Visual impairment

Definition

Total blindness is the inability to tell light from dark, or the total inability to see. Visual impairment or low vision is a severe reduction in vision that cannot be corrected with standard glasses or contact lenses and reduces a person's ability to function at certain or all tasks. Legal blindness (which is actually a severe visual impairment) refers to a best-corrected central vision of 20/200 or worse in the better eye or a visual acuity of better than 20/200 but with a visual field no greater than 20° (e.g., side vision that is so reduced that it appears as if the person is looking through a tunnel).

Description

Vision is normally measured using a Snellen chart. A Snellen chart has letters of different sizes that are read, one eye at a time, from a distance of 20 ft.

People with normal vision are able to read the 20 ft line at 20 ft—20/20 vision—or the 40 ft line at 40 ft, the 100 ft line at 100 ft, and so forth. If at 20 ft the smallest readable letter is larger, vision is designated as the distance from the chart over the size of the smallest letter that can be read.

Eye care professionals measure vision in many ways. Clarity (sharpness) of vision indicates how well a person's central visual status is. The diopter is the unit of measure for refractive errors such as nearsightedness, farsightedness, and astigmatism and indicates the strength of corrective lenses needed. People do not just see straight ahead; the entire area of vision is called the visual field. Some people have good vision (e.g., see clearly) but have areas of reduced or no vision (blind spots) in parts of their visual field. Others have good vision in the center but poor vision around the edges (peripheral visual field). People with very poor vision may be able only to count fingers at a given distance from their eyes. This distance becomes the measure of their ability to see.

The World Health Organization (WHO) defines impaired vision in five categories:

• Low vision 1 is a best corrected visual acuity of 20/70.
• Low vision 2 starts at 20/200.
• Blindness 3 is below 20/400.
• Blindness 4 is worse than 5/300
• Blindness 5 is no light perception at all.
• A visual field between 5° and 10° (compared with a normal visual field of about 120°) goes into category 3; less than 5° into category 4, even if the tiny spot of central vision is perfect.

Color blindness is the reduced ability to perceive certain colors, usually red and green. It is a hereditary defect and affects very few tasks. Contrast sensitivity describes the ability to distinguish one object from another. A person with reduced contrast sensitivity may have problems seeing things in the fog because of the decrease in contrast between the object and the fog.

According to the WHO there are over forty million people worldwide whose vision is category 3 or worse, 80% of whom live in developing countries. Half of the blind population in the United States is over 65 years of age.

Causes and symptoms

The leading causes of blindness include:

• macular degeneration
• glaucoma
• cataracts
• diabetes mellitus

Other possible causes include infections, injury, or nutrition .

Infections

Most infectious eye diseases have been eliminated in the industrialized nations by sanitation, medication, and public health measures. Viral infections are the main exception to this statement. Some infections that may lead to visual impairment include:

• Herpes simplex keratitis. A viral infection of the cornea. Repeated occurrences may lead to corneal scarring.
• Trachoma. This disease is responsible for six to nine million cases of blindness around the world, of the third of a billion who have the disease. Trachoma is caused by an incomplete bacterium, Chlamydia trachomatis, that is easily treated with standard antibiotics. It is transmitted directly from eye to eye, mostly by flies. The chlamydia gradually destroy the cornea.
• Leprosy (Hansen's disease). This is another bacterial disease that has a high affinity for the eyes. It, too, can be effectively treated with medicines.
• River blindness. Much of the tropics of the Eastern Hemisphere are infested with Onchocerca volvulus, a worm that causes “river blindness.” This worm is transmitted by fly bites and can be treated with a drug called ivermectin. Nevertheless, twenty-eight million people have the disease, and 40% of them are blind from it.

Other causes

Exposure of a pregnant woman to certain diseases (e.g., rubella or toxoplasmosis) can cause congenital eye problems. Injuries to the eyes can result in blindness. Very little blindness is due to disease in the brain or the optic nerves. Multiple sclerosis and similar nervous system diseases, brain tumors , diseases of the eye sockets, and head injuries are rare causes of blindness.

Nutrition

Vitamin A deficiency is a widespread cause of corneal degeneration in developing nations. As many as five million develop xerophthalmia from this deficiency each year. Five percent end up blind.

Diagnosis

A low vision exam is slightly different from a general exam. While a case history, visual status, and eye health evaluation are common to both exams, some things do differ. Eye charts other than a Snellen eye chart will be used. Testing distance will vary. A trial frame worn by the patient is usually used instead of the instrument containing the lenses the patient sits behind (phoropter). Because the low vision exam is slightly more goal oriented than a general exam, for example, what specifically is the patient having trouble with (reading, seeing street signs, etc.) different optical and nonoptical aids will generally be tried. Eye health is the last thing to be checked so that the lights necessary to examine the eyes will not interfere with the rest of the testing.

Treatment

There are many options for patients with visual impairment. There are optical and nonoptical aids. Optical aids include:

• Telescopes. May be used to read street signs.
• Hand magnifiers. May be used to read labels on things at the store.
• Stand magnifiers. May be used to read.
• Prisms. May be used to move the image onto a healthy part of the retina in some eye diseases.
• Closed circuit television (CCTV). For large magnification (e.g., for reading).

Nonoptical aids can include large print books and magazines, check-writing guides, large print dials on the telephone, and more.

For those who are blind, there are enormous resources available to improve the quality of life. For the legally blind, financial assistance for help may be possible. Braille and audio books are increasingly available. Guide dogs provide well-trained eyes and independence . Orientation and mobility training is available.

Prognosis

The prognosis generally relates to the severity of the impairment and the ability of the aids to correct it. A good low vision exam is important to be aware of the latest low vision aids.

Prevention

Regular eye exams are important to detect silent eye problems (e.g., glaucoma ). Left untreated, glaucoma can result in blindness.

Corneal infections can be treated with effective antibiotics . When a cornea has become opaque beyond recovery it must be transplanted. Good hygiene (e.g., washing hands frequently) to prevent infection, proper use of contact lenses, and not sharing makeup are just some ways to guard against corneal infections.

Cataracts should be removed when they interfere with a person's quality of life.

Primary prevention addresses the causes before they ever begin. Fly control can be accomplished by simple sanitation methods. Public health measures can reduce the incidence of many infectious diseases . Vitamin A supplementation (when appropriate) will eliminate xerophthalmia completely. It is possible that protecting the eyes against ultraviolet (UV) light will reduce the incidence of cataracts, macular degeneration, and some other eye diseases. UV coatings can be placed on regular glasses, sunglasses, and ski goggles. Patients should ask their eye care professional about UV coatings.

KEY TERMS

Cornea —The clear dome-shaped structure that is part of the front of the eye. It lies in front of the colored part of the eye (iris).

Diabetic retinopathy —Retinal disease caused by the damage diabetes does to small blood vessels.

Phoropter —The instrument used to measure refractive status of the eyes. It contains many lenses which are then changed in front of the eyes while the patient is looking at an eye chart. This is when the doctor usually asks, “Which is better, one or two?”

Xerophthalmia —A drying of the cornea and conjunctiva.

Secondary prevention addresses treating established diseases before they cause irreversible eye damage. Having general physical checkups can also detect systemic diseases such as diabetes or high blood pressure . Control of diabetes is very important in preserving sight.

J. Ricker Polsdorfer MD