Depression in Age-Related Macular Degeneration Patients Forgot Username

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07/09/2014 09:00:00 AM
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First clinical trial of integrated approach underlines need
for inclusion of behavior activation therapy in low vision
rehabilitation
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SAN FRANCISCO The first clinical trial to examine
integrated low vision and mental health treatment has
shown that the approach can reduce the incidence of
depression by half among people with low vision due to
age-related macular degeneration (AMD). The results of the
study were published online today in Ophthalmology, the
journal of the American Academy of Ophthalmology.
Low vision is a visual impairment that interferes with a
persons ability to perform everyday tasks and cannot be
corrected with glasses, contact lenses, medicine or surgery.
A common cause of low vision is AMD, a condition that
causes irreversible vision loss in a majority of cases. An
estimated 11 million Americans currently have AMD, and
the prevalence is expected to grow to 21.6 million persons
by 2050.[1] Up to 30 percent of those living with AMD
develop depression, which is associated with higher levels
of disability, medical costs and mortality.[2] Despite this,
many depressed persons receive no treatment because they
perceive depression as a personal failure or an expected part
of aging, they are uncertain how to access specialty care, or
their physicians lack the resources to effectively diagnose
and treat depression.[3]
Currently, the most common treatment for low vision due to
AMD is low vision rehabilitation. This treatment involves
the assessment of a patients functional vision, prescription
of assistive devices and instruction in the use of these
devices, but it does not include any form of psychological
support for the patient. To investigate the value of
integrating psychological therapy with low vision
rehabilitation, a group of researchers from the Sidney
Kimmel Medical College at Thomas Jefferson University,
Dartmouth Medical School and Johns Hopkins School of
Medicine studied 188 patients, averaging 84 years of age,
with AMD in both eyes and early signs of depression.
Named the Low VIsion Depression Prevention TriAL
(VITAL), the 2013 study first provided each participant
with two sessions of outpatient low vision optometric
rehabilitation in clinics. Then the patients were randomly

assigned to two types of psychological therapy: either six

one-hour sessions of in-home behavior activation over eight
weeks or six one-hour sessions of in-home supportive
therapy over eight weeks, which served as a control.
Behavior activation promotes self-sufficiency and social
connections to improve mood and counter withdrawal.
Delivering behavior activation in the context of low vision
occupational therapy involves environmental modifications,
such as marking specific temperatures on the thermostat
with high-contrast markers, and aims to improve functional
vision as well as help patients achieve valued personal and
functional goals. Nondirective supportive therapy facilitates
personal expression about illness, disability and vision loss.
After four months, the researchers assessed eight variables,
including depression, vision status, vision-related quality of
life, physical health status and device use, and found that
the incidence of depressive disorders was half in the
behavior activation group than of that in the supportive
therapy group (12.6 percent versus 23.7 percent,
respectively). The rate of depression found in the supportive
therapy group was also similar to that reported in the
absence of any treatment.
The risk reduction was strongest in participants with worse
vision than in participants with better vision (20 percent
versus 3.4 percent, respectively). In addition, behavior
activation was associated with improved near functional
vision, but the difference between the two groups was not
statistically different. The researchers also found that
participants who self-rated their own health lower were
associated with a higher incidence of depression regardless
of the treatment used, indicating that those with worse
health perceptions require more intensive intervention.
"Our findings demonstrate that referring patients with
AMD-related low vision for low vision optometric
rehabilitation alone does not fully meet the patients
rehabilitative needs," said Barry W. Rovner, M.D., the trials
lead researcher. "Although low vision occupational
therapists do not currently receive training in mental health
care, our results indicate that interdisciplinary care like this
could significantly help reduce the incidence of depression
in patients with AMD."
The American Academy of Ophthalmology encourages
ophthalmologists to provide information about
rehabilitation resources to patients with vision loss and,
when available, referral to multidisciplinary rehabilitation

and group support that focuses on social activation,

problem-solving and self-management skills.
The study (DOI: 10.1016/j.ophtha.2014.05.002) is available
online at www.aaojournal.org/article/S01616420(14)00422-9/abstract. The work was supported by
National Eye Institute grant U01 EY018819.
For more information about AMD, low vision and general
eye health, visit the American Academy of Ophthalmology's
public education website at www.geteyesmart.org.
The July 2014 issue of Ophthalmology, in print now,
features a number of new research reports, including:

Collagen Cross-Linking with Photoactivated

Riboflavin (PACK-CXL) for the Treatment of
Advanced Infectious Keratitis with Corneal
Melting
Corneal collagen cross-linking with ultraviolet A
light and photoactivated riboflavin may represent a
promising adjuvant therapy in the treatment of
advanced microbial keratitis associated with corneal
melting.

