Rehabilitation and intraocular telescopes.
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ABSTRACT: To investigate the efficacy of a new surgical and rehabilitative procedure designed to improve vision in patients with central scotoma due to macular diseases. Case series of 40 consecutive surgical and rehabilitative procedures. Forty eyes of 35 consecutive patients with a stable central scotoma due to macular disease underwent phacoemulsification cataract surgery with the implant of the IOL-Vip System. The IOL-Vip System consists of a biconcave high minus-power intraocular lens (IOL) in the capsular bag and a biconvex high plus-power IOL in the anterior chamber, reproducing an intraocular Galilean telescope with x1.3 magnification for distance. Selection of the candidate patients was carried out by means of a low-vision diagnostic and rehabilitative program (IOL-Vip software) that evaluates the residual visual function of patients and prognosis for visual improvement based on simulation of the postoperative condition. The software also designs the rehabilitation strategies based on preoperative and postoperative training of the preferred retinal locus. Best-corrected visual acuity (BCVA), evaluated by means of the Early Treatment Diabetic Retinopathy Study charts and procedure; reading magnification; and reading distance. All patients showed an improvement of visual acuity (VA) due to the surgical and rehabilitative procedure, confirming or exceeding the preoperative expected results. Mean postoperative BCVA was 0.77 (logarithm of the minimum angle of resolution), compared with 1.28 preoperatively. The mean postoperative best reading magnification gain was x6.2, and the mean postoperative reading distance gain was 7.66 cm. No cases of intraoperative or postoperative complications were detected, and the implant was subjectively well tolerated in both monocular and binocular procedures. In this pilot study, the IOL-Vip System was shown to be effective and apparently well tolerated in improving the vision of patients with macular disease. Best-corrected VA, reading magnification, and reading distance improved in all cases of this low-vision patient series.Ophthalmology 06/2007; 114(5):860-5. · 5.56 Impact Factor
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ABSTRACT: To assess the effects of a visual rehabilitation program on visually impaired subjects' visual ability and ability to perform activities. Prospective observational study. Telephone interviews of respondents in their homes the