Challenges and Enablers for Smartphone Use by Persons With Vision Loss During the COVID-19 Pandemic: A Report of Two Case Studies.

Purpose: Studies have reported that knowledge and skills to operate smartphones among people with profound visual loss are limited especially in low- to middle-income countries as many important functions of smartphones are unknown to them. This report presents smartphone use, its challenges, and enablers in two persons with profound visual impairment while executing their daily routine and instrumental living activities amidst the COVID-19 pandemic. Case selection and interview: During the lockdown period, we provided tele (vision) rehabilitation service. From the list of the callers, we purposely selected two callers with significant visual impairment, one woman and one man, to allow us to gather rich information related to smartphone use, enablers, and challenges faced during the usage. A semistructured interview was done to obtain insights into the information. The selection criteria were (1) continuous smartphone use independently for more than 5 years; (2) graduation-level education or higher; and (3) no additional disabilities. Discussion: We found substantial use of smartphones in executing their daily and instrumental daily living activities by these two participants. The extent of the use of mainstream apps for various tasks was almost equivalent to what we observed among sighted persons. The most important enabling factors were the presence of a screen reader "TalkBack" on Android phones and data connection of the mobile, followed by the ability to assess multiple languages using the text-to-speech feature. A supportive environment from peers or family members is important for the beginner. Poor battery backup, frequent unwanted ads or pop-ups while using the phone, not readable contents with a screen reader, e.g., CAPTCHA, and slow or unresponsiveness of the screen reader were frequent challenges faced by them. Both cases reported that around 80% of daily solutions were helped by using a smartphone. Conclusions: The current advances in accessible technology of smartphones enable an individual with profound visual loss to use them almost equivalently as a sighted person. To reduce the gap in digital inclusion, people with visual impairment should be encouraged to use the smartphone for their daily solutions with attention to proper training.

Coronavirus Disease 2019-Related Health Disparities in Ophthalmology with a Retrospective Analysis at a Large Academic Public Hospital.

The coronavirus disease 2019 pandemic has disproportionately affected racial and ethnic minorities in the United States. Although recent meta-analyses have identified the prevalence of ocular manifestations in severe acute respiratory syndrome coronavirus 2 infection, no studies with these potential findings have been implemented in examining ophthalmic disparities in racial and ethnic minorities. It is additionally clear that patient access to eye care from coronavirus disease 2019 has been disproportionate in underserved communities. Large public hospitals and urban academic medical centers provide a unique opportunity to further study ocular disease presentation and health disparities from coronavirus disease 2019 in these populations.

Reducing visual health disparities in at-risk community health center populations.

Community health centers (CHCs) have an impressive record of addressing health disparities through consistently delivering high-quality and affordable care in a culturally competent manner, while also producing cost savings to the nation's healthcare system. Thus CHCs are optimally positioned to reduce visual health disparities and improve visual health outcomes by being included in the primary care services that they deliver. An estimated three million health center patients have risk factors for vision disorders and eye disease, yet a recent policy briefing survey conducted by The George Washington University reported that about 20 percent of centers provide on-site eye and vision care.

Reorganization of visual processing is related to eccentric viewing in patients with macular degeneration.

PURPOSE: Neural evidence exists for cortical reorganization in human visual cortex in response to retinal disease. Macular degeneration (MD) causes the progressive loss of central visual acuity. To cope with this, MD patients often adopt a preferred retinal location (PRL, i.e., a functional retinal area in their periphery used to fixate instead of the damaged fovea). The use of a PRL may foster cortical reorganization. METHODS: We used fMRI to measure brain activity in calcarine sulcus while visually stimulating peripheral visual regions in MD patients and age-matched control participants. RESULTS: We found that visual stimulation of the PRL in MD patients increased brain activity in cortex normally representing central vision relative to visual stimulation of a peripheral region outside the patients' PRL and relative to stimulation in the periphery of age-matched control participants. CONCLUSIONS: These data directly link cortical reorganization in MD to behavioral adaptations adopted by MD patients. These results not only confirm that large-scale cortical reorganization of visual processing occurs in humans in response to retinal disease, but also relate this reorganization to functional changes in patient behavior.

Disparities in eye care utilization among the United States adults with visual impairment: findings from the behavioral risk factor surveillance system 2006-2009.

