Contributors MS Raju President, Vision-Aid, India Deepak K Bagga Consultant, LV Prasad Eye Institute (LVPEI), Hyderabad, Andhra Pradesh, India Rituparna Ghoshal Consultant, LV Prasad Eye Institute (LVPEI), Hyderabad, Andhra Pradesh, India USN Murthy Ophthalmologist, Professor and Civil Surgeon Manjula Ketharaju Specialist Ophthalmic Practitioner, UK With Ram Raju Principal Consultant CSC Founder Director, Vision-Aid Inc, USA Revathy Ramakrishna Principal Business Systems Analyst Fresenius Medical Care Co-Founder Vision-Aid Inc.
Sightsavers InternationalForeword Elizabeth Kurian Regional Director, Sightsavers International, Mumbai, India
Jitendar P Vij
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Management of Vision Impairment
(Low Vision, Vision Enhancement and Vision Rehabilitation)
© 2010, Jaypee Brothers Medical Publishers (P) Ltd.
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher.
First Edition: 2010
Typeset at JPBMP typesetting unit
Printed at Ajanta OffsetDedicated to
Mrs Prameela Devadas of Lexington MA, USA, the noble and ardent supporter of service to Vision ImpairedForeword
It gives me great pleasure to introduce the book Management of Vision Impairment (Low Vision, Vision Enhancement and Vision Rehabilitation). We at Sightsavers are particularly happy that it is our partner, Vision-Aid that has taken the lead in developing this book.
It is very important to sensitize everyone regarding the needs of people with irreversible visual impairment and this book is well designed to raise awareness among medical professionals and the general community. It gives a roadmap to optimize vision care and deal with challenges. I am particularly happy that the book lays equal emphasis on rehabilitation of people with blindness and low vision.
One of the first benefits of the book I foresee will be that it can spur introduction of Management of Vision Impairment as a subject in the Medical and Optometry Colleges. Secondary, the book will be an invaluable guide and handbook for practitioners, clinicians, social workers and NGO administrators working in the field of vision impairment.
The Editor and Contributors have taken good care to give pictorial explanations, examples, practical tips and guidelines that make the book useful to professionals and at the same time, comprehensible to lay persons.
Sightsavers is happy to be associated with the book and we wish it all success.
A3 Shiv Dham, New Link Road
Management of Vision Impairment (Low Vision, Vision Enhancement and Vision Rehabilitation), which includes Management of Low Vision and Vision Rehabilitation is receiving some due attention only of late as far as developing countries are concerned. In India, even this belated attention is to some extent due to the lead taken by enlightened organizations like LV Prasad Eye Institute, Vision-Aid and the push by global service organizations like Sightsavers International, and Vision-Aid Inc and the generous budgets being allotted by them for the particular area.
In the first place, at least as far as the developing world is concerned, treating vision impairment had low motivation because of certain reasons as under.
Eye care specialists were not able to spare the large time spans needed to treat vision impairment cases whereas twice to three times of effort, counseling and evaluation times are required per vision impairment client as compared to general eye patients. Some eye care specialists especially optometrists do take up this area and emerge as vision impairment clinicians. But this tribe is small and they too may not find the profession remunerative as a private practice.
As far as hospitals go, the private commercial ones find treatment of vision impairment unremunerative and cost in-effective and the government run hospitals are swamped with routine eye treatment. It was therefore a handful of major corporate eye hospitals that took treatment of vision impairment as a cultivated discipline depending on overseas contributions for the activity.
On the clients' side, there was helplessness as well as lack of awareness of the advances being made elsewhere in the West. The tendency was to accept the situation and demand nothing. A few clients who do seek medical treatment go through a cycle of high expectations, disappointment and despair. Satisfaction levels are typically low, even in case of clients who are given the best care and time. This in turn led to an alround despondency for the clients and low job satisfaction for specialists who spend time for management of vision impairment.
Even medical colleges and teaching hospitals had side-lined vision impairment. They, as well as the funding agencies do know that the population needing vision impairment attention is huge but action was limited to sympathy, admitting that the problem is severe and special. The problem is relegated as a social problem to be addressed by special mechanisms and NonGovernmental Organizations (NGOs). With this background, proper place for this subject is not given in the curricula and even adequate university books did not take birth. Some low key treatment is however given to the subject in the general ophthalmology Textbooks. With sparse attention given to the subject in the syllabus and examinations, an eye specialist emerging out of a medical college could not know much about low vision and vision rehabilitation. This field did not count for much as a specialization in the postgraduate levels.
It is therefore no wonder that we have a society where as far as management of vision impairment is concerned; facilities and even awareness are scarce. It is practically a situation of vacuum, knowingly endured by medical education in general and in most eye care hospitals. Only some students, professors and some enlightened hospital managements are now taking to management of vision impairment in a serious fashion. Even if this seriousness comes due to pressure from the government and international charitable organizations, it will still be a welcome development.
The starting point for rectifying this situation is in addressing the syllabi of medical colleges in creating training material. This book attempts to fill the vacuum mentioned above and help to install Management of Vision Impairment as a compulsory subject in the curricula in the medical colleges. The book also intends to be a ready handbook for practitioners whether they are in the Eye Care Hospitals or in the NGOs. May their tribe increase!
This book is the combined effort of several contributors and they welcome feedback, queries, suggestions and critiques about the book.
