SIGHT, The Story of Vision2

CHAPTER 13 Low Vision, Visually Impaired, Blind AN INTRODUCTION TO LOW VISION Kara Pasner OD, MS (Adapted from 20/20 Magazine, Jobson Medical Information LLC, Feb. 2016)They say growing old is a privilege but growing up is optional. Regardless of how young we feel or act, age does take its toll on our bodies – our eyes non-withstanding. With age, there are 251

ocular changes, which are considered ‘normal’ and then there are changes, which aren’t. LOW VISION OR LEGAL BLINDNESS?According to the World Health Organization (WHO), a range of visual acuity from 20/70 to 20/400 (inclusive) is considered moderate visual impairment or low vision. At its core, low vision is an uncorrectable vision loss that impairs one’s ability to function normally and perform the activities needed to live independently. The actual visual acuity causing this disability varies from person to person.Results of the Lighthouse National Survey on Vision Loss (The Lighthouse Inc1995) indicated that there is great fear and limited understanding about vision loss and aging among older adults. Among persons age 65 and older, an estimated 21% report some form of vision impairment, representing 7.3 million persons. (Lighthouse International Survey,1995). As the population ages, the number of people with vision impairments that significantly impact their quality of life grows. Vision rehabilitation services are largely underutilized despite the need and benefit such services would provide.Low vision should not be confused with legal blindness. \"Legal blindness\" is mainly used as a determinant of eligibility for government services. In the United States, it is typically defined as visual acuity with best correction in the better eye, which is worse than or equal to 20/200 or a visual field of less than 20 degrees in diameter. Total blindness is marked by a complete lack of light or form. Though many patients who are legally blind are low vision patients, the majority does not fall into that category.EFFECTS OF LOW VISIONSigns of low vision interfering with normal activities can be subtle at first. People may notice that even with glasses or contact lenses, they have difficulty with tasks like recognizing familiar 252

faces, reading, cooking, matching clothes, writing checks and watching TV. Lights may seem dimmer, and glare harsher. These problems often lead to a gradual loss of independence and the ability to enjoy leisure activities – like playing cards or hobbies. It is not uncommon to develop feelings of confusion, frustration, avoidance, isolation, fear and even depression. Ironically, these feeling can debilitate people and prevent them from seeking out and utilizing low vision care, leaving them to further spiral downward.Most age related vision loss occurs as a result of eye conditions like macular degeneration, cataracts, diabetic eye disease or glaucoma. Other contributing factors may be systemic diseases and the medications used to treat them. Each condition affects vision differently. Whatever the cause, lost vision cannot be restored. It can, however, be managed with proper treatment and low vision care.LOW VISION IN THE AGING POPULATION: COMMON CAUSESAge-related macular degeneration (AMD) primarily affects the macula, the part of the eye that sees fine detail. Though it is painless, it gradually destroys the sharp, central vision needed for activities such as reading, sewing, and driving. People describe it as a dark or empty area appearing in their center of vision. Sometimes, a person may tilt their head or appear to be looking at an angle; this is a way of compensating in order to use their remaining peripheral vision. AMD can also distort vision so that straight edges appear wavy. The primary risk factors are age, being female, Caucasian and a history of smoking.Glaucoma is an eye disease in which the pressure inside the eyes slowly rises, causing damage to the optic nerve. This can lead to vision loss or even blindness. Glaucoma is treated with medication, lasers, and surgery. As the disease progresses, a person may notice their side vision gradually failing; objects in front may still be seen clearly, but objects to the side may be 253

missed. In addition, depth perception is often impaired. The primary risk factors are advanced age, positive family history and African descent. Cataracts are a clouding of the eye’s lens. Most cataracts start small and then, with time, grow larger and cloud more of the lens and decreasing visual acuity. This hazy, cloudy vision can make it difficult to read, watch TV, see food on a plate, and travel safely. Some people complain of the appearance of spots in front of their eyes, bothersome glare from headlights or sunlight and colors appear duller. Age-related cataract is the most common type of cataract; though excessive exposure to ultraviolet radiation, smoking or the use of certain medications, are also risk factors. Diabetic Retinopathy: The longer a person has diabetes, the greater their chance of retinopathy – when new blood vessels grow on the surface of the retina. These vessels can bleed and impair vision - blurring side or central vision. Often times, visual fields are affected as well. Therefore, other visual cues become important; namely: contrast sensitivity, glare and color discrimination. LOW VISION IN THE YOUNGThough usually associated with the elderly, the low vision population encompasses people of all ages. In the younger population, vision loss can occur because of eye injuries, birth defects or diseases such as retinitis pigmentosa, Stargardt’s maculopathy, albinism and optic nerve abnormalities. People of middle age may experience vision and /or field loss due to the occurrence of strokes and traumatic brain injuries.Children below the age of three should be referred to the state’s early intervention program. A multidisciplinary team of special education professionals will work with the parents to enable the child to develop their abilities and potential. School-aged children who meet the criteria of visual impairment in their state are 254

eligible to receive services from a certified teacher of students with visual impairments (TVI). They should receive instruction in literacy, visual efficiency, accessing the core curriculum, compensatory skills and more. These patients are generally very active as they are of school and working age. The low vision devices, which will accommodate their needs, should be portable and practical for the settings they are in. It is also important to try to maintain a good cosmetic appearance, if possible, as it is an important consideration for this age group’s emotional well-being.LOW VISION CARE Low Vision Care tries to maximize any remaining vision through the use of various optical and electronic products. It is rehabilitation, not a cure. It should always be stressed that low vision aids do not restore the sight they once had. The people who are most helped have accepted their vision loss, have realistic expectations and goals and are motivated to try to cope with their ‘new normal’. By offering low vision care, we try to improve someone’s quality of life, regain some independence and allow him or her to live more safely. Many people can learn to make better use of their low vision and function efficiently with even small amounts of visual information. Practice, patience and proper training will go a long way in low vision care. The ideal time to offer low vision services is as early as possible in the course of the disease. Early on, patients are more emotionally and psychologically stable and may be more motivated to try low vision aids. With mild to moderate vision loss there is a larger choice of low vision aids available. These devices will usually be of lower powers – with wide fields of view - which allows for more fluent reading as more words are seen at once. Ultimately, this makes it easier for most patients incorporate the devices into their daily routines. 255

