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Introduction
Blindness and Low Vision – definitions according to WHO
According to WHO, visual acuity of less than 3/60 or corresponding visual field loss in the better eye with the best possible correction is a definition of blindness (ICD-10 Codes 3,4, 5) (1). Low Vision for the other hand corresponds to visual acuity of less than 6/12 but equal to or better than 3/60 in the better eye with best correction (ICD-10 Codes 1 and 2) (1).
Recently, some experts have adopted a more stringent cut-off for categorizing vision impairments (i.e. a visual acuity of less than 6/12 in the better eye) in recognition of a growing body of evidence that milder reductions in visual acuity impacts every day functioning of individuals (2).
For the purpose of this work the term VI will be used to describe both blindness and low vision, according to WHO definition.
Epidemiology and etiology of visual impairment
Some form of VI may affect even 2.2 billion people worldwide. Vision loss may occur at any age, although blindness and VI are reported mainly over the age of 50 years (3). According to the estimates from a 2021 study, there were 43.3 million blind people in 2020 with 55% of them being female. Researchers have also calculated that 295 million people had moderate and severe VI, of whom 55% were female; 258 million had mild VI, of whom 55% were female; and 510 million had VI from uncorrected presbyopia, of whom 55% were female (4). In 2020, the main cause of blindness in patients aged 50 years and older was cataract followed by glaucoma, undercorrected refractive error, age-related macular degeneration and diabetic retinopathy. Most common causes of moderate to severe VI were undercorrected refractive error and cataract (5). Although the age-standardized prevalence of blindness has decreased globally, the crude prevalence is rising and as the population ages and grows, VI continues to be a crucial public health concern (4). Recent technological development has reshaped how vision problems are detected and followed. Growth of teleophthalmologic tools, such as autonomous diabetic retinopathy screening and home optical coherence tomography monitoring has begun to address accessibility issues to specialized care, which we also reflect in this review (6,7).
Aims: Blindness and visual impairment are widely diagnosed conditions, however, it is challenging to differentiate them. Patients suffering from low vision face numerous difficulties ranging from performing daily activities to those related to healthcare. In this research we will explore the definitions of both conditions, identify the key issues faced by patients with visual impairments. In addition, we seek to outline the available strategies and interventions that may support this patient group across home, outpatient, and hospital care settings. We would like to define common problems faced by people with vision impairment (VI) despite their education, age, culture or religion and propose solutions to these problems.
Methods: The literature review was conducted using the PubMed and Google Scholar databases. Publications were found using keywords “visual impairment”, “blindness”, “home care”, “hospital care”, “outpatient care”.
Review of the literature
Special problems among VI population
VI has a significant impact on almost every aspect of life both for people suffering from it and for their closest environment. Numerous studies suggest that VI is often associated with lower quality of life (QOL), which is characterized by worsened physical, emotional and social well-being (8). According to a study from 2007, the QOL starts to slowly decline as the vision loss occurs and then more suddenly decreases as visual defect progresses (9). There is also some evidence that health care providers tend to underestimate the impact of vision loss on a patient’s QOL (10).
Another special problem that affects these patients is their dependence on others. Basic self-care activities like eating or dressing, as well as instrumental activities of daily living like shopping, money management and driving, are way more challenging to complete when one has VI. The ability to perform a wide range of tasks that require reading (such as reading medication labels or balancing bank statements), identifying faces and images (such as playing cards, socializing, or using a smartphone), or handling small objects (such as sewing or changing batteries) is also decreased (10). Seniors with VI may need long-term care more often and have an increased risk of subsequent nursing home placement given the diminished self-reliance caused by vision loss (11). A study from Norway has shown that the employment rate is lower in people with VI than in the general population, which may also affect their financial independence (12).
Given the importance of intact eyesight to navigate in the surrounding environment, mobility is also significantly affected in individuals with vision loss. VI is heavily associated with difficulties with walking or climbing stairs (13). Multiple studies have shown associations between visual problems and an increased risk of falls and therefore with an increased risk of fractures (14–16). What’s interesting, a study from 2005 has shown that up to 46% of elderly patients admitted to hospital because of hip fracture had some form of VI (17). Vision problems have been also related to a higher chance of hospitalization due to serious injuries in older persons (18).