Rates of Retinal Nerve Fiber Layer Thinning in

Glaucoma Suspect Eyes
In glaucoma suspect eyes, faster rates of longitudinal
retinal nerve fiber layer loss as measured with
spectral-domain optical coherence tomography were
significantly associated with higher risk of
developing visual field damage.

Vision Loss and Hearing Loss in Painting and

Musical Composition
The effects of impaired vision and hearing on
painting and composing are analyzed. Poor vision
limits painting, but also complicates the writing of
music. Deafness can be circumvented through
reading music, but tinnitus is disruptive.

About the American Academy of Ophthalmology

The American Academy of Ophthalmology, headquartered
in San Francisco, is the world's largest association of eye
physicians and surgeons Eye M.D.s with more than
32,000 members worldwide. Eye health care is provided by
the three "O's" ophthalmologists, optometrists, and
opticians. It is the ophthalmologist, or Eye M.D., who has
the education and training to treat it all: eye diseases,

infections and injuries, and perform eye surgery. For more

information, visit www.aao.org.
The Academy's EyeSmart program educates the public
about the importance of eye health and empowers them to
preserve healthy vision. EyeSmart provides the most trusted
and medically accurate information about eye diseases,
conditions and injuries. OjosSanos is the Spanishlanguage version of the program. Visit
www.geteyesmart.org or www.ojossanos.org to learn more.
About Ophthalmology
Ophthalmology, the official journal of the American
Academy of Ophthalmology, publishes original, peerreviewed, clinically-applicable research. Topics include the
results of clinical trials, new diagnostic and surgical
techniques, treatment methods, technology assessments,
translational science reviews and editorials. For more
information, visit www.aaojournal.org.
[1]Rein DR, Wittenborn JS, Zhang X, et al; Vision Health
Cost-Effectiveness Study Group.
Forecasting
age-related macular degeneration through the year 2050: the
potential impact of new treatments. Arch Ophthalmol
2009;127:53340.
[2] http://www.ncbi.nlm.nih.gov/pubmed/15728748
[3]Lebowitz B, Pearson J, Schneider L, et al. Diagnosis and
treatment of depression in late life: consensus statement and
update. JAMA 1997;278:118690.
###
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http://www.aao.org/newsroom/release/depression-in-AMD-patients-with-lowvision-halved-by-integrated-therapies.cfm

Low Vision
Reviewed by Donna M. Wicker, O.D.
On this page:

What Is Low Vision?

Symptoms

Causes

Tests and Diagnosis

Treatment and Drugs

Additional Resources

Clinic Information

What Is Low Vision?

Low vision is a reduced level of vision that cannot be fully corrected with conventional
glasses. It is not the same as blindness. Unlike a person who is blind, a person with low
vision has some useful sight. However, low vision usually interferes with the performance of
daily activities, such as reading or driving. A person with low vision may not recognize
images at a distance or be able to differentiate colors of similar tones.
You are legally blind when your best corrected central acuity is less than 20/200 (perfect
visual acuity is 20/20) in your better eye, or your side vision is narrowed to 20 degrees or less
in your better eye. People who are legally blind may still have some useful vision. If you are
legally blind, you may qualify for certain government benefits. It is estimated that
approximately 17 percent of people over the age of 65 are either blind or have low vision.

Symptoms

Difficulty recognizing objects at a distance (street signs or bus signs)

Difficulty differentiating colors (particularly in the green-blue-violet range)

Difficulty seeing well up close (reading or cooking)

The symptoms described above may not necessarily mean that you have low vision.
However, if you experience one or more of these symptoms, contact your eye doctor for a
complete exam. Your eye doctor can tell the difference between normal changes which are
common with age and changes caused by eye disease.

Causes
Although low vision can occur at any stage in life, it primarily affects the elderly, but is not a
natural part of aging. Although most people experience some physiological changes with age
(presbyopia), these changes usually do not lead to low vision. Most people develop low
vision because of eye diseases. Common causes of low vision, particularly with older adults,
include macular degeneration, glaucoma, and diabetic retinopathy. When vision impairment
is recognized early, treatment can be more effective, enabling people to maintain as much
independence as possible.