THE LOW VISION EXAMThe low vision exam has a different flow and focus than a conventional eye exam: less medical and more problem focused review of the activities of daily living that their diminished vision has made difficult. A detailed history should elicit clear and realistic goals such as “I want to read and/or watch TV better”. The word “better” is key. Some patients think there are ‘magic glasses’ that will restore their vision. Usually “better” is the best we can hope for.The exam itself can be very long - often a full hour – and tiring for many patients. The refraction is carefully done with a trial frame and loose lenses. However, it is usual that glasses alone won’t help sufficiently. Further tests such as contrast sensitivity, visual fields and color vision will help determine the device best suited to meet the patient’s needs. Low Vision aids are like tools in a toolbox. Just as a workman requires different tools to complete different tasks, someone who is visually impaired may need a number of devices to perform various activities. It is best to categorize the aids into distance, intermediate and near demands and work on each area separately – paying most attention to the devices, which directly address the goals of the exam, as initially stated by the patient. The initially determination of magnification needed is derived from Kestenbaum’s Formula: the inverse of the Snellen acuity is equal to the dioptric power needed to read standard 1M, newspaper size print. Further dividing the dioptric power by 4 will yield the magnification ‘X’. (Ex. 20/400 yields 20D, or 5X). Once the magnification required is determined, the appropriate visual aid(s) is selected and the patient is trained in its use.A complete exam also includes exploration of non-optical solutions to promote independent living. This can include suggesting products, which would enhance illumination, contrast and spatial relationships. A useful mantra here is ‘Bigger, Bolder, 256

Brighter’. Examples include lamps; reading stands, check registers, writing guides, bold-lined paper, needle-threaders, magnifying mirrors, high contrast watches, and large print books.Glare control can be a significant disabling factor in some conditions. Tinted lenses and visors are routinely prescribed. Absorptive filters are tinted lenses, which are used to counter glare. They come in different tints at various levels of absorption and different cut-off points for the visible spectrum of light.MAGNIFIERSThere are several types of magnifiers, which can be recommended for the near demands of low vision patients. Available in a wide variety of designs and magnifications, many are also illuminated to provide additional light. All magnifiers come in different powers represented by an ‘X’ or ‘times magnification’. ‘X’ is the ratio of the size of a magnified retinal image to the original image size. Conventionally, ‘X’ is equal to approximately 4 Diopters.The laws of physics and optics dictate that as the plus power of the lens increases, the diameter gets smaller and the center thickness gets greater. As the lens power increases the field of view gets smaller. This can frustrate many patients who require high magnification in order to see. The selection of devices must then balance the magnification needs with a field of view that will be tolerable. Magnifiers can be found for purchase in many non-optical outlets – like craft stores, office supply and even some of the big box retailers. These over-the-counter (OTC) versions of hand, stand, and spectacle magnifiers are often of a low power and aren’t strong enough to help individuals with low vision. There are also qualitative differences in these products and the products sold by optical professionals. Some high quality magnifiers use a diffractive lens design instead of a simple 257

refractive lens design, which makes the lenses up to 25% larger and about a quarter of the thickness of comparably powered refractive lenses.Quality magnifiers are manufactured so that the lenses do not shrink or change shape in the manufacturing process. This helps to minimize distortion, making images seem clearer – an important attribute when the retinal resolution itself is poor. Sometimes, poor quality magnifiers display distortion in the lens periphery, making the outer border of the lens unusable and field of view effectively smaller so that only a few letters can be seen clearly at a time. This leads to a slower reading speed and makes comprehension that much more difficult. Quality magnifiers have lenses with strong scratch resistant coatings on them to minimize scratching. This is important since most magnifying lenses are made of plastic. Scratched lenses can obstruct the view of what is being magnified and render the magnifier useless. Lower quality magnifiers generally do not have this and will scratch easily.Another attribute of quality magnifiers is their use of superior illumination. The quality and positioning of lighting is an important factor that directly impacts image quality. Many patients use magnifiers that have built-in illumination, the most common type being the LED (light emitting diode). Proper regulation of the voltage provides a steady, strong light with minimal glare. They should last a very long time and there are no bulbs that need replacing. They also draw very little current and so require infrequent battery changing. Hand Magnifiers - Hand magnifiers are portable, relatively lightweight and can be used with or without glasses. The basic hand magnifier design consists of a lens on a handle. They can come non-illuminated or illuminated with incandescent lighting or light emitting diodes (LEDs). The distance between the eye and the lens is easy to adjust to 258

improve focus and field of view. They are ideal for ‘spotting’ tasks: when a near object will be viewed for a short period of time. An example would be reading a medicine bottle, menu or price tag. To use the device, a patient needs to put the magnifier on the page and lift it slowly until the print comes into focus, Once in view, the magnifier must be held at exactly that distance or focus is lost. It is important that these magnifiers are held with a steady hand - those with tremors may find hand-held magnifiers difficult to use.Stand Magnifiers - A stand magnifier is basically a lens mounted on legs or in a holder that maintains a set distance from the lens to the object. Some have self- contained illumination. The magnifier sits directly on top of the text so is always focused. The user simply glides the magnifier over the page. Additional magnification may be gained by bringing the magnifier closer to their eyes (relative distance magnification). Stand magnifiers are helpful for tasks requiring more fluent reading – like books and magazines. They are ideal for people who cannot hold a hand magnifier steady for long periods of time. TELESCOPES/BIOPTICSThere are a variety of telescopes including monocular and binocular, focusable and fixed-focus, Galilean and Keplerian designs, hand-held and spectacle mounted—all in a range of magnifications. Most help patients see at intermediate and far distances. Hand held telescopes - Sometimes called “monoculars”, these are the most common type of distance optical device. They are inexpensive, small, inconspicuous, portable and focusable. They are held next to one eye for a short time as the patient ‘spots’ things, buses, faces and street signs. The patient must be stationary while looking through the telescope because depth perception and balance are affected and they risk falling if used when mobile. Also, steady hands are important as even slight 259

hand movements or tremors can affect the clarity of the image.Spectacle mounted telescopes - These devices can be made as monocular or binocular models and are available in a range of magnification powers. They are a ‘hands free’ device and are therefore steadier than hand-held telescopes. Usually, they are used for watching TV, seeing a stage (theater or church) or watching sport games. As with hand held telescopes, the user must be seated and cannot move around while wearing these telescopes. Bioptic Telescopes - Unlike other telescopes, these are meant for mobile use. Small telescopes are mounted on the upper part of an spectacle lens. This placement allows the user to look through the bottom half of the lens while walking or driving and then drop their head and look through the telescopes to read a sign or identify a person. In some states, under strict conditions and proper training, bioptic telescopes can be used while driving.ELECTRONIC AIDSIncorporating technology into low vision has lead to an ever-expanding range of options to help people live more independently.Personal Computers and Tablets - The Apple iPad or similar tablet can be an excellent option for the low vision patient willing to learn how to use it. The high contrast screen, built-in accessibility features and downloadable apps for the vision impaired may make it an alternative to conventional magnifiers for some patients. Braille and Text Readers - Screen readers are software programs that allow its users to read the text that is displayed on the computer screen with a speech synthesizer or Braille display. Most new computers come standard with assistive technologies like a built-in screen reader, screen and cursor magnification, and dictation (converts spoken words into text). 260