Moreover, individuals with VI have an increased risk for depression, anxiety and many other mental health issues (19,20). The reason for this relationship is still unclear but it may be multifactorial. Vision problems drastically change people’s lives and impact most daily activities, especially social ones. People with VI are also more often discriminated against and usually lose some self-confidence (21). According to the evidence from 2021 meta-analysis, depression may be observed in 25% of people with VI who attend eye clinics (22). Therefore, given that depression can be treated, screening for mental health issues and their proper management should be carried out by health care providers.
Numerous studies have shown that cognitive impairment is more common and advances more rapidly in patients suffering from VI (23–25). This connection may be explained in two ways. Firstly, both visual and cognitive impairment in older people may be caused by similar pathological processes (such as vascular disease) and secondly, the lack of cognitively stimulating activities (such as reading) may diminish other cognitive abilities (10,23).
Compared to control groups with normal vision, in VI groups association with a higher risk of mortality has been reported (27–29). There are a variety of possible mechanisms explaining this relationship. As mentioned before, people with VI have an increased risk of accidents and falls. A reduced capacity for self-care and disease management may also be a significant factor in some deaths (28).
Home care
Vision problems make already lonely people even more isolated from their surroundings (30). Most of them need help from others, but live alone because they are singles, divorcees, or widowers. Therefore, when caring for people affected by VI, it is important to create a friendly environment in their home, as this is the place where they spend most of their time. “Friendly” means one that will allow him to function independently as much as possible, while also being safe. It is also extremely important to ensure the constancy of the environment. Objects should have their place, and people with VI should be informed about every modification made in their surroundings. Stability in a patient’s environment allows them to have a sense of security and to be as much independent as possible doing everyday activities. Ideally, all home improvements should also be relatively inexpensive, because despite access to modern technology, many people are unable to afford them for financial reasons (31). We have divided home aids into 3 categories: lighting, magnifying instruments, and home and object modifications.
Regarding lighting, most people with VI require more light, both in terms of intensity and number of light points. Some works suggest that it would be wise for every person with VI to have a handy flashlight with them at all times. Properly placed points of light help navigate between rooms, warn of changing heights, such as thresholds or ceilings, and help identify hazards (32). The way the light is turned on is also extremely important. There are a number of solutions available on the market, including remote controls or voice-operated systems that allow you to turn on different points of light without moving. In addition to the light source itself, the environment on which the light falls is also extremely important. The colour of paint on the walls, or the presence of glossy surfaces, such as floors, is not without significance (31). Greater contrast in colours will enable easier recognition of objects, while reducing glare and reflections will reduce the risk of misleading visual impressions (32). The best solutions are those tailored to the needs and capabilities of the person with VI, which is why it is so important to accurately determine their needs and resources.
Another equipment without which the people with VI have great difficulty functioning are optical magnification devices. The basic equipment is eyeglasses. It has been proven that appropriate prescription of eyewear and exercise may be mildly effective in reducing fall risk (33). It is worth noting that the safer eyeglass lenses are monofocal lenses. Multifocal lenses have been proven to increase the risk of tripping in older people (34). Replacing multifocal lenses with monofocal lenses reduces falls during outdoor activities and improves safety when stepping up onto raised surfaces (35,36). However, eyeglasses are not the only vision-enhancing device. There are many handheld and stationary magnifying glasses available on the market. These can be magnifying glasses, magnifying reading rulers, magnifying glass workstations, or advanced digital magnifiers. Some are lightweight and portable, others are large and stationary. There are also models that are neck-mounted or rest on the abdomen so that they do not occupy the hands. The best results can be obtained by using different instruments in different situations (32).
When it comes to modifications of everyday items, they can range from extremely simple and practically free to very advanced and therefore expensive. Low-cost improvements praised by the people with VI include, for example marking the front door key with a different colour, using safety stair nosing, mats and non-slip surfaces on the floors and installing additional handrails on the walls. A slightly larger cost, but a significant improvement in life is buying a larger TV or replacing faucets with single lever taps (31). The best but also the most expensive solution is to invest in smart-home systems, which allow you to program scenes and routines for specific situations, such as turning on lights when you enter a room, closing and opening the front door by themselves, raising and lowering the blinds. They can be controlled by voice commands while inside or via applications from outside the home, which allows the people with VI to control systems from anywhere in the house as well as enabling the family to monitor what is happening to the patient and assist him remotely. The future also looks interesting, as artificial intelligence is entering more and more areas of life. Extensive work is underway to prepare ready-made, commercial technologies to help the individuals with VI, and the first results seem very promising. Virtual assistants that will help people with VI navigate independently both outdoors and indoors are being prepared using advanced sensors such as gyroscopes, Inertial Measurement Units (IMUs) and laser imaging, detection, and ranging (LiDAR) combined with machine learning algorithms and wireless communication. Moreover they might enable or improve independent handling of many daily errands hitherto unattainable, due to the visual barrier. Combination with artificial intelligence can enhance obstacle detection capabilities and machine learning models can be trained to identify specific scenarios, analyse vast amounts of information provided by environment sensors, and to respond to complex situations (37). It is also worth mentioning that some patients with VI may need systems that allow to track them or make an emergency call. There are tracking bracelets with such functions, or phones designed specifically for a certain group of senior citizens, with simplified use to make operating them as easy and effortless as it could be. Sometimes cameras could also be a good solution to monitor patients with VI by family or attendants but patients should give consent for such proceedings.
