Role of ophthalmic nurses with visually

impaired patients
Willow Barton, BSN

In 7987, it was estimated that over 73 million people in the world

were visually impaired, and more than 27 to 35 million were classi-
fied as blind. Greater than 6 million visually impaired people live in
the United States. There are many causes of visual impairment,
including age-related macular degeneration, cataracts, glaucoma,
diabetic retinopathy, autoimmune deficiency syndrome, and trauma.
Some patients may be helped or visual loss delayed with surgery.
Many may have dramatic visual improvement with optical devices,
large-print publications, and improved lighting. The ophthalmic
nurse may assist in accurately assessing the patient’s vision and iden-
tifying his or her lifestyle and ability to function independently
Assisting the patient to overcome psychosocial and economic barriers
and helping to obtain assistance is critical to enable patients to func-
tion independently. Ophthalmic nurses may be instrumental in
increasing patients’ awareness of community resources and services
available to those who are visually impaired. (Insight 1998;23:5- 70)
Willow Barton is a staff
nurse in the Department
of Ophthalmology at the
n 1987, it was estimated that more casesof visual impairment and 43,000 cas- Veteran Administration
than 13 million people in the world es of legal blindness are the result of Puget Sound Health
cataracts.Becausethis is a treatable cause Care System in Seattle.
were visually impaired, and another She joined ASORN in
27 to 35 million were classified as of impairment, it is important to deter- 7 990.
blind.’ More than 6 million of these visual- mine the best way to provide cataract
ly impaired people live in the United surgery that is both cost-effectiveand safe. Reprint requests:
Most cataractsin adults are a result of the Willow Barton, BSN,
States.The generally accepteddefinition of
Staff Nurse, Department
a low vision patient is one with impaired aging processbut some may be causedby
of Ophthalmology, Vet-
vision as a result of reduced visual acuity intraocular trauma or surgery,chronic eran Administration
that cannot be corrected by conventional intraocular inflammation, and long-term Puget Sound Health
spectaclesor contact lenses,or reduced steroid use. Other factors that may affect Care System, 7 660 5.
visual ability becauseof a restricted visual cataract formation are diabetes,diet, sun Columbian Way, Seattle,
field. The generally accepteddefinition of exposure,smoking, and dehydration. WA 98108
a legally blind patient is one whose best Other major causesof low vision are Copyright 0 1998 by
corrected visual acuity is 20/200 or less in glaucoma, diabetic retinopathy (DR), auto- the American Society of
the better eye or a visual field of 20 degrees immune deficiency syndrome (AIDS), trau- Ophthalmic Registered
of less.2 ma, optic atrophy, degenerativemyopia, Nurses.
Cataractsaccount for more than 55,000 and retinitis pigmentosa. Two and a quar-
7 060- 735X/98 $5.00 + 0
casesof legally blind people in North ter million Americans over age40 have
America. In the United States,3.3 million glaucoma, with 80,000 of these people 72/l/83 942

INSlGtIT The Journal of the American Society of Ophthalmic Registered Nurses, Inc. Volume XXIII, No. 1, March 1998 5
 being bilaterally blind from glaucoma.’
Three characteristics requisite for the diag-
nosis of glaucoma are increasedintraocular
pressure,optic disc changes,and visual
field loss. Diagnostic criteria for glaucoma
include intraocular pressure,cup to disc
ratio, disc hemorrhage, and myopia. Risk
factors for developing glaucoma include
age, race, family history of glaucoma, dia-
betes and hypertension, with studies show-
ing increased incidence of glaucoma with
increasing ageof patient, and increased
prevalence in people of African ancestry.
DR is the leading caseof blindness
among Americans age20 to 74 years,with
the incidence of blindness 25 times more
common in personswith diabetes.’
Patients with insulin-dependent diabetes
mellitus (IDDM) are at an increasedrisk for
developing severeproliferative DR (PDR)
compared with those with non-insulin-
dependent diabetesmellitus (NIDDM).
However, because90% to 95% of persons
with diabetes in the United Stateshave
NIDDM, a greaterpercentageof casesof
PDR are causedby NIDDM. The duration
of the patient’s diabetes and his or her lev-
el of hyperglycemia are important risk fac-
tors to be considered for development of
DR.