Closed Circuit Television (CCTV) - Also referred to as video magnifiers, CCTVs have been available for decades and keep evolving. They use a video camera to capture an image of text and display it on a monitor. The text is on a table that is movable from the top of the page to the bottom and from side-to-side. The device allows a patient to magnify this image as much as is needed without the peripheral distortion of magnifiers. The brightness and contrast of an image can also be manipulated. Some products offer reverse polarity (white on black) and HD image quality. Most are compatible with any computer monitor. This is particularly helpful for writing tasks because a hand can easily fit under the camera and patients can watch themselves write. Portable electronic magnifiers - Though CCTVs can be very helpful; they are limited in their practicality because of their high price point, bulk and size. In contrast, portable electronic magnifiers are moderately priced, small, hand-held devices, which are easily transported. Many have high-tech features for enlarging and enhancing images, including an LCD light, a built-in camera, and a \"freeze image\" function for capturing magnified text and graphics. Overall, they are easy to use and extremely portable – making them a very popular option. Smartphones - There are several apps designed to help the visually impaired with tasks like magnification, object recognition, money reading and color identification. Depending on how comfortable someone is with technology, this can be a viable option in low vision care. As the image quality and screens of 261

many smartphones continue to improve and increase in size, smartphones may be able to take the place of handheld video magnifiers for some patients.REHABILITATION SERVICESRestoring and maintaining the ability to function independently, sometimes calls for the collaboration of various healthcare professionals. The low vision professional is often an essential part of a multidisciplinary team including ophthalmology, social workers, occupational therapy and orientation and mobility specialists.CERTIFIED LOW VISION THERAPIST (CLVT)From the ACVREP website, “The CLVT uses functional vision evaluation instruments to assess visual acuity, visual fields, contrast sensitivity function, color vision, stereopsis, visual perceptual and visual motor functioning, literacy skills in reading and writing, etc. as they relate to vision impairment and disability. The CLVT also evaluates work history, educational performance, ADL and IADL performance, use of technology, quality of life and aspects of psychosocial and cognitive function.” OCCUPATIONAL THERAPISTOccupational therapists are essential members of the multidisciplinary rehabilitation team providing such interventions. Many already work in settings with clients who may have a visual impairment in addition to other issues. Addressing the patient’s vision is a natural extension of the work they are already doing. Occupational therapists are educated on disability and aging; they also have the appropriate background to address psychosocial issues related to vision loss, such as depression and lack of social participation. Occupational therapists also advise people how to modify their homes so they are able to perform the tasks they need to live independently. They will suggest solutions to problems like poor 262

lighting, poor contrast and kitchen safety. They also will try to get rid of excessive clutter and other tripping hazards in order to prevent falls. In some cases, the occupational therapist can train a patient how to use their magnifier or visual aid properly as well. ORIENTATION AND MOBILITY INSTRUCTORMobility is an important issue for many low vision patients. For instance, a person may have limited side vision that could put them at risk for falls, making it difficult or impossible to drive or even take a walk around the neighborhood. An Orientation and Mobility (O&M) Specialist is a skilled professional who provides instruction to relearn the skills needed to travel safely and independently both within a home and a person’s community. They can teach patients how to use their other senses in combination with self-protective techniques to do things like cross streets and identify intersections. They can also assist the visually impaired with safely navigating public transportation and proper cane use, if needed.REHABILITATION COUNSELOR FOR THE BLINDRehabilitation Counselors assist people with severe visual impairments to achieve their personal, career and independent living goals in the most integrated setting possible. Contact the rehabilitation services centers available through local state government offices. GETTING STARTEDAs with everything, the first thing to do is to educate yourself about the field. There are a variety of websites to get you started such as the National Eye Institute’s National Eye Health Education Program’s site, the American Foundation for the Blind, the Lighthouse International and Envision University. LOW VISION AND LEGAL BLINDNESS TERMS AND DESCRIPTIONS 263

Maureen A. Duffy, M.S., CVRT (courtesy of The American Foundation for the Blind)FACTS ABOUT LOW VISIONMost surveys and studies indicate that the majority of people in the United States with vision loss are adults who are not totally blind; instead, they have what is referred to as low vision. You may have heard the terms \"partial sight\" or \"partial blindness\" also used to describe low vision. Those descriptions are no longer in general use, however.Here is one definition of low vision, related to visual acuity:• Low vision is a condition caused by eye disease, in which visual acuity is 20/70 or poorer in the better-seeing eye and cannot be corrected or improved with regular eyeglasses. (Scheiman, Scheiman, and Whittaker)VISUAL ACUITY AND LOW VISIONVisual acuity is a number that indicates the sharpness or clarity of vision. A visual acuity measurement of 20/70 means that a person with 20/70 vision who is 20 feet from an eye chart sees what a person with unimpaired (or 20/20) vision can see from 70 feet away.20/70 can best be understood by examining a standard eye testing chart that you may have used in your own doctor's office during an eye examination. 264

In the United States, the Snellen Eye Chart (pictured at left) is a test that ophthalmologists and optometrists use to measure a person's distance visual acuity. It contains rows of letters, numbers, or symbols printed in standardized graded sizes.Your eye doctor will ask you to read or identify each line or row at a fixed distance (usually 20 feet), although a 10-foot testing distance is also used.If you can read line 8 (D E F P O T E C) from 20 feet away while wearing your regular glasses or contact lenses, the doctor records your vision (or visual acuity) as 20/20 with best correction.If the smallest print you can read is line 3 (T O Z) from 20 feet away while wearing your regular glasses or contact lenses, the doctor records your vision (or visual acuity) as 20/70 with best correction.Please note: An actual Snellen Eye Chart is much larger than the one depicted here; therefore, it's not recommended that you use this chart to test your own (or a friend's or family member's) visual acuity.A FUNCTIONAL DEFINITION OF LOW VISIONNot all eye care professionals agree with an exclusively numerical (or visual acuity) description of low vision. Here's another – more 265

functional – definition of low vision:• Low vision is uncorrectable vision loss that interferes with daily activities. It is better defined in terms of function, rather than [numerical] test results. (Massof and Lidoff)• In other words, low vision is \"not enough vision to do whatever it is you need to do,\" which can vary from person to person.• Most eye care professionals prefer to use the term \"low vision\" to describe permanently reduced vision that cannot be corrected with regular glasses, contact lenses, medicine, or surgery.• If you have low vision, it is necessary to have a different kind of eye examination that uses different and more detailed tests to determine what you can and cannot see. You can learn more about these specialized eye charts and testing procedures at What is a Low Vision Examination?LOW VISION VS. LEGAL BLINDNESS\"Legal blindness\" is a definition used by the United States government to determine eligibility for vocational training, rehabilitation, schooling, disability benefits, low vision devices, and tax exemption programs. It's not a functional low vision definition and doesn't tell us very much at all about what a person can and cannot see.Part 1 of the U.S. definition of legal blindness states this about visual acuity:• A visual acuity of 20/200 or less in the better-seeing eye with best conventional correction (meaning with regular glasses or contact lenses).This is a 20/200 visual acuity measurement, correlated with the Snellen Eye Chart (pictured above): 266

