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Purpose: Visual impairment-related disabilities have become increasingly pervasive. Current reports estimate a total of 36 million persons with blindness and 217 million persons with moderate to severe visual impairment worldwide. Assistive technologies (AT), including text-to-speech software, navigational/spatial guides, and object recognition tools have the capacity to improve the lives of people with blindness and low vision. However, access to such AT is constrained by high costs and implementation barriers. More recently, expansive growth in mobile computing has enabled many technologies to be translated into mobile applications. As a result, a marketplace of accessibility apps has become available, yet no framework exists to facilitate navigation of this voluminous space., Materials and Methods: We developed the BLV (Blind and Low Vision) App Arcade: a fun, engaging, and searchable curated repository of app AT broken down into 11 categories spanning a wide variety of themes from entertainment to navigation. Additionally, a standardized evaluation metric was formalized to assess each app in five key dimensions: reputability, privacy, data sharing, effectiveness, and ease of use/accessibility. In this paper, we describe the methodological approaches, considerations, and metrics used to find, store and score mobile applications., Conclusion: The development of a comprehensive and standardized database of apps with a scoring rubric has the potential to increase access to reputable tools for the visually impaired community, especially for those in low- and middle-income demographics, who may have access to mobile devices but otherwise have limited access to more expensive technologies or services.

Purpose: To examine the use and underuse of mobility aids in individuals with visual impairment., Methods: A telephone survey including a probability sample of 736 adults who were members of the Norwegian Association of the Blind and Sighted (response rate: 61%). The interviews took place between January and May 2017, collecting information about access, use, underuse and training in five types of mobility aids (white cane, guide dog, GPS, door-to-door transport and sighted guide). For each mobility aid, we obtained data for underuse defined as non-use despite expecting benefits of use in terms of increased mobility or safety. Participants also answered questions about loneliness (Three-Item Loneliness Scale) and life satisfaction (Cantril's Ladder of Life Satisfaction)., Results: Of the participants, 69% reported using at least one type of mobility aid. Use of specific aids ranged from 12% for the GPS to 52% for door-to-door transport. Estimates of underuse ranged between 14% for door-to-door transport and 28% for GPS. Underuse was not related to lack of resources, as many non-users expecting benefits had access to mobility aids and had undergone training in its use. For example, 81% of non-users of the white cane had access to a cane. In post hoc analyses, non-users who expected benefits from use had lower life satisfaction compared with users., Conclusions: Many individuals with visual impairment do not use mobility aids. Strategies that help visually impaired individuals overcome barriers to the use of mobility aids may improve their sense of safety, mobility and quality of life.Implications of rehabilitationThe best mobility aids are those being used. Rehabilitation professionals involved in the provision of mobility aids should be sensitive to the user's lived experiences, and be alert of the cultural meanings of mobility aids and on disability in general.Rehabilitation professionals, social service workers and others need more knowledge of the psychosocial and cultural aspects related to why people do not use their mobility aids.A successful integration of mobility aids in people's daily life cannot be achieved by sufficient accessibility alone. Structured routines for follow-up of those who receive aids should be implemented, so that the aids are actually used.Due to the high rates of underuse and its possible relation to quality of life, promoting regular use of mobility aids should be prioritized.

As the efficacy of low vision service provision is facilitated by clients' access to and proper use of low vision devices, the objective of this study was to evaluate an outpatient clinic-based low vision device lending library program and the functional and psychosocial impact that device use had upon clients. Twenty individuals borrowed portable video magnifiers during the study period. Line items from the Revised-Self-Report Assessment of Functional Visual Performance and the Reading Behavior Inventory were analyzed before and after device loan at two months. The Psychosocial Impact of Assistive Devices Scale-10 and a semi-structured interview were also completed at two months. Reported improvements in reading performance and satisfaction levels on the Reading Behavior Inventory were significant (p<.001). The Revised-Self-Report Assessment of Functional Visual Performance indicated improved independence in reading medications, bills and labels. Higher scores in happiness, independence, sense of control and adaptability on the Psychosocial Impact of Assistive Devices Scale-10 indicated device retention at two months. Qualitative themes included improved independence, time needed to acclimate to the device, personal appraisal impacting motivation and challenges specific to low vision. This article provides occupational therapists a model to facilitate access, person-device fit and successful use of low vision devices to promote therapy outcomes.

Purpose: To evaluate the efficacy of visual rehabilitation with microperimeter biofeedback in patients with central scotoma., Materials and Methods: 35 consecutive patients with central scotoma (17 age-related macular degeneration (AMD), 14 Stargardt disease, and 4 cone dystrophy) were included in the study. Visual acuity, reading performance by Minnesota Low Vision Reading Test (MNREAD), quality of life by 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25), and fixation analysis by MAIA microperimeter were evaluated before and 1 month after training. The rehabilitation program consisted of 10 training sessions of 10 minutes., Results: The median best-corrected visual acuity (BCVA) was 0.80 logMAR (range 0.3 to 1.3 logMAR). Fifty-nine percent of patients with AMD developed a preferred retinal locus (PRL) nasal to the fovea, and 64% of the patients with Stargardt disease preferred a PRL superior to the fovea. The PRL location in 3 of 4 cone dystrophy patients was nasal to the fovea. The mean PRL distance from the fovea was 7.57 ± 3.61 degrees. Fixation stability improved with P1 values of 22.34 ± 11.81 versus 32.05 ± 18.79 ( p = .003) and 95% bivariate contour ellipse area (BCEA) values of 41.6 versus 23.6 ( p = .018) before and after training, respectively. There was a significant difference in reading acuity between before and after training ( p = 0.008). The overall score and near activities score of NEI VFQ-25 were found to be increased at the end of the rehabilitation ( p < 0.001)., Conclusion: Rehabilitation with acoustic biofeedback in patients with central scotoma looks like a useful technique for improving fixation stability, reading performance and quality of life.

