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Saudi Journal of Ophthalmology, Volume21, No. 3, July September 2007

Review Article
Low Vision Rehabilitation and Diabetic Retinopathy
Sarfaraz A. Khan, MD
Abstract
Diabetic retinopathy is emerging as a major cause of blindness. Diabetic retinopathy calls for a multidisciplinary
to the patients. Management of the patient requires a team work by the internist, diabetologist, dietician, oph-
thalmologist and low vision therapist. Diabetic retinopathy very often results in vision loss. It is important for
ophthalmologists to recognize the importance of low vision rehabilitation in formulating appropriate treatment
strategies. People with vision loss due to diabetic retinopathy usually experience difficulty in daily life. Most
people with diabetic retinopathy (who have remaining useful vision) can be helped with low vision devices.
However, often one low vision device may not be suitable for all purposes. A comprehensive low vision evalua-
tion is required to assess the persons current visual status, identify the goals and visual needs, and then design an
individualized vision rehabilitation program to meet these needs.
Key Words: diabetic retinopathy, vision loss, low vision rehabilitation
L
ow Vision is a bilateral impairment of vision that
significantly reduces the functioning of the indi-
vidual and cannot be adequately corrected with medi-
cal or surgical therapy, conventional eyewear or con-
tact lenses. The World Health Organization (WHO)
estimates that more than 180 million people world-
wide have diabetes. This figure is likely to more than
double by 2030.
1
There is a high potential for vision
loss in persons with diabetes, and approximately two-
thirds of diabetics are likely to have vision loss after 35
years of diabetes. Diabetic retinopathy very often re-
sults in low vision and it is 25 times more likely to lead
to blindness than other conditions.
2
Low vision rehabilitation services do not curelow
vision; rather, they utilize the remaining vision to its
fullest potential. Low vision does not replace the need
for other concurrent treatments such as surgery or medi-
cal care.
Diabetic Retinopathy
3
Diabetes is unique in that it can cause visual loss
in all three categories-media opacity, central field loss
and peripheral field loss. Diabetics are at greater risk of
developing other eye diseases, including cataract and
glaucoma. Risk of heart disease, stroke and neuropa-
thy also add more complexity to their treatment and
vision rehabilitation. There are several ways that dia-
betes contributes to visual dysfunction:
Cloudy Media in Diabetes
RefractiveChanges: Fluctuating blood sugars cause
the lens to swell, resulting significant changes in refrac-
tive error. This is a common problem before the initial
diagnosis, and patients may notice frequent changes in
their prescriptions in a matter of days or weeks. Once
sugars are controlled, this is usually not a problem, but
occasionally patients report ongoing fluctuations in vi-
sion. While annoying, this does not, itself, cause irre-
versible damage. Patients should be advised to have re-
peated refractions and not to change their glasses until
blood sugars have been stabilized for months.
Vitreous Hemorrhage: Retinal ishemia causes
neovascularization that can lead to vitreous hemorrhage.
Correspondence to Sarfaraz A. Khan, MD, Dirctor, Low Vision Services,
Ebsar Foundation, PO Box 4573, Jeddah 21412, Kingdom of Saudi Arabia.
Telephone: +966-2-2830001 Ext. 1603; Fax +966-2-2832265; Email:
sarfaraz@ebsar.org, sarfarazkhan.sak@gmail.com
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Saudi Journal of Ophthalmology, Volume21, No. 3, July September 2007
Mild to severe hemorrhages can occur that obstruct
vision by causing cloudy media. The blood may clear
by itself with time, or a vitrectomy may be required to
remove it.
Central Vision Loss
Macular Edema: Leaking blood vessels in the
macula can cause retinal swelling and permanent dam-
age to photoreceptors. Central vision is blurred, and a
relative scotoma results. Edema may wax and wane,
causing fluctuating vision. Treatment involves laser
photocoagulation to stop leakage and preserve vision,
although some patients do experience an improvement
as well. Laser scars in the macula may affect both acu-
ity and contrast sensitivity. Further more all patients
with macular edema do not necessarily develop im-
proved vision following treatment.
Peripheral Vision Loss
Retinal Detachment: In severe cases of prolifera-
tive diabetic retinopathy, tractional retinal detachments
may occur and cause complete blindness if left un-
treated. Treatment in these cases is very difficult.