If you can only read line 1 (the big \"E\") from 20 feet away while wearing your regular glasses or contact lenses, the doctor records your vision (or visual acuity) as 20/200 with best correction.• Update: In 2007, the Social Security Administration updated the criteria for measuring legal blindness when using newer low vision test charts with lines that can measure visual acuity between 20/100 and 20/200. Under the new criteria, if a person's visual acuity is measured with one of the newer charts, and they cannot read any of the letters on the 20/100 line, they will qualify as legally blind, based on a visual acuity of 20/200 or less.Part 2 of the U.S. definition of legal blindness states this about visual field:• OR a visual field (the total area an individual can see without moving the eyes from side to side) of 20 degrees or less (also called tunnel vision) in the better-seeing eye.This is a representation of a constricted visual field: A living room viewed through a constricted visual field. Source: Making Life More Livable. Used with permission. 267

For more information on the definitions of legal blindness, you can read Disability Evaluation Under Social Security, a publication from the Social Security Administration.WHAT CAN I STILL DO IF I AM LEGALLY BLIND?• You can still read.• You can still cook.• You can still work.• In other words, you can still enjoy life!• Check out our Getting Started Kit for more ideas to help you live well with low vision.• Read about Ben Karpilow, a visually impaired attorney who practices disability law in California.• Sign up with VisionAware to receive free weekly email alerts for more helpful information and tips for everyday living with vision loss.VISUAL IMPAIRMENTMuch like low vision, there are many different definitions of visual impairment. \"Visual impairment\" is a general term that describes a wide range of visual function, from low vision through total blindness.Here is an example of the variations in the term \"visual impairment\" or \"visually impaired\" from the World Health Organization Levels of Visual Impairment:Moderate Visual Impairment:• Snellen visual acuity = 20/70 to 20/160Severe Visual Impairment:• Snellen visual acuity = 20/200 to 20/400• OR visual field of 20 degrees or lessProfound Visual Impairment:• Snellen visual acuity = 20/500 to 20/1000 268

• OR visual field of 10 degrees or lessLike the term \"legal blindness,\" \"visual impairment\" is not a functional definition that tells us very much about what a person can and cannot see. It is a classification system, rather than a definition.LIGHT PERCEPTION AND LIGHT PROJECTIONThese terms describe the ability to perceive the difference between light and dark, or daylight and nighttime. A person can have severely reduced vision and still be able to determine the difference between light and dark, or the general source and direction of a light.The stereotypical assumption – that people who are blind or have low vision live in a type of \"blackness\" that sighted people see when they close their eyes – is generally not accurate.• Although every person sees differently, including persons with low vision, an individual who has light perception/projection can perceive the presence or absence of light. Some people describe light perception as knowing when a room light is on or off, or being able to walk toward a lighted lamp on a table in an otherwise darkened room.TOTAL BLINDNESSTotal blindness is the complete lack of light perception and form perception, and is recorded as \"NLP,\" an abbreviation for \"no light perception.\"Few people today are totally without sight. In fact, 85% of all individuals with eye disorders have some remaining sight; approximately 15% are totally blind.USING LOW VISION OPTICAL AND NON-OPTICAL DEVICESLow vision optical, non-optical, and electronic magnifying devices can make it possible for you to do a variety of everyday tasks, such as managing your medication, crafting, and preparing 269

meals. To learn more about the different types of reading options that are available, see Reading, Writing, and Vision Loss on the VisionAware website. Living room image source: From Maureen A. Duffy, Making Life MoreLivable: Simple Adaptations for Living at Home After Vision Loss (New York, NY: AFB Press, American Foundation for the Blind, 2015), p. 11. © 2015 by American Foundation for the Blind. All Rights Reserved. THE VISION COUNCIL The Vision Council released a report about low vision highlighting research that shows that only approximately 20 percent of adults with severe vision impairment use devices that could help maintain activities of daily living. You can access the report, Vision Loss in America: Aging and Low Vision, here.VISUALLY IMPAIRED OR BLIND CHILDREN?Learning your child is visually impaired or blind... WonderBaby.org, started by Amber Bobnar, is a project funded by Perkins School for the Blind. It is dedicated to helping parents of young children with visual impairments as well as children with multiple disabilities. Here you'll find a database of articles written by parents who want to share with others what they've learned about playing with and teaching a blind child, as well as links to meaningful resources and ways to connect with other families. 270

Blind Babies Foundation From Junior Blind, “As of July 1, 2014, Blind Babies Foundation became a program of Junior Blind. Blind Babies Foundation has been providing critical early intervention and education services to infants and preschoolers in Northern California who are blind or visually impaired since 1949. The program’s family-centered services are provided in the homes of the families we serve, encouraging every child’s development to the fullest degree possible with careful attention to their individual abilities and needs.” National Association of Parents of Children with Visual Impairments (NAPVI). NAPVI is s non profit organization that supports the parents of children with visual impairments. From The National Federation of the Blind website. “The National Federation for the Blind knows that blindness is not the characteristic that defines you or your future. Every day we raise the expectations of blind people, because low expectations create obstacles between blind people and our dreams. You can live the life you want; blindness is not what holds you back.”NEWLY BLIND OR VISUALLY IMPAIRED ADULT?There is a tremendous amount of information available to assist people with severe visual impairments/blindness. The following 271

resources, for community based services, will help you or someone close to you that is facing a severe vision loss or blindness. The American Foundation for the Blind is a wealth of resources to connect individuals with visual impairments and blindness with resources, information and services. Vision Aware is a comprehensive resource for basic information about adjusting to vision loss, including tips for adapting your home & daily living. FamilyConnect offers a virtual lifeline to parents of children with visual impairments. We provide information and resources, and host an online community where families find support, comfort and help. AFB CareerConnect helps students exploring careers, job seekers investigating work options, employers planning to diversify their workforce, professionals working with visually impaired people, and friends or family members assisting someone who is blind or has low vision. Braille Bug® AFB's award-winning website that introduces children to the magic of braille through games, secret messages, and other fun activities. 272

Blind Rehabilitation Services (BRS) The American Council of the Blind strives to increase the independence, security, equality of opportunity, and quality of life, for all blind and visually-impaired people. From The National Federation of the Blind website. “The National Federation for the Blind knows that blindness is not the characteristic that defines you or your future. Every day we raise the expectations of blind people, because low expectations create obstacles between blind people and our dreams. You can live the life you want; blindness is not what holds you back.” The International Agency for the Prevention of Blindness (IAPB) is an alliance of civil society organizations, corporates and professional bodies promoting eye health through advocacy, knowledge and partnerships. National Association of Parents of Children with Visual Impairments (NAPVI). Lighthouse 273

