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SIGNIFICANCE This research is significant because, although vision-related quality of life (VRQoL) is improved after vision rehabilitation (VR), patients with certain characteristics respond less positively on VRQoL measures, and this should inform future care. PURPOSE The purposes of this study were to evaluate how two VRQoL questionnaires compare in measuring change in patient-reported outcomes after VR and to determine if patient characteristics or occupational therapy (OT) predict higher scores after rehabilitation. METHODS In a prospective clinical cohort study, 109 patients with low vision completed the Impact of Vision Impairment (IVI) and the National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25) before and after VR. Comprehensive VR included consultation with an ophthalmologist and OT if required. The relationships of six baseline characteristics (age, sex, visual acuity, contrast sensitivity, field loss, diagnosis) and OT were assessed with VRQoL scores using multivariable logistic regression. RESULTS The mean (SD) age was 68.5 (19.2) years, and 61 (56%) were female. After rehabilitation, increases in scores were observed in all IVI subscales (reading [P < .001], mobility [P = .002], well-being [P = .0003]) and all NEI VFQ-25 subscales (functional [P = .01], socioemotional [P = .003]). Those who were referred to OT but did not attend and those who had hemianopia/field loss were less likely to have higher VRQoL in IVI mobility and well-being. Those attending OT for more than 3 hours were less likely to have better scores in emotional NEI VFQ. Men were less likely to have increased scores in functional and emotional NEI VFQ, whereas those with diagnoses of nonmacular diseases had higher odds of having increased scores on the emotional NEI VFQ (all, P < .05). CONCLUSION Both the IVI and the NEI VFQ-25 detected change in patients' VRQoL after rehabilitation. Most of the patient characteristics we considered predicted a lower likelihood of increased scores in VRQoL.

To systematically review the evidence for effectiveness of rehabilitation interventions in people who are visually impaired, living in low- and middle-income countries. Fifteen databases and the grey literature were searched up until February 2020; papers were identified according to eligibility criteria, and assessed for risk of bias. Eligible studies were controlled trials (randomised or non-randomised) of rehabilitation interventions for blind or visually impaired adults or children from low- and middle-income countries. Possible outcomes included visual acuity, activities of daily living, safety, quality of life and psychological status. Fifteen eligible studies were identified from India, Turkey, Nigeria, Croatia and Iran. Six studies were randomised, seven were non-randomised trials, and in two the method of allocation was not clear. Participants were adults, children and both adults and children. Seven studies were small (n ≤ 65) and examined the effect of training programmes. Remaining studies compared the effect of low vision aids, economic rehabilitation, goalball, rehabilitation compliance and service delivery methods, including one large four-arm randomised trial (n = 436). Studies measured a variety of outcomes, and mostly showed a positive effect of interventions for pre- and post-intervention assessment, although between intervention group comparisons were often inconclusive. Overall, only four studies had a low risk of bias. A lack of high-quality evidence for rehabilitation interventions is a barrier to provision of low vision services in low- and middle-income countries. Future research should focus on establishing effectiveness and cost-effectiveness of devices and models of vision rehabilitation appropriate for low-resource settings.IMPLICATIONS FOR REHABILITATIONThe systematic review found a lack of high-quality evidence for rehabilitation interventions is a barrier to provision of low vision services in low- and middle-income countries.Consider how visual rehabilitation interventions which have been shown to be effective can be delivered by non-specialists.Ensure that service providers for people who are visually impaired are trained in recognising depression and anxiety and have pathways for referral to mental health services, as appropriate. The systematic review found a lack of high-quality evidence for rehabilitation interventions is a barrier to provision of low vision services in low- and middle-income countries. Consider how visual rehabilitation interventions which have been shown to be effective can be delivered by non-specialists. Ensure that service providers for people who are visually impaired are trained in recognising depression and anxiety and have pathways for referral to mental health services, as appropriate.

