Low Vision Rehabilitation in AMD: What Helps

Low vision rehabilitation in AMD helps patients who have lost central vision to use the vision they have left.

It can restore independence even when no treatment can improve acuity.

Many patients are told that nothing more can be done, when a referral to rehabilitation would help.

Ophthalmologists can also make the difference by raising the subject early.

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Why Low Vision Rehabilitation in AMD Matters

Advanced AMD affects reading, recognizing faces, driving, and daily tasks, and it is a common cause of depression and social withdrawal.

Peripheral vision is usually preserved, so patients can learn to use the remaining retina.

Rehabilitation improves reading ability and quality of life in trials, even though it does not change the eye (see age-related macular degeneration).

Low Vision Rehabilitation in AMD: What Services Include

• Assessment: measurement of acuity, contrast sensitivity, reading speed, visual fields, and functional goals
• Optical aids: handheld and stand magnifiers, spectacle-mounted magnifiers, telescopes for distance, and prisms
• Electronic aids: video magnifiers, tablets and phones with magnification, text-to-speech tools, and smart glasses
• Lighting and contrast: task lighting, high-contrast materials, and glare control, with tinted lenses where helpful
• Training: in the use of aids and in eccentric viewing, learning to use a spot of retina near the scotoma as a new point of fixation
• Occupational therapy and orientation: adaptations at home, safety, and mobility
• Counselling and support groups, and advice about benefits and driving

Eccentric Viewing and Preferred Retinal Locus

When the fovea is lost, patients tend to develop a preferred retinal locus, a spot of retina that takes over fixation.

Training can also help patients to find and use a good locus, usually above or to the side of the scotoma, which improves reading.

Microperimetry can help to locate a good area (see microperimetry).

Also, the process takes weeks to months, with support from a therapist.

Low Vision Rehabilitation in AMD: Evidence of Benefit

The Veterans Affairs Low Vision Intervention Trial showed that a program of low vision rehabilitation improved reading ability and function in patients with macular disease compared with a waiting list (see the references).

Systematic reviews support the effectiveness of rehabilitation services in improving function and quality of life, though the quality of studies varies.

Counselling and psychological support reduce depression and improve coping in some trials.

Charles Bonnet Syndrome

Many patients with severe vision loss see vivid visual hallucinations, with normal insight, called Charles Bonnet syndrome (see Charles Bonnet syndrome).

Reassurance and information are the main treatments.

Patients should be told in advance that it is common and not a sign of mental illness.

Low Vision Rehabilitation in AMD: When to Refer

• When the better eye has acuity of 20/70 or worse, or when the patient has difficulty reading, recognizing faces, or doing daily tasks
• When a field defect interferes with function
• If the patient has lost the ability to drive
• Early in the course, when the patient is in distress, since training works better before function has collapsed

Do not wait for the vision to reach the legal definition of blindness, since many patients benefit before that point.

Practical Steps for the Clinic

• Ask every patient with advanced AMD about reading, mobility, and mood
• Keep a list of local low vision services, charities, and support groups
• Give a simple handout about the options
• Offer a basic magnifier and lighting advice at the visit, when possible
• Screen for depression, and refer when needed
• Support the patient through the transition from active treatment to rehabilitation

Counselling

Tell patients that they will not go blind from AMD in the sense of losing all sight, because peripheral vision remains.

Encourage them to ask for help, to try different aids, and to be patient with the learning process.

Explain that the aim is function, independence, and quality of life.

Working With Other Professionals

A multidisciplinary team gives the best results, with the ophthalmologist, the low vision optometrist, the occupational therapist, the orientation and mobility specialist, and a social worker.

The ophthalmologist provides the diagnosis and the prognosis, and the other members teach skills and arrange services.

Communicate with the family doctor about mood and cognition, since depression and falls are common.

Driving and Safety

Discuss driving frankly, and know the local legal requirements for vision.

Help patients to find alternatives, such as public transport and community services, and give advice on home safety, including lighting, stairs, and contrast markings.

Talking about these issues early helps to reduce anxiety and to support independence.

Review progress at each visit, asking about reading and daily tasks, and adapt the referral if new problems arise.

For the latest studies, see the PubMed results for low vision rehabilitation in AMD.

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References

1. Stelmack JA, Tang XC, Reda DJ, et al. Outcomes of the Veterans Affairs Low Vision Intervention Trial (LOVIT). Arch Ophthalmol. 2008;126:608-617.
2. Binns AM, Bunce C, Dickinson C, et al. How effective is low vision service provision? A systematic review. Surv Ophthalmol. 2012;57:34-65.
3. Ryan SJ, Schachat AP, Wilkinson CP, et al, eds. Retina. 6th ed. Elsevier; 2018.
4. American Academy of Ophthalmology. Basic and Clinical Science Course, Section 3: Clinical Optics and Vision Rehabilitation. AAO; current edition.