Panretinal photocoagulation, although necessary, may
affect vision as well. Decreased peripheral retinal sen-
sitivity may result, causing poor peripheral vision, de-
creased contrast sensitivity and possible mobility prob-
lems at night. People with low vision due to diabetic
retinopathy usually experience loss of sharpness or acu-
ity, but may present with a loss of field of vision, light
sensitivity, loss of contrast and metamorphopsia.
Visual Problems
A person with low vision due to diabetic retin-
opathy usually experience difficulty in daily life. They
may see dark spots or have restricted side vision due to
decreased contrast sensitivity as a result of scatter laser
treatment, which prevents them from being indepen-
dent. Laser surgery may also slightly reduce your color
and night vision. Some common problem areas are:
1. Seeing faces or reading bus numbers from a dis-
tance
2. Reading fine newsprint, mails, or bills
3. Writing in a straight line
4. Reading low contrast material
5. Increased intolerance to light
6. Inability to move about alone outdoor after dusk
7. Locating food in a plate
8. Seeing the time on a wristwatch
9. Differentiating between coinsof similar dimensions
10. Seeing in dim illumination
Low Vision Management
Special problems unique to diabetes patients are
the following:
1. Reading insulin syringe and medicine labels
2. Loss of tactile sensation leading to difficulty with
learning Braille.
3. Insulin dependent diabetic patients may go into
hypoglycemia due to stress during rehabilitation
program mobility training or learning to use
devices. Hence the training program should be
in short sessions with frequent intervals.4
4. Diabetic patients are prone to injury to feet due
to bumping in reduced illumination and poor
contrast.
Enhancing Impaired Vision
Impaired vision can be enhanced in a variety of ways.
Magnification isthe most obviousand common method.
Improving the lighting not only adds to the effective-
ness of magnification but also enhances contrast. The
progressive nature of the disease and the effects of ongo-
ing treatment influence the prescription of low vision
optical devices. Ideally prescription should be postponed
until some stability is achieved. However, one should
not neglect the patients needs. The biggest disservice is
to continually postpone help because vision may im-
prove or another treatment may be planned by the oph-
thalmologist. Patients should understand that the na-
ture of their fluctuations and progression may require
frequent follow-up and optical device change.
Low Vision Evaluation
Briefly, low vision evaluation includes history, re-
fraction, functional vision assessment, determination
of magnification and prescription of devices, regular
follow-up and finally making appropriate referrals to
other services if required. The relevant rehabilitation
services include instructions in device use, activities of
daily tasks, orientation and mobility, patient educa-
tion, counseling, educational and vocational guidance.
Prescribing Low Vision Devices
Asa rule, expensive optical devicesare not prescribed
for the diabetic with proliferative retinopathy, particu-
larly if there is a history of recurrent hemorrhages. The
good news is that most people with diabetic retinopathy
(who have remaining useful vision) can be helped with
low vision devices such as spectacle devices, stand mag-
nifiers, hand magnifiers, absorptive lenses, adaptive de-
vices like closed circuit television systems (CCTV), com-
puter software magnification and screen readersand non-
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Saudi Journal of Ophthalmology, Volume21, No. 3, July September 2007
optical devices. However, these patients also needed
counseling for adjustment to the vision loss and instruc-
tional training in independent living.
Optical Devices
4-7
SpectacleMagnifiers (Figure1A & 1B)
Patientswith moderate vision lossmay benefit from
binocular half-eye prism glasseswith base-in to aid in con-
vergence or simple low add spectacle devicesin powersof
6 or 8 diopters. Patientswho have undergone photoco-
agulation may achieve periodsof relatively stable vision
and may be given moderate addsto use during their re-
missions. It must be recognized that patientswith macu-
lar edema may require repeated photocoagulation treat-
mentsasnew microaneurysmsand intraretinal microvas-
cular abnormalitiesmay develop. Furthermore, all patients
with macular edema do not necessarily develop improved
vision following treatment. Spectacle devicesconsist of
convex high power lenses(lenticular design); the reading
material hasto be held close to the face at the focal dis-
tance of the lens. The major advantage isthat they are
psychologically more acceptable and ideal for long term
reading tasks. The disadvantage isthat some patientsare
not comfortable with the close/ fixed reading distance and
difficult to use in patientswith eccentric viewing.
Hand Magnifier (Figure2A)
Hand magnifier also uses convex lenses mounted
with a handle are useful for short-term reading tasks.