International is a leading resource worldwide on vision impairment and vision rehabilitation. Through its pioneering work in vision rehabilitation services, education, research, prevention and advocacy, Lighthouse International enables people of all ages who are blind or partially sighted to lead independent and productive lives. Founded in 1905 and headquartered in New York, Lighthouse International is a not-for-profit organization that depends on the support and generosity of individuals, foundations and corporations. Foundation Fighting Blindness Founded as the National Retinitis Pigmentosa Foundation,Inc.. Their mission was to research Retinitis Pigmentosa. It has expanded to study a wider range of blinding diseases such as macular degeneration and Usher’s Syndrome. Helen Keller International Works to save the sight and lives of millions of people living in 21 countries in Africa and Asia, as well as in the United States. If you, or someone you know, suffers from a vision impairment, ask your optometrist about low-vision rehabilitation. An optometrist who provides low-vision rehabilitative services can help people with low vision regain their independence. People with low vision can learn a variety of techniques to help them perform daily activities with what vision remains. Government and private programs offer educational and vocational counseling, occupational therapy, rehabilitation training and more. 274

The Low Vision chapter was compiled and edited by Ilene Mattison-Shupnick, MA 275

CHAPTER 14 The Not So Distant Future Of VisionHaving the perspective of the patient and the doctor helps understand the daily issues, motivation and the positive outcomes of new technologies. As many of the obstacles as you have read about or can imagine, there are those creative individuals thinking of new ways to remove those obstacles. TELESCOPE IMPLANT FOR MACULAR DEGENERATION Dan Dunbar, Mechanical/Electronics Engineer (Rockets, Defense 276

Electronics ), Retired “It was probably in late 1995-97 I started having vision troubles. Quit driving about 2005, just really couldn't see well enough to drive. I had AMD and it just steadily got worse after that. I was a candidate for the telescope at IMT and they notified me in 2011, had the operation in November 2011, and have enjoyed the telescope everyday since then. It keeps getting better and better for me.”Before the telescope?“I gave up playing cards cause I couldn't see the cards. I gave up reading... went to all audiobooks because I really couldn't read well enough, fast enough to enjoy it, and I was never really big on crosswords puzzles, but I did do some of that and I couldn't do that either cause it takes a good deal of vision to be able to do those things, I was a model railroader and I had problems with the gauge that I was in which was N-gauge, that's, cars are about four inches long and it was below my resolution. I couldn't see whether I had a car in the track or not. Then, I moved up to bigger gauge which helped some, but each year it got worse. I saw less each year then I saw the year before.”Right after the implant, what was that like?“You have to learn how to use it. You start off with really two visions... with the big (magnified) vision of the telescope and regular vision which is your other eye in my case. It suffers from AMD also, it has a blind spot in the center. You learn not to look directly at what you want to see, you look out the corner of your eyes and when you have the telescope you can't do that because the telescope has a small field of view and if you look out the corner of your eye at something the telescope is no longer aimed at the item you want to see. You have to train yourself to look directly at the object and that's hard to do if you have AMD. 277

Make sure that the eye containing the telescope is your dominant eye so it provides your brain the signal that you want to have and avoid using the old eye for your visual information. You use that only for the peripheral vision because peripheral vision is limited with the telescope.”What other activities have you changed since the implant?I can do wood working now because I can see the pencil line I draw. I can find out where the center of the pencil line is and I can drill or make the saw cut. I can see my model trains, I can see exactly where the axles are, where the oils are going in and what the controls are and most importantly I can see the train from one end of the layout to the other. Couldn't do that before. I now can ski better. I almost gave up skiing because I couldn't see where I was going. I ran into fences and stuff like that before. Now I don't have that problem. I read on the computer easily. I read only some books because it's too easy to just read on the computer. I can write letters, I can you know, sign checks fill out checks, fill out all kinds of paperwork with this telescope.One last question and you don't have to answer it. What emotional shifts did you go through as you lost your vision and as you got the telescope? I was kind of depressed because my vision dropped but, but I had the Retinologist who kept telling me I was a candidate for something that would help. That gave me hope. 278

After the implant and trying to work with the telescope, I couldn't do what I thought I could do and I got depressed and then through the help of my optometrist, and the physical therapist, that worked. They told me just use your training and those issues will go away, and they were right. So it's really important to do the training because you have to train your mind to use a different part of your eye in a different way than you've always used them. That takes time and once you do it it works really well. They measured me at about 20/400 in one eye and 20/500 in the other at about age 70. So it wasn't very good and it wasn't good enough to drive. It was good enough to do a lot of things, What does your wife think?She thinks it's great. Yeah. Samit Garg, MD, Medical Director, Gavin Herbert Institute, UC IrvineLet's talk about the telescope how does the telescope work?“The telescope is a very unique device and it's the only device that actually will restore vision in people with bilateral central scotomas. Back to the camera analogy... when you look at someone with macular degeneration you can see the center part of their face. The telescope is implanted in one of your two eyes. What it does is it magnifies the image so that that the blind spot becomes smaller. Imagine if you couldn't see someones face, their eyes, their noes, 279

their mouth... you have the telescope, it'll magnify the image to fall onto working parts of the retina. Perhaps you can't just see their nose but you can see their eyes and their mouth.The telescope is implanted in one eye of a patient and you use that eye for central vision and the other eye for peripheral vision. It's a very unique and very exciting tool for us because it does actually give us something to restore vision in patients who have these bilateral central scars, or atrophy from macular degeneration.SENSORY SUBSTITUTION Joel Schuman, MD, Professor and Chairman of Ophthalmology Department, University of Pittsburgh, Director of UPMC Eye Center and Louis J. Fox Center for Vision Restoration“Sensory substitution is giving visual information through an organ other than the eyes. Here we're talking about, there are a few devices, there's one that provides that information on the tongue, and then there's another that will provide it through your ears so that gives you audio information that represents vision. The exciting things about this, number one, it works. If you take somebody who's blind and they use one of these devices, they actually can navigate, they can perceive the visual world. It is not vision and they will be the first to tell you that it's not vision although they'll use the word, \"I can see this\" or that. They are perceiving objects, but not seeing them in the sense that you and I perceive. 280

The curious thing though is, through experiments that we've done here at the University of Pittsburgh, specifically Kevin Chan and Amy Nau and others, we know that when patients are presented with that information on the tongue who are blind, they use their visual pathways in order to process that information. Whereas if sighted people are given the same information on their tongue, they do not use their visual pathways. There's some plasticity within the brain that allows the information to be processed in the visual system in people who are blind. That happens relatively quickly, within days to weeks of training with the device, but it never happens in people who are sighted.With the tongue based device, it's an array of electrodes. That array of electrodes right now is designed to just sit on the tongue kind of like a lollipop. The reason the tongue was chosen, is that it's moist, so it conducts electricity well, and also it's very sensitive, so it has a very high density of nerve tissue that will help you to discriminate this sensor's stimulating, not that sensor over there. Some people have described it as champagne bubbles. The sensation is really a discriminator between men and women in terms of understanding what this sensation is. Most men have, at some time in their lives, taken a nine volt battery and put it on their tongue. Most women have not done that. It feels like a weak version of that nine volt battery on your tongue.”VISION BY BRAINPORT Ellen Mitchell MD, Pediatric and Neuro-Ophthalmologist, Assistant Professor of Ophthalmology, UPMC Eye Center, 281