Purpose: To estimate the number of patients accessing eye care with low vision (LV) at a large multi-site ophthalmology institute who utilize low vision rehabilitation (LVR) services and compare their characteristics to individuals who do not utilize LVR services., Methods: This is an electronic health record-based retrospective chart analysis. Patients with LV were identified as having at least one encounter in 2014 where the best visual acuity (VA) in the better-seeing eye was worse than 20/40. Utilization of LVR services across 9 clinic locations was evaluated. Logistic regression analyses were used to examine patient characteristics associated with service utilization., Results: Of the 7,752 LV patients, 1,585 (20%) utilized LVR services over the 17-month period. Those utilizing LVR were more likely to have VA between 20/60 and 20/200 or between 20/200 and 20/500 than non-users ( P < .001). The highest LVR utilization rates were in patients evaluated in retina (23%), glaucoma (22%), and neuro-ophthalmology (18%) subspecialties. Patients seen at clinic locations with onsite LVR services available were more likely to utilize services (odds ratio [OR] ranged from 2.69 [95% confidence interval, 95% CI: 1.63-4.44] to 4.94 [95% CI: 2.12-11.48] across location categories), as were patients who had evidence of fluctuations in VA measurements (OR = 3.33, 95% CI: 2.89-3.84)., Conclusions: Patients are more likely to utilize services when VA is moderately to severely impaired, VA fluctuations are present, or when LVR services are provided at the same location where other ophthalmic services are obtained. These estimates are important for developing interventions aimed at improving LVR utilization.

Purpose: To evaluate the effectiveness of Visual Evoked Potential (VEP) biofeedback rehabilitation in selected low vision patients with advanced age-related macular degeneration (AMD)., Design: Retrospective observational cohort study., Methods: Patients affected by advanced AMD, central macular atrophy with unstable fixation and best corrected visual acuity (BCVA) between 20/100 and 20/320 were considered. Selected patients underwent fundus photography and microperimetry with fixation analysis for the selected eye (highest BCVA). Ten consecutive training sessions of 10 min each were performed twice a week in the selected eye with Retimax Vision Trainer (CSO, Florence). BCVA, reading acuity and reading speed, contrast sensitivity, fixation, retinal sensitivity and quality of life questionnaire (VFQ-25) were evaluated at baseline and 7 days following the final session., Results: Significant improvements in terms of BCVA [ p = .011], reading speed [ p = .007], VFQ-25 score [ p = .007], retinal sensitivity [ p = .021] and fixation stability in the central 2° and 4° [ p = .048; p = .037] post-treatment were observed for the 9 patients enrolled, with insignificant improvements observed in reading acuity and contrast sensitivity [ p = .335; p = .291]., Conclusions: Preliminary results support VEP biofeedback rehabilitation improvements for visual function and quality of life in advanced AMD patients with low vision.

Purpose: Patients with visual impairment are constantly facing challenges to achieve an independent and productive life, which depends upon both a good visual discrimination and search capacities. Given that visual search is a critical skill for several daily tasks and could be used as an index of the overall visual function, we investigated the relationship between vision impairment and visual search performance., Methods: A comprehensive search was undertaken using electronic PubMed, EMBASE, LILACS, and Cochrane databases from January 1980 to December 2016, applying the following terms: "visual search", "visual search performance", "visual impairment", "visual exploration", "visual field", "hemianopia", "search time", "vision lost", "visual loss", and "low vision". Two hundred seventy six studies from 12,059 electronic database files were selected, and 40 of them were included in this review., Results: Studies included participants of all ages, both sexes, and the sample sizes ranged from 5 to 199 participants. Visual impairment was associated with worse visual search performance in several ophthalmologic conditions, which were either artificially induced, or related to specific eye and neurological diseases., Conclusions: This systematic review details all the described circumstances interfering with visual search tasks, highlights the need for developing technical standards, and outlines patterns for diagnosis and therapy using visual search capabilities.

Purpose: To understand the source of between-person variance in baseline health utilities estimated from EuroQol 5-dimension questionnaire (EQ-5D) responses of a representative sample of the US low vision outpatient population prior to rehabilitation., Methods: A prospective, observational study of 779 new low vision patients at 28 clinic centers in the US. The EQ-5D, Activity Inventory (AI), Telephone Interview for Cognitive Status (TICS), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) physical functioning component, and Geriatric Depression Scale (GDS) were administered by telephone interview prior to rehabilitation. EQ-5D responses were transformed into health utilities, which served as the dependent variable in all analyses. Data were then analyzed to determine how much overall visual ability, functional domains of visual ability, and comorbidities (e.g. physical functioning, depression, cognition) independently contribute to the EQ-5D-based health utility index., Results: Multivariable regression analyses showed that the GDS and SF-36 physical account for nearly 40% of the variance observed in health utilities estimated from EQ-5D responses of low vision patients. Age was also a significant predictor of health utilities, but accounted for very little variance. None of the other variables were significant predictors., Conclusions: Health utilities of low vision patients estimated from the EQ-5D primarily are associated with comorbid factors that are not likely to be responsive to low vision rehabilitation, thereby rendering the EQ-5D an unsuitable outcome measure for this population. However, because the EQ-5D is responsive to comorbid states, it could be a useful tool for evaluating the impact of comorbidities on low vision patient quality of life.

