Low Vision Rehabilitation/Case study 1: Thelma Scope

Your first patient at See Well Australia is Mrs Thelma Scope. Through working with Mrs Scope you will come to understand the concept of low vision and the impact of eye disease when treatment is no longer an option. You will be exposed to the roles and approaches of a range of professionals who might work with a patient with vision impairment. You will be challenged to determine your role as an Orthoptist in this multidisciplinary environment. There is an overarching question you will need to answer, and scenarios with supporting information to help guide your understanding and formulate your answer. You should spend around 6-8 hours with this topic.

Question
'''What is the impact of eye disease on how you see and how you feel? Who can help you with the challenges you will face as a vision impaired person?''' Use the scenarios and resources below to formulate your own response to this question. You are looking for reasons as well as proposed solutions.

Case studies
Primary case study: Mrs Thelma Scope - coping with vision loss Supplementary case studies:
 * 1) A group of elderly ladies with bilateral AMD
 * 2) A young woman with Stargardt disease
 * 3) A variety of patients: Edith Wright; Mark Bollinger; Jack Tomazetti; Barry Gentle; Peter Brown; Margaret Moriartis and Martin Skase

Mrs Thelma Scope is a patient at See Well Australia. Through Mrs Scope you will come to understand what low vision is, how it is defined and what it means to have an impairment. In addition, you will consider the epidemiology and impact of low vision in Australia.

Activities
Task 1 (Keywords: #low vision #vision impairment #legal blindness)

Watch the What is Low Vision? lectorial where you will find out about your new patient Mrs Thelma Scope.

Consult the resources below in addition to finding your own resources to answer the Task 1 questions. When answering the questions, think about what you know so far about Mrs Scope. Discuss and compare your answers with the students in your group.


 * Terminology in Eye Health
 * WHO | Visual Impairment and Blindness factsheet
 * Oxford Dictionary

Questions - Task 1
 * 1) Why is it important to a patient that we define disability or vision impairment?
 * 2) How does the World Health Organization (WHO) define ‘low vision’
 * 3) According to the WHO definition, can you classify Mrs Scope as having ‘low vision’?
 * 4) What is the definition of ‘impairment’? How does this definition specifically relate to vision?
 * 5) Do you think Mrs Scope has an ‘impairment’? Discuss.
 * 6) Define ‘disability’ and explain how this relates to the sense of vision.
 * 7) Do you think Mrs Scope is disabled? Explain why/why not.
 * 8) Define ‘handicap’ and explain whether this definition can be applied to Mrs Scope.
 * 9) Do you think you have enough information about her case history in order to classify Mrs Scope as either having impairment, disability or handicap? What other information would you need?

Task 2 (Keywords: #economic cost #financial impact #direct & indirect costs)

Referring to the Eye Research Australia (Clear Insight) Economic Impact and Cost of Low Vision in Australia publication, answer Task 2 questions. Don't forget to consider your patient Thelma when answering the questions.

Questions - Task 2
 * 1) Of a composition of the total cost of vision disorders in 2004, what is the total cost of suffering? What do you think “cost of suffering” means? Explain your answer in the context of Mrs Scope.
 * 2) On page 4 of the report it states: “the share of pharmaceutical costs has increased to 11.4% of the total and of ‘other health practitioners’ to 10.6%. Why would this be so? What would contribute to this?
 * 3) There are significant indirect costs associated with vision impairment. In the context of Mrs Scope, explain how each indirect cost could impact on her life.
 * 4) Mrs Scope is 73 years old and she is expected to live quite a few more years, especially as she is generally healthy.  What are the most likely reasons that her vision impairment would prevent healthy and independent ageing in her case?
 * 5) What are the top 3 causes of blindness in people aged over 40 in Australia?
 * 6) What age groups are most pre-disposed to each of the 3 causes you selected?
 * 7) What are the projected forecasts for visual impairment and blindness in Australia for the future?
 * 8) Why is addressing vision impairment a serious issue in this country?

Task 3 (Keywords: #visual function #blurry vision #central field loss #peripheral field loss)

Next, we will analyse the likely impact of a particular ocular disease on a person’s visual function. You will also consider the impact vision impairment might have on a person's social interactions and general well-being. You will therefore be able to discuss the psychosocial and physical impacts related to different forms of vision impairment.

Begin by watching this introductory video

Task 4 (Keywords: #functional vision #blury vision #central field loss #peripheral field loss)

Watch the three short lectorials on the three areas of functional vision loss and answer the related questions.
 * 1) Blurred vision
 * 2) Central field loss
 * 3) Peripheral field loss

Questions - Task 4

1. Blurred vision no field loss:
 * What are the ocular structures involved?
 * What is the function of these structures?
 * Explain in terms of these functions the impact these types of eye diseases or systemic conditions will have on sight.

2. Central field loss:
 * What is the ocular structure involved?
 * What is the function of this structure?
 * Explain in terms of these functions the impact on sight of disease impacting this part of the eye.