Objective To conduct a needs assessment to identify gaps in communication skills training in ophthalmology residency programs and to use these results to pilot a communication workshop that prepares residents for difficult conversations. Design A mixed-methods design was used to perform the needs assessment. A pre-and postsurvey was administered to workshop participants. Setting Mass Eye and Ear Infirmary, Harvard Medical School (HMS), Department of Ophthalmology. Participants HMS ophthalmology residents from postgraduate years 2-4 participated in the needs assessment and the workshop. Ophthalmology residency program directors in the United States participated in national needs assessment. Methods Ophthalmology program directors across the United States were queried on their perception of resident communication skills training through an online survey. A targeted needs assessment in the form of a narrative exercise captured resident perspectives on communication in ophthalmology from HMS residents. A group of HMS residents participated in the pilot workshop and a pre- and postsurvey was administered to participants to assess its effectiveness. Results The survey of program directors yielded a response rate of 40%. Ninety percent of respondents agreed that the communication skills training in their programs could be improved. Fifteen of 24 residents (62%) completed the needs assessment. Qualitative analysis of the narrative material revealed four themes; (1) differing expectations, (2) work role and environment, (3) challenges specific to ophthalmology, and (4) successful strategies adopted. Nine residents participated in the workshop. There was a significant improvement post-workshop in resident reported scores on their ability to manage their emotions during difficult conversations (p = 0.03). Conclusions There is an opportunity to improve communication skills training in ophthalmology residency through formalized curriculum.

Purpose To examine whether individuals with Stargardt disease macular dystrophy (STGD) change the location of fixation with instruction. Design Case-control study. Participants Thirteen normally sighted and 37 STGD participants. Methods Using an Optos scanning laser ophthalmoscopy/OCT microperimeter (Optos plc, Dunfermline, UK), fixation was measured under 2 different instructions: “look at the cross” (LC) and “look straight ahead, even if you do not see the cross” (LS). Visual acuity, contrast sensitivity, disease duration, and age at disease onset were obtained from medical records. Main Outcome Measure Change in fixation with instruction. Results Mean age of the STGD participants was 39.2 years, and 24 were women. Mean acuity was 1.01±0.29 logarithm of the minimum angle of resolution (logMAR), and mean contrast sensitivity was 1.16±0.41 log. The largest number of fixations under the LC condition were in the superior retina. Patients with STGD were divided into 3 groups, depending on the change in fixation locus when asked to look straight ahead: those having fixation closer the fovea, those with no change in the location of fixation, and those looking farther away from the fovea. Fifty-one eyes of 32 participants had fixations closer to the fovea when asked to look straight ahead (average change, –6.3°), whereas 13 eyes of 11 participants did not change fixation. There were no significant differences between groups in age, visual acuity, contrast sensitivity, bivariate contour ellipse area, and age at disease onset. Conclusions Despite having eccentric fixation, most STGD participants did not have a complete directional re-referencing from the fovea to the eccentric location, and moved fixation when asked to look straight ahead. This finding emphasizes that reliable assessment of visual function during evaluations of disease progression or in therapeutic intervention trials requires consistent instructions and monitoring of fixation. Otherwise, a patient's interpretation of fixation instruction may confound the results.

Eccentric fixation is a commonly used adaptive strategy in patients with central vision loss. A common complaint in patients with central vision loss is reading difficulty. The mechanisms as to how and why eccentric fixation develops comprise an exciting area of research. As we better understand this phenomenon, we may apply these findings to the clinical setting and in particular to reading rehabilitation. Biofeedback is a new technique that can be applied to eccentric fixation and may have a role in reading rehabilitation.

Purpose Provide item calibrations estimated for the Impact of Vision Impairment (IVI) questionnaire by pooling data from several studies of people with vision impairment (VI) representing a variety of countries and causes of VI. Methods Eight data sets from six principal investigators representing responses to IVI items from 2867 VI patients were pooled for analysis. Eligible patients were 18 years or older and from Australia, India, and the United States. Rasch analysis, using the Andrich Rating Scale Model (Winsteps version 3.65), was performed on preintervention IVI responses to estimate item and person measures, reliability coefficients, and response category thresholds. Differential item functioning (DIF) analysis and analysis of variance (ANOVA) were used to examine the effects different data sets and covariates on item estimates. Results Patient age range was 18 to 103 years (median 62 years); 55% were male. Visual acuity ranged from 20/20 to no light perception and primary diagnosis was macular degeneration in 29% of patients. Item measure estimates showed good separation reliability (R2 = 0.99). DIF magnitude did not preclude use of all IVI-28 data. ANOVA showed VA (P < 0.001) and gender (P < 0.002) were predictors of visual ability. Conclusions Analysis from pooled data support the provision of calibrated IVI item measures for researchers and clinicians to use, thus better enabling direct comparisons of patients with VI. Translational Relevance Validity testing of the IVI show that we can combine disparate data sets of patient responses to calibrate item measures and response category thresholds, and provide to others for use in comparing patients across clinical trials and on an individual basis.