Outpatient care
Outpatient care must confront numerous challenges to deliver optimal treatment for every patient. Healthcare professionals working in the outpatient clinics play a vital role as the first point of contact for patients, guiding them throughout their initial encounter with their condition. This step is crucial for shaping all subsequent stages of care. It has been discussed in recent studies that using a patient-related communication style and thus providing emotional support and allowing patient involvement in the consultation process may be a significant factor to future compliance (38). This shows how important it may be to better understand your patients and obstacles they have to overcome to achieve clinical success.
People with VI are a specific group of patients, which require special attention from healthcare professionals. For the patient it may be challenging to adequately address the issue of VI with the physician. Patients may not connect it with their primary conditions like diabetes and hypertension. Minor vision loss may seem insignificant to them and they may also not recognize an outpatient healthcare professional as the correct person to discuss this issue. Although some sources suggest that adding to the medical interview questions about face recognition, reading difficulties, and problems with performing regular tasks could be of use to the diagnostic process (39), systematic review conducted on 4,340 individuals aged 75 years or older revealed no evidence to justify the inclusion of vision screening in multidimensional screening programs for the elderly (40). Other studies have also not yet identified the ideal combination of tools to effectively diagnose vision loss associated with aging (41).
Alongside the diagnostic difficulties there is also an economic reason to enhance awareness about people with VI in primary care institutions. One study showed that, on average, individuals with VI spent 6.8% more on outpatient healthcare expenditures than individuals without VI. The biggest increase in expenditures occurred in the year prior to the onset of impairment, rising by 21%. This was followed by a decrease to approximately 14% and 6% during the first and second years of impairment, respectively (42). Another study performed on 3,570 individuals showed that people with VI used outpatient facilities more frequently than the general population and also exhibited increased expenditures. Both increased frequency of utilization of outpatient care and expenditures were more prevalent during three years before the onset of disease (43). That emphasizes the importance of increased awareness of the vision loss screening among medical professionals.
Another important factor contributing to challenges for outpatient care practitioners is that the VI population has a higher prevalence of comorbidities compared to the population without VI. The most common comorbidities were hypertension (55.6%), coronary heart disease (28.8%) and diabetes (25.9%). VI may significantly hinder the maintenance of a healthy lifestyle, meal preparation, and participation in exercise. It may also make the therapeutic process more difficult, as patients with VI may struggle with consuming prescribed pharmaceuticals and may not be able to self-monitor important symptoms such as the development of diabetic foot syndrome (20). Therefore, these patients should be regularly monitored for hypertension and diabetes complications. Teleophthalmology services, such as screening for diabetic retinopathy, have been found to be cost effective, reduce the need of in-person consults and increase completion of recommended screening (44).
VI is an acknowledged risk factor for depression (18.2%) (20). Screening patients for depression may be addressed by using the Geriatric Depression Scale which is a reliable and valid self-rating depression screening scale for elderly populations (45) or the PHQ-9 which is the most tested depression screening tool for universal use (46). Given the increased risk of depression and anxiety (47), as well as the possibility that individuals with VI may experience complex visual hallucinations (Charles Bonnet Syndrome), which can sometimes serve as an additional source of distress (48), psychological and psychiatric assistance ought to be considered.
Hearing loss is also more prevalent in patients with VI (17.7% compared to 9.3% in the control group) (20). Moreover, combined vision and hearing impairments have a greater effect on patient independence and functional status than single sensory impairments. Interventions to improve sensory function may be beneficial to the patient’s self-sufficiency (49). In the case of hearing loss, appropriate devices, such as hearing aids, speech recognition systems and cochlear implants may be offered to patients. Dual sensory loss can create specific challenges in the process of rehabilitation. Many devices used in rehabilitation of people with VI use auditory signals. Clinicians should be mindful that this assistive technology is supposed to be optimized and adjusted to the patient. Auditory signals should be easily detected, discriminated, and recognized by its users. Environmental adaptations, such as enhanced contrast and lighting can be introduced to facilitate daily activities and movement. Currently, there are still not enough therapeutic options designed specifically for people with dual sensory impairment (50).
