+falls) compared to single fallers. METHODS: Participants were 104 community-dwelling people 65 yr of age or older. The data were collected from June 1, 2008 to June 30, 2009 using the Residential Assessment Instrument-Home Care. RESULTS: Over the past 90 days, 55.7% of the 104 participants fell once, and 44.2% experienced recurrent falls (2+falls). In comparison of recurrent fallers with single fallers, there were significant differences in scores on the following factors: gender (χ(2)=4.22, p=.040), age (χ(2)=5.74, p=.017), educational level (χ(2)=5.22, p=.022), living arrangements (χ(2)=35.02, p<.001), cardiovascular diseases (χ(2)=17.10, p<.001), hypertension (χ(2)=4.43, p=.035), diabetes mellitus (χ(2)=4.44, p=.035), glaucoma (χ(2)=13.95, p<.001), Minimal Data Set (MDS)-Pain (t=-2.56, p=.012), fear of falling (χ(2)=4.08, p=.034), reduced vision (t=-3.06, p=.003), MDS-activity of daily living (t=3.46, p=.001), MDS-Instrumental Activities of daily living (t=3.24, p=.002), cognition (MDS-Cognition Performance Scale) (t=3.40, p=.001), and 'difficulties entering and leaving the house' (χ(2)=4.53, p=.033). CONCLUSION: It is important to assess the risk factors for recurrent falls and develop differentiated strategies that will help prevent recurrent falls. Additionally, utilizing a standardized tool, such as RAI-HC, would help health professionals assess multi-variate fall risk factors to facilitate comparisons of different community care settings.

Making diabetes education accessible for people with visual impairment.

PURPOSE: The purpose of this study was to identify changes needed to make the diabetes education materials and programs of the Diabetes Association of Greater Cleveland (DAGC) accessible for people who have visual impairment and diabetes (PVID). METHODS: Using the principles and techniques of participatory action research (PAR), 5 PVID and 4 staff members of a local diabetes association met once a month for a year to plan, implement, and evaluate progress toward full accessibility of all diabetes education materials and programs. The researcher served as facilitator. RESULTS: Four "transformational moments" are presented through which the PAR process enabled PVID and diabetes professionals to learn to understand and trust each other. Changes made to increase accessibility included production of 2 recordings for providing access to print information about diabetes; planning public education program publicity and locations for access; development of guidelines to help speakers make their diabetes education presentations accessible for people who cannot see slides and gestures; and presentation of an inservice for the entire staff of the diabetes association, including information about how they live with visual impairment, and common courtesies that make communication with PVID more effective. CONCLUSIONS: Diabetes education programs should include planning for full accessibility for PVID. Diabetes organizations should publish teaching materials in accessible format.

Self-management programs for adults with low vision: needs and challenges.

OBJECTIVE: To explore the needs of individuals with low vision in order to inform the contents of a low vision self-management (SM) program and determine potential barriers to participation. METHODS: Semi-structured interviews were conducted with 48 participants with low vision resulting different from eye conditions. Qualitative analysis was conducted in order to identify major themes. RESULTS: All participants described a range of consequences as a result of vision loss including difficulties with functional activities, social interaction and emotional distress. Less than half were interested in attending a SM program. Barriers included practical reasons as well as a perceived lack of need and unclear or negative perceptions of such a program. CONCLUSION: SM programs for low vision are a promising way to help address the range of difficulties experienced by this population if barriers to participation can be overcome. PRACTICE IMPLICATIONS: SM programs should include vision-specific strategies, training in generic problem-solving and goal setting skills and how to cope with emotional reactions to vision impairment. Programs should be delivered and promoted in such a way to enhance access and encourage uptake by those with a range of vision loss in the community.

Audiological assessment, rehabilitation, and spatial hearing considerations associated with visual impairment in adults: an overview.

The purpose of this paper is to increase awareness and interest among audiologists regarding the needs of adults who have both hearing loss and visual impairment, particularly people who are blind and travel independently. Case history, audiometric testing, and rehabilitation issues are considered, and extensive discussion of spatial hearing research as it relates to orientation and mobility is provided.

Persecutory symptoms and perceptual disturbance in a community sample of older people: the Islington study.

BACKGROUND: While there are extensive studies of paranoid symptoms and perceptual disturbance (PPD) in younger adults, relatively little is known about older adults with similar symptoms. METHOD: This study took place in Islington, an inner London borough. Enumeration Districts were randomised to provide a sampling frame. Residents aged 65 or over were interviewed at home. The Short-CARE was used to elicit psychiatric symptoms and diagnosis. Sociodemographic particulars were elicited using the Client Sociodemographic and Service Receipt Inventory. Questions were asked regarding sight and hearing. We used subsections of the geriatric mental scale to identify people who had PPD symptoms. Medications taken were recorded. We asked 'Do you have any health problems?' as a screening question for subjective health problems. RESULTS: We interviewed 720 people. Twenty-eight (3.9%) participants scored positively on the PPD sub-scales of the GMS. A forward logistic regression analysis for independent predictors of PPD found the significant independent predictors were dementia (p = 0.0000; odds ratio 6.8), drinking alcohol in last 6 months (p < 0.03; odds ratio 0.3), drinking alcohol to help sleep (p < 0.005; odds ratio 9.6), subjective memory loss (p < 0.007; odds ratio 3.3) and uncorrected visual impairment (p < 0.02; odds ratio 2.8). CONCLUSION: There is a relatively high prevalence of PPD in older people living in the community. This is not associated with higher use of services despite the increased needs. Further studies should consider interventions to meet this unmet need.

Low-vision aids in age-related macular degeneration.

In spite of the many patients with low vision due to age-related macular degeneration, the year's publications on their rehabilitation are few. The most common complaint of these patients is their inability to read. For this purpose, simple optical devices, eg, overcorrection in reading glasses, hand-held or stand magnifiers, are usually best. With closed-circuit television systems, reading speed may be faster and reading time may be longer but these systems are still too expensive for most users. Results on bifocal intraocular lenses used as a Galilean telescopic system are still unconfirmed. New ideas for many technical devices suitable also for elderly patients have been presented.