Purpose Vision loss from age-related macular degeneration (AMD) has a profound effect on vision-related quality of life (VRQoL). The pupose of this study is to identify clinical factors associated with VRQoL using the Rasch- calibrated NEI VFQ-25 scales in bilateral advanced AMD patients. Methods We retrospectively reviewed 47 patients (mean age 83.2 years) with bilateral advanced AMD. Clinical assessment included age, gender, type of AMD, high contrast visual acuity (VA), history of medical conditions, contrast sensitivity (CS), central visual field loss, report of Charles Bonnet Syndrome, current treatment for AMD and Rasch-calibrated NEI VFQ-25 visual function and socioemotional function scales. The NEI VFQ visual function scale includes items of general vision, peripheral vision, distance vision and near vision-related activity while the socioemotional function scale includes items of vision related-social functioning, role difficulties, dependency, and mental health. Multiple regression analysis (structural regression model) was performed using fixed item parameters obtained from the one-parameter item response theory model. Results Multivariate analysis showed that high contrast VA and CS were two factors influencing VRQoL visual function scale (β = -0.25, 95% CI-0.37 to -0.12, p

PurposeBoth optical and electronic magnification are available to patients with low vision. Electronic video magnifiers are more expensive than optical magnifiers, but they offer additional benefits, including variable magnification and contrast. This study aimed to evaluate the effect of access to a video magnifier (VM) added to standard comprehensive vision rehabilitation (VR). MethodsIn this prospective study, 37 subjects with central field loss were randomized to receive standard VR (VR group, 18 subjects) or standard VR plus VM (VM group, 19 subjects). Subjects read the International Reading Speed Texts (IReST), a bank check, and a phone number at enrollment, at 1 month, and after occupational therapy (OT) as indicated to address patient goals. The Impact of Vision Impairment (IVI) questionnaire, a version of the Activity Inventory (AI), and the Depression Anxiety and Stress Scale (DASS) were administered at enrollment, 1 month, after OT, 1 month later, and 1 year after enrollment. Assessments at enrollment and 1 month later were evaluated. ResultsAt 1 month, the VM group displayed significant improvement in reading continuous print as measured by the IReST (P = 0.01) but did not differ on IVI, AI, or DASS. From enrollment to 1 month all subjects improved in their ability to spot read (phone number and check; P < 0.01 for both). The VM group improved in their ability to find and read a number in a phone book more than the VR group at 1 month after initial consultation (P = 0.02). All reported better well-being (P = 0.02). ConclusionsAll subjects reported better well-being on the IVI. The VM group read faster and was better at two spot reading tasks but did not differ from the VR group in other outcome measures.

The slow progression of nonexudative age-related macular degeneration (dry AMD) presents challenges for drug discovery. The standard endpoint used for ophthalmic clinical trials, best-corrected visual acuity (BCVA), is insensitive to the early stages and slow progression of dry AMD. Effective drug discovery for dry AMD treatments will therefore require novel applications of more effective visual function endpoints. This review will present candidates for visual function endpoints for dry AMD clinical trials. The promising visual assessments include contrast sensitivity, reading speed, microperimetry and dark adaptation. Their adoption as exploratory endpoints in future trials will be crucial for determining their accuracy, precision and applicability, and ultimately determine their value for drug discovery.

