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340 Occupational therapy and low vision—Markowitz

Occupational therapy interventions in low vision rehabilitationMichelle Markowitz, MSc OT

ABSTRACT • RÉSUMÉ

Low vision can significantly decrease a person’s functional ability and independence.With the continuing risein age of our population, the number of people with low vision will increase substantially. Restoring andmaintaining their ability to function independently through the use of specific interventions is an intricateprocess that calls for the collaboration of various health care professionals. Occupational therapists (OTs) andoccupational therapy assistants are essential members of the multidisciplinary rehabilitation team providingsuch interventions. OTs in low vision rehabilitation enhance performance for specific activities of daily livingby training skills that are dependent on residual vision, such as reading and writing. OTs also conductenvironmental assessments in the home and in the workplace or school to improve and promote a safeenvironment for patients with low vision. OTs may also assist in developing rehabilitation programs fororientation and mobility, driving, and vision rehabilitation therapy. To prepare for the future needs of the ageingCanadian population, more low vision rehabilitation practitioners and more funding for multidisciplinaryrehabilitation programs are required.

La déficience visuelle peut réduire considérablement le fonctionnement et l’autonomie d’une personne, et lenombre des malvoyants augmente parallèlement au vieillissement de la population. Le redressement et lemaintien de l’autonomie de ces personnes par des interventions spécifiques sont un processus complexe quidemande la collaboration de divers professionnels de la santé. Les ergothérapeutes (ET) et les aides energothérapie forment une composante essentielle de l’équipe multidisciplinaire de réadaptation qui fait detelles interventions. L’ergothérapeute œuvrant en réadaptation visuelle améliore l’exécution des activités dela vie courante par le développement d’aptitudes que permet le déficit visuel. L’ergothérapeute évalue aussil’environnement du foyer, du lieu de travail ou de l’école afin d’y améliorer la sécurité des patients malvoyants.Il ou elle peut procurer de l’aide additionnelle en élaborant des programmes de réadaptation en matièred’orientation, de mobilité, de conduite automobile et de soins de réadaptation visuelle. Pour être en mesurede répondre aux besoins futurs de la population vieillissante du pays, on aura besoin d’accroître les effectifsen réadaptation visuelle ainsi que le financement des programmes multidisciplinaires de réadaptation.

INTRODUCTION

We rely on sight to function in daily life; for many,it is perhaps the most important sense of all.

Impaired vision therefore makes many daily tasks, suchas driving, reading the newspaper, and navigating one’senvironment, difficult or impossible. Approximately2.7 million Canadians over the age of 65 will experiencesevere vision loss.1

Low vision (LV), defined as vision that cannot be corrected by standard glasses or by medical or surgicalintervention, can result from age-related maculardegeneration (AMD), cataracts, glaucoma, or diabeticretinopathy. More than 2 million Canadians over theage of 50 have some form of AMD, and in 25 years

that number could triple.2 With the predicted increasein the older population, the number of individuals withLV will rise substantially.

LV can have a negative impact on quality of life byreducing functional ability and independence. Overtime, people with LV find it increasingly difficult to par-ticipate in activities of daily living (ADLs) such asreading and writing, although there may be little or noimpact on such skills as bathing and dressing. LV canalso substantially increase the risk for falls and injuriesleading to disability and placement into institutionalcare. Since a significant proportion of older adults preferto remain in their homes, helping seniors preserve theirindependence and quality of life while maintaining theirsafety becomes a priority.3

The author is in private practice in Toronto, Ont.

Originally received Sep. 1, 2005Accepted for publication Mar. 7, 2006

Correspondence to: Michelle Markowitz, MSc OT, 1225 Davenport Rd.,Toronto ON M6H 2H1; [email protected]

This article has been peer-reviewed.

Can J Ophthalmol 2006;41:340–7

Occupational therapy and low vision—Markowitz

CAN J OPHTHALMOL—VOL. 41, NO. 3, 2006 341

Restoring and maintaining the functional ability andindependence of a person with LV is an intricate processthat requires a multidisciplinary effort and involves thecollaboration of a number of different health care pro-fessionals. Occupational therapists (OTs) are importantand essential participants of this multidisciplinary reha-bilitation team.