As stated in the previous part of the review, healthcare professionals should be aware of increased fall risk in the people with VI (50). To minimize the risk of falls, clinicians should recommend appropriate footwear to patients and remain vigilant about the adverse effects of sedatives, psychotropic, and antihypertensive medications, particularly orthostatic hypotension (51). Strength and balance training is recommended, as well as home hazard assessment and intervention (52).
Low vision rehabilitation has proven to be an excellent tool for outpatient practitioners in enhancing the quality of life for individuals with VI. According to the American Academy of Ophthalmology the primary role of outpatient practitioner is to refer patients with VI to vision rehabilitation (53). However, several barriers need to be considered beforehand.
In the study conducted at the University of Texas Medical Branch, patients were screened for legal blindness, impaired vision, and low vision, searching for adequate International Classification of Disease (ICD) codes. Individuals meeting the criteria were contacted to fill questionnaires regarding their experience with rehabilitation. Eye care practitioners were contacted to complete additional questionnaires regarding their referred patients. Among the eligible patients, 64% were referred to vision rehabilitation by eye care practitioners. Patients reported barriers such as mental health issues, denial of the need for low-vision aids (71%), poor physical health (67%), lack of transportation (57.1%), and lack of referrals (36%). Practitioners reported barriers to referring patients to vision rehabilitation, including the patient’s overall health (67%), older age (44%), lack of social support (44%), poor cognitive function (44%), and low likelihood of follow-up (44%) (54).
Hospital care
Patients with VI use inpatient care more frequently than ones without ophthalmologic disorders (20,43,55). Knowing this fact it is important to evaluate problems with which patients with VI struggle during hospitalizations. In Carlson’s 2020 publication one of the most crucial issues in relation between patient and health professionals reported by surveyed was lack of recognition of patient’s disability. These may be easily changed by introducing in hospitals bracelets in particular colour for patients to wear (for example green ones with VI tag) and door magnets with specific symbols informing of the presence of the patient with VI in the room (56). The fact of VI should be also stated in the patient’s medical record to enable preparing optimal conditions for him/her before future admission (55). Aware of a patient’s condition, the nurse should always introduce himself/herself first to ensure that the patient feels safe and oriented in the presence of people around (56). It is also worth remembering that VI encompasses a broad spectrum of individuals with different levels of vision loss, therefore maintaining eye contact with the interlocutor is crucial for showing them respect (57). It should be understood by healthcare providers that patients may need assistance with filling in written forms during admission to the hospital (58). It is worth noting that many patients with VI exhibit greater sensitivity to sounds, therefore noises in the surroundings should be explained to them to prevent disorientation. Additionally, locating the patient in a quieter area of the ward may be beneficial by reducing the risk of delirium. Access to personal technology such as phones should be provided to patients to enable him/her communication with relatives and friends, which can decrease the risk of delirium and alleviate stress associated with hospitalization. Additionally, they should be informed about call light placement and a way of using it (55). Stability of the environment during hospitalization is crucial for patients’ wellbeing. Patients should be guided around their new room, the location of furniture and toilet should be explained, and the patient should be informed about any changes in the room during hospitalization.