To examine whether individuals with Stargardt disease macular dystrophy (STGD) change the location of fixation with instruction.Case-control study.Thirteen normally sighted and 37 STGD participants.Using an Optos scanning laser ophthalmoscopy/OCT microperimeter (Optos plc, Dunfermline, UK), fixation was measured under 2 different instructions: "look at the cross" (LC) and "look straight ahead, even if you do not see the cross" (LS). Visual acuity, contrast sensitivity, disease duration, and age at disease onset were obtained from medical records.Change in fixation with instruction.Mean age of the STGD participants was 39.2 years, and 24 were women. Mean acuity was 1.01±0.29 logarithm of the minimum angle of resolution (logMAR), and mean contrast sensitivity was 1.16±0.41 log. The largest number of fixations under the LC condition were in the superior retina. Patients with STGD were divided into 3 groups, depending on the change in fixation locus when asked to look straight ahead: those having fixation closer the fovea, those with no change in the location of fixation, and those looking farther away from the fovea. Fifty-one eyes of 32 participants had fixations closer to the fovea when asked to look straight ahead (average change, -6.3°), whereas 13 eyes of 11 participants did not change fixation. There were no significant differences between groups in age, visual acuity, contrast sensitivity, bivariate contour ellipse area, and age at disease onset.Despite having eccentric fixation, most STGD participants did not have a complete directional re-referencing from the fovea to the eccentric location, and moved fixation when asked to look straight ahead. This finding emphasizes that reliable assessment of visual function during evaluations of disease progression or in therapeutic intervention trials requires consistent instructions and monitoring of fixation. Otherwise, a patient's interpretation of fixation instruction may confound the results.

We have previously reported that transcranial direct current stimulation (tDCS) delivered to the occipital cortex enhances visual functional recovery when combined with three months of computer-based rehabilitative training in patients with hemianopia. The principal objective of this study was to evaluate the temporal sequence of effects of tDCS on visual recovery as they appear over the course of training and across different indicators of visual function.Primary objective outcome measures were 1) shifts in visual field border and 2) stimulus detection accuracy within the affected hemifield. These were compared between patients randomized to either vision restoration therapy (VRT) combined with active tDCS or VRT paired with sham tDCS. Training comprised two half-hour sessions, three times a week for three months. Primary outcome measures were collected at baseline (pretest), monthly interim intervals, and at posttest (three months). As secondary outcome measures, contrast sensitivity and reading performance were collected at pretest and posttest time points only.Active tDCS combined with VRT accelerated the recovery of stimulus detection as between-group differences appeared within the first month of training. In contrast, a shift in the visual field border was only evident at posttest (after three months of training). tDCS did not affect contrast sensitivity or reading performance.These results suggest that tDCS may differentially affect the magnitude and sequence of visual recovery in a manner that is task specific to the type of visual rehabilitative training strategy employed.

Introduction Some persons with Charles Bonnet syndrome (CBS) suffer significant anxiety because of their visual hallucinations, while others do not. The aim of the study presented here was to compare levels of anxiety in persons with low vision with and without CBS. Methods This retrospective study compared the level of anxiety in 31 persons with CBS and 26 persons without CBS. These participants were recruited voluntarily from senior centers, a low vision support group, and an ophthalmology practice in October and November 2010. All were administered surveys to measure cognitive function (TICS: Telephone Interview for Cognitive Status), anxiety (STAI: State and Trait Anxiety Inventory), and general health (GHQ: General Health Questionnaire). The responses of the two groups were compared. Results The participants with CBS exhibited higher levels of anxiety than did those without CBS on both the STAI and GHQ surveys, but this difference did not reach statistical significance. The proportion of participants who were pharmacologically treated for anxiety was four times higher in the CBS cohort than in the cohort without CBS: CBS: 36% (11 of 31), those without CBS: 9% (2 of 22), p value = .03. The participants with CBS who took medication for anxiety scored higher on the STAI and GHQ than did those without CBS, but these differences did not reach statistical significance. Discussion The findings indicate that persons with CBS have higher levels of anxiety than do those without CBS. The highest levels of anxiety occurred in the participants with CBS who were being treated for anxiety with medications. Although the findings did not reach statistical significance, they suggest that anxiety is an important consideration when treating individuals with CBS. Implications for practitioners Persons with CBS who have difficulty tolerating visual hallucinations may benefit from interventions that are directed at managing anxiety, such as counseling, visual rehabilitation, and pharmacological treatment.