Purpose: The iPad and iPhone have a number of low-vision accessibility features including Siri Voice Assistant, Large Text, Zoom Magnification, Invert Colors, Voice Over, and Speech Selection. We studied their usage within a low-vision population., Methods: Patients were recruited to participate in an IRB-approved survey regarding their usage of the iPad and/or iPhone. Participants met one of the following criteria: best corrected visual acuity (BCVA) of 20/60 or worse, or significant peripheral visual field defects., Results: Thirty-three low-vision patients agreed to participate (mean age 54.3 years). There were 18 different diagnoses represented and the average visual acuity of respondents was 20/119 in the right eye and 20/133 in the left eye. The most commonly used vision accessibility features were Zoom Magnification and Large Text., Conclusions: Although many patients are using the low-vision accessibility features, few are receiving training or recommendations from their eye care specialist.

Purpose: We surveyed bioptic and non-bioptic low-vision drivers in Illinois, USA, to determine their usage of global positioning system (GPS) devices., Methods: Low-vision patients completed an IRB-approved phone survey regarding driving demographics and usage of GPS while driving. Participants were required to be active drivers with an Illinois driver's license, and met one of the following criteria: best-corrected visual acuity (BCVA) less than or equal to 20/40, central or significant peripheral visual field defects, or a combination of both., Results: Of 27 low-vision drivers, 10 (37%) used GPS while driving. The average age for GPS users was 54.3 and for non-users was 77.6. All 10 drivers who used GPS while driving reported increased comfort or safety level., Conclusions: Since non-GPS users were significantly older than GPS users, it is likely that older participants would benefit from GPS technology training from their low-vision eye care professionals.

Purpose: To identify the referral pattern and identify causes of missed referrals to low-vision services in a tertiary eye care center., Methods: A retrospective review of all the hospital records of patients seen from September-December 2012 was done to identify patients with visual impairment. Low vision was defined as has a best-corrected visual acuity (BCVA) in the better eye of <20/60 to light perception (as per WHO definition); or a visual field of <20° from the point of fixation. The frequency of referrals in this database was used to identify referral patterns of physicians and also causes for missed referrals for these patients., Results: Of 14,938 hospital medical records reviewed during the period, 499 patients missed low-vision services with a mean age of 46 ± 18.2 years, including 158 females. Among those missed, 12.07% were in the age group 0-15 years, while 30.9% of the patients were >60 years, with 157 requiring rehabilitative services and training. Causes for missed referrals were clear misses or non-referrals by the physician (39%), non-acceptance of services by the patient (53%), loss from appointment desks (4.5%), and loss to follow-up (3.5%)., Conclusion: Missed referral to low-vision services in tertiary centers can be considerable; these need to be identified for optimal utilization and delivery of these services to patients with low vision.

Purpose: To determine how people attending outreach eye care clinics in Papua New Guinea (PNG) perceive eye health and eye health services., Methods: An interview-based questionnaire was administrated to a convenience sample of 614 adult participants across four provinces and perceptions of eye health and eye health services were recorded. Presenting and near visual acuity were measured and cause of visual impairment (VI) determined., Results: In this sample, 113/614 participants (18.4%) presented with distance VI, 16 (2.6%) with distance blindness, and 221 (47.6%) with near VI. Older participants and those with near VI were more likely to indicate that it is hard to have an eye examination due to travel time, lack of transport and transport costs. Female participants and those from underserved areas were more likely to report shame and fear of jealousy from others when asked about their attitudes towards spectacles. Participants reporting that they were willing to pay higher amounts for testing and spectacles/treatment also reported higher education levels, higher household incomes and were more likely to be male. A quarter of participants (25.9%) indicated that they did not like having an eye examination because their reading and writing was poor., Conclusions: People attending outreach eye care clinics in PNG reported finding it difficult to attend eye health services due to transport difficulties and anticipated high costs. Negative attitudes towards spectacles were also prevalent, and negative perceptions appeared more frequently among older participants and those with less education.

Purpose: To examine gender, ethnic, and socioeconomic differences in access to eye care services in marine fishing communities in Karachi, Pakistan., Methods: The Karachi Marine Fishing Communities Eye and General Health Survey was a door-to-door, cross-sectional survey conducted between March 2009 and April 2010 in fishing communities in Keamari, Karachi, located on the coast of the Arabian Sea. Adults aged ≥50 years living on three islands and in four coastal areas were enrolled. Participants underwent a detailed interview regarding sociodemographics, eye problems and eye care service use, testing of presenting and best-corrected visual acuity with a reduced logMAR chart, and detailed eye examination., Results: A total of 700 people were planned to be included in the study; 638 (91.1%) were interviewed and examined. Most participants were extremely poor and had no formal education. Only 45.3% (95% confidence interval, CI, 41.4-49.2%) of participants reported having had an eye examination in the past; 12.1% (95% CI 9.5-14.6%) and 30.9% (95% CI 27.3-34.5%) had seen an eye doctor within the last year or prior 5 years, respectively. In the multivariable analysis, ethnicity was the strongest independent predictor of eye care service use, followed by self-reported eye problems and diabetes. Ethnic Bengalis were 4.2 times less likely (adjusted odds ratio 0.24, 95% CI 0.15-0.38; p < 0.001) to have had an eye examination in the past than Kutchis., Conclusions: Despite a high prevalence of visual impairment and blindness, levels of eye care examinations in fishing communities, especially among ethnic Bengalis, are disappointingly low. Such communities deserve particular attention in Vision 2020 and other national and international strategies and plans.