University of Pittsburgh Medical Center, Current Director of the Sensory Substitution Lab and Chris Fisher, Research Assistant, Greenport Lab, University of Pittsburgh.“The BrainPort is a sensory substitution device that was initially developed for mobility, to assist patients with mobility. The device is being tested and is being used for patients with low vision or no vision for navigation in the non-seeing world. The way the device works is that a camera is mounted on a pair of glasses and this camera, I guess, inputs the visual information and turns it in to an electrical stimulus that's on a lollipop that you place on a tongue.This device is not on the market yet. The creators of the device, Wicab, are currently submitting for FDA approval, so it's not it's not commercially available at this point.” “The device would go on his tongue and then as he scans and looks at various objects the stimulus will change on his tongue to help him determine whether or not something is closer or further away from him or whether or not the object is lighter or darker, and that image that he is seeing is on the computer. The sensors basically paint that onto the tongue .We've had patients who were blind using the device for walking in their neighborhood and a patient who used this device a lot for his walks. He was able to tell where a driveway would be because of the different senses that he would get on his tongue, be able to delineate the driveway versus the grass.” 282

“Another patient reported she was able to make out the letters on her mail, she could know which one was the gas bill, which one was the cable bill, because she used the device enough that she was able to make out letters.There's definitely a learning curve with the device. It's not an easy device to use, you have to be motivated to use the device and be successful with it. It's not going to make you see, however it's a way to help increase the sensory information that you're getting from your world that you no longer are able to see.” HOW DO WE GET THE BRAIN TO TALK TO THE EYE?00:00 / 00:00 283

Dr. Sheila Nirenberg and her team have decoded the signal that the retina sends to the brain and developed a transmitter that generates the code. Sheila Nirenberg, PhD, Professor of Physiology and Biophysics, Weill Medical College of Cornell University.RETINAL IMPLANT PROJECTJoseph F. Rizzo III MD, Professor of Ophthalmology, Harvard Medical School, Director of Mass. Eye and Ear’s Neuro-Ophthalmology ServiceYou've been involved in 2 ground-breaking trials, the bionic eye and the retinal implant. Can you describe the two?“The bionic eye concept, in our hands at least, was the development of a retinal prosthesis. That led to the formation of the Boston Retinal Implant Project. The design of the Boston Retinal Implant is to have a system that is part external and part implant or internal. The external part is a pair of glasses with a camera and the camera takes the pictures of images that the blind patient can't see. Those images are then processed with a device that's like a small cellphone that would be worn in a pocket. So the visual image is processed and turned into a digital signal, which is then sent wirelessly to the implant. Much like you receive a picture on your cellphone, that image is sent digitally to the implanted components which sit around the back of the eye.The computer chip of the implant receives this information, as 284

well as the electrical power to stimulate the retina. The received image is transformed into a series of electrical pulses that are delivered to a grid that lies on the retina. The concept is, by creating points of stimulation on the retina, you will activate clusters of nerve cells that sit on top of those electrodes and create visual images, which reach the brain through the optic nerve.You called the grid a polymer?The substrate of the grid is a polymer. It's a piece of plastic basically, into which we micro-fabricate wires and metal electrodes and the electricity passes down the wires and through the electrodes that are sitting underneath the retina. We have 256 points of stimulation We have not implanted our device in humans yet. We have been involved in development work to design the device, to test its biocompatibility, to test the ability of the device to survive inside of the saltwater environment of the body.We are just beginning the testing that's required by the FDA to hopefully obtain an approval for a phase one study, which would be a safety study in humans. At that point, we'll be able to answer the question about what patients might be able to see with our device. Isn’t controlling electric impulses in a saltwater environment difficult?There are a lot of complexities in trying to deliver these electrical pulses to the retina. The first is that the design of the chip has to be pretty sophisticated. It receives this visual image captured by the camera and it has to be transformed into points of electrical stimulation. For each point, you have to adjust the strength of that pulse and how long it last and its polarity, whether it's positive or negative, for each one of these electrodes. Then the electricity enters the retina from multiple electrodes and 285

so there is the likelihood that the electrical fields that are released from each of these electrode sites will cause some interference with one another. Much like if you threw two pebbles into a lake and they created a series of ripples, those would come together at some point and create either additive or subtractive waves. The same thing is going to happen with the electrical fields in the retina. So it becomes pretty complicated. It's very difficult really to understand how the electrical fields will interact with the nerve cells. The only way to really know how well it works is to implant it in humans and to test the device.This computer chip is inside of the body, the body is filled with saltwater. To protect the computer chip from the saltwater, you have to seal it up inside a hermetic enclosure. Little wires come out of the enclosure. It's vulnerable to leakage of sodium inside of the case so these are called hermetic feed-throughs.A structure that can have 256 hermetic feed-through’s in a small enough space to be able to fit behind the eye has been a real challenge. We've been able to accomplish that and that really is a state of the art. In the future, I'm sure with newer techniques and even some techniques that are available now, that number could multiply quite easily to the thousands.But the question of how many electrodes would be needed is unresolved and it's not obvious if thousands of electrodes would actually be more beneficial than hundreds. It's not clear because, for instance, of the potential for the interference of electrical fields to develop … the more electrodes you have and the closer they are together, the more likely you are to get these patterns, unpredictable patterns of electrical field propagation through the retina. 286

IMAGE: ILENE MATTISON-SHUPNICK CHAPTER 15 HumanityBRIEN HOLDEN INSTITUTE Kovin Naidoo, OD PhD, Chief Executive Officer, Brien Holden Institute Foundation“During apartheid, I think most young people in our country at that time took a stand against apartheid because it was a moral, ethical, legal evil in our society. I, like many people, became a student leader and got involved in the anti-apartheid movement, got arrested, spent some time in prison. When the country changed many of us who got involved from the perspective of 287