Central scotomas--areas of the nonseeing retina within the central 20 degrees of the visual field--are present in approximately 90% of vision rehabilitation patients (Fletcher & Schuchard, 1997). They vary in size and shape and can be small or large, symmetrical or asymmetrical, round or irregularly shaped. Most central scotomas border fixation on one side and can be overcome with magnification and sometimes eccentric viewing. However, these strategies seldom suffice in the case of ring scotomas (see Figure 1), which border three or four sides of fixation and have been present in 20%-47.5% of patients with eye conditions that affect central vision (Fletcher & Schuchard, 1997; Messias et al., 2007; Mogk, 2009). Patients with ring scotomas generally have near-normal acuity (Maguire & Vine, 1986; Moil et al., 2001; Rotenstreich, Fishman, & Anderson, 2003), which does not reflect their functional impairment in reading and activities of daily living (Fletcher & Schuchard, 1997; Sarks, Sarks, & Killingsworth, 1988; Sunness et al., 1999; Sunness, Rubin, Zuckerbrod, & Applegate, 2008). They display a characteristic slow-fast-slow reading pattern when performing tests such as the MNREAD acuity chart (Legge, Ross, Luebker, & LaMay, 1989; Sunness, 2008). They read the largest print slowly, speed up with the middle print sizes as more letters fit within the central island of vision, and then slow again when the print drops below the size they can discern (Fletcher & Schuchard, 2006; Fletcher, Schuchard, Walker, & Raskauskas, 2008). Most patients with ring scotomas fixate centrally even for targets that are larger than the central island (Messias et al., 2007; Mori et al, 2001), possibly because reorganization of cortical visual processing only occurs in the absence of foveal vision (Baker, Dilks, Peli, & Kanwisher, 2008). Three principles characterize the approach to intervention for patients with fovealsparing scotomas: education about the scotoma, supporting the use of the limited central vision, and maximizing the potential to use the peripheral retina. AWARENESS OF THE SCOTOMA The most essential issue for successful intervention for ring scotomas is that both the clinician and the patient are aware of the visual pattern and its clinical significance. Ring scotomas can be confusing and nonsensical to patients. Training may include increasing awareness of the difficulty of reading large print and of the negative impact of substantial magnification that causes the target to fall on the scotomatous area. Education about the nature of the ring scotoma can prepare patients to learn effective reading strategies and engage in vision rehabilitation. Families and caregivers may think that the patient's description of his or her vision seems illogical, leading to distrust and doubt about the patient's visual function and performance of activities. Education can avoid such misunderstandings (Cimarolli & Boerner, 2005) and thus support optimal functioning by improving the patient's social environment. One of the most concrete methods for successful education is providing a visual image of the ring scotoma with either a Scanning Laser Ophthalmoscope (SLO; SLO-101, Rodenstock, Dusseldorf, Germany) or California Central Visual Field Test (CCVFT; Mattingly, California), defining the scotoma in lay terms (for example, a doughnut-shaped blind spot), and then discussing precisely how the patient's scores on reading acuity tests changed with the print size. [FIGURE 1 OMITTED] USING THE CENTRAL ISLAND OF VISION The second step is to evaluate and support the use of the central island when it is functional. Practitioners need to determine the size, visual acuity, and contrast sensitivity of the seeing central area, the extent of the surrounding scotoma, and the nature of the patient's habitual fixation. Does the patient consistently fixate centrally or shift to eccentric fixation when viewing larger images? …

