Research and Treatment Advances in Low Vision Therapy

Patients with low vision are in excellent hands at the Vision Institute at UPMC Mercy Pavilion. William Smith, OD, and Holly Stants, MS, OTR/L, SCLV, CLVT, provided information on low vision, current treatment options, and advances in research and potential future treatments in the Eye & Ear Foundation’s August 25^th webinar, “Research and Treatment Advances in Low Vision Therapy.”

The Vision Institute

Dr. Smith, Assistant Professor in the Department of Ophthalmology at UPMC and Director of the Low Vision Service, described the new Vision Institute, which includes Low Vision Rehabilitation, a Low Vision Rehabilitation Garden, and a Low Vision Rehabilitation Life Skills Apartment. The Low Vision division has three exam rooms, three fully equipped exam lanes, and a number of rehabilitation rooms. The art depicts patients that have participated in low vision rehabilitation, with a QR code that allows visitors to hear them describe their experiences.

The Garden has landing strips of gravel, turf, brick, and pavement, along with stairs. This way the team can look at people’s mobility and make recommendations to help them maneuver about more safely. Lighting and contrast assessments are also conducted outside, in the natural environment of the sensory garden. Plants are tactile and fragrant. The Western Pennsylvania School for Blind Children is helping with the garden. A sculpture made by a visually impaired artist is also in the garden.

The Life Skills Apartment is a fully functional apartment with multiple stoves and microwaves. It has a refrigerator, a full functioning washer and dryer, a living space with a television, a bedroom, and a bathroom with a shower and tub.

The Low Vision team provides rehabilitation and compensatory strategies on how to integrate low vision devices into someone’s daily activities within their home environment in an environment similar to patients’ homes. This way, they make sure what they are doing in the clinic works in patients’ homes and that people feel safe, comfortable, and independent within their home environment.

“These have been tremendous additions to the low vision program,” Dr. Smith said.

Studies

The Iris Vision Study is a functional visual assessment with the Iris Vision Low Vision Device. It helps people with facial recognition, check writing, and medication management. Dexterity is also worked on via a nine-hole peg test in conjunction with the Human Balance and Movement Lab at Pitt.

The inclusion criteria for this study are as follows:

• Central visual acuity loss
• Ages 18-80
• No previous experience with head mounted electronic magnification systems
• VA from 20/200 to poorer
• Intact Peripheral VF

Patients must have a visual acuity of 20/200 or worse with intact or without deficits in their peripheral vision. It involves a digital head mounted system virtual reality headset that uses a smartphone to provide magnification, changes in contrast, color changes, and some speech-controlled commands.

The Prima Study is a subretinal implant powered by IR light. The goal is to elicit functional artificial vision in the form of light perception replacing the damaged retinal tissues. It is done in patients with dry macular degeneration, implanted outside of the area that is still functional. A special type of glasses or goggles is used. “It is a nice advance in moving forward to try to restore some vision,” Dr. Smith said.

The PIONEER Study involves intraocular injection combining gene therapy and optogenetics. It uses gene encoding for light-sensitive protein into the ganglion cells, making them responsive to light and bypassing the damaged retinal layers. This study is working with patients that have minimal vision to be able to help them detect objects, doorways, and even letters and words to function in their daily activities.

The PRODYGY Study determines the rod-derived cone viability factor via subretinal injection. Participants must have retinitis pigmentosa due to RHO, PDE6A or PDE6B, and be at least 18 years old.

“Within the low vision program, we provide access to genetic counselors that can do genetic testing to help identify genes,” Dr. Smith added.

The Uni-Rare Study is a universal natural history study for patients with retinal dystrophy due to 350+ rare genes. It is open to people above four years of age.