The person with LV has typically been diagnosed andtreated by an ophthalmologist or optometrist andreceived the appropriate medical or surgical interven-tions available. When these treatments are concluded,the rehabilitation process begins, often with a formallow vision assessment (LVA) performed by an ophthal-mologist or optometrist with a special interest in lowvision rehabilitation (LVR). The purpose of the assess-ment is to document and quantify residual visual func-tions and skills as well as to assess the willingness of thepatient to participate in a LVR program. Once a patienthas been referred to such a program, it is the duty of themultidisciplinary rehabilitation team to ensure thecooperation and active participation of the patient inthe entire rehabilitation process.

On the basis of the LVA, the LV specialist can pre-scribe devices to enhance residual visual functions, orvision rehabilitation therapy (VRT) to enhance occupa-tional performance of residual skills, or frequently both.LV devices include magnifying spectacles, telemicro-scopes, hand magnifiers, stand magnifiers, electro-optical magnifiers such as closed-circuit televisions(CCTV) and telescopes, and nonoptical devices such ascolor filters or illumination devices.4 A dispensing opti-cian can manufacture or arrange to provide to thepatient the devices that have been prescribed and caninstruct the patient in their use, according to the pre-scriber’s or manufacturer’s instructions.

The provision of rehabilitation training plans with orwithout devices falls within the domain of the multidis-ciplinary rehabilitation team of which occupationaltherapy is a member. Occupational therapy as a profes-sion has the expertise to devise and implement rehabili-tation plans that improve a person’s ability to participateand function independently in all aspects of daily life,including work, self-care, and leisure activities.5 The roleof the OT in the multidisciplinary rehabilitation team ismultifaceted. It encompasses environmental assessmentsin the home, workplace, and school to improve environ-mental factors detrimental to the patient, such as glareor contrast. It includes training residual vision-relatedskills to improve function and enhance performance forspecific ADLs. The OT can also provide instruction inthe use of adaptive strategies and is a source of informa-tion regarding available community resources.6

LVR, although an integral part of the surgical andmedical specialty of ophthalmology, is in essence and byconcept a rehabilitation subspecialty following all prin-ciples of rehabilitation medicine. As such, any contem-plated and prescribed intervention is based on and startswith the selection of a rehabilitation task most impor-tant to the patient at that time. To succeed, such inter-ventions need the full and active cooperation of thepatient. OTs can prepare and implement plans for reha-bilitation of residual vision-related skills such as reading,writing, and others, and they may give important inputin planning rehabilitation of orientation and mobility(O & M) and driving. The focus of this paper is to reviewand discuss the methods and inputs OTs can use inrehabilitation of these skills.

INTERVENTIONS IN LOW VISION REHABILITATION

Reading

The goal for rehabilitation of reading skills in apatient with LV is to enable readers to retain functionalliteracy, not only to live daily life independently but alsofor enjoyment purposes.7 The importance of being ableto read in order to function in daily life cannot beoveremphasized.

In the absence of professional help, many LV patientsdevise adaptive and sometimes ingenious strategies tocompensate for lost reading skills. Many rely on othersenses such as hearing and touch or upon help fromfriends and family to substitute for missing readingskills. For example, a person with LV may use tactilemarkers on the stove dial and use their sense of touch todetermine various heat positions when cooking.8 Manylisten to books on audio tapes instead of reading. Somemay call a friend to accompany them to the grocerystore and read out items on a list that need to be pur-chased. Such adaptive methods significantly improvethe independence of a person with LV. With profes-sional rehabilitation training of residual visual skills, it ispossible to support this independence and even restorefunctional reading skills.