Purpose: To evaluate the quality and efficacy of the Ban Phaeo Mobile Eye Clinic (BPMEC) model in providing cataract surgery to rural Thailand., Methods: Retrospective review of 4-week postoperative visual acuity (VA) of 7040 patients receiving unilateral cataract surgery at 75 sites from October 2008 to March 2011. BPMEC conducted screening, surgery, and follow-up at partnering local hospitals that otherwise do not offer eye care. The primary outcome was achievement of VA ≥20/70, which was secondarily analyzed by cataract extraction method (phacoemulsification, phaco, or extracapsular cataract extraction, ECCE) and intraocular lens (IOL) type (foldable acrylic or rigid polymethylmethacrylate)., Results: Preoperatively, 249 eyes (4%) had uncorrected VA ≥20/70. Four weeks postoperatively, 5957 (85%) had VA ≥20/70, 3288 (47%) had VA ≥20/40, and 69 (1%) were lost to follow-up. Phaco was performed in 6324 eyes (90%), 1581 (25%) receiving foldable IOLs. A total of 1403 eyes (89%) undergoing phaco with a foldable IOL had postoperative VA ≥20/70, compared to 4058 (85%) and 496 (69%) of those undergoing phaco with a rigid IOL (p < 0.05) and ECCE with a rigid IOL (p < 0.001), respectively. Overall, 37 eyes were left aphakic. Reported intraocular complications included zonular dehiscence (37 eyes), retained lens fragment (2 eyes), wound leakage (1 eye), and posterior capsule tear (1 eye)., Conclusions: The 4-week uncorrected postoperative VAs met the World Health Organization's quality target of VA ≥20/70 for eyes undergoing phaco and were comparable to those published by an urban hospital in Bangkok.

This study evaluated changes in occupational therapists' practice behaviors after completion of an online continuing education (CE) program delivered over a hospital Intranet system. The setting was a large rural medical system covering parts of two southeastern states. A convenience sample of 28 occupational therapists and occupational therapy assistants was recruited from the facility therapy staff. A CE module on low vision assessment and treatment was delivered using the hospital Intranet and a follow-up survey assessing practice change was carried out 8 weeks later. Most participants reported an increase in their comfort level when treating clients with low vision after course completion. Fifty percent of participants reported screening for vision impairments, increased use of environmental modifications, and more referrals to other vision specialists. Outcomes suggest that Internet-delivered CE programs can improve knowledge and affect practice.

Purpose: This paper reports on research aimed at advancing understanding haptic capability and needs of users with low vision. The objective is to apply this understanding to the design of haptic-incorporated user interfaces., Method: Study 1 investigated the haptic perception between sighted participants and those with low vision through the magnitude estimation technique, and Study 2 explored the degree to which similar user interface needs were observed among the two vision groups., Results: Overall, our findings indicate there was no significant difference between the two vision groups in terms of haptic perception and user interface needs. A few differences in user interface preference did exist, however, and designers should take these into account., Conclusions: Participants with low vision were a group who relied on their vision in everyday life instead of touch. Thus, their haptic capability was less likely to be enhanced via brain plasticity, which probably contributed to no significant difference in haptic-incorporated user interface needs., Implications for Rehabilitation: No significant different haptic capability and haptic user interface (UI) needs exists between cited participants and those with low vision. UI designers should take into consideration that a certain range of magnitude/type of haptic feedback is available to accommodate preferences of both vision groups, which would ultimately increase the likelihood of successfully developing universal designs.

Purpose: Depression is a common problem among people with visual impairment and contributes to functional decline. This article presents a study protocol to evaluate a new model of care for those patients with depressive symptoms in which psychological treatment is integrated into low vision rehabilitation services. Low vision staff will be trained to deliver "problem solving therapy for primary care" (PST-PC), an effective psychological treatment developed specifically for delivery by non-mental health care staff. PST-PC is delivered in 8 weekly telephone sessions of 30-45 minutes duration and 4 monthly maintenance sessions. We predict this new integrated model of care will significantly reduce depressive symptoms and improve the quality of life for people with visual impairment., Methods and Design: A randomized controlled trial of PST-PC will be implemented nationally across low vision rehabilitation services provided by Vision Australia. Clients who screen positive for depressive symptoms and meet study criteria will be randomized to receive PST-PC or usual care, consisting of a referral to their general practitioner for more detailed assessment and treatment. Outcome measures include depressive symptoms and behaviors, quality of life, coping and psychological adjustment to visual impairment. Masked assessments will take place pre- and post-intervention as well as at 6- and 12-month follow-up., Conclusion: We anticipate that this innovative service delivery model will lead to sustained improvements in clients' quality of life in a cost effective manner and provide an innovative service delivery model suitable for other health care areas in which depression is co-morbid.