AIDS is another causeof impaired vision
that affects 1 to 1.5 million personsin the
United States.’ Ocular lesions as a result of
AIDS include retinal microvascular disease,
opportunistic infections, ocular neoplasm,
and neuro-ophthalmologic abnormalities;
retinal microangiopathy is the most com-
mon ocular manifestation of AIDS.
Cytomegalovirus retinopathy is the most
common opportunistic infection causing
loss of vision, but other infections include
herpes zoster virus, toxoplasmosis, candidi-
asis,Pneumocystiscarinii, and syphilis. Ocu-
lar neoplasms associatedwith AIDS are
Kaposi’s sarcoma and lymphomas.
Patients with AIDS also may have neuro-
ophthalmic abnormalities causedby HIV
infection of the central nervous system,
such as HIV encephalopathy, opportunistic
infections, and intracranial neoplasm.
Visual changesmay include nystagmus,
gazepalsies,hemianopsia, papilledema,
and central nerve palsy.
6 Volume XXIII, No. 1, March 1998 INSIGHT The Journal of the American
More than 2.4 million injuries occur in
the United Statesevery year; 5% of all visu-
al impairments are due to trauma.’ Risk
factors for ocular trauma in adults include
age,sex, time of day, occupation, recre-
ational activities, motor vehicles, con-
sumer products, and behavioral patterns.
The increasing life span of individuals is
another important factor to consider.
Vision impairment is the third most fre-
quently reported chronic health problem
in people over age 65; more than 40% of
these people report difficulty in perform-
ing their usual activities. Approximately
30% of people over age85 years report
extreme difficulty accomplishing everyday
tasks.l One study shows that factors
including residing in a nursing home, old-
er age,glaucoma, IDDM, cataract, and low-
er income are significantly associatedwith
both functional blindness and visual
impairment.3 Visual acuity, contrast sensi-
tivity, color vision, depth perception, and
pattern recognition all decreasewith
increasing ageof a person. Some of these
gradual visual decreasesfrom normal aging
processescan be treated with refractive
correction and behavioral adjustments.
CAUSES
More than 75% of people seeking treat-
ment for low vision are over 65 years of
age,with macular degeneration accounting
for more than 50% of all cases.2Approxi-
mately 15 million people in the United
Statesare affected by age-relatedmacular
degeneration (AMD). The causeof AMD is
unknown, but some hypotheses are chron-
ic exposureof retina to ultraviolet light,
nutritional effects, and cardiovascular dis-
ease.Becausemany people may have had a
potentially treatable lesion, increasedfre-
quency of monitoring is imperative to
identify high-risk persons.
MANAGEMENT
Low vision may be classified into four
groups (Table I).
After classifying the degreeof visual
impairment, the ophthalmic nurse can
help determine which patients have vision
that can be improved with new lenses,
surgery,or use of magnifying devices.An
Society of Ophthalmic Registered Nurses, Inc.
 Table I. Four classifications
Problem Cause
Blurred vision Cornea1 disorders, lens opaci-
ties, or vitreous opacities
Impaired focal Macular edema
resolution
Central scotomas Atrophic and exudative AMD,
macular holes, or optic
nerve disease
Peripheral End-stage glaucoma, retinitis
scotomas pigmentosa, peripheral reti-
nal disease, and cerebral
vascular disease
accuratevisual assessmentis critical in
identifying treatable causesof low vision,
such as cataracts.The BeaverDam Eye
Study shows results that indicate education
and income are associatedwith cataract
formation, receipt of cataract surgery, and
incidence of impaired vision.4 Lesseduca-
tion and less income resulted in higher fre-
quency of cataracts.These findings may be
due to decreaseduse of health care
resourcesas a result of a lack of education
and decreasedincome, high-risk behaviors,
(i.e., heavy drinking and cigarette smok-
ing), exposureto noxious work, adverse
home environments, and poor nutrition.
To best plan for the management of
patients with low vision, the ophthalmic
nurse may be instrumental in obtaining a
history by documenting visual impair-
ment, length of duration of visual difficul-
ties, and rapidity of onset. The nurse may
then perform an examination, assistwith
selection of devices, and provide patient
instruction and follow-up.