Initially and in principle, the fundamental visual skillsrequired for reading need to be retrained. Techniquesfor enhancing performance are used to retrain fixationstability, saccades, and tracking eye movements.9 Onesuch exercise instructs the patient while seated to hold aflashlight at arms length from their face. While keepingtheir head still, the patient uses their eyes to follow theflashlight horizontally, diagonally, and vertically.Circular movements are done as well. A different exerciseinstructs the patient to maintain the flashlight station-ary at arms length from their face. While fixating their


342 CAN J OPHTHALMOL—VOL. 41, NO. 3, 2006

eyes on the flashlight, the patient swings their head inthe same directions as in the first set of exercises. Theseexercises train smooth and accurate eye movements andfacilitate fixation stability on distant targets.10,11

To increase the speed and accuracy of saccadic fixa-tion, Warren’s exercises can be used for training.12 Thepatient is presented with 2 vertical columns of lettersthat are situated on opposite ends of the page. Thepatient is instructed to read the letters aloud following atypical reading sequence. The patient starts reading thefirst letter in the left column and then reads the firstletter in the right column, continuing to the secondletter of the left column, followed by the second letter ofthe right column. The patient continues to read theletters in each column until the bottom of the page isreached. A second exercise in Warren’s workbook thatcan be presented to the patient contains several rows ofrandom letters. In each row, 2 or 3 letters are under-lined. The patient is instructed to read aloud only theunderlined letters. An advantage of Warren’s exercisesfor saccadic training is that the exercises are provided invarious print sizes so that patients with a range of visualacuities from 20/70 to 20/200 can be trained. Otherreading rehabilitation programs with documented suc-cessful outcomes are those that incorporate eccentricfixation with the steady-eye strategy. With such exer-cises, the text is scrolled past the eyes rather than theperson making eye movements.13

Components of the King-Devick test (KDT) fordetermining pediatric oculomotor functions are toolsone can use with adults when retraining fixation stability,saccades, and tracking eye movements.14 The purpose ofusing the KDT in adult LVR is to provide sets of home-work exercises in a similar way one uses pediatric texts forreading training in adults. The testing cards that are partof the KDT can be enlarged to an appropriate print sizeto match the training needs of an LV population.15 TheKDT consists of 1 demonstration card and 3 test cards.The demonstration and test cards, which become pro-gressively more difficult, contain several rows of randomnumbers. In the demonstration card, the patient is pro-vided with arrows indicating the direction to followwhen completing one row and switching to the next row.In the third test card, there are no clues provided and thespacing between rows has been minimized. The patientis instructed to read the numbers printed on the cards asif reading continuous print. A shortcoming of thismethod is that after practicing their ocular motility skillsusing the KDT cards, over time patients can memorizethe numbers on each card, making it difficult to measureimprovement in eye tracking skills; in such cases, addi-tional methods are needed to measure progress.

Training for eccentric viewing and scotoma awarenessand for using a preferred retinal locus (PRL) are the nextsteps in the rehabilitation process. Macular damageresulting in the formation of a scotoma in the visualfield can make tasks requiring high acuity, like reading,extremely difficult. To circumvent this disability, thePRL develops in the peripheral retina and takes over thefunction of the damaged fovea.7 It is not uncommon forpatients to develop more than one PRL. Training onePRL at a time allows the patient to concentrate on themore challenging skill of learning to view eccentrically.“Reading with the peripheral part of the visual field …is different from reading with the fovea not only becausethe visual acuity is lower than at the fovea but alsobecause adaptation of the oculomotor system is neces-sary to accurately search for, position and stabilize textat a nonfoveal location.”16 Once the patient is comfort-able with the trained PRL, they can choose to train asecond PRL if necessary.

There is no consensus on the criteria for selecting thebest eccentric viewing area and there is an inconsistentstandard of practice among practitioners when it comesto efficacy, effectiveness, and cost–effectiveness of train-ing for eccentric viewing.17 Wright and Watson18

describe a method to train for scotoma awareness andeccentric viewing. Variations of their method are usedtoday in clinical practice and one is given below. Thepatient is presented with a board containing a largeclock placed approximately 1 m from their face. Over eachnumber on the clock is a large letter and in the centre ofthe clock there is a picture of a face. The patient looksdirectly at the picture of the face and notes which fea-tures they are or are not able to see. Once the patient isaware of the location of their scotoma they are trainedto view eccentrically. The patient is instructed to lookdirectly at the picture of the face and then switch theirgaze to the letter in the twelve o’clock position. As theyare looking at the letter in the twelve o’clock position,they are instructed to notice the face in their lowerperipheral vision. The patient then compares this viewto the direct view of the face. As the patient continuesto view the face from different positions on the clockthey continually evaluate how well they see the facewhen looking directly at it or when viewing it eccentri-cally. The goal is for the patient to become aware oftheir scotoma as well as identify 1 or 2 eccentric viewingpositions from which they can see an object of interestmore clearly.