wanting to oppose an evil, but not necessarily wanting a political career, decided to get involved in other spheres. By then I had graduated as an optometrist and public health optometry was a natural flow for me. It catered for my interest in people, my interest in addressing poverty and inequality in the world. In that respect it was the perfect road for me.”Tell us about your ideas of an eyecare pyramid?“In a situation of limited resources, when you have few optometrists a few ophthalmologists, not enough to cater for the population, spread out mainly in key cities, most other communities are deprived of service. You need to have a team approach for the delivery of eye care. We also have to consider that in poor communities, people spend a lot of money traveling and that becomes a barrier to accessing care. Even if services are available, if it’s going to cost them a lot to get to a center, the would forgo that to buy food or to pay for other expenses. You need to ensure that services are closer to them. The only way to do that is to create a kind of pyramidal structure where you have more primary healthcare nurses or primary eye care nurses at the base of the pyramid who are in clinics that are close to communities that can provide basic eye care like treating red eyes, screening of patients, picking out that somebody needs a pair of glasses and referring them then to an optometrist who would be at a district hospital or a bigger clinic in a center that caters to a larger population. The optometrist provides a refraction, detects the diseases, in some cases may even in some countries, manage some of the basic diseases but then refers on to the ophthalmologist only those patients that need treatment and surgical treatment. Treatment for the disease, for example, maybe glaucoma management. By doing that, fewer people are traveling to secondary and tertiary centers and most of your services will be provided at the primary level. That allows us to see more people 288

and have firstly a teams approach but also a systems approach to the delivery of eye care.”What is the Brien Holden Institute doing?In terms of the Brien Holden Vision Institute, we look at a world of 7 billion people. The pre-dominant approach in the past amongst NGOs and development organizations was a single model or approach. We believe that the approach needs to be varied. Amongst the 7 billion people in our world, there is a sector, not a very large sector, but in the developing world, a significant sector that can afford private healthcare and they should then access services. At the other extreme, you have the poorest of the poor who cannot afford any services and we believe that it’s the responsibility of government to provide that service and that we should be supporting and working with governments to do that. For example, we've set up 14 vision centers in Tanzania for example and we've also set up vision centers in Vietnam which are in government hospitals. These help us to utilize the resources of government facilities. They employ the optometrists or the other clinicians, we provide the equipment and provide some of the supply of spectacles, etcetera. are able to, in partnership, provide that service.Then, there is the middle group, the working poor who may have some money to buy eye care services but not enough to source the private sector. With that group, we created the ‘social franchise’ model. The social franchise model is where we take young graduates in the developing world setting them up in loan finance to own their own practices. The advantage of doing that is that we can get people to go to areas that they may not want to normally go but because they now have the opportunity of ownership, they're willing to go to an outlying town. What this does is that through this process we establish the framework for affordability of services and spectacles. It’s like a regular franchise that you may experience in the US or other parts of the 289

world but it’s targeting the bottom of the pyramid and using entrepreneurship to drive the system.This also says that NGOs and development organizations should not always be trying to own things and do it on their own. If you really want to scale up, you need to mobilize all sectors of society. That is essentially the approach that we have adopted in trying to reach the massive number of people that are visually impaired because of uncorrected refractive error. That is close to 614 million people in our world who cannot afford an eye exam and a pair of glasses.”How does that compare with past models?“When you compare what we do with providing, for example, recycled spectacles, we found that people in the developing world are very fashion conscious like anybody else in the world. Even though they are poor, they don't want to look silly so people want to select a frame that suits their face. Using recycled spectacles becomes a challenge for us. Then, given the supply chain that exists now, especially out of India and China, and the fact that we've set up direct supplies from those countries and partner with big companies, we have access to frames and lenses. We can deliver them at a price point that's affordable to the patient. We want to ensure that children and adults use the spectacles that they get and that the type of spectacles we provide is not a barrier for them to be wearing spectacles.”What’s the magnitude of the problem?It costs the world economy $272 billion per annum in lost productivity because people do not have access to eye exams and a pair of spectacles. For example, people aren't able to continue working because they cannot see. They've turned 40 and they've lost their near vision. Some people still continue but at a slower pace because they struggle to see. Some people are 290

not able to progress within the job.If you consider the loss to society of all of that, you're talking about $272 billion yet we have shown that it will cost probably $39 billion to fix the problem. That would mean setting up schools of optometry, training people, installing the system. It’s much cheaper for our world to actually address the issue of uncorrected refractive error than to leave it as it is. So it’s not only a government issue, it’s not only an NGO issue, it’s a major issue for the private sector as well. Nils Koenig, Associate Producer, Tanzania Why a problem for the private sector?Take a country like South Africa which in the African context would have one of the better health systems. The private sector only caters for 20 percent of the population. Most people in the developing world get their eye care service through either the public sector which as we know is oversubscribed. Quality sometimes becomes a big issue in that context and so creating a middle provision through a social franchise vision center set up by NGOs, others, helps ease that burden. Most countries in the developing world would prioritize malaria, tuberculosis, HIV, and other conditions before they get to 291

eye care. I think because it seems so simple to those of us who have the resources to get a pair of glasses, many people underestimate the importance of uncorrected refractive error. The World Health Organization should do its projections and measure blindness and visual impairment after you are corrected with a pair of glasses. How many people on the day that study is conducted, do not have glasses if they needed them or not? That has made uncorrected refractive error the leading cause of visual impairment in the world and the second leading cause of blindness in the world after cataracts. If we take both of them together, they have very successful solutions. Cataract surgery is an inexpensive surgery even in part of developing world as well as spectacles can be provided inexpensively. We can eradicate 50 percent of blindness and visual impairment in our world. We have the solution in our hands but society is abrogating it’s responsibility to the disadvantaged.When HIV came on the scene, people were dying of it. Malaria, the same situation. I think the impact with vision is that there is evidence that people with bad vision live less years but it’s not as immediate an effect like HIV, malaria. It was also felt that providing glasses are simple things. Somebody else can do that. Governments don't have to add that responsibility until research showed that huge numbers of people suffer. 640 million is a lot of people that are vision impaired which means they can't function properly in society just because they don't have a pair of glasses.In Tanzania, we've gone to the private optometrist and have now convinced them to carry an affordable eyeglass package that becomes available to anybody who doesn't have a lot of money. If all these different sectors start taking a small share from this bigger group, we can collectively meet the challenge.You used the term ‘eye disease of poverty’, what does that mean? 292

Refractive error contributes to blindness in the developing world. In the developed world it's almost non-existent or very limited. There's a very big difference in the profile of the disease. Eye disease of poverty exists in In the developing world. Solutions are there but poverty is limiting people from getting access. Therefore, in order to succeed, we need concerted interventions, to gain much traction. You don't have to develop new solutions, they are already there.ORBISORBIS INTERNATIONAL, FLYING EYE HOSPITAL 00:00 / 00:00The only way to solve the problem is to train the people, who do the work, in the societies to advantage the people...” Brien Holden PhD, DSc, OAM, Ahmed Gomaa, MD, PhD, Medical Director, Orbis. 293