Ocular Conditions

Dr. Smith described the basic anatomy of the eye and explained that any issues with any of its structures can cause loss of vision or an impairment. The risk for vision loss increases substantially with age. Causes include:

• Cataracts
• Glaucoma
• Macular
• Diabetic retinopathy
• Genetic causes (albinism, retinitis pigmentosa)
• Stroke
• Trauma
• Nutritional/vitamin deficiency

Definitions

A visual impairment or low vision means a reduction in vision that cannot be corrected with standard glasses, contact lenses, medications, or surgical interventions. It reduces a person’s ability to function at certain or all tasks. It includes the inability to see images clearly and distinctly, loss of the visual field, inability to detect small changes in brightness, color blindness, and a sensitivity to light.

Low Vision Evaluation

In a low vision evaluation, goals are defined, visual function is measured and compared to functional visual performance. It also includes an evaluation and recommendation of devices/rehabilitation to meet visual needs and goals. Visual function is measured via reading charts and specialized color vision testing.

Rehabilitation/Treatment Options

When it comes to distance, there are two categories: spot and sustained. Spot is the ability to read bus numbers, signs, and a chalkboard. Devices to help with this are a monocular HHTS, binoculars, and a bioptic spectacle mounted telescope. Sustained relates to TV and movies and long-term viewing of distance detailed targets. A full-field spectacle mounted telescope, binoculars, and IrisVision can help with this kind of vision loss.

Driving

Thanks to House Bill #2296, bioptic driving has been approved in the state of PA. The requirements to obtain a permit are as follows:

• An individual with VA less than 20/100 combined BA but at least 20/200 VA in the best corrected eye
  • Color vision sufficient to respond correctly to traffic signals
  • Proof of having a prescription bioptic telescope lens system
  • Provide a letter of enrollment with Low Vision Rehabilitation Professional

The bioptic telescope power cannot exceed 6 x and must be fixed into spectacles. This is for daylight driving only. Once a permit is obtained, 20 hours of behind the wheel driver’s training is required. A minimum of 45 hours of observed driving hours with a licensed driver who is at least 21 years old is a must. Once this is completed, the driver will be re-evaluated by a low-vision rehabilitation professional and then recommended for an on-road examination.

Once the driver passes the exam, there are still restrictions:

• No freeway driving
• Vehicles weighing no more than 10,000 pounds and excludes motorcycles
• Daylight only if VA through telescope is less than 20/50
• Nighttime driving application can be made after one year on road with a VA of 20/40 or better through the telescope
• Professional may limit driving to a limited radius of a person’s residence

Additional Devices

For seeing things nearby, like price tags, labels, and menus, HHM, IHHM, and ISM devices help. For sustained distance vision, like newsprint, books, and magazines, a microscope/loupe, ISM, and CCTV/electronic magnification can help. Intermediate tasks, like computer, crafts, home repair, and writing, can utilize loupes, technology, computer software programs, and non-opticals/lighting/contrast/glare control.

Rehabilitation

The next presenter was Holly Stants, who holds a dual certification: the American Occupational Therapy (AOTA) Specialty Certification in Low Vision SCLV and Academy for Certification of Vision Rehabilitation & Education Professionals (ACVREP) board certified low vision therapist CLVT (less than 500 worldwide). She is the UPMC Rehabilitation Institute Low Vision Team Leader who works at the UPMC Vision Institute.

One device used is the Dynavision D2, which is a big square approximately 3×5 feet with five circles of LED-type lighting with four quadrants that Stants can program. She can select a special quadrant to have the light come on and stay for as little as half a second or as long as ten minutes. Patients are told to look in the direction of the light. Their progress can be recorded, and the team can see how training is helping them become faster and more aware of the environment. There are lots of ways to use this to implement strategies and it is very useful.

A patient can work on the device and then go to the Life Skills Apartment and look for things in the kitchen to see if they can scan a bit faster to find the item. The purpose is to give them more opportunities to learn about scanning patterns and engage in a functional task. It can be used sitting or standing. People enjoy it and it becomes very competitive, Stants said.

The BITS device is another great device that is used as a functional scanning capacity. There are different programs, like the Bell’s cancellation test, where patients have to find a certain number of bells in a certain pattern of scanning. Vision and memory tasks can also be integrated to promote additional scanning.