In the next stage of the rehabilitation process, thepatient learns to apply these skills while reading. Blackprint on white paper is used for optimal contrast levels



to facilitate ease of reading. Print size and word lengthare two important variables that must be considered asthe patient’s reading ability improves. To enable thepatient to become familiar and comfortable with theirpreferred eccentric viewing position, large print is usedfirst. As the patient masters the ability to read largeprint, smaller print is substituted, until ideally mostpatients will reach a print size comparable to that usedfor reading a newspaper. For word length, the patient istrained initially to read single letters. Starting withsingle letters allows the patient to become reacquaintedwith all the details of a letter when viewed eccentrically.Upon mastery of letters and numbers, words of increas-ing length are presented, until the patient is comfortablereading words of all lengths and continuous text.

The final rehabilitation aspect for reading skills istraining to improve comprehension. In addition toincreasing reading speed, improved comprehensionallows increasing complexity of the text and provides amethod for comprehensive rehabilitation of readingskills. Wright and Watson’s workbook, which is a com-plete reading rehabilitation program, includes readingexercises to improve comprehension.18

Finally, consideration needs to be given to otheraspects of rehabilitation related to reading. Illuminationof the text is an important factor for rehabilitationsuccess. Incandescent frosted 60 watt bulbs, preferablypositioned behind the reader on the side of the better-seeing eye, may be useful for reading tasks with orwithout devices. Full-spectrum lights may also behelpful to certain individuals. External lighting usedwith a device may create more glare and in most cases isnot useful. Ergonomic considerations such as seatingarrangements for the patient and positioning of thereading text in front of the reader must be addressed bythe OT to reduce patient fatigue.

A reading rehabilitation program is incomplete if noattempt is made to transfer newly trained skills intodaily life. Once continuous text with optimal contrast ismastered, the patient must practice daily, reading mate-rial of equal or poorer contrast. For example, manypatients express the desire to read the newspaper whileothers long to read prayer books, menus, magazines,bills, or letters from family and friends. These materialsare reviewed with patients to improve function andindependence.

Writing

The ability to write is essential for daily function. Forexample, day-to-day tasks such as balancing finances,recording notes while at work, or simply making a to-dolist require the ability to write, yet for individuals withLV, writing is a skill that becomes challenging.

Common complaints include not being able to seewhere the pen or pencil is being placed on the line, notseeing the line itself, and not being able to read whatwas written due to poor legibility. To rehabilitatewriting skills, it is important for the clinician to under-stand the basic components that make up writing.

Writing requires a combination of visual, motor, andcognitive skills. The visual system allows the writer toidentify where the writing will occur and to scan whathas been written. Gross motor skills such as adequatetrunk posture for forearm stabilization and proper arm,wrist, and hand coordination are required. Essential finemotor skills include ample small muscle developmentfor hand and finger dexterity to properly hold writingtools and correctly form letters and numbers. Cognitiveskills are necessary to concentrate on the task at hand,express oneself accurately, and comprehend what hasbeen written. Since writing is a combination of visual,motor, and cognitive skills, visual motor skills are fun-damental to the process. Eye–hand coordinationinvolves the ability to visually track the pen as the handmoves it. Visual–perceptual skills are important for rec-ognizing forms and the relationships between forms.19,20

Since reading is an important aspect of the writingprocess, it is logical to first train the patient’s residualvision skills for reading purposes as described in the pre-vious section. Once the patient has sufficient readingability, visual motor skills, specifically eye–hand coordi-nation, are trained to enable the patient to track thepen.19 Training can begin with gross eye–hand coordi-nation skills. The patient is presented with large blocksand instructed to stack 1 block on another in a verticalfashion. The task is then made progressively more chal-lenging. For example, at the start the patient may stack3 large rectangular blocks using the widest surface area.By the end of the task, the patient may stack 6 small rec-tangular blocks using the narrowest surface area.Additional eye–hand coordination tasks include stack-ing dice, pouring fluid into containers with progres-sively smaller openings, and threading thick stringthrough large spools.