3. Peripheral field loss: This is the most complex area in relation to function and can be considered as disseminated or scattered field loss, hemianopia or half field loss and severely constricted field loss.
 * What structures of the vision pathway might be impacted?
 * What is the function of these structures?
 * Explain in terms of these functions the impact on sight.

Task 5 (Keywords: #impact of vision loss #psycho-social)

As an introduction to this task, have a look at the RNIB's website on Coming to Terms with Sight Loss. Next, listen to the two audio recordings of patients from See Well Australia who have vision impairment. They are describing the impact of the impairment on their lives. Make notes to help you answer the questions related to each recording.


 * Audio 1 - Three elderly ladies
 * Audio 2 - Lesley, a young woman with Stargardt disease

After you have listened to the recordings, work through these questions. Questions - Task 5 Meet Mrs Kirkman, Mrs Muirhead and Mrs Sevoir.

All are older women who have bilateral AMD that has progressed to the wet phase - all are legally blind. Mrs Kirkman is a widow who also has significant hearing loss, she wears hearing aids. Mrs Muirhead is also a widow she lives in a large rural city. Mrs Sevoir is married and living with her husband in metropolitan Melbourne. As you listen to their stories make notes on the following:
 * 1) How has sight loss impacted on the lives of the three women?
 * 2) Do any of them refer to their living situation?
 * 3) What are the emotions they express in relation to losing their sight?
 * 4) How has sight loss impacted on their social relationships?
 * 5) What are some of the strategies they are using to overcome the handicaps of sight loss?
 * 6) One has a very philosophical out look, describe this lady’s response.
 * 7) Is there a difference in response between the ladies and what seems to be making this difference?

Now meet Lesley a young woman in her 30’s. She is legally blind due to Stargardt Disease. Lesley lives alone in an inner Melbourne suburb. As you listen to Lesley’s story make notes about the following questions: Consider the differences in response and impact between Lesley and the older ladies. Discuss your answers with your group and try to provide answers to all of the above questions.
 * 1) How did Lesley first realize she was losing her sight?
 * 2) What was her initial response to sight loss?
 * 3) How did sight loss impact on Lesley’s working life?
 * 4) How did sight loss impact on Lesley’s personal life?
 * 5) What has been Lesley’s emotional response to sight loss and her perception of the thoughts of others?
 * 6) What are Lesley’s strategies for coping?
 * 7) What comments does Lesley make about the way people treat her?

Task 6 (Keywords: #psycho-social #impact)

This task utilises case studies and additional materials that will allow you to consider the impact of sight loss on social and emotional well-being.

First, watch the interview with Krister Inde Support needed when one loses his or her vision

Once you have watched Krister's movie, work through the questions below. Refer to Krister Inde's book See bad feel good.

Questions - Task 6

1. The following passage has been taken from Krister Inde’s book See Bad Feel Good, an autobiographical account of sight loss. Discuss the following statements and think about what they are telling you of Krister’s response to his diagnosis. "There are a lot of aids and devices that I’m sure you can make great use of. But as I said, there is, unfortunately, no medical treatment that we can offer you at this time.” Period. Nowhere to run. It’s a fact. You are locked in a room and there is no key to the nonexistent door. It comes as a shock: You are losing your sight and it is hell. A hell you have not chosen, for which you are not responsible, and that you hate so much that you avoid believing it’s true, avoid thinking about it and you suppress it entirely. It simply hasn’t happened!" 2. What are the phases a person goes through after losing sight as described by Krister Inde in his book See Good Feel Bad? 3. Discuss in your groups how you would feel if you lost your sight – prepare a brief group statement to share with the class summarising your thoughts. The RNIB has a good resource Coming to terms with sight loss that you can refer to.

Task 7 (Keywords: #multidisciplinary #teams)

Do some research on each of the following professions to determine the assistance they provide for a person with vision impairment.


 * Low Vision Therapist
 * Occupational Therapist
 * Orientation and Mobility Instructor
 * Physiotherapist
 * Social Worker
 * Special Education Teacher (Vision Impaired)

These two YouTube movies might also help: Low vision occupational therapy Orientation and mobility

Other resources & links

Statewide Vision Resource centre Who does what in vision care Better Health Channel - Orthoptists

Task 8 (Keywords: #case study)

In your group, work through the following case studies related to functional impact of sight loss & multi-disciplinary intervention, which require you to analyse information and then discuss the likely functional impact associated with each case. You will then determine the appropriate professionals to assist in the management of each patient.

Edith Wright is 70 years old. She has been diagnosed age-related macular degeneration (AMD). Visual Acuity: R)< 6/60 L) HM. Background information: When Ms Wright arrives she is a very forceful lady who is vocally decrying the lack of services and assistance available to her. You establish the following history: her left eye deteriorated some years ago, the right eye only began to deteriorate two months ago following the death of her sister with whom she lived. Her Ophthalmologist has told her she is blind and nothing further can be done. Ms Wright is a retired academic; she was particularly involved in women’s issues and was on a number of Government advisory bodies in this regard.