President, Vision-Aid IndiaContributors
MS Raju is the founder and currently president of Vision-Aid India, the charitable services society serving the Vision Impaired. He has over 50 years of global experience in industry, education and management and was formerly the Executive Chairman of Stone Telecom and Professor XLRI. An alumnus of Indian Institute of Technology and Administrative Staff College of India, B Tech (Hons), MIE, Chartered Engineer, Diploma in Low Vision and Diploma in Access Technologies. He authored several books on management and career planning. His books published in English and Chinese languages are taught in university level business schools in India, France and China.
MS Raju is the recipient of the 2009 BJ Modi award for outstanding service to the disabled, awarded by the National Society for Equal opportunities for Handicapped, India.
Apart from being the editor and general editorial contributor for all chapters, he is the core contributor for the chapters on Technologies, Education, Rehabilitation, Coping and seven of the eight appendices in the book.
Deepak K Bagga the core contributor of Chapters Evaluation and Management of Vision Impaired and Evaluation, Early Intervention and Management of Vision Impaired Infants and Children is currently Optometrist, Consultant and Trainer at LV Prasad Eye Institute (LVPEI), Hyderabad, Andhra Pradesh. BBA (Business Administration) Diploma in Refraction and Optometry, Diploma in Management (IGNOU) and Fellow-LVPEI. He has experience of over 10 years in Vision Management.
Rituparna Ghoshal the core contributor of Chapters Vision Impairment, its Functional Evaluation and Management and Assistive Devices, is currently Consultant Optometrist and Trainer at LV Prasad Eye Institute (LVPEI), Hyderabad, Andhra Pradesh. Bachelor of Optometry and Vision Science (BOVS), and, fellow-LVPEI, she has 4 years of experience in Vision Management.
USN Murthy contributor of Ophthalmic Notes and general editorial associate is Professor and Senior Surgeon in State Service and past-President Indian Medical Association, Visakhapatnam. He is MS (Ophthalmology), DMRT, he has over 25 years of experience in eye care.
Manjula Ketharaju general contributor and review editor is currently Specialist Ophthalmic Practitioner in United Kingdom. She is MRC Ophth (London), ICO (Cambridge), MS (Osmania), she has 10 years of global experience in eye care.
Ram Raju past contributor for the chapter on Technologies, is currently Principal Consultant Computer Sciences Corporation of USA. He is the Founder Director of Vision-Aid Inc. of USA. He is BEE (BIT), ME (Pennsylvania), SOA specialist. He has 20 years of experience in hardware/ software development and Low Vision related services.
Revathy Ramakrishna bee (bit) dhs, general contributor and editorial associate is currently, Principal, Business Systems Analyst at FRESINIUS Medical Care, USA. She is a cofounder of Vision-Aid Inc and has 20 years of experience in Health Services, IT and vision care projects.Acknowledgments
The editor and contributors are obliged to:
- Sightsavers International for all the encouragement and support.
- Vision-Aid Inc USA and Vision-Aid Charitable Services Society, Visakhapatnam for valuable inputs and reproduction permissions.
- LV Prasad Eye Institute for reproduction permission of photographs.
- Dr PVKS Varma MS, Ophthalmic Surgeon and Consultant, LV Prasad Eye Institute (LVPEI), Visakhapatnam, for valuable suggestions and technical checks.
- Ms Vijaya K Gothwal, Senior Consultant, LV Prasad Eye Institute (LVPEI), Hyderabad for the encouragement.
- Ms Beula Christy, Senior Consultant, LV Prasad Eye Institute (LVPEI) Hyderabad for valuable inputs.
- Dr K Sarojini Devi, Dr K Venugopala Rao, Dr CV Gopala Raju, Doctor, Optometrist Ramnarayan Satapathy and Dr T Raveendra for valued pre-publication reviews.
- Ms Ramya Ramakrishna, volunteer from Lexington High School, Massachusetts, USA, for web research and valuable inputs.
In the book, where chapters are from material contributed by individual experts, it is not possible to maintain a hundred percent uniformity of nomenclature and terminology. The contributing experts in some places might have chosen terminology with which they are most comfortable. However, a good bit of uniformity and standardization are brought about editorially.
In this book, we are principally concerned with nomenclature relating to vision or visual impairment. For its terminology, we adopted the latest recommendations of International Classification of Diseases (ICD-10).
Our readers may make a note of the following adaptations. Those interested in deeper study may browse http://www.who.int/classifications/apps/icd/icd10online.
Visual Impairment (VI): The general word denoting functional limitations of the eye.
Vision Impairment: Same as visual impairment (VI).
Low Vision: Hitherto a common term currently fits into “mild vision impairment” Categories 1 and 2.
Visual Disability: Effect imposed by VI, on Individual's ability.
Visual Handicap: Impact (on mobility, suitability for employment, etc.) felt by VI individual.
Clinician: An ophthalmologist or an optometrist evaluating vision impaired clients, includes the terms professional, therapist or consultant.
Client: A patient or a person affected by Vision Impairment and under treatment/advice of clinician.
Category of visual impairment
Visual acuity with best possible correction
Maximum less than
Minimum equal to or better than
Categories 1 and 2 are mild VI or Low Vision Categories 3, 4 and 5 are severe VI or blind
1/60 (finger counting at 1 meter)
1/60 (finger counting at 1 meter)
Based on field: <10 degrees around central fixation is Category 3
<5 degrees around central fixation (even if the central acuity is not impaired) is Category 4