Tests and Diagnosis

To determine the extent of your useful vision, you will need to have your eyes examined. The
examination for low vision differs from a typical eye examination. During a low vision
examination, your doctor may administer the following tests:

Refraction (to assess your vision and determine the prescription for your glasses, if
glasses may be of any use)

Visual field (to assess your peripheral vision)

Because low vision examinations may involve a variety of tests, they are often more time
consuming than standard examinations. For instance, refraction may be done through a
telescope or trial lens frame so you can judge which lens is best.

Treatment and Drugs

The Kellogg Eye Center Low Vision and Visual Rehabilitative Services Clinic embraces a
multi-disciplinary approach to the treatment of low vision. Ophthalmologists, optometrists,
and occupational therapists make up the team of health care professionals who will work with
you starting with your vision examination, and continuing with you to identify treatment
options, which include:

Optical devices to help you adapt, such as magnifiers, telephones, or closed-circuit

televisions

Techniques to help you utilize your remaining vision

Environmental modifications to maximize your remaining vision

Adaptive non-optical devices, such as large-print cookbooks and talking watches.

Occupational Therapy
Occupational therapy programs at Kellogg may last as long as several months or be as brief
as one session. Sessions may include an evaluation of your environment and suggestions for
modifying your home to enable you to become more independent and to improve safety.

Low Vision Aids

Many types of assistive devices are available to help people with low vision. These items
include special glasses and other magnification devices and large print reading materials.
Other communication aids include computer software and various other technological
devices.

Additional Resources
Kellogg Eye Center Resources
The U-M Kellogg Eye Center has a number of publications available for our patients with
low vision and their families. Helpful Hints for Families of the Visually Impaired is available
in PDF format which can be viewed with Acrobat Reader. If you don't already have it on your
computer you can download Acrobat Reader.
Join the Living with Low Vision support group sponsored by the Kellogg Eye Center. The
group meets on the second Wednesday of each month from 2:00 - 4:00 in the Faculty Dining
Room on the mezzanine level of the Kellogg Eye Center.
The Henderson library is open to use by patients and their families, members of the
community, physicians and other health care providers. Please see the library for a list of low
vision resources.
The Washtenaw Library for the Blind and Physically Disabled's online Resource Guide offers
an alphabetical listing of businesses and agencies providing products and services to
individuals with vision loss, including subject index. http://wlbpd.aadl.org/wlbpd/resources

Other Resources
These websites are not operated by the University of Michigan Kellogg Eye Center. Kellogg
Eye Center is not associated with these websites in any way, nor does it endorse or take
responsibility for any of the content. These links are provided for the convenience of our
users.

American Academy of Ophthalmology

o Living with Limited Vision
Definitions, symptoms, diagnosis, tips, etc. of low vision
o Making the Most of Remaining Vision
Tips and list of resources

American Foundation for the Blind (AFB)

o SeniorHealth
Living with low vision

Lighthouse International
o Vision Loss is Not A Normal Part of Aging
o Family and Friends Make a Difference! How to Help When Someone Close to
You is Visually Impaired
o When Your Partner Becomes Visually Impaired...Helpful Insights and Coping
Strategies
o All About Low Vision

Low Vision Support Groups in Michigan

o Support Group Guide
Listing of low vision support groups by city

Michigan Commission for the Blind (MCB)

o Main Webpage
o Welcome Brochure
Provides overview of services offered, including vocational rehabilitation,
business services, and a variety of training programs.
o Youth Services
Questions and answers about MCB services for youth

National Eye Institute (NEI)

o What You Should Know About Low Vision

National Federation for the Blind

o New Approaches to Consider: Suggestions for Individuals with Recent Vision
Loss
16 page document with helpful information
o So You Don't See as Well as You Used To: Advice and Stories That Will Help
You
Online book (98 pages) of encouraging stories written by low vision patients
(Takes a minute to download)

National Institutes of Health (NIH)

o SeniorHealth
NIH's website for seniors covers the topic of low vision

National Library of Medicine (NLM)

o MedlinePlus
Extensive list of resources

Prevent Blindness American

o Living Well with Low Vision
Website offering information and free materials for people living with low
vision, including extensive up-to-date directory of products and services.

Clinic Information
For more information, see the Low Vision and Visual Rehabilitation and the complete Clinic
Services listing of the U-M Kellogg Eye Center.
http://www.kellogg.umich.edu/patientcare/conditions/lowvision.html