In the next part of eye–hand coordination training,the patient learns to place the tip of the pen in a specificlocation.19 For example, the patient may be required tocolor in various shapes without going “over the lines.”Crossword puzzles and fill-in-the-missing-letter wordproblems are also used to train the patient to place theirpen in an intended location.19 The skill of correctlyplacing the tip of the pen in a desired location is con-tinuously reinforced as the patient copies letters andnumbers of various sizes.



The next visual motor skill to be trained is tracing.Tracing involves the patient’s visual ability to track thepen as it is steered by the hand.19 Examples of trainingexercises include tracing various shapes, connecting thedots, and circling words in word-search puzzles. Thepatient must learn to combine eye–hand coordinationand tracing skills to write. As these skills develop, thepatient is trained to copy short words followed bylonger words and eventually sentences on lined paper.Various print sizes are trialed to determine which size isnot only the most comfortable but also the most legiblefor the patient. Like reading rehabilitation, transferringskills into daily life is essential. Patients can apply whatthey have learned while writing cheques, making lists, orwriting thank-you notes.

Driving

The ability to drive a motor vehicle often plays asignificant role in an independent lifestyle. This is espe-cially true for people who are not within walking dis-tance of their bank, grocery store, or work, and who livein communities where public transportation is not anoption. An individual with low vision may not only finddriving to be a daunting task but more importantly theymay not be allowed to drive due to provincial legisla-tion. Within Canada, patients with low vision are notpermitted to drive while using an assistive device.According to the driving recommendations of theCanadian Ophthalmologic Society, “there are signifi-cant problems associated with [the] use [of low visionaids] in driving a motor vehicle. These include loss ofvisual field, magnification causing apparent motion andthe illusion of nearness. It is felt, therefore, that the useof such aids is incompatible with safe driving.”21

Driving standards within the United States varybetween states, and many American jurisdictions permitpatients with LV to use an assistive device such as a tel-escope while driving.22

For those individuals with LV who can demonstrateand maintain a legally acceptable driving performanceon the road with their current residual visual acuity and(or) visual fields, it is important that they receive appro-priate training before returning to driving for their ownsafety as well as the safety of their fellow motorists andpedestrians. Driving is a complex task that depends oncombined functioning of visual, motor, and cognitivesystems. For the person with LV to drive safely, rehabil-itation should attempt to maximize all residual visualfunctions such as visual fields, visual acuity, contrastsensitivity, glare control, color perception, binocularityand stereopsis.23 Many of these skills are managed by theLV specialist. For example, optical devices can be used

to improve distance vision and binocularity, while lenscoatings and filters reduce glare and enhance contrast.Prisms can be used to shift the object of interest so it isobserved in an area of the retina that is functioning, andto expand the visual field and improve binocularity.4,10,24

OTs rehabilitate driving skills by training the patient’soculomotor, spotting, scanning, and eye-hand-footcoordination skills. Spotting techniques are required totrain the patient to fixate and maintain fixation usinghis PRL on a stationary or moving object while thepatient is either stationary or moving. Recommendedmethods to train this skill include having the patientlook at a stationary object on a wall or a moving objectwhile in a stationary position. As the task becomes easierthe patient can practise spotting while they themselvesare moving.10 Separate training is required for spottingand viewing distance targets with telescopes. Thepatient must also be trained to scan their environmentso that they are aware of their full visual field. Onemethod places colored stickers or pictures on thecorners of an object and trains the patient to look at allcorners before proceeding with the object. For example,the patient must look for stickers at all 4 corners of afood tray before proceeding to eat.10 This method canthen be applied to the front windshield of the car wherethe patient is repeatedly trained to scan within andoutside the boundaries of the windshield. The intendedoutcome is that the patient will actively scan their envi-ronment without any external cues.10

