Low Vision for Optometry Program: A Residency Rotation

Low Vision Optometry Rotation 1

Low vision is described as a bilateral impairment of one’s ability to see. The impairment has a significant impact on the functionality of the affected individual. The condition cannot be adequately reversed or corrected with conventional interventions, such as contact lenses and standard glasses. As a result, it is necessary to put in place rigorous and large-scale preventive interventions. The interventions are undertaken to stop the increase in the number of affected persons (Acton 2013). It is noted that most optometrists, ophthalmologists, and other professionals working in this field are unfamiliar with the low vision needs and care for the patients. However, in spite of this limitation, it is possible to provide some services that help the patients to use their residual vision. As a result, such patients are able to effectively make use of their vocational opportunities. It is important for the professionals to make full use of the services that are currently available. To this end, they should increase their awareness and enhance their skills in the field of low vision care. The objective can be achieved through qualitative training programs.

The residency training is supposed to advance the training of optometric post graduates as eye care.providers. The residency in low vision entails an intensive program that is dedicated to the provision of extensive clinical orientation in eye care. The experience includes evaluation of ocular health, detection of eye disease and anomalies, as well as advanced diagnostic practices (Acton 2013). The residents are expected to develop the skills needed to carry out the evaluation and assessment of low vision patients. In addition, the residents are expected to identify and develop the appropriate assessment procedures for all the low vision patients. They should also take care of the health of the eyes of patients with low vision problems. According to Acton (2013), the residents should also be able to minimise the adverse effects associated with low vision, as well as the complications affecting the patients who present these problems. They achieve this through detection, treatment, education, and management (Lakshminarayanan 2012). Finally, it is the responsibility of the residents to inform the patients under their care about the importance of getting frequent vision examinations as a prerequisite for better interventions.

Medical Expert

1. Obtain the necessary knowledge and skills required to manage low vision conditions among patients.
2. The resident should acquaint themselves with requisite assessment procedures for low vision patients (Stanfield, Hui & Cross 2011).
3. They should familiarise themselves with the methods used in dealing with ocular health evaluations and treatment of ocular problems.
4. They are expected to know the relationship between vision and learning (Rosenfield, Logan & Edwards 2009).
5. In addition, the resident should know how to assess low vision among children and adult patients.
6. Finally, they should be able to manage the visual problems of individuals with low vision disease.

Technical Skills and Procedures

1. With regards to technical skills and procedures, the resident should acquire knowledge on low vision examination strategies and techniques.
2. The resident should also adopt the strategy of obtaining patient history, including:

   • The type of the problem and complaint presented by the patient.
   • The general health history of the client, including their family’s medical and eye health history.
   • Gather the patient’s comprehensive ocular and visual history.
   • Construct the patient’s workplace or school performance history.
3. The resident should acquire skills needed in the evaluation of visual acuity with regards to:

   • Evaluating the patient’s vision.
   • Checking for eye disease by aiming bright lights at the eyes.
   • Asking the patient to look through various lenses during examination (Cross & McWay 2016).
   • Check the functionality of the eye by evaluating the external part of the organ.
   • Check for any diseases or injuries.
   • Test the patient for visual acuity to determine how well they can see.
   • For preschool children, the evaluation should be done using matching task.
   • School going children should be evaluated using the Snellen acuity chart (Rosenfield, Logan & Edwards 2009).
4. Objective measures of refraction (Retinoscopy):

   • The resident should conduct low vision test and then follow it with low vision refraction.
   • Low vision test charts with a large range of letters should be used to determine the starting point of measurement.
   • The resident should test for decreased acuity with telescopic systems (Irlen 2011).
   • They should conduct eye health testing using bio-microscopic examination (Lakshminarayanan 2012).
   • It is also important to conduct glaucoma tests.
5. Taking precaution when performing retinoscopy on low vision patients:

   • To this end, the resident should choose and perform a careful refraction for low vision patient (Cattaneo & Vecchi 2011).
   • Look out for uncorrected errors among the patients.
   • Take into consideration the history of the patient, especially for pseudophakia, astigmatism, and diabetic retinopathy. The conditions are dependent on blood sugar levels (Cross & McWay 2016).
   • The resident should not omit the evaluation and recording of the near visual acuity. They should carefully evaluate the uncorrected near vision indicating myopias.
6. Be aware of the application of the auxiliary refractive techniques such as auto-refractive and photo-refraction, the methods and principles. Imaging the papillary reflexes.
7. Investigation of binocularity. Have an understanding of the basic principles of binocular visual functions such as heterophoric and heterophoria tests. It is also necessary to understand the accomodation0convergence relationship and ratios. The measurement and applications of the principles of binocular analysis and status. Heterophoria asymptomaticism and fusion vengeance. Principle of decompensate heterophoria and strabismus.
8. Direct ophthalmoscopy: sign of ocular disease, appearances of the fundus and its characteristic including its various manifestations. It is also necessary to have an understanding of the clinical practice and skills in ophthalmoscopy. The resident must take meticulous care while carrying out the procedures accompanied by an intelligent interpretation of the tests (Stanfield, Hui & Cross 2011).
9. Indirect ophthalmoscopy: learn the principles of indirect ophthalmoscopy including the clinical and instrumentation procedures. The clinical application of the skills essential. Observation of normal fundus as well as abnormal changes.