Essential parts of the ocular examination
include careful refraction, determination
of the dominant eye, Amsler grid assess-
ment to locate central scotomas, Gold-
mann peripheral field test, contrast sensi-
tivity, glare testing, and color testing. This
testing helps to identify monocular and
binocular distortion, glaucoma, neurologic
deficits, predictability in difficulty in read-
ing print, need for cataract extraction or
keratoplasty, or difficulty in identifying
INSIGHT The Journal of the American Society of Ophthalmic
of low vision
Treatment
Modification of lighting, image con-
trast, contact lenses, pseudophakic
bullous keratoplasty, cataract
extraction, or YAC capsulotomy
Mechanical refraction or magnifying
glasses
Eccentric head positions, magnify
ing lenses, or long canes
Spectacles, telescopes, guide dogs,
or canes
color cues.Near vision testing is important
to establish reading skills with selected
optical devices.
Accurate refraction is the first step for
prescribing optical devices for distance and
near vision, becausethe spectaclecorrec-
tions produce sharp retinal images. A mag-
nified sharp retinal image is more clear and
legible than a magnified blurred image. In
one study assessingoptical treatment of vi-
sion in patients with diabetic retinopathy,
spectaclecorrection improved vision for
29% of patients, high-add bifocal magni-
fiers increasedvision for 30% of patients,
half-eye spectaclemagnifiers increasedvi-
sion for 45% of patients, and handheld
magnifiers increasedvision for 11% of pa-
tients. Overall, the study shows that multi-
ple optical devicesfor 63% of the patients
resulted in a successrate of 68%.5
It helps to understand which activities
are difficult for the patient to perform in
order to establish realistic expectations and
to guide in the counseling and education
of the patient’s capabilities and limita-
tions. The provider may then evaluate and
maximize the patient’s remaining vision
by prescribing lensesand other devicesand
providing instruction in techniques for
using remaining vision.
For low vision training to be effective, it
is important to consider the individual’s
level of function, visual objectives, and
available low vision devices.The best time
to start low vision training is when the
Registered Nurses, Inc. Volume XXIII, No. 1, March 1998 7
 patient has difficulty accomplishing every- tions, and clarify goals. Proper patient in-
day tasks. Early intervention allows time struction is the key to successin manage-
for the patient to adjust to new techniques ment of low vision patients. Studiesshow a
and devices. 90% successrate compared with a 50% suc-
The ophthalmic nurse should stressthe cessrate with prescription of lenseswith-
importance for the patient to bring all out instruction2 It is useful to loan optical
spectaclesand magnifiers to the initial eye devicesfor a 6-week trial becausethe rejec-
examination. One can then evaluate the tion rate may be close to 25%. Telephone
patient’s experiencewith devices, useful- follow-up is also helpful for patient suc-
nessof currently used devices, and cess,which is determined by the patient’s
patients’ objectives for additional devices, ability to achieve their visual objectives.
such as desirefor sharper distance vision, Support of family, spouse,and friends is
reading mail, books, magazines and news- very important in helping to incorporate
papers,playing cards and bingo, or reading devicesinto daily life activities.
music.
SPECIALTY PROGRAM
SELECTION OF DEVICES Many federal, state, and community agen-
The provider should select the type of low- cies servepeople with vision impairment.
vision device best suited to the task and The Department of Veterans Affairs (VA)
degreeof vision loss, after establishing the has establishedthe Blind Rehabilitation
dioptric range for the task objectives. There Service (BRS)whose goal is to provide a
are many types of optical devices including variety of servicesto legally blind veterans.