Technology

Every few months, operating systems are updating, and people’s use of technology is more frequent. Smartphones can help with the following:

• Functional Communication: Voice calls, text, email and video, reminders
• GPS and Way Finding
• Financial, medical, health self-management
• Text to speech
• Leisure: web search, social media, and entertainment
• Increases success with ADL/IADL, reduces caregiver burden

Stants always asks patients if they have access to this technology because then she can show them something they can take home, like the camera function, magnifier, or Speak Screen on iOS. Amazon Echo is a device to have on the counter. You can ask it, “What do I have in front of me?” It will tell you what it is looking at, whether it is a food product or a medication bottle. There is even a stove that can be voice activated and used with phone apps.

Apps: Seeing AI

This app has nine different channels:

• OCR: optical character recognition
• Free and available on IOS only
• Reads short text, document, handwriting
• Describes scene
• Describes person
• Currency reader
• Color identification
• Lighting identification

“Oftentimes in our society, the biggest thing is not being able to see faces and recognize people,” Stants said. “It is really important to have access to that.”

Free Apps

An Optical Character Recognition system (OCR) reader that is free is Prizmo Go. Orientation apps that are free include Talking Compass, Lazarillo, Nearby Explorer, Soundscape, and Google Maps.

OT Low Vision Interventions

A Zoom text computer magnifier and reader that can be magnified up to 30 or 40 x is helpful.

Computer Software

Things are moving fast in the technology world when it comes to computers, Stants said. A lot of computers now have built-in features that do not need an additional program added.

Some helpful computer software:

• www.zoomtext.com/download-zoomtext-free-trial
• https://yourdolphin.com/product/try?id=5
• www.freedomscientific.com/downloads/jaws

iOS Accessibility and iOS Resource App

AppleVis is like a blog that gives people a lot of information about updates and technology for people with vision loss.

Windows Accessibility

If you type “ease of access” into the Windows search bar on your computer, you will access different tools for your vision. One example is Immersive Reader. It works in Word or PowerPoint and will read to you as well as figure out the best spacing for words, size, and contrast.

“These are all things that I would share with people if they come to see Dr. Smith and myself for the rehab,” Stants said. “There are other things on the horizon. There is an app called Look that helps people start to read better. It has the ability to put print on the screen, comes across the computer screen, and can be read at your pace.”

OT Low Vision Evaluation

An evaluation will include:

• Oculomotor/Visual field
• Visual attention
• Reading: critical print size, writing
• Contrast sensitivity
• Depth perception
• Functional mobility/fall prevention
• Technology
• ADL/IADL
• PHQ-9: Revised self-report assessment of functional visual performance (R-SRAFVP)

Lighting

The LuxIQ is a machine put over text with the ability to identify best lighting using a slide side to determine the temperature of the light (and color Kelvin); it also determines Lux, which is the brightness. The team can then identify the lumens needed for best lighting. This information is provided so patients can purchase light bulbs.

Glare control and contrast enhancement goals are defined in an evaluation as well. One of the things that becomes challenging for people when they have vision changes is the ability to go from different types of lighting. Contrast enhancement strategies include mobility safety and daily tasks. Take drinking and pouring coffee; there is a little device in the coffee mug that beeps so you know how much liquid is needed. Environmental challenges are assessed.

Auditory

Text-to-speech like the orCam MyEye 2 is another helpful device. It is magnetic and applies to the side of glasses. The wearer taps and points to whatever they are looking at, and the material is read to them.

Rehab

Rehab is a multi-layered process:

• Key components for success
• Eccentric viewing
• Integration of devices into daily living situations and environments
• Mobility
• Safety
• Independence

“We are always bringing patients into the process,” Stants said. She uses a patient specific functional scale by asking patients what the most important thing to them is, and how they can get to that point. That helps guide the intervention. “We want patients to know it’s patient centered and that we are looking at everything we can do to help them,” Stants said. “It is very important to have that success and to encourage that success to keep going.”

“We bring the hope in this Department,” she added. “With the new technologies and different rehab strategies we’re involved in, we believe that we’re giving the person the best experience that they can possibly have in this area.”