# Low Vision Rehabilitation/Case study 1: Thelma Scope

Your first patient at See Well Australia is Mrs Thelma Scope. Through working with Mrs Scope you will come to understand the concept of low vision and the impact of eye disease when treatment is no longer an option. You will be exposed to the roles and approaches of a range of professionals who might work with a patient with vision impairment. You will be challenged to determine your role as an Orthoptist in this multidisciplinary environment.
There is an overarching question you will need to answer, and scenarios with supporting information to help guide your understanding and formulate your answer. You should spend around 6-8 hours with this topic.

## Question

What is the impact of eye disease on how you see and how you feel? Who can help you with the challenges you will face as a vision impaired person? Use the scenarios and resources below to formulate your own response to this question. You are looking for reasons as well as proposed solutions.

## Case studies

Primary case study:
Mrs Thelma Scope - coping with vision loss Supplementary case studies:
* A group of elderly ladies with bilateral AMD
* A young woman with Stargardt disease
* A variety of patients: Edith Wright; Mark Bollinger; Jack Tomazetti; Barry Gentle; Peter Brown; Margaret Moriartis and Martin Skase
Mrs Thelma Scope is a patient at See Well Australia. Through Mrs Scope you will come to understand what low vision is, how it is defined and what it means to have an impairment. In addition, you will consider the epidemiology and impact of low vision in Australia.