spectacles,hand-held magnifiers and stand Among these servicesare Visual Impair-
magnifiers, spectacletelescopes,clip-on ment ServicesTeams (VIST), Blind Rehabil-
telescopic loupes, and hand-held devices. itation Outpatient Specialists(BROS),and
Nonoptical devices include writing aids, Blind Rehabilitation Centers (BRC).The
large print publications, improved light- VIST is responsible for providing compre-
ing, yellow filters, reading stands, and
antireflective lenses.Electronic reading sys- hensive servicesto eligible blinded veter-
tems such as closed-circuit television read- ans at VA Medical Centers and Outpatient
Clinics. The VIST coordinator ensuresthe
ing machines and computers with large
print or speechcapability are useful to delivery of appropriate servicesto eligible
veterans. In 1996, Blind Rehabilitation Ser-
some patients. A variety of magnifiers are
frequently recommended to meet a vices implemented a new approach for
patient’s multiple needsat close, interme- delivering Blind Rehabilitation Services
diate, and distance ranges.It is best to rec- and started the BROS program. BROSare
ommend a trial of spectaclemagnifiers first multi-skilled professionals who provide
for some conditions and tasks becausethe outpatient rehabilitation servicesto veter-
field of vision is 2.5 times wider. This ans waiting to attend the residential BRC.
enablesthe patient to have both hands Their servicesare shown to reduce the
free and is best for prolonged close work. length of time veterans remain at BRCs.
Half-eye spectaclemagnifiers are useful The BROS are also able to provide services
where binocular vision can be obtained to veterans who may not be able to attend
with powers up to +14.00 diopters. They a BRC. BRCs provide comprehensive resi-
are light-weight, cosmetically acceptable, dential blind rehabilitation. Specialistsand
and the person can easily look over the support staff help patients identify realistic
top. Telescopic devicesare useful for dis- goals for achieving appropriate levels of
tant tasks such as reading street signs, and independence, aid in adjustment to sight
handheld magnifiers are helpful for shop- loss, and help in reorganization of their
ping, spot reading, and reading labels. lives, enabling them to return to their fam-
It is important to provide close supervi- ilies and communities.
sion during the initial instruction period, The BRCsprovide training 8 hours a day,
review proper use of devices, answer ques- Monday through Friday, by specially

8 Volume XXIII, No. 1, March 1998 biSlGHT The Journal of the American Society of Ophthalmic Registered Nurses, Inc.

trained blind rehabilitation specialists.
During the day, patients participate in one
to one instruction in five main skill areas;
Orientation and Mobility, Activities of Dai-
ly Living, Written Communications, Visual
Skills, and Manual Skills. In each skill area
the patient’s current level of functioning is
evaluated, realistic goals for the patient are
established, and training is provided to
achieve the goals.
Orientation and mobility teachesthe
principles of independent travel. Maxi-
mum use of residual vision as a travel aid is
evaluated. Low vision aids, such as monoc-
ulars, are incorporated into the training as
are the use of primary travel devices,such
as the long cane. Instruction is done in the
community using environments most like
the patient’s home area.At the completion
of instruction, the patient should be able
to travel in familiar and unfamiliar envi-
ronments with safety and confidence.
Activities of daily living teach the
patient to use various techniques, skills,
and aids to perform a wide variety of daily
tasks.Everyday tasks, such as making a cup
of coffee or planning and preparing meals,
are evaluated and then patient learning is
accomplished by repetitive performance of
those tasks.
Written communications is geared
toward providing patients with the ability
to record and retrieve written or spoken
communication. Braille, typing, handwrit-
ing, time telling, tape recording, record
keeping and use of other electronic devices
is taught.
Visual skills training, for those patients
having some functional residual vision,
includes a thorough low vision optometric
or ophthalmic examination, during which
special lensesand devices are prescribed in
an effort to maximize the patient’s remain-
ing vision. Low vision specialiststhen train
the patient in the use of the aids that will
enable him or her to perform near, inter-
mediate, and distance tasks.Educating the
patient about his or her diagnosis, progno-
sis, capabilities, and limitations is also an
integral,part of the visual skills class.
Manual skills training helps patients to
develop tactile perception, bimanual coor-
dination, and manual dexterity. It also is
II’iSlG)lT The Journal of the American Society of Ophthalmic
Barton
successfulin introducing or reintroducing
personsto avocational and leisure time in-
terests,including leather working, ceram-
ics, wood working, and home mechanics.
