Low vision: a parochial view.

Evaluation of success is a relatively recent development in health care delivery, although in the prescribing of low vision aids (LVAs) it has been common for many years. Surveys which showed that 60-80% of unselected patients could be helped with LVAsl-3 tried to convince professionals that this 'Cinderella' of ophthalmic and optometric services was worthy of their attention. It was accepted that some patients would not benefit, and explanations included poor general health, too poor acuity, senile dementia, lack of motivation for the tasks that LVAs can be applied to, or not having reached the required psychological state of realistic acceptance of the acquired loss. Such an analysis is reinforced by studies of well motivated young patients with stable pathology of congenital origin where 100% success can be achieved.4 It is now recognised that these short term, clinic based perspectives on successful prescribing are too simplistic: reaching a threshold performance for letters of newsprint size, for example, does not guarantee efficient reading by the individual with low vision.5 In a survey by Leat et al,6 75% of patients could read newsprint equivalent in the clinic, but only 35% admitted to reading normal print at home. A major reason for this discrepancy is the lack of 'training'; that process by which a patient (or client in this rehabilitation context) is restored to normal function, despite the continuing impairment. Mehr and Freid summarised the problem some 20 years ago, saying 'even those applications of aids and procedures that seem fundamental and natural to the practitioner are, in fact, in many cases highly technical and complex to the patient. New sensorimotor coordination patterns of eye, head, hand and body movements must be developed',7 but recognition of this has been slow in the UK. The traditional UK Hospital Eye Service (HES) provision (there is no official supply route through the General Ophthalmic Services (GOS)) is typically of complex aids in a single visit to an outpatient clinic,8 and has been criticised since the patients are then often left to their own devices to learn to use the appliance.9 That many patients do not achieve this has been shown by surveys suggesting that considerable numbers of LVAs are used irregularly, or not at all.8 10 11 From countries with a longer history in this field, early anecdotal reports and qualitative support for formalised trainingl'2 13 are now beginning to give way to quantitative surveys,'1'6 although scientific methodology and statistical analysis are still sadly lacking. Despite one dissenting voice,17 there is widespread acceptance of the concept, with training forming a major part of comprehensive rehabilitation models which consider the individual's needs (vocational, educational, social, psychological, financial, optometric, and medical) and encourage the optimal use of residual vision.18 While concentrating on the range of care which must be provided by such a service, and deliberately avoiding dictating which professionals should be responsible for that care, it seems axiomatic that this range of expertise cannot be found in a single professional group. Yet while much is made of the range of professionals involved'9-2' in the models currently operating an educationalist, employment specialist, physiotherapist, occupational therapist, social worker, lighting engineer, orthoptist, psychologist, and audiologist, among others, may be called into the team for particular clients it is more usual to concentrate on a core of ophthalmologist, optometrist (carrying out refraction and prescribing), 'low vision trainer', and social worker. Interest in such low vision rehabilitation is enormous at present, particularly in mainland Europe. An international workshop is scheduled for September 1995 where it is intended that practitioners of this developing science (tentatively termed videology by the organisers) can exchange ideas, and disseminate worldwide models of good practice. It is hoped that several models applicable in the UK situation will come forth, since no one solution will be appropriate in all cases: the scope of services provided by a given profession will vary between individual practitioners, depending on the individual's experiences, geographical location, and local resources. The UK is unlikely to be setting the trend, being closer to the guard's van than the vanguard in the development of such clinics. Some multidisciplinary clinics apparently exist,22-24 although reports of their working methods are anecdotal so far and seem to indicate a stage of development reached in the USA and Australia some 15-20 years ago.25 26 No results have been reported to date. Success is difficult to define and statistics have to be interpreted carefully, but such reports are essential. They will act to encourage the spread of optimal patient care and, when the results pass into the wider community, will prevent each clinic from having to 're-invent the wheel'. Reports need to include controlled, scientific analyses of how well the clinic achieves its aims so that interested parties can decide which model is best suited to their situation. The study by Shuttleworth et al in this issue (p 719) is therefore extremely significant in the context of the future development of low vision services in the UK. It describes the effectiveness of one practical model of 'integrated' service (although unfortunately not truly 715