## Activities

Task 1
(Keywords: #low vision #vision impairment #legal blindness)
Watch the What is Low Vision? lectorial where you will find out about your new patient Mrs Thelma Scope.
Consult the resources below in addition to finding your own resources to answer the Task 1 questions. When answering the questions, think about what you know so far about Mrs Scope. Discuss and compare your answers with the students in your group.
* Terminology in Eye Health
* WHO | Visual Impairment and Blindness factsheet
* Oxford Dictionary
Questions - Task 1
* Why is it important to a patient that we define disability or vision impairment?
* How does the World Health Organization (WHO) define ‘low vision’
* According to the WHO definition, can you classify Mrs Scope as having ‘low vision’?
* What is the definition of ‘impairment’? How does this definition specifically relate to vision?
* Do you think Mrs Scope has an ‘impairment’? Discuss.
* Define ‘disability’ and explain how this relates to the sense of vision.
* Do you think Mrs Scope is disabled? Explain why/why not.
* Define ‘handicap’ and explain whether this definition can be applied to Mrs Scope.
* Do you think you have enough information about her case history in order to classify Mrs Scope as either having impairment, disability or handicap? What other information would you need?
Task 2
(Keywords: #economic cost #financial impact #direct & indirect costs)
Referring to the Eye Research Australia (Clear Insight) Economic Impact and Cost of Low Vision in Australia publication, answer Task 2 questions. Don't forget to consider your patient Thelma when answering the questions.
Questions - Task 2
* Of a composition of the total cost of vision disorders in 2004, what is the total cost of suffering? What do you think “cost of suffering” means? Explain your answer in the context of Mrs Scope.
* On page 4 of the report it states: “the share of pharmaceutical costs has increased to 11.4% of the total and of ‘other health practitioners’ to 10.6%. Why would this be so? What would contribute to this?
* There are significant indirect costs associated with vision impairment. In the context of Mrs Scope, explain how each indirect cost could impact on her life.
* Mrs Scope is 73 years old and she is expected to live quite a few more years, especially as she is generally healthy. What are the most likely reasons that her vision impairment would prevent healthy and independent ageing in her case?
* What are the top 3 causes of blindness in people aged over 40 in Australia?
* What age groups are most pre-disposed to each of the 3 causes you selected?
* What are the projected forecasts for visual impairment and blindness in Australia for the future?
* Why is addressing vision impairment a serious issue in this country?
Task 3
(Keywords: #visual function #blurry vision #central field loss #peripheral field loss)
Next, we will analyse the likely impact of a particular ocular disease on a person’s visual function. You will also consider the impact vision impairment might have on a person's social interactions and general well-being. You will therefore be able to discuss the psychosocial and physical impacts related to different forms of vision impairment.
Begin by watching this introductory video
Task 4
(Keywords: #functional vision #blury vision #central field loss #peripheral field loss)
Watch the three short lectorials on the three areas of functional vision loss and answer the related questions.
* Blurred vision
* Central field loss
* Peripheral field loss
Questions - Task 4
1. Blurred vision no field loss:
* What are the ocular structures involved?
* What is the function of these structures?
* Explain in terms of these functions the impact these types of eye diseases or systemic conditions will have on sight.
2. Central field loss:
* What is the ocular structure involved?
* What is the function of this structure?
* Explain in terms of these functions the impact on sight of disease impacting this part of the eye.
3. Peripheral field loss: This is the most complex area in relation to function and can be considered as disseminated or scattered field loss, hemianopia or half field loss and severely constricted field loss.
* What structures of the vision pathway might be impacted?
* What is the function of these structures?
* Explain in terms of these functions the impact on sight.
Task 5
(Keywords: #impact of vision loss #psycho-social)
As an introduction to this task, have a look at the RNIB's website on Coming to Terms with Sight Loss. Next, listen to the two audio recordings of patients from See Well Australia who have vision impairment. They are describing the impact of the impairment on their lives. Make notes to help you answer the questions related to each recording.
* Audio 1 - Three elderly ladies
* Audio 2 - Lesley, a young woman with Stargardt disease
After you have listened to the recordings, work through these questions. Questions - Task 5 Meet Mrs Kirkman, Mrs Muirhead and Mrs Sevoir.
All are older women who have bilateral AMD that has progressed to the wet phase - all are legally blind. Mrs Kirkman is a widow who also has significant hearing loss, she wears hearing aids. Mrs Muirhead is also a widow she lives in a large rural city. Mrs Sevoir is married and living with her husband in metropolitan Melbourne.
As you listen to their stories make notes on the following:
* How has sight loss impacted on the lives of the three women?
* Do any of them refer to their living situation?
* What are the emotions they express in relation to losing their sight?
* How has sight loss impacted on their social relationships?
* What are some of the strategies they are using to overcome the handicaps of sight loss?
* One has a very philosophical out look, describe this lady’s response.
* Is there a difference in response between the ladies and what seems to be making this difference?
Now meet Lesley a young woman in her 30’s. She is legally blind due to Stargardt Disease. Lesley lives alone in an inner Melbourne suburb.
As you listen to Lesley’s story make notes about the following questions:
* How did Lesley first realize she was losing her sight?
* What was her initial response to sight loss?
* How did sight loss impact on Lesley’s working life?
* How did sight loss impact on Lesley’s personal life?
* What has been Lesley’s emotional response to sight loss and her perception of the thoughts of others?
* What are Lesley’s strategies for coping?
* What comments does Lesley make about the way people treat her?
Consider the differences in response and impact between Lesley and the older ladies. Discuss your answers with your group and try to provide answers to all of the above questions.
Task 6
(Keywords: #psycho-social #impact)
This task utilises case studies and additional materials that will allow you to consider the impact of sight loss on social and emotional well-being.
First, watch the interview with Krister Inde Support needed when one loses his or her vision
Once you have watched Krister's movie, work through the questions below. Refer to Krister Inde's book See bad feel good.
Questions - Task 6
1. The following passage has been taken from Krister Inde’s book See Bad Feel Good, an autobiographical account of sight loss. Discuss the following statements and think about what they are telling you of Krister’s response to his diagnosis.
"There are a lot of aids and devices that I’m sure you can make great use of. But as I said, there is, unfortunately, no medical treatment that we can offer you at this time.” Period. Nowhere to run. It’s a fact. You are locked in a room and there is no key to the nonexistent door. It comes as a shock: You are losing your sight and it is hell. A hell you have not chosen, for which you are not responsible, and that you hate so much that you avoid believing it’s true, avoid thinking about it and you suppress it entirely. It simply hasn’t happened!" 2. What are the phases a person goes through after losing sight as described by Krister Inde in his book See Good Feel Bad?
3. Discuss in your groups how you would feel if you lost your sight – prepare a brief group statement to share with the class summarising your thoughts. The RNIB has a good resource Coming to terms with sight loss that you can refer to.
Task 7
(Keywords: #multidisciplinary #teams)
Do some research on each of the following professions to determine the assistance they provide for a person with vision impairment.
* Low Vision Therapist
* Occupational Therapist
* Orientation and Mobility Instructor
* Physiotherapist
* Social Worker
* Special Education Teacher (Vision Impaired)
These two YouTube movies might also help: Low vision occupational therapy Orientation and mobility
Other resources & links
Statewide Vision Resource centre Who does what in vision care Better Health Channel - Orthoptists
Task 8
(Keywords: #case study)
In your group, work through the following case studies related to functional impact of sight loss & multi-disciplinary intervention, which require you to analyse information and then discuss the likely functional impact associated with each case. You will then determine the appropriate professionals to assist in the management of each patient.

## Resources and help

* Focus on Low Vision is an excellent publication by the Centre for Eye Research which will be useful to complete all the topics in this enquiry. You should refer to it often.