Vision rehabilitation is a clinical discipline in which there is a great deal of discussion with patients--reviewing patients' goals; educating patients about their ocular condition; outlining rehabilitation options; and often conveying "bad news," such as the assessment that a patient can no longer drive or that it is anticipated that a patient's vision will never improve. This article reviews two published models of physician-patient communication and addresses how each may apply to health care professionals in vision rehabilitation who communicate with patients, such as discussing the need to stop driving with patients who have age-related macular degeneration (AMD). Communication with patients is a core clinical skill for all health care professionals that can be evaluated, taught, and improved. Medical schools historically taught this skill informally and referred to physicians as having or not having a "good bedside manner." Today, more emphasis is placed on communication as a teachable skill in the health care setting, with a shift toward communication skills being more explicitly taught and evaluated. In the United States, the Accreditation Council for Graduate Medical Education requires that "residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients' families, and professional associates" (Hutul, Carpenter, Tarpley, & Lomis, 2006, p. 401). One can consider how clinicians communicate with patients who have AMD by considering how one would approach a discussion in the following hypothetical scenario: Mr. B is a spry 80 year old who lives alone. He was diagnosed with AMD three years ago and has had photodynamic treatment in one eye and antivascular endothelial growth factor intravitreal treatment to his left eye. Mr. B's acuity is now 20/100 OD and 20/200 OS. His contrast sensitivity is markedly reduced, and he has large scotomas in the left eye and scotomas encircling the central retina in the right eye. His wife recently died, and he moved to a neighboring city to be closer to his two daughters. Mr. B drives only during the day. He reported that he is depressed, having fallen recently and experiencing the symptom of seeing "people and faces" that he knows are not there. He set his car keys on the desk beside him when the interview started and cried twice during the interview. How does a clinician approach a patient who needs to be told that he cannot continue to drive? How does a clinician approach a patient who begins to cry during the interview? This scenario presents many issues for a vision rehabilitation clinician to discuss with Mr. B. THE SPIKES STRATEGY Robert Buchman is an oncologist who wrote both a text, How to Break Bad News: A Guide for Health Care Professionals (Buchman, 1992), and an article entitled, "Breaking Bad News: The SPIKES Strategy" (Buchman, 2005). He defined bad news as any news that is contrary to a patient's expectations. It is the patient's perception of the situation that determines how bad the news is, not the clinician's perception of the significance of the discussion. The SPIKES protocol is a strategy, not a scripted language, for approaching discussions with a patient. It recommends that health care professionals consider the sequential steps outlined by Buchman: setting, perception, invitation, knowledge, empathy, and strategy and summary. The SPIKES protocol first recommends that clinicians attend to the setting, so that significant news is discussed at a time when privacy is assured, the appropriate individuals are present, the clinician can be comfortably seated at the same level as the patient, and the clinician can be attentive and not rushed. In the second step, perception, the clinician asks before he or she tells. As Buchman (1992, p. 140) noted, "Before you break bad news to your patients, you should glean a fairly accurate picture of their perception of the medical situation--in particular, how they view the seriousness of the condition. …

Traditionally, vision rehabilitation was directed towards patients who were blind or had very low vision.There is increasing evidence that less severe vision loss is associated with increased risk of falls, hip fractures, medication errors, poor nutrition, reduced physical activity, social isolation, clinical depression, longer hospitalizations, and mortality.The American Academy of Ophthalmology (AAO) 2003 SmartSight initiative in low vision rehabilitation outlined a model of graduated low vision interventions.This paper is a review of the AAO SmartSight model and how it can apply in the Canadian setting.All patients with visual acuity less than 20/40, a scotoma, field loss, or loss of contrast sensitivity would be offered information about available low vision rehabilitation. Eye physicians would be encouraged to communicate with other health care providers to coordinate existing services and integrate graduated services. Enhanced communication among caregivers about the consequences of vision loss, such as depression, falls, and visual hallucinations, could help ensure that all patients who would benefit receive appropriate vision rehabilitation.

Of 224 patients referred to a low vision clinic, 74 (33%) reported visual hallucinations. Hallucinations stopped for 30% of patients after 1 year. Patients with visual hallucinations reported significantly more depression and less independence compared to patients without hallucinations.

This resource describes a simulation-based training program focused on teamwork skills for managing critical events and the effective use of perioperative emergency manuals. Emergency manuals are context-relevant sets of cognitive aids, such as crisis checklists, that are helpful for assisting clinical management during critical events and for training clinicians. In this case, both the resource and training program are geared towards the perioperative setting and operating room teams, but the concepts of why, how, and when to use emergency manuals are relevant to many areas of health care. Both crisis resource management skills and appropriate use of cognitive aids support the ultimate goal of assisting trained clinicians in delivering effective and efficient care to patients during critical events. To help other teams, we have included a complete set of resources to assist in inspiring, planning, and evaluating related training programs at their institutions. We successfully implemented this simulation training curriculum in our institution's operating rooms. In total, 126 staff participated in the training curriculum, including 64 nurses, 30 surgical technicians, 15 operating room assistants, 12 anesthesia technicians, and five staff members from other operating room roles. Following the training sessions, familiarity with the existence and format of the emergency manual increased significantly. Participants reported a greater willingness to use the emergency manual for pre-crisis educational review and as a resource for debriefing. Additionally, participants reported a significant increase in willingness to suggest the emergency manual for use during rare, refractory, and complex events. Participant satisfaction with the sessions was high, with many qualitative responses expressing desire for more trainings of this type.