Before starting an examination or any other interaction with the patient, such as placing a tourniquet or sphygmomanometer cuff on the patient’s arm, medical personnel should explain and describe the upcoming procedure to ensure that the patient feels comfortable and safe (56). The fact of leaving the room also should be announced, preventing confusion and the embarrassment of talking to someone not being in the room anymore (55). When it comes to eating, it is a good practice to inform the patients with VI about the location of food on their plates, for example “potatoes at 9:00” or “meat at 3:00”. Description of the food, like texture, temperature, taste and consistency would be also very helpful. It is recommended to establish a toolbox at a nursing station containing bracelets for the patients affected by VI, paper forms with bigger font, magnifying glasses, coasters to put under patients cups to help them easily orient of the cup’s placement on the table, pair of glasses, walking cane and raised stickers to identify bed controls more easily. Although many patients with VI cannot read braille, having some useful information such as menus written in this system gives patients a sense of autonomy (56). In relation with the patients with VI it is important to firstly ask if they need assistance and how they would like to be assisted during completing specific tasks (57). Accomplishing tasks independently provides patients with a sense of agency and leads to a more active form of cooperation with hospital staff. Instructions for patients should be specific and not be given with vague terms like “there, this, here” – patients will get a better idea of a task and won’t become embarrassed when they will be instructed to put their documents on the table in front of them instead of putting them “here”. Similarly, instead of saying “follow me” a nurse should tell the patient where exactly they will go, if they will go through any doors or go up/down the stairs (58). While walking with the patient it is recommended to walk side by side if there is enough space around with a steady pace, the patient should hold with his/her hand nurse’s arm just above the elbow. In the narrower places the leading person should move his/her arm closer to his/her own back, consequently the patient should position himself/herself behind the nurse. Coming to the doorway, the patient should be informed if the door opens towards or in the opposite direction of them, then the door can be opened with the guiding hand of the medical provider. Now a patient can access with their free hand door’s handle and knowing where the door is, they can slowly walk through a doorway one after another. Similarly, when going up or down the stairs, the medical provider should go first, and after them holding the handrail the patient should go. It is essential to take one step ahead (57). Healthcare providers may also benefit from help of a person accompanying the patient (family member or a friend), who can potentially help by leading the patient (55). Patients should be given extra time for usage of paratransit services, always given clear information about where they should await the vehicle (58).
The significant problem and cause of frustration for many patients is the fact that most of the information in hospitals (e.g. health reports, test results) is given in the written form, forcing them to rely on another person’s help to access information about their own health. It may be wise to record some important information for patient usage or direct them to a specific source of information for example a website, if the patient is able to use the internet with voice commands (58). Phones and smartwatches may reduce the inequalities in access to information. Patients with VI may use speech-to-text software or navigational aids through their personal devices. Many hospitals already provide mobile apps or online portals for scheduling appointments, viewing laboratory results, or communicating with clinicians. It is essential to ensure that these digital solutions are fully accessible to individuals with VI (59).
Finally, it should be stated that many patients are in the hospital for different reasons than a VI, therefore medical personnel shouldn’t over-focus on this issue at the expense of other medical conditions (55).
Conclusions
It’s important to highlight the most significant issues mentioned in our research, keeping in mind that visually impaired patients require a special approach in daily life across various levels.
VI is associated with lower quality of life, which tends to be underestimated by healthcare providers. It is a result of their dependance on other people, loneliness or social exclusion.
Home environment must be safe and constant for people affected by VI – their living space should have optimal lighting, floors should be covered by non-slip surfaces and additional handrails may need to be installed on the walls.
Usage of optical magnification devices in the population of people with VI may increase their comfort and reduce the risk of complications, such as falls.
Patients with VI may use special programmed electronic devices (such as phones or bracelets) that can help them better manage their environment. These devices may also allow their families to assist them remotely.
In outpatient care, it’s important for healthcare professionals to remember that VI is often associated with other illnesses – hypertension, diabetes or depression. Patients may not connect their vision problems with these comorbidities. That emphasizes the importance of increased awareness of the vision loss screening among medical professionals.
It’s worth mentioning that VI can affect patient’s adherence to medical recommendations – it may hinder their functioning, rehabilitation and treatment.
During the hospitalization of a patient with VI, it’s necessary for the medical staff to first recognize the patient’s disability. This would enable them to prepare optimal conditions during hospitalization, such as locating the patient in a quieter area, providing personal assistance, or preparing supportive tools (e.g., paper forms with larger fonts, magnifying glasses) for the patient with VI.
It’s crucial to inform the patient about upcoming procedures and explain to them what will happen.
In communication with a patient suffering from a VI, the medical personnel should avoid vague terms (like „here, there, this”) and replace them with precise descriptions, which will allow the patient to have a better understanding of the task.
It may be helpful to record important information (e.g., reports, laboratory tests) or upload them into a website, where the patient, with the help of voice commands, can listen to it.
In the end, we would like to emphasize that working with a patient with VI is a complex process, requiring attention to several aspects. Due to the patient’s dependence on others and limitations in performing daily activities, people with VI experience a reduced quality of life. Moreover, difficulties in following medical recommendations may worsen the course of existing disorders and increase the risk of developing additional health issues. Considering all these elements, discussed patients require an appropriate, individualized approach focused on understanding their daily challenges and optimization of the guidance provided to them.