Questions:
 * 1) Consider the functions associated with the macula. Describe the functional difficulties Ms Wright might be experiencing justifying why you select
 * 2) these functions.
 * 3) What impact do you think this change in vision will have on Ms Wright’s well being? Discuss this response in both emotional and social terms
 * 4) Ms Wright is your patient. Select a multi disciplinary team to support her vision rehabilitation. Which professionals will you include and why?

A referral comes to you from the visiting teacher service, asking you to assess a 17 year old boy who has been recently diagnosed with Leber's optic atrophy. Mark presents as a mature and intelligent young man. The history is of a sudden onset, bilateral centre field loss. Visual Acuity: R & L <6/ 60 Field: Bilateral central scotoma, extending 15 degrees from the fovea. Background: Mark has just completed year 11, he hopes to do well in year 12 to enable him to study law at university. His parents are keen to encourage his studious ambitions and have promised him a car if he gains university entrance. He has promised to take his girlfriend to visit her family in Queensland when he gets his car. Mark presents as a very calm and self controlled young man.

Questions:
 * 1) What is the likely impact on visual function of Leber’s optic atrophy?
 * 2) What do you think the social impact of sight loss is for Mark?
 * 3) How has Mark responded to his sight loss? Is this what you would expect?
 * 4) Select an appropriate multi disciplinary team to work with Mark indicating what roles each team member will play.

Jack is a 17 year old boy who had acid thrown in his face in a classroom fight and has severe corneal scarring as a result. Jack's vision is reduced to 6/24 bilaterally. He is hoping to gain an apprenticeship in the building industry and has a prospective employer. Questions:
 * 1) Explain the impact on vision of corneal scaring and the impact this might have on Jack’s functional abilities.
 * 2) Discuss the range of issues that might be confronting Jack now.
 * 3) What might be the social implications for Jack?
 * 4) Consider an appropriate team to support Jack’s rehabilitation.

Whilst sitting in the staff room at See Well Australia eating lunch, you are approached by the Occupational Therapist (OT), she is particularly concerned about a patient who has lost all interest in the cookery class. She thinks his sight has deteriorated and would like you to assess him. Mr Gentle is a courteous and softly spoken 80 year old. Diagnosis; age-related macular degeneration. VA: R <6/60    L 6/36 Field: The right eye has extensive loss of the central field; the field loss in left eye at this stage is restricted to the foveal area.

Mr Gentle has been completely devastated by the sudden loss of vision in his left eye. He has given up any hope of retaining some independence and is prepared to rely on his wife totally. Mrs Gentle has always looked after the household and is prepared to do anything for her husband, but she has cataracts and her vision is now reduced to Visual Acuity R) 6/18 L) 6/ 12.

Questions:
 * 1) What might be the impact on the daily activities for both Mr and Mrs Gentle as a result of their respective sight loss?
 * 2) What might be the longer term implications for this couple? - consider social and emotional implications.
 * 3) What are the main issues for rehabilitation planning and which professional groups will assist with this?

Peter is a 23 year old university student who is studying accounting. Peter has significantly reduced visual fields due to retinitis pigmentosa (RP), he was first diagnosed with this disorder when he was 7 years old. Peter’s father also has RP. Visual Acuity R&L) 6/ 6, Near n5 Visual field in both eyes severely constricted to within only 8-10 degrees. Questions:
 * 1) Discuss the functions of the part of the retina impacted by RP.
 * 2) Discuss the impact of the loss of these functions on Peter’s daily activities.
 * 3) Discuss the social implications of RP for Peter.
 * 4) Who will be the most appropriate multi-disciplinary team members to support Peter’s rehabilitation program.

Margaret is a 50 year old type 2 diabetic. She has a demanding job and is inclined to miss lunch and buy take away for her evening meal. She currently takes tablets to control her diabetes which she often forgets when racing out in the morning. Her GP has warned that if she does not reduce her blood sugar she will be put on insulin.

Questions:
 * 1) What are the likely changes to vision that Margaret will experience if she cannot control her diabetes?
 * 2) Discuss the types of functional problems Margaret might have with the vision loss associated with diabetes.
 * 3) Discuss the social implications of sight loss for Margaret.
 * 4) Suggest an appropriate rehabilitation care team for Margaret.

Martin is a 45 year old business man who has suffered a stroke impacting his right temporal lobe. Martin is married with two teenage children. His distance vision is 6/6 R&L but you are unable to assess his near vision as he has trouble reading and he has a left hemianopia.

Questions:
 * 1) Discuss the range of functional issues that might be facing Martin now.
 * 2) Who will be the team members involved in Martin’s rehabilitation program?

Resources and help

 * Focus on Low Vision is an excellent publication by the Centre for Eye Research which will be useful to complete all the topics in this enquiry. You should refer to it often.