The ability to perceive color is another skill neededfor safe driving. Road signs with specific colors andshapes warn drivers of upcoming road conditions or sit-uations. Hazard signs are always triangular and yellow;danger signs are always red. Training with repeat reviewsof various road signs that can be encountered is onemethod that can be used to compensate for a lack ofcolor perception. Ultimately the patient will increasethe rate at which they respond to the signs without nec-essarily having to rely on their ability to perceive color.Such a method of training works also to develop thevisual memory skills of the driver.10

Another aspect of the driving rehabilitation programthat usually falls within the domain of driving rehabili-tation specialists and driving instructors includes expos-ing the patient to various driving conditions. Thepatient needs to practice driving under different lightingconditions, on different roadways, with different speedlimits, and with different levels of noise, for example,loud conversation or the radio.23

In addition to these training techniques used toimprove residual vision skills for driving, the patient



must also be encouraged to visit their LV specialist on aregular basis to ensure that they maintain the visualcapabilities for driving and are not endangering otherswhile on the road.

Orientation and mobility

The ability to navigate independently through one’senvironment is crucial for daily function. Walking, stairclimbing, and balance rely heavily on the visualsystem.25 In individuals with LV, O & M are signifi-cantly affected. “Orientation is a process by which posi-tion is established within the environment, and mobil-ity is the capacity to move about.”26 Visual skills thatplay an important role in mobility include visual acuity,contrast sensitivity, and field of view. Orientationwithin the environment is maintained and organized byinternal cognitive maps that were initially developed bythe visual system. Visual landmarks are also commonlyused to orient oneself to the environment.27

The O & M specialist’s primary role is to teach indi-viduals with LV how to travel safely, efficiently, andindependently. Common training techniques includelearning to use canes, sighted guides, and electronicdevices.28 Additional training methods include protectiveuse of arms, trailing techniques to travel in straight lines,and the ability to orient oneself in the environment.26

The OT can work in collaboration with the O & Mspecialist by conducting an environmental assessment ofthe individual’s home, work, and school to ensure safety.Based on the assessment, the OT can also provide rec-ommendations for modifications. Concerns for safetravel in the home and in the community are para-mount. Simple adaptations for safe mobility such asincreased lighting in hallways, glare control outdoors,and contrasting stripes on steps can be implementedwith relatively little effort and cost at home. The OTcan work also towards safe reintegration of the visuallyimpaired person in the community. Lighting, color, andcontrast are aspects of the environment that can beaddressed. Individuals with LV generally require anincreased amount of lighting. Each type of lighting—natural, incandescent, fluorescent and halogen—has itsown advantages and disadvantages.28 For example, someare better suited for general room lighting, others forclose work. Certain forms of lighting create shadowsand glare, while others create a significant amount ofheat. The amount of illumination produced is animportant factor as well. Lighting is specific to the envi-ronment and the task for which it is used.

Color and contrast can be used to facilitate safety andindependent participation in daily life. Colors are best

seen when they are bright, solid, and illuminated. Brightsolid colors are easiest to see because of their ability toreflect light and their high level of saturation. Thus theycan be used to indicate changes in surface levels, forexample, on stairs, as well as the location of certainitems, for example, light switches. Bright solid colorscan also be used for depth perception.27 Contrast can beused to make objects stand out and to provide cues fordepth perception. In some instances, light-coloredobjects are seen better when they are placed on a soliddark background, or dark objects on solid light back-grounds. For example, a dark handrail is better seenwhen placed on a light wall.28

EFFECTIVENESS OF OCCUPATIONAL THERAPY WITHIN

LOW VISION REHABILITATION

Little research has evaluated the effectiveness of OT inLVR, and most of the available research has focused ontraining for reading. These studies have concluded,however, that formal training in the use of opticaldevices and residual vision skills, such as eccentricviewing, is extremely effective in improving readingabilities and speed.29 In their study, Fletcher et al foundan improvement in reading accuracy and rate after only4 hours of training. Training techniques includedscotoma awareness and learning to move the scotomawith eye movements. Stabilization of eccentric viewingposition, scanning techniques, eye–hand coordinationtraining, and applying visual skills for reading were alsoreviewed and showed improvement in skills when train-ing was provided.30 In addition, research has shown thatindividuals who do not receive training in the use ofprescribed optical devices are likely to discontinue usingthem because of dissatisfaction and reported difficultiesin their use.