Purpose: This study evaluated the effect of an evidence-based magnifier training on viewing behavior in visually impaired children aged 3 to 6½ years., Methods: Effects of a training with a stand magnifier were evaluated by analyzing recordings of 21 visually impaired children, obtained from a miniature camera mounted in the magnifier. In a pre-test, post-test design, 11 of the children trained without magnifier and 10 children trained with magnifier. Three measures were compared from pre- to post-test assessment: 1) observation time in seconds through the magnifier during task performance; 2) the eye that was used during task performance with the magnifier (right eye/left eye as recorded by the camera); and 3) the self-chosen eye-to-chart distance (in cm) in near visual acuity measurement., Results: Three important changes were found by analyzing the eye-camera recordings: (1) There was a significant shift in average observation time (i.e., the duration of looking through the magnifier in a single glance), before and after training. In the pre-test children used less than 10 s for a glance through the magnifier, whereas in the post-test this was 10-30 s. (2) In 5 children there was no preference with respect to the number of glances through the magnifier with right or left eye during pre-test measurement. However, such a task-specific dominance was clearly observed in this subgroup after training (post-test measurement). (3) The eye-to-chart distance, as measured during near-vision testing with LH-single and LH-line test, decreased significantly over the training period (from 9.5 cm to 7.9 cm, pre- to post-test). There were no differences in the outcome measures between the with-magnifier and without-magnifier training groups. We can conclude that (1) the magnifier training had a positive effect on viewing behavior and the development of dominance, and (2) camera observations provide valuable data on children's viewing behavior.

As the population of the United States ages, there is an increase in the number of persons with age related macular degeneration (ARMD). Even as new prevention and treatment techniques are developed, the vision loss associated with ARMD may lead to loss of independence and quality of life. Low vision is a rehabilitative process designed to improve visual function and restore independence. This paper is a review of the current research related to low vision in the areas of magnification, contrast and illumination, reading, training, driving and outcomes assessment.

Purpose: To assess the impact of cataract surgery on vision related quality of life (VRQoL) and generic health related quality of life (HRQoL) in Kenya, Bangladesh and the Philippines., Methods: A multi-center intervention study was conducted. At baseline 651 cases aged ≥50 years with visually impairing cataract (corrected visual acuity (VA) <6/24) and 561 age- gender-matched controls with normal vision (VA>6/18) were interviewed about VRQoL (using the World Health Organization/ Prevention of Blindness and Deafness 20-item Visual Functioning Questionnaire [WHO/PBD VF20]) and generic HRQoL (EuroQol). Cases were offered free/subsidized cataract surgery. Approximately 1 year later participants were re-interviewed., Results: Response rate at follow up was 84% for operated cases and 80% for controls. At baseline, cases had significantly poorer VRQoL scores, were more likely to report problems with the EuroQol 5D five descriptive (EQ-SD) domains (mobility, daily activities, self-care, pain, depression/anxiety) and had significantly poorer self-rated health compared to controls. At follow up VRQoL scores of operated cases improved significantly to approximately equal those of controls. Effect sizes were large (> 0.8) regardless of pre-operative VA. Poor outcome from surgery (VA < 6/60) was associated with smaller VRQoL gains. Among operated cases frequency of reported problems with all the EQ-5D reduced significantly compared to baseline in Kenya and the Philippines, and in mobility, daily activities and self-care in Bangladesh. Self-rated health scores increased significantly in each country. HRQoL of controls remained stable from baseline to follow up., Conclusion: This study among adults undergoing cataract surgery in 3 different low-income settings found evidence of improved VRQoL and generic HRQoL to approximately equal that of controls with normal vision.

Purpose: To develop a valid and reliable instrument to systematically investigate visual rehabilitation needs of visually impaired older adults, which is compatible with the "International Classification of Functioning, Disability and Health" (ICF) structure: a new Dutch ICF version of the Activity Inventory (D-AI)., Methods: The original AI was translated, adjusted and expanded. After studying literature and investigating patient records, focus group discussions were conducted until the input was just confirmatory. Six (n = 41) and seven (n = 50) discussions with patients and professionals respectively contributed to the first draft of the D-AI, which was further improved by professionals., Results: The D-AI now consists of 10 domains, 68 goals and 813 tasks. Goals are organized into the "Activities and Participation" domains of the ICF. The original routing was maintained; only tasks organized under important (0 [not important] to 3 [very important]) and difficult (0 [not difficult] to 4 [impossible]) goals were assessed., Conclusion: Rehabilitation needs can be organized in the "Activities and Participation" domains of the ICF. The D-AI offers a way of systematically assessing and measuring functional limitations and disabilities, and provides detailed information about activities that are needed to perform a certain goal. Focus group discussions with Dutch patients and experts revealed additional items that will probably be relevant for other populations. Involving patients in the first step of the developing process is important to provide face and content validity. The D-AI can prioritize rehabilitation goals by multiplying importance and difficulty scores, which is helpful in formulating a rehabilitation plan.