Aim: To examine the association of reported visual hallucinations and measured visual parameters in adult patients referred for low vision rehabilitation. Methods: All patients (N = 225) referred to a low vision rehabilitation clinic for a calendar year were asked a standardised question about symptoms of formed visual hallucinations. Best corrected visual acuity and contrast sensitivity using the Pelli-Robson chart were measured. We conducted multiple logistic regression analysis of the association between visual hallucinations and visual parameters. Results: Of the total cohort, 78 (35%) reported visual hallucinations. Visual acuity and contrast sensitivity were considered in four quartiles. In multiple logistic regression controlling for contrast sensitivity, age, gender, report of depression and independence, measured acuity in each of the poorer three categories (compared to the best) was not associated with reported hallucinations. Contrast sensitivity in the three poorer quartiles (compared to the best) was strongly associated with the report of hallucinations (OR 4.1, CI 1.1, 15.9; OR 10.5, CI 2.6, 42.1; OR 28.1, CI 5.6, 140.9) after controlling for acuity, age, sex, depression and independence. Conclusions: Lowest contrast sensitivity was the strongest predictor of reported hallucinations after adjusting for visual acuity.

Importance To facilitate comparative clinical outcome research in low vision rehabilitation, we must use patient-centered measurements that reflect clinically meaningful changes in visual ability. Objective To quantify the effects of currently provided low vision rehabilitation (LVR) on patients who present for outpatient LVR services in the United States. Design, Setting, and Participants Prospective, observational study of new patients seeking outpatient LVR services. From April 2008 through May 2011, 779 patients from 28 clinical centers in the United States were enrolled in the Low Vision Rehabilitation Outcomes Study. The Activity Inventory, a visual function questionnaire, was administered to measure overall visual ability and visual ability in 4 functional domains (reading, mobility, visual motor function, and visual information processing) at baseline and 6 to 9 months after usual LVR care. The Geriatric Depression Scale, Telephone Interview for Cognitive Status, and Medical Outcomes Study 36-Item Short-Form Health Survey physical functioning questionnaires were also administered to measure patients’ psychological, cognitive, and physical health states, respectively, and clinical findings of patients were provided by study centers. Main Outcomes and Measures Mean changes in the study population and minimum clinically important differences in the individual in overall visual ability and in visual ability in 4 functional domains as measured by the Activity Inventory. Results Baseline and post-rehabilitation measures were obtained for 468 patients. Minimum clinically important differences (95% CIs) were observed in nearly half (47% [95% CI, 44%-50%]) of patients in overall visual ability. The prevalence rates of patients with minimum clinically important differences in visual ability in functional domains were reading (44% [95% CI, 42%-48%]), visual motor function (38% [95% CI, 36%-42%]), visual information processing (33% [95% CI, 31%-37%]), and mobility (27% [95% CI, 25%-31%]). The largest average effect size (Cohen d = 0.87) for the population was observed in overall visual ability. Age ( P = .006) was an independent predictor of changes in overall visual ability, and logMAR visual acuity ( P = .002) was predictive of changes in visual information processing. Conclusions and Relevance Forty-four to fifty percent of patients presenting for outpatient LVR show clinically meaningful differences in overall visual ability after LVR, and the average effect sizes in overall visual ability are large, close to 1 SD.