PURPOSE: To estimate the prevalence of annual eye care among visually impaired United States residents aged 40 years or older, by state, race/ethnicity, education, and annual income. DESIGN: Cross-sectional study. METHODS: In analyses of 2006-2009 Behavioral Risk Factor Surveillance System data from 21 states, we used multivariate regression to estimate the state-level prevalence of yearly eye doctor visit in the study population by race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and other), annual income (≥$35,000 and <$35,000), and education (< high school, high school, and > high school). RESULTS: The age-adjusted state-level prevalence of yearly eye doctor visits ranged from 48% (Missouri) to 69% (Maryland). In Alabama, Colorado, Indiana, Iowa, New Mexico, and North Carolina, the prevalence was significantly higher among respondents with more than a high school education than among those with a high school education or less (P < .05). The prevalence was positively associated with annual income levels in Alabama, Georgia, New Mexico, New York, Texas, and West Virginia and negatively associated with annual income levels in Massachusetts. After controlling for age, sex, race/ethnicity, education, and income, we also found significant disparities in the prevalence of yearly eye doctor visits among states. CONCLUSION: Among visually impaired US residents aged 40 or older, the prevalence of yearly eye examinations varied significantly by race/ethnicity, income, and education, both overall and within states. Continued and possibly enhanced collection of eye care utilization data, such as we analyzed here, may help states address disparities in vision health and identify population groups most in need of intervention programs.

Baseline traits of low vision patients served by private outpatient clinical centers in the United States.

OBJECTIVE: To characterize the traits of low vision patients who seek outpatient low vision rehabilitation (LVR) services in the United States. METHODS: In a prospective observational study, we enrolled 764 new low vision patients seeking outpatient LVR services from 28 clinical centers in the United States. Before their initial appointment, multiple questionnaires assessing daily living and vision, physical, psychological, and cognitive health states were administered by telephone. Baseline clinical visual impairment measures and disorder diagnoses were recorded. RESULTS: Patients had a median age of 77 years, were primarily female (66%), and had macular disease (55%), most of which was nonneovascular age-related macular degeneration. More than one-third of the patients (37%) had mild vision impairment with habitual visual acuity (VA) of 20/60 or greater. The VA correlated well with contrast sensitivity (r = -0.52) but poorly with self-reported vision quality. The intake survey revealed self-reported physical health limitations, including decreased endurance (68%) and mobility problems (52%). Many patients reported increased levels of frustration (42%) and depressed mood (22%); memory and cognitive impairment (11%) were less frequently endorsed. Patients relied on others for daily living support (87%), but many (31%) still drove. CONCLUSIONS: Most patients seeking LVR are geriatric and have macular disease with relatively preserved VA. The disparity between VA and subjective quality of vision suggests that LVR referrals are based on symptoms rather than on VA alone. Patients seen for LVR services have significant physical, psychological, and cognitive disorders that can amplify vision disabilities and decrease rehabilitation potential.

Vision health disparities in the United States by race/ethnicity, education, and economic status: findings from two nationally representative surveys.

PURPOSE: To assess vision health disparities in the United States by race/ethnicity, education, and economic status. DESIGN: Cross-sectional, nationally representative samples. METHODS: We used national survey data from the National Health and Nutrition Examination Survey (NHANES) and the National Health Interview Survey (NHIS). Main outcome measures included, from NHANES, age-related eye diseases (ie, age-related macular degeneration [AMD], cataract, diabetic retinopathy [DR], glaucoma) and from NHIS, eye care use (ie, eye doctor visits and cannot afford eyeglasses when needed) among those with self-reported visual impairment. The estimates were age- and sex-standardized to the 2000 US Census population. Linear trends in the estimates were assessed by weighted least squares regression. RESULTS: Non-Hispanic whites had a higher prevalence of AMD and cataract surgery than non-Hispanic blacks, but a lower prevalence of DR and glaucoma (all P < .001 in NHANES 2005-2008). From 1999 to 2008, individuals with less education (ie, high school) and lower income (poverty income ratio [PIR] <1.00 vs ≥ 4.00) were consistently less likely to have had an eye care visit in the past 12 months compared with their counterparts (all P < .05). During this period, inability to afford needed eyeglasses increased among non-Hispanic whites and Hispanics (trend P = .004 and P = .007; respectively), those with high school education (trend P = .036), and those with PIR 1.00-1.99 (trend P < .001). CONCLUSIONS: Observed vision health disparities suggest a need for educational and innovative interventions among socioeconomically disadvantaged groups.