James Brandt, MD, Professor of Ophthalmology, University of California, Davis“There are many different kinds of glaucoma. We don’t fully understand what the causes are. It does run in families, quite strongly. If you have a grandfather who went blind from glaucoma, you should probably get checked cause the likelihood of you as a first degree relative or a second degree relative developing glaucoma during your lifetime is raised quite a bit. Other risk factors include African American heritage, Latino heritage as well, and then there is certain forms of glaucoma that tend to occur in different populations. There is really nothing that you can do to prevent the disease... like wearing wide brimmed hats or sunglasses to prevent UV exposure or so on. We don't understand the disease well enough to be able to guide people in terms of what they should or should not do.”What type of patients are you seeing?Well I have a particular interest in glaucoma in children. That's what I think about day and night, and it's a large part of my practice. Part of the reason that I got so involved with ORBIS is that glaucoma in children is not well managed in the rest of the world. It's not even that well managed sometimes in the United States but in the rest of the world, these children really could be prevented from going blind. Primary glaucoma in children is unlike the adult forms, generally quite treatable, and we have very good operations that often 294

lasts decades if not an entire lifetime in these children. I've made it my mission, over the last few years with Orbis to visit different countries and teach the ophthalmologists the newest and best treatments for managing glaucoma in children. We saw a variety of patients today, some adults, some children. The children that we saw today have relatively end stage or very advanced glaucoma, but I'm unguardedly optimistic with some of the surgeries that we can do, we can stabilize things so that we can hold onto their vision somewhat longer. The first case tomorrow is a young boy, he's about ten years old. He had glaucoma at birth, he has a younger sister actually who we also saw who we really could not help. Her glaucoma is so severe that we have really nothing to offer to her. The 10 year old has had surgery which is holding onto vision in one of his eyes. That surgery is no longer holding its own. So we are going to place a glaucoma drainage device in the eye. This is a special artificial tube made of silicon, that drains the fluid out of the eye to lower the pressure.How does the aircraft allow you to do more then you would if you just came down here to do the procedure in a hospital?The Flying Eye Hospital is a unique resource because it's more then just a hospital on wings, it's a teaching hospital with wings. The FEA, or Flying Eye Hospital allows us to perform surgery with state of the art equipment but also with an auditorium of 48 ophthalmologists sitting, listening and watching and asking questions during the surgery. In an interactive way, that allows them to take those skills back and employ them in their own practices. With the Flying Eye Hospital I can train 30 or 40 doctors in the management of that surgical disease.”From orbis.org, “The Flying Eye Hospital is the world’s only state of the art teaching eye hospital on board an MD-10 aircraft. It is equipped with everything needed to unite the world to fight avoidable blindness. The plane provides hands-on training to 295

local eye care professionals in the heart of under resourced communities around the world. Not only does it ensure a sustainable eye care legacy is left in its wake, it acts as a flying ambassador waving the flag for improved eye care services wherever it lands.The aircraft itself was generously donated by FedEx and custom designed to incorporate the latest in avionics, hospital engineering, technology and clinical expertise. It includes a fully accredited surgical suite, treatment rooms and a 46-seat classroom: a hub for skills transfer, learning and innovation. It has the latest in 3D technology and broadcasting capabilities ensuring that, with your help, we can train more doctors, nurses and medical professionals than ever before. DO PEOPLE AROUND THE WORLD KNOW THAT THERE IS A CRISIS THAT WE CAN SOLVE? 00:00 / 00:00Jason Singh, OD, former Executive Director, OneSight, describes the opportunity that we have to help the rest of the world see clearly and by doing that improve the lives and 296

productivity of individuals and the world.Bruce Johnson, Director of Aircraft Operations, Orbis International (photo Dickie Tam, ctgoodjobs.hk)“A one year itinerary? Generally we like to do approximately eight to ten programs a year. An eight to ten programs a year consists of either eight to ten countries or possibly multiple programs in any country but overall eight to ten. Along with that comes good will tours, where we show off the airplane where people become aware of blindness. Sometimes just we may do a airshow in that region in which we are present. We generally stay between two to three weeks on each one of those eight to ten programs.”What are the countries that you've visited in the last eight, nine months?“We are in Peru now, we just came from Mongolia, prior to that we were in the Philippines for two programs, Indonesia before that, and then China, EYE REFRACTOR/PHOROPTER FOR THE BUSH 297

Karen Roberts, VP Customer Enablement, Carl Zeiss Vision“We have, in many parts of the world, people that have no access to good quality eye care and eye wear solutions and not being able to see correctly accounts for many world problems. The idea of using an analog phoropter rather then a new modern digital device ,which has an application for auto-refraction, is you don't need power, you don't need special training, you don't replace batteries. Therefore, you have the opportunity for people to be able to self refract, and then to have access to a frame and lens package that will allow them to see.”How does it work? 298

“You can place the phoropter on your head, make the necessary adjustments and by rotating this special lens you can stop at the point where you get good focus. Do that for both eyes, and then prescribe a pair of lenses that satisfy that vision need.”ONE SIGHT Jason Singh, OD, former Executive Director, OneSightYou're wearing glasses, tell me about when you first received eyeglasses?“I got my first pair of glasses around age 9. I didn't know what I was missing. Went to the eye doctor myself and had that glorious moment when I was the world clearly for what felt like the first time. As I walked out of the office with those big old pair of glasses that I noticed the leaves on the trees but I also noticed I could hit the fast ball so much better. Honestly I think my parents noticed I might have a vision problem just because I couldn't hit the fast ball. I couldn't play well on Little League because it was during the summer, it actually wasn't during school time. So it was again part of my interest that really helped them notice that I might be having a vision problem.”How important is this for parents to pay attention, to have an annual eye exam?“Sometimes it's not as obvious for parents to recognize that there is a vision problem because a child may not recognize themselves 299

that they have a vision problem. They don't know what it is like to see the world clearly if they are gradually loosing vision and so it is really important for the parents to be aware and it's really important for the parents to get their child that comprehensive eye exam at a early age because it will have such an impact on the ability to learn, to develop and especially their academic performance.”Tell us about OneSight.“OneSight is committed to changing lives with the power of a simple pair of glasses. Because the reality is that vision care is not just a health care issue, its an education issue. Because 80% of what we learn is visual, and yet one in four kids in a developed country like the United States has an undiagnosed vision problem. We like to keep things simple. Children who see better, learn better. So we know its an education issue. We also know its an economic development issue, because adults who see clearly produce 35% more at work. This increases their earning potential by as much as 20%. Vision care, although most of us think of it as a health care issue, is an education and a economic development issue. The OneSight Vision Center at Olyer school is a huge success because of the public and private partnership. It brings together the public school system, the public health partner, and a non profit like OneSight and many others in this local community. It leverages the access, the coverage these kids have because 75% of them are Medicaid eligible. It leverages that reimbursement from those kids that are Medicaid eligible to provide access to vision care for the 100% of the community. Part of the OneSight ongoing commitment is to make sure that the pair of glasses is provided for every kid whether they are insured or not.”Marilyn Crumpton, Medical Director, Division of School and Adolescent Health, Cincinnati Health Department added to Dr. Singh’s description of the program. “There are a number of social 300