Low Vision Optometry Rotation 2

The residents will get exposure to eye practical training that deliver high standard of care for patients with low vision or visual impairment. The learners will acquire knowledge, understanding, and skills at an advanced level regarding what low vision patients might want and need to do (Cross & McWay 2016). They will also learn the roles of the other professionals and care provider in supporting people with low vision. The resident trainees will also be able to apply the knowledge to certain scenarios and offer a demonstration on how they would adapt the optometric procedure to patient presenting with visual impairment (low vision). They will also be able to determine comprehensive history of patients with low vision and prioritise their needs (Stanfield, Hui & Cross 2011). Additionally, the resident trainees are expected to educate and inform the other health professionals including the physicians, nurses, parents, teachers and patients on the visual complications of low vision, convergence and accommodation anomalies with emphasis on the condition management

Medical Expert

1. Be able to give description of vision therapy concepts related to low vision, the procedures and instrumentation such as synotiscope and physiological diplopia techniques and their use.
2. Describe the retinitis pigmentosa and retinal pigment epithelium. Identify diffuse granularity and pigment clumping.
3. The trainee should understand the concepts of accommodation and convergence problems, excess, and insufficiency. How to carry out an investigation and draw a management plan
4. Describe sensory adaptation with patients with low vision, clinical signs and appropriate investigations.
5. Adapt the optometric routine to patients with visual impairment. Include the Measure visual functions in the assessment of low visual assessment.
6. Determine the appropriate magnification with accompanying advice on lighting and contrast.
7. Prescribe and dispense a hyper-ocular low vision aid.
8. Adapt the refractive factor of the low vision assessment.
9. Describe the heterophoria and possible management.
10. Investigate sensory and possible motor adaptations including the various methods of vision therapy.
11. Apply vision therapy to a specific binocular vision anomaly. Describe possible prognosis for specific binocular vision condition.
12. Describe the characteristics and management of incomitant strabismus, its clinical signs and appropriate investigations as well as indication for referrals
13. Identify nystagmus, its manifestation, clinical investigation, and possible optometric interventions.

Procedures and Technical Skills

1. The resident will demonstrate a performance of extra-ocular examination drawing from the knowledge of physiology and anatomy of ocular motility.
2. Demonstrate knowledge on the vision therapy instrumentation and procedures such as synoptophore, stereoscope, anaglyphs, synopticope, physiological diplopia methods and their applications.
3. Heterophoria: classification and aetiology, symptomology and clinical signs as well as compensation and decompensation. Explore the factors that affect compensation including investigation of compensation, management of heterophoria issues, visual therapy, refractive correction, and prismatic therapy with their prognosis.
4. Deal with the anomalies of accommodation and convergence, their excess and insufficiency, and the appropriate investigation and management.
5. Heterotropia: Comitance and incomitance, aetiology and classification.
6. Sensory adaptations: sensory adaptation development in strabismus, eccentric fixation, amblyopia, anomalous correspondence with clinical sign and investigations.
7. Sensory adaptation and Comitant strabismus management: anti-suppression training, pre-optics, occlusion therapy,
8. comitant strabismus Management: assessment of the development of the adaptations of the neural motor, clinical manifestation and investigations, referral indications, and optometric management, training of the motor angle of the cases of strabismus, identification of the cases for prognosis and treatment, and the role of refractive prisms and corrections.
9. Incomitant strabismus management: clinical signs and evaluation, motor adaptations development, optometric management, and indication for referral.
10. Nystagmus: manifest and latent Nystagmus, forms, clinical significance and investigation, optometric management.
11. Laboratory work: the laboratory work is meant to introduce the trainee to the instruments and techniques that are applicable and essential to the investigation and management of low vision and the appropriate therapy techniques (Rosenfield et al., 2009). Patients may be presented from time to time for demonstration of the available clinical techniques.

Low Vision Optometry Rotation 3

The third rotation is intended to perfect and enhance the objectives and goals of the two previous rotations. The rotation lays emphasis on the following factors:

1. Develop confidence in dealing with low vision patients.
2. Develop confidence and comfort in making the evaluation and managing patients with low visual conditions.
3. Develop quality care for patients with low vision.
4. Develop optical competence and skills in the management of low vision comitant as well as incomitant strabismus.
5. Recognise and identify the differences between adult and child refractive norms as well as the possible reasons for the difference in the management of the refractive conditions.

Medical Expert

1. Undertake a review of the skills and knowledge regarding the examination techniques that were discussed in the previous two rotations.
2. Describe the binocular sensory evaluation such as the Bagolini lenses or Randot stereo evaluation test.
3. Describe the evaluation, etiology, and management of low vision, vertical strabismus such as myogenic and neurogenic.
4. Describe the clinical application of sensory motor adaptations for low vision patients.
5. Identify and apply the principles of binocular vision such as diplopia, the physiology associated with binocular vision, confusion and suppression, and abnormal and normal retinal correspondence.

Procedures and Technical Skills

1. Assesses and investigates the more advanced ocular problems including thyroid eye illness.
2. Carrying out advanced measurement of low vision and strabismus through the use of synoptophone.
3. Perform evaluation tests on patients presenting difficulties such as those who are mentality impaired and elderly patients.

References

Acton, A 2013, Issues in ophthalmology and optometry research and practice, Oxford University Press, Oxford.

Cattaneo, Z & Vecchi, T 2011, Blind vision: the neuroscience of visual impairment, MIT Press, Cambridge.

Cross, N & McWay, D 2016, Stanfield’s introduction to health professions, Jones & Bartlett Publishers, Burlington.

Irlen, H 2011, Reading by the colours: overcoming dyslexia and other reading disabilities through the Irlen method, Penguin, London.

Lakshminarayanan, V 2012, Basic and clinical applications of vision science: the Professor Jay M. Enoch Festschrift volume, Springer Science & Business Media, Berlin.

Rosenfield, M, Logan, N & Edwards, K 2009, Optometry: science, techniques and clinical management, Elsevier Health Sciences, Amsterdam.

Stanfield, P, Hui, Y & Cross, N 2011, Introduction to the health professions, Jones & Bartlett Publishers, Burlington.