Surveillance of disparities in vision and eye health in the United States: an expert panel's opinions.

PURPOSE: To define surveillance approaches and metrics to capture the burden of vision health disparities and to identify properties of a surveillance system to guide public health interventions. DESIGN: Expert panel. METHODS: Analysis of relevant literature and deliberations of expert panel. RESULTS: The panel identified that the purpose of vision surveillance was to link data to public health interventions. Panel members noted the importance of assessing vision through self-reported and performance-based measures. Defined populations should be included in a surveillance system to assess disparities in utilization of eye care and vision loss. The panel suggested that ophthalmic/vision measures should be sustained in national surveys and suggested that a vision surveillance system should be forged among federal agencies. CONCLUSIONS: Employing the 6 outlined strategies would improve vision surveillance and help reach the vision-related objectives of Healthy People 2020.

Implantable miniature telescope: lessons learned.

BACKGROUND: The Implantable Miniature Telescope (IMT) is a telescopic prosthesis that, combined with the optics of the cornea, constitutes an intraocular magnifying system. It is indicated for use in patients with stable, nonfoveal sparing, bilateral, stable, age-related macular degeneration (end-stage) with associated scotomas. The telescope prosthesis is implanted in only one of the patient's eyes. In this way, the implanted eye provides improved visual acuity, and the nonimplanted eye continues to provide peripheral vision for ambulation. Two hundred seventeen patients with end-stage AMD were enrolled in a prospective, multicenter, open-label trial (IMT-002) beginning in 2003. The implanted eye was the worse eye for most patients based on a selection rule set by the U.S. Food and Drug Administration (FDA) protocol; however, in most cases (90%), visual acuity improvement goals were met with the device. This report will retrospectively look at 2 selected patients implanted at the Emory Eye Center in Atlanta as part of that trial to derive lessons for subject and eye selection criteria. CASE REPORTS: Two cases were selected to represent patients' levels of functional success and satisfaction. Determination of their visual and functional outcome at 1-year postimplantation was based on best-corrected visual acuity and the National Eye Institute Visual Functioning Questionnaire 25-Item quality-of-life survey. Four years after implantation, 1 patient continued to use the telescope prosthesis eye for all visual activities; the other patient did not perceive any benefit from the device and continued to primarily use the fellow nonimplanted eye. The benefit of the telescopic prosthesis was most likely accounted for by the level of visual acuity in both eyes postimplantation and eye dominance. CONCLUSION: Proper eye selection chosen for implantation with the telescope prosthesis appears to be an important if not critical factor in determining patient satisfaction for visual processing and functional success. Based on the author's experience with the IMT, optometrists can aid the multidisciplinary team by preoperatively determining which eye, if implanted, offers the optimal potential functional benefit for appropriate candidates.

An exploratory study of factors influencing glaucoma treatment adherence.

PURPOSE: To understand the factors that influence glaucoma treatment adherence with medication taking, prescription refills, and appointment keeping to develop an intervention for a specific population. PATIENTS AND METHODS: In-depth interviews were conducted with 80 individuals diagnosed with open-angle glaucoma, glaucoma suspect, or ocular hypertension. Additional eligibility requirements were that all participants were: between the ages of 18 to 80; white or African American; spoke and understood English; and were taking daily doses of topical glaucoma treatments for at least the past year. Cross-tabulations and chi2 tests were conducted to compare adherent and nonadherent individuals, classified as such based on self-report and medical chart/pharmacy data. RESULTS: Compared with adherent participants, nonadherent participants were less likely to: believe their eye doctors spent sufficient time with them; ask their eye doctor if they had any questions; know of benefits to taking their glaucoma medication regularly; and have someone help them take their glaucoma medications or drive them to eye appointments. Conversely, compared with adherent individuals, nonadherent participants were more likely to have difficulty remembering to take their medications and to believe their glaucoma would affect their eye sight in the future. CONCLUSIONS: Nonadherent glaucoma patients struggle with a variety of issues related to consistent use of glaucoma medicine and routine eye care. Interventions are needed to address these modifiable factors related to glaucoma treatment adherence.