They are generally inexpensive and readily available in
the market. However, they may be slow and uncom-
fortable for prolonged reading and less effective for pa-
tients with limited dexterity or with hand tremors.
FoldablePocket Magnifier (Figure2B)
Foldable pocket magnifier are useful for spot read-
Figure 1A and B. Spectacle Magnifiers
Figure 2A. Hand magnifiers; B, Pocket magnifiers
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Saudi Journal of Ophthalmology, Volume21, No. 3, July September 2007
ing, such as bills, medicine or price labels during shop-
ping they are easy to carry.
Stand Magnifier (Figure3)
Stand magnifier isa fixed focusconvex lenson a rigid
mount stand set by the manufacturer to focuscloser to
the page than itsfocal distance to reduce peripheral aber-
ration. Most stand magnifiersare designed for use with
standard bifocal and/or reading glasses. They are useful
for patientswith hand tremorsand in patientswith con-
stricted visual field asthey provide greater stability.
DistanceTelescopes (Figure4)
As per our experience the distance vision telescopes
are rarely preferred in diabetic patients and this could
be due to cosmetic blemish. They could be prescribed
as hand held or spectacle mounted.
GlareControl Devices (Figure5)
Glare is distracting scattered light, which is a sig-
nificant problem for patients with low vision. Glare
Figure 3. Stand magnifiers Figure 4. Distance telescope
Figure 5. Filters
can be controlled with devices such as sun wear or ab-
sorptive filters, tints and ultraviolet and anti- reflective
coatings.
Electronic Magnification
Closed Circuit Television (CCTV)(Figure 6)
CCTV provides maximum contrast and uses a cam-
era to capture the image and project it on to a television
screen. The magnification can be as high as 60 times
Non-optical Devices (Figure 7)
Patients with diabetic retinopathy have impaired
contrast sensitivity, which resultsin problemsin activities
of daily living. Simple contrast enhancing measureslike
non-optical devicescan help diabetic patientsto overcome
these problems. Non-optical devicesdo not use lensesbut
improve viewing conditionsthrough bright illumination
and contrast. Some devicesunder thiscategory are:
1. Reading Stands are better for the posture as
most optical devices have to be held at a short
reading distance.
Figure 6. Closed circuit television
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Saudi Journal of Ophthalmology, Volume21, No. 3, July September 2007
Figure 7. Non-optical devices
2. Reading lamps improve the contrast and pro-
vide focused illumination
3. Felt-tip pens have dark and thick writing that
improves the contrast.
4. Letter writers enable a person to write in a
straight line.
5. Signature guides enable a person to sign prop-
erly.
6. A notex enables a person to differentiate between
currency of various denominations.
7. Reading guide / Typoscope helps patients in lo-
calizing the text.
Computer Software Magnification and Screen Readers
Individuals that are visually impaired wanting to
use computers can use innovative softwares such as
computer magnification software (Zoom text, Magic
8.0) and screen readers (Jaws, Kurzweil) so that they
do not have to depend on vision.
Non-visual Devices and Adaptive Techniques
Sensesother than vision are used to perform daily
activities. Examplesof non-visual devicesinclude talking
books, tape recorders, talking wrist watchesand calcula-
tors, folding and support canes, and tactile markings.
Viewing Techniques
Eccentric viewing or looking at the side of an ob-
ject instead of directly is an adapted viewing useful.
Orientation and Mobility Training
Many people with diabetic retinopathy find it dif-
ficult to navigate independently, especially in unfamil-
iar areas. This is especially true of people who have
undergone extensive panretinal photocoagulation. They
can be taught to use the cane so that they need not
depend upon others.
Specific Management
1. Numerous insulin-loading devices are available
to help insulin-dependent patients with low vi-
sion. Large-print and talking blood glucose
monitors are available and most no longer re-
quire color matching.
2. Protective shoes
3. Control of Blood Sugar: Regular follow-up with
physician and ophthalmologist. Most often one
low vision device may not be suitable for all pur-
poses. A comprehensive low vision evaluation is
required to assesses the persons current visual
status, identify the goals and visual needs, and
then design an individualized rehabilitation pro-
gram to meet these needs.
Tips & Tricks
Use the lowest possible magnification to solve the
required visual task. Select the design of the low vision
device (i.e., hand-held, stand, etc.) appropriate to the vi-
sual task. Different low vision devicesneed to be used for
different visual tasks. No single low vision device can of-
fer a solution for all eye conditionsand all visual tasks.
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