Age-Related Macular Degeneration: Four Strategies to Promote Independence

Age-Related Macular Degeneration (AMD) is the leading cause of vision loss among people age 50 and older. Damage to the macula affects central vision or seeing objects straight ahead. AMD’s onset can be slow or fast, and results in a blurred area near the center of vision that may grow into a blank spot.

AMD does not lead to complete blindness. However, loss of central vision interferes with everyday activities such as seeing faces, reading, writing, cooking, fixing things around the house or driving. There are two forms of AMD: neovascular and non-neovascular. Non-neovascular is most common. Neovascular AMD leads to more serious vision loss. Risk factors include smoking, race, age, obesity, heredity, HBP, and eye color.

Who Can Help AMD Patients Adjust to Their Diagnosis?

Several different team members can assist a patient with AMD. The primary eye care professional may be the first person to diagnose AMD, at which point a referral is made to an optometrist or ophthalmologist specializing in low vision. To help the patient adapt or adjust to their new diagnosis they may also be referred to:

  • Low Vision Therapist/Specialist – To educate the client on use of peripheral vision, assist clients in adapting their home and/or fit them with the most appropriate glasses, magnifiers, and other low vision devices.
  • Occupational Therapist – To educate and train in the use of adaptive equipment or techniques to maintain independence and safety in the home or at work.
  • Orientation and Mobility Specialists – To train persons with vision impairments to get from one place or location to another as safely, efficiently and independently as possible.
  • Counselors and/or Social Workers – To assist clients in identifying appropriate community resources.
  • Certified Driver Rehabilitation Specialist – To evaluate persons with AMD, to determine the impact of vision loss on driving safety, and train in compensatory techniques for continued safe driving if appropriate.

What Tools or Strategies Encourage Renewed Independence?

There is no cure for macular degeneration; however, there are several ways to monitor and compensate for vision losses. As therapists, we can use our knowledge to improve independence and not remediate the situation. Below are four tools or strategies that help patients regain their independence.

1. Amsler Grid

The Amsler grid is commonly used to track vision changes. It also allows the patient to gain a more concrete idea of the location and degree of their scotoma (blindspot).

2. Low Vision Devices and Techniques

Occupational therapy allows the exploration and use of strategies and equipment through functional daily activities thus increasing the overall functional visual scanning skills. Use of the following low vision devices and techniques allows for increased independence and functional mobility:

  • Reading glasses
  • Handheld magnifiers
  • Adaptations to computers (large print or speech output)
  • Large print reading materials/e books
  • High contrast items
  • Increasing lighting
  • Decreasing glare

3. Preferred Retinal Locus

Many individuals compensate naturally for disturbed central vision by shifting their vision slightly so that they can see things sharper and try to “look around” the scotoma. They are using the “next‐best spot” (the Preferred Retinal Locus, or “PRL”).

Adapting to non-central vision can be challenging. Therapists can optimize remaining vision by teaching patients how to identify “the best” area of the retina to use and how to shift the visual field from straight ahead to peripheral vision. This may be different depending on if they use binocular or monocular vision.

One way to learn to use peripheral vision is through eccentric viewing and fixation. Most patients find this clumsy at first, but as they train, they are soon able to utilize the PRL. There are also various adaptable protocols to increase specific abilities such as reading or far visual scanning. For example, if you look directly at something, such as a person’s nose, you can make it disappear in the blind spot. However, if you look slightly to the side, the blind spot moves off to the side, and using your peripheral vision, you can see the person’s nose again.

4. Steady Eye Strategy

Another strategy is Steady Eye Strategy (SES). It is a technique specifically for reading. SES requires the person to keep their gaze still and scroll text right to left, through their best functioning piece of vision. This technique improves accuracy and reading speed, although not to pre-macular disease levels.

These are just a few strategies you can use to allow patients to increase their overall independence level and get back to everyday activities.

References
  1. https://nei.nih.gov/health/maculardegen/armd_facts
  2. http://www.aao.org/eye-health/diseases/amd-low-vision
  3. http://www.aao.org/Assets/e533393e-7af1-4679-9701-57175a882a8b/635755913307230000/smartsight-2015-update-pdf
  4. https://www.enhancedvision.com/low-vision-info/preferred-retinal-locus.html
  5. http://lowvision.preventblindness.org/library/low-vision-rehabilitation/self-training-in-eccentric-viewing/