Background: Patients with Parkinson’s disease (PD) experience visual hallucinations, which may be related to decreased contrast sensitivity (ie, the ability to discern shades of grey). Objective: The objective of this study was to investigate if an online research platform can be used to survey patients with Parkinson’s disease regarding visual hallucinations, and also be used to assess visual contrast perception. Methods: From the online patient community, PatientsLikeMe, 964 members were invited via email to participate in this study. Participants completed a modified version of the University of Miami Parkinson’s disease hallucinations questionnaire and an online vision test. Results: The study was completed by 27.9% (269/964) of those who were invited: 56.9% of this group had PD (153/269) and 43.1% (116/269) were non-Parkinson’s controls. Hallucinations were reported by 18.3% (28/153) of the Parkinson’s group. Although 10 subjects (9%) in the control group reported experiencing hallucinations, only 2 of them actually described formed hallucinations. Participants with Parkinson’s disease with a mean of 1.75 (SD 0.35) and the control group with a mean of 1.85 (SD 0.36) showed relatively good contrast perception as measured with the online letter test ( P =.07). People who reported hallucinations showed contrast sensitivity levels that did not differ from levels shown by people without hallucinations ( P =.96), although there was a trend towards lower contrast sensitivity in hallucinators. Conclusions: Although more Parkinson's responders reported visual hallucinations, a significant number of non-Parkinson's control group responders also reported visual hallucinations. The online survey method may have failed to distinguish between formed hallucinations, which are typical in Parkinson's disease, and non-formed hallucinations that have less diagnostic specificity. Multiple questions outlining the nature of the hallucinations are required. In a clinical interview, the specific nature of the hallucination would be further refined to rule out a vague description that does not indicate a true, formed visual hallucination. Contrary to previous literature, both groups showed relatively good contrast sensitivity, perhaps representing a ceiling effect or limitations of online testing conditions that are difficult to standardize. Steps can be taken in future trials to further standardize online visual function testing, to refine control group parameters and to take steps to rule out confounding variables such as comorbid disease that could be associated with hallucinations. Contacting subjects via an online health social network is a novel, cost-effective method of conducting vision research that allows large numbers of individuals to be contacted quickly, and refinement of questionnaires and visual function testing may allow more robust findings in future research. [Interact J Med Res 2014;3(1):e1]

PURPOSE AMD results in loss of central vision and a dependence on low-resolution peripheral vision. While many image enhancement techniques have been proposed, there is a lack of quantitative comparison of the effectiveness of enhancement. We developed a natural visual search task that uses patients' eye movements as a quantitative and functional measure of the efficacy of image modification. METHODS Eye movements of 17 patients (mean age = 77 years) with AMD were recorded while they searched for target objects in natural images. Eight different image modification methods were implemented and included manipulations of local image or edge contrast, color, and crowding. In a subsequent task, patients ranked their preference of the image modifications. RESULTS Within individual participants, there was no significant difference in search duration or accuracy across eight different image manipulations. When data were collapsed across all image modifications, a multivariate model identified six significant predictors for normalized search duration including scotoma size and acuity, as well as interactions among scotoma size, age, acuity, and contrast (P < 0.05). Additionally, an analysis of image statistics showed no correlation with search performance across all image modifications. Rank ordering of enhancement methods based on participants' preference revealed a trend that participants preferred the least modified images (P < 0.05). CONCLUSIONS There was no quantitative effect of image modification on search performance. A better understanding of low- and high-level components of visual search in natural scenes is necessary to improve future attempts at image enhancement for low vision patients. Different search tasks may require alternative image modifications to improve patient functioning and performance.

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

Vision loss that cannot be corrected medically, surgically, or by refractive means is considered low vision. Low vision often results in impairment of daily activities, loss of independence, increased risk of fractures, excess health care expense, and reduced physical functioning, quality of life, and life expectancy. Vision rehabilitation can enable more independent functioning for individuals with low vision. The Centers for Medicare and Medicaid Services recognizes the importance of rehabilitation for achieving medically necessary goals but has denied Medicare coverage for vision assistive equipment that is necessary to complete these goals, although they provide coverage for assistive equipment to provide compensation for other disabilities. We believe that this is discriminatory and does not comport with congressional intent. The Centers for Medicare and Medicaid Services should provide coverage for vision assistive equipment, allowing beneficiaries with vision loss to benefit fully from Medicare-covered rehabilitation to achieve the cost-effective results of these services.