Purpose: To design a randomized controlled trial (RCT) to compare the effectiveness of four different strategies to deliver low vision rehabilitation services., Methods: The four arms of the RCT comprised-center based rehabilitation, home based rehabilitation, a mix of center based and home based rehabilitation, and center based rehabilitation with home based non interventional supplementary visits by rehabilitation workers. Outcomes were assessed 9 months after baseline and included measuring changes in adaptation to age-related vision loss, quality of life, impact of vision impairment and effectiveness of low vision rehabilitation training. The socio-demographic and vision characteristics of the sample in each of the 4 arms were compared to ensure that outcomes are not associated with differences between the groups., Results: Four hundred and thirty six individuals were enrolled in the study; 393 individuals completed the study. One-fifth of participants were children aged 8 to 16 years. At baseline, socio-demographic and clinical characteristics were similar between individuals in the four arms of the trial. Socio-demographic and clinical characteristics did not differ significantly, except for age, between the 393 individuals who completed the trial and the 43 individuals who dropped out of the study. Twenty six (60.46%) of the forty three drop outs were from the center based arm of the trial., Conclusions: Information from this trial has the potential to shape policy and practice pertaining to low vision rehabilitation services.

Purpose: To conduct a survey of willingness to pay for ready-made spectacles in the low-resource country of Timor-Leste, and, uniquely, subsequent validation with actual payment information., Methods: A systematic random sampling strategy was used to apply a binary with follow-up stated willingness to pay methodology. Findings were validated by comparing the amount declared willing to pay with the actual price paid at a subsequent visit., Results: Of the 152 participants (96.2%; mean age 50.9 +/- 13.2 years; 50.0% female) agreeable to wearing spectacles if required, 84.9% were willing to pay for them, with 82.9% of these willing to pay at least United States dollars (USD) 0.10. By multivariate analysis, increasing age and owning fewer animals were significantly and independently associated with unwillingness to pay at least USD 0.10. Of the survey participants agreeable to wearing spectacles who attended a later visit (113/152; 74.3%; 53.1% female), the 80.5% who would benefit were offered spectacles, first for USD 1.00. If declined, this was revised to USD 0.10. If this was declined, the spectacles were dispensed, unknown to subsequent attendees, at no charge. The predictive value of stated willingness to pay at least USD 0.10 was 96.3%., Conclusions: Binary with follow-up stated willingness to pay with validation against actual payment was successfully applied to spectacles in Timor-Leste.

Purpose: To examine the effects of bias and distortion from general health status on Rasch model-based measurements of visual function, and establish measurement equivalence across different health status groups in low vision patients., Methods: Self-reported data were obtained from 1746 low vision patients who completed the Activity Inventory (AI) and an intake health-related questionnaire prior to their first visit to the low vision rehabilitation service. Differential Item Functioning (DIF) analysis by health status and separate Rasch analyses adjusted by health status were performed on the responses to both a DIF-free scale and the full scale of the AI., Results: Of 48 Goal-level items, only 15 items showed significant DIF (P < 0.001). Comparing the vision-related estimates from the original full set of items with those from the DIF free scale; we found that only 25% of the person measure estimates differed by 0.5 logits or more and there was a strong intraclass correlation between the two scales in measuring the patients' vision-related functional ability (IC = 0.75). Patients' health status influenced the Rasch model based estimation of visual function by the AI (ANOVA, p = 0.005), but this effect was within accepted range of MISFIT statistics., Conclusion: Taken together, our results indicate that despite confounding effects of general health status on vision-related ability, we can still regard visual ability to be a single theoretically constructed variable for the low vision population. It appears that self-perceived comorbidities add to vision-related disability, but do not distort its measurement.

Purpose: To evaluate the prevalence of visual hallucinations in Charles Bonnet Syndrome (CBS) among patients at a Low Vision Clinic. To determine whether Low Vision Rehabilitation (LVR) intervention results in a decrease of these visual hallucinations., Methods: We surveyed 50 consecutive new patients in a low vision clinic to determine whether they had experienced visual hallucinations consistent with CBS. All patients were: questioned about the presence of visual hallucinations; given an educational handout that described CBS and reassured them of the benign nature of these hallucinations; and administered Folstein's Mini Mental Status Examination (MMSE). During their low vision examination, all patients received low vision aids to improve their visual function. At follow-up patients who had symptoms of CBS were administered a second survey to evaluate whether they had experienced any change in the frequency of their visual hallucinations., Results: Of the 50 patients surveyed, 12 of 50 (24%) had visual hallucinations typical of CBS. 6 of these 12 patients (50%) had daily recurring hallucinations. At mean follow-up of 34.9 +/-30 days, a second survey was administered to 11 of the 12 patients diagnosed with CBS. One patient was lost to follow-up. Three of the 11 patients (27.3%) experienced a decrease in the frequency of their hallucinations by 43.33% +/-30.55%. Eight of 11 patients (72.7%) did not note a change in their symptoms., Conclusions: It is important to include direct questions regarding visual hallucinations in the case history of a low vision examination. LVR may decrease the frequency of CBS hallucinations in some patients. Rehabilitation strategies should include low vision devices that allow for improved visual function and patient education to provide needed reassurance.