DISCUSSION

The functionality of the visual system is critical formaintaining independence in ADLs. Countless day-to-day activities rely on vision-based skills: reading,writing, driving, and O & M, to name a few. When lossof vision occurs, the first stage of any vision rehabilita-tion plan is an initial LVA and counselling, along withprescription of devices and brief instructions in theiruse. The essential second stage of the vision rehabilita-tion process should always be training and enhancingresidual visual function. Acquiring and practicing newvisual skills are integral to any vision rehabilitation plan.Recent research supports this understanding. As anexample, reading accuracy and rate are effectivelyimproved in LV populations with use of training



programs for reading skills. Writing rehabilitation pro-grams are also a significant part of LVR.19 Trainingresidual vision skills related to driving is crucial, partic-ularly in areas where laws permit individuals with LV todrive. Lastly, in collaboration with the O & M special-ist, environmental assessments and recommendationsfor modifications must be conducted to enable inde-pendence in daily life. Occupational therapy is the pro-fession eminently suited to deliver the services in thissecond stage of LVR. Today, proven LVR training pro-grams are available and ready for many LV conditions.Beyond specific interventions to enhance skills depend-ent on visual perception, OTs can provide compensa-tory devices and alternative visual or nonvisual strategiesfor LVR. OTs also have a role in addressing the psy-chosocial implications of vision loss, and in providinginformation to LV patients on available resources forLVR.

The reality is, however, that with few multidiscipli-nary LVR programs in use, only a comparatively narrowrange of services are in fact being delivered to the LVpopulation. A significant factor contributing to thisnarrow scope of service delivery is that “only a handfulof ophthalmologists and optometrists across Canada—few by any account—are engaged in active LVR prac-tice.”31 LVAs are covered sporadically and at minimalrates of remuneration across Canada by the variousprovincial health plans. This has a detrimental impacton practitioners interested in developing an LVR prac-tice. Therefore most Canadians do not have access toprofessional LVAs by ophthalmologists and optome-trists. With respect to training and enhancement ofresidual visual function and of newly acquired visualskills, services are typically delivered by LVR and O & Mspecialists with virtually no occupational therapyinvolvement. While LVR is part of the curriculum cur-rently taught in ophthalmology and optometry pro-grams in Canada, it is not present in the curriculum forOTs in Canada. Accordingly, it is estimated that only25% of all LV patients in Canada receive some kind ofLVR.31

Occupational therapy as a profession entered the fieldof LVR only recently, being preceded by orientation andmobility (O & M) specialists, vision rehabilitation ther-apists, low vision therapists, and teachers of the visuallyimpaired. OTs started working in LVR in the UnitedStates some time after 1990. A similar situation devel-oped in Canada with a handful of OT practitionersapplying LVR. As such, OTs in Canada do not haveeducational programs in LVR or accredited LVR train-ing leading to LVR certification nor do they have adefined scope of practice in LVR. To address this situa-

tion, in April 2006, the American OccupationalTherapy Association launched a certification in LVR forall OT practitioners. The certification outlines the stan-dards for professional competency that OT practitionersseeking to practice in the field of LVR will need todemonstrate.

The limited number of practitioners available forLVR restricts the number of prescriptions issued acrossthe country for LV devices and VRT. While someprovinces will pay for a portion or the entire cost of LVdevices, no provincial health plan covers the cost ofVRT. In provinces that do fund LV devices, additionalfunding for LV training programs should be consideredas a necessary step toward improving the independenceof this population on a long-term basis. By comparison,in the United States, occupational therapy services forfunctional deficits due to LV are covered under Medicare.6

With those on the leading edge of the baby boomgeneration now entering their sixties, demands for com-prehensive LV services will likely be rising in the yearsahead. Steps that can be taken to prepare for the future ofthe ageing Canadian population are needed, and it is clearthat this will include more LVR practitioners and morefunding for effective multidisciplinary LVR programs.

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Key words: occupational therapy, low vision, rehabilitation

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