In addition to the BRS,severalother sup-
port staff play an integral role in the reha-
bilitation process.Individual and group
counseling provided by a psychologist or
staff social worker is available for each
patient in the blind rehabilitation program
to aid in the adjustment to the sight loss
process.Twenty-four-hour nursing care is
provided to meet any medical needsof the
patient. In addition, there is a strong nurs-
ing education component that assists
patients in understanding their medical
conditions and strives to assistthem in
gaining independence in dispensing med-
ications and in management of diabetes.
A family training program is another
important aspectof the blind rehabilita-
tion process.If appropriate, a family mem-
ber, care giver, or friend of the patient is
offered the opportunity to come to the
BRC at VA expense.The purpose is to help
the family become involved in the rehabil-
itation processand to better understand
the patient’s visual loss and how it affects
his or her ability to function indepen-
dently.
CONCLUSION
Accurate assessmentof vision-related per-
formance and consequencesof changesin
vision is essential.This is especially true for
the elderly becausevisual impairment may
significantly alter their lifestyle and com-
promise their ability to function indepen-
dently. Becauseof the increasein average
life span of the population, it is important
to consider quality of life issuesthat many
elderly define by their ability to function
independently. A primary concern to
many elderly is decreasedability to per-
form routine tasksessential to their every-
day living.
Many interventions may be done for per-
sons with low vision. It is essentialto accu-
rately assessthe problem for causesthat
can be remedied, such as cataracts,and as-
sist the patient in overcoming the psycho-
social and economic barriers to surgeryand
obtaining low cost optical correction. AMD
Registered Nurses, Inc. Volume XXIII, No. 1, March 1998 9
 is another significant causeof functional
visual loss interfering with reading and
driving. Becausethe causesof AMD are un-
known, it is difficult to prevent its occur-
rence. However, controlling cardiovascular
disease,preventing damage from ultra-
violet light, and maintaining good nutri-
tion may help to delay vision loss.
A patient’s mental and emotional health
and social support may also affect his or
her visual impairment and functional dis-
ability. Better vision may have dramatic
effects on both individual functioning and
psychological well-being. Proper instruc-
tion and use of spectaclemagnifiers is
essential for patient success.Low vision
aids enable people to maintain employ-
ment and lead to improved quality of life
and independence. The impact of
decreasedvision affects everyday abilities,
such as dressing, eating, writing, reading,
mobility, social interaction and recreation-
al pursuits. Significant loss of vision may
causeearly retirement and loss of income,
adding increasedstressdue to decreased
self-esteemand questionable future.
Ophthalmic nursesmay be instrumental
in increasing awarenessof community
resourcesand informing patients of free
servicesavailable to visually impaired,
such as talking books, large-type books and
magazinesat the library, home services
through state agencies,directory assistance
from the telephone company, tax deduc-
tion for legally blind, and support groups.
As the causeof blindness is individualized,
the care and treatment also must be indi-
vidualized with consideration of the
patient’s physical and medical condition,
age,learning ability, and overall needsand
lifestyle.
I thank Ellen Martin, MA, Coordinator for Visual
Impairment Services Team, for her contributions
to this article.
REFERENCES
1. Albert D, Jalobiec F. Principles and practice of oph-
thalmology basic sciences. Philadelphia: WB Saun-
ders Co.; 1994. p. 1249-321.
2. Faye E. Low vision. In: Vaughan D, Asbury T,
Riordan-Eva P, editors. General ophthalmology.
14th ed. East Norwalk (CT): Appleton STLange;
1995. p. 388-95.
3. Salive M, Guralnik J, Christan W, Glynn R, Colsher
P, Ostfeld A. Functional blindness and visual im-
pairment in older adults from three communities.
Ophthalmology 1992;99:1840-7.
4. Klein R, Klein B, Jensen SC, Moss SE, Cruickshanks
KJ. The relation of socioeconomic factors to age-
related cataract, maculopathy and impaired vision
(the Beaver Dam Eye Study). Ophthalmology
1994;101:1969-79.
5. Fonda GE. Optical treatment of residual vision in
diabetic retinopathy. Ophthalmology
1994;101:84-8.

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10 Volume XXIII, No. 1, March 1998 biSlGHT The Journal of the American Society of Ophthalmic Registered Nurses, Inc.