Purpose: To obtain statements describing the impact of vision impairment on participation in every day activities of school-aged children (8-18 years) capturing their opinion, as the primary step in developing a pediatric vision-related quality of life instrument., Methods: Separate focus groups for students with low vision, parents and teachers plus in-depth individual interviews were conducted in Victoria, Australia. Focus groups followed a topic guide, were digitally audio recorded and transcribed verbatim. Statements were identified, coded and ascribed into major themes., Results: 102 participants provided just over 2600 statements (an average of 146 statements per verbatim transcript) which were classified into 5 themes: school/specialist instruction, social interaction, family, community and vision impairment peer interaction. The identified areas likely to facilitate good participation in every day activities, and accounted for 79% of the statements were class teacher knowledge and specialist support (40%) and social interaction (39%). The student perspective focused on communication skills and orientation and mobility whereas the specialist instructors' emphasis was on specialist support. Emphases across the themes varied between focus groups and highlight the benefit of including the perspectives of all stakeholders in questionnaire design., Conclusions: The multi-perspective development strategy for a new questionnaire has established that it is crucial to integrate different stakeholders' perspectives. By doing so, it will be possible to develop a balanced questionnaire.

Purpose: To assess if the Impact of Vision Impairment (IVI) is a valid instrument to measure participation in daily activities and rehabilitation in patients with age-related macular degeneration (AMD) and varying levels of visual impairment., Methods: Participants, recruited from a public eye hospital and low vision centers, completed the IVI questionnaire. The IVI and its three subscales were assessed for fit to the Rasch model. Unidimensionality, item fit, response category performance, and targeting of items to patients were assessed. Confirmatory factor analysis (CFA) was used to assess the three-factor model of the IVI in this sample of AMD patients., Results: 219 patients (mean +/- SD age = 83.5 +/- 7.4 yr) were recruited. Of these, 22%, 55% and 23% had mild (< 6/12-6/18), moderate (< 6/18-6/60) and severe (< 6/60) vision loss, respectively. The IVI total and three subscales displayed discrete thresholds indicating that the respondents understood the response categories. The IVI items fitted the scale and unidimensionality was established. Person separation reliability for the IVI score was substantial (0.94) indicating that the scale can discriminate between several groups of AMD patients. The IVI items were significantly targeted to the AMD patients with the means of the two distributions shown to be very close (0.0 and 0.1, respectively). Substantial targeting was also evident for the subscales. Poorer visual acuity was significantly associated (ANOVA; F (2, 216) = 23.4; p < 0.001) with greater restriction of participation suggesting that the IVI has substantial construct validity. CFA supported the IVI three-factor model which includes items from the "emotional well-being, "reading and accessing information" and "mobility and independence" subscales., Conclusions: Clinicians and researchers can reliably use the IVI to assess the impact on daily life and the effectiveness of clinical trials and rehabilitation interventions in patients with AMD across a range of vision loss.

Purpose: To establish the proportion of patients who are blind or have low vision prior to undergoing cataract surgery at tertiary referral centers in Tanzania. To assess which patient groups presenting for cataract surgery are more likely to be blind or visually impaired., Methods: Using pre-existing computerized audit systems we gathered data on pre-operative visual status, age, gender and presentation mode (walk-in or outreach) for 3765 patients undergoing 4258 cataract operations at 2 hospitals in Tanzania. Visual status was defined based on vision in the better eye., Results: 32% of operations were performed on blind patients, 37% on patients with low vision and 31% on normally sighted patients. Predictors of blindness at presentation were: female sex (OR 1.15; 95% CI 1.00-1.32); referral from a rural outreach program (OR 1.75; 95% CI 1.51-2.02) and older age (OR 1.02; 95% CI 1.01-1.02)., Conclusions: It is not only the blind who present to cataract services in Tanzania. The demand for surgery amongst patients who or are normally sighted represents a positive move towards prevention, and not only cure of cataract blindness in Tanzania. However, it also highlights the need to target those left blind from cataract in order to deliver services to those most in need. Cataract programs targeting patients in rural areas and older patients are likely to increase the number of blind patients benefiting from cataract services.

Assistive devices (AD) have long played an important role in occupational therapy practice as a way of enabling activities of daily living (ADL), but no studies to date have investigated the use of low vision AD among older persons with age-related macular degeneration (AMD) as well as devices for ADL performance and hearing. The purpose of this study was to describe AD users and to investigate the association of AD and ADL. A health promotion program versus an individual program was investigated within a randomised design. The study was based on data from 131 participants, 28-months after intervention. Data on prescribed ADs were examined through medical records and registers. The participants in the health promotion program used low vision AD in combination with ADL devices to a higher degree, whereas participants in the individual program used just optical AD. Greater use of non-optical AD within the individual program and greater use of ADL devices within the health promotion program was weakly associated with higher level of ADL dependence. There was no significant association between the number of low vision AD and having a decreased, a maintained or improved level of dependence at 28 months.

Objective/purpose: This survey was conducted to determine the effect on activities of daily living of persons who report that they have received vision rehabilitation., Design/methodology: This study used a clinical sample to gather information from 417 patients. Of the 417, 105 reported receiving vision rehabilitation. The efficacy of rehabilitation was assessed by asking 20 questions about their activities of daily living prior to and after their rehabilitation. A retrospective pretest (post-then-pre) design was used. Paired t tests were conducted to evaluate the effect of rehabilitation., Results: A significant difference was found for 13 of 20 questions. Difficulty reading ordinary prints in newspapers showed a large effect size (p=0.0005). Difficulty reading the small print in a telephone book showed a large effect size (p=0.0005). Difficulty doing work or hobbies that require one to see up close showed a moderate effect size (p=0.0005). Difficulty finding something on a crowded shelf showed a moderate effect size (p=0.0005). Difficulty figuring out whether bills received are accurate showed a moderate effect size (p=0.0005). Difficulty shaving, styling one's hair, or putting on makeup showed a small effect size (p=0.016). Difficulties seeing and enjoying programs on television showed a moderate effect size (p=0.0005)., Conclusion: Patients with low vision who report having received vision rehabilitation show significant improvements in activities of daily living or specific types of functioning after rehabilitation. Improvement in both near and distance vision activities and in social activities indicates daily functioning was improved and that barriers to activities of daily living were removed.

Few studies have examined the effectiveness of low vision rehabilitation for age-related maculopathy (ARM) patients and its impact on vision-specific health-related quality of life (HRQoL). However, before a multi-site clinical trial can be conducted, appropriate outcome measures need to be identified for ARM patients who seek out low vision rehabilitation, including a vision-specific HR QoL instrument. The 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was developed to assess vision-specific HRQoL for low vision patients, including those with ARM. This study examines the performance of the NEI VFQ-25 among ARM patients who seek out low vision services and examines its relationship with visual acuity and self-reported use of low vision aids. One hundred and twenty-seven patients were recruited from a University-affiliated low vision clinic. During two telephone interviews, subjects completed the NEI VFQ-25 and a short cognitive test and provided information on general health and use of low vision aids. Additional information on visual acuity and eye health were collected from the medical record. Our results indicate that ARM patients who seek out low vision services report significant impairment in their vision-specific HRQoL. Their NEI VFQ-25 scores were lower compared to other ARM and low vision rehabilitation samples previously studied. The VFQ subscales with the largest deficits were near and distance visual acuities and psychosocial issues (near vision, distance vision, role difficulties, dependency, social functioning, mental health). These subscale scores were lower for those with greater visual acuity impairment. The VFQ subscale scores most impacted by the disease had wide variability and were higher for those who used low vision aids, suggesting that the NEI VFQ-25 is suitable for measuring further decline and treatment-related improvements. Thus, it should be strongly considered for a multi-site clinical trial on the effectiveness of low vision rehabilitation.

Purpose: To test the hypothesis that vision rehabilitation using optometry, occupational therapy and social work services increases patients' functional ability and to assess whether involving families in the intervention results in more successful outcomes., Methods: We conducted an outcome study of 97 patients new to the Vision Rehabilitation Service. Subjects were between the ages of 19 and 91 years, with a median age of 76. Their visual acuities were 20/100 or worse in the better eye, with 50% of the subjects having acuities worse than 20/200. Macular degeneration was the most prevalent diagnosis. Subjects were assigned to either an individually focused (n=48) or a family focused (n=49) intervention. The outcome measure was change in function, as assessed by speed and accuracy of performance (objective measure) and by the patients' self-reports of difficulty and dependency in performing daily activities (subjective measures). Data were collected before and after the intervention., Results: Most patients had documented improvement after rehabilitation on both objective (p=.0001) and subjective (decreased dependency, p=.01) measures of function. The sample size did not provide adequate statistical power to show differences between family focused and individually focused interventions., Conclusions: This study documents significant improvement after vision rehabilitation for a predominantly elderly population. Patients in both family and individually focused interventions improved comparably.

Patients with irreversible vision loss are understandably distressed, but physicians can help guide them to successful independent living. In this practical article, Dr Faye discusses the causes of low vision, offers tips for working with visually impaired patients in the office setting, and describes rehabilitation programs for such patients. A list of resources on low vision is also included.

The design of low vision aids for partially sighted people, such as magnifiers, is evaluated theoretically in order to identify meaningful directions of research for improving these aids. Both reading with and without a magnifier involves alternating sequences of locating and recognizing textual information. Little is known, however, about these processes in magnifier reading. On the basis of an extensive review of the literature, two topics are identified that stand out as being in need of experimental investigation: (1) the relationship between the (typo)graphical characteristics of printed text and the location and recognition of textual information, and (2) the interplay of location and recognition processes in magnifier reading, including the role of non-visual factors, such as movements of the hand, trunk, head and eyes in this interplay. With regard to the first topic, it is expected that the visibility and, hence, the recognition of textual information by partially sighted people can be improved by matching the fundamental spatial frequencies of graphical structures with the spatial contrast sensitivity of partially sighted people. With regard to the second topic, it is argued that persistent problems in the design of the magnifiers, such as the optimal window size, can only be resolved by studying reading with a magnifier as a (multimodal) perceptual-motor activity.

Measures of functional vision are needed to assess elderly low vision patients, their success in using devices, and their ability to manage outside the treatment setting. A new test devised to measure functional ability through the performance of everyday tasks was administered to 94 patients who had acuities of 20/100 or worse in their better eye. Consisting of three versions and four subtests: spot reading, short-term text reading, identifying paper currency and clock reading, the test used standardized items and was timed. In a multiple regression model predicting test performance higher scores were associated with better near acuity (P = .002), higher education (P = .022) and higher levels of self-reported visual skills (P = .072). These predictors plus distance acuity, age and sex only accounted for 35 percent of the variance in test scores. Repeated administration of the test to a different group of 21 patients showed the test to be reliable (intraclass correlation = .85, P < .01) and to have no practice or version effects or differences between raters. This new test may be useful for natural history studies and clinical trials involving low vision patients but further evaluation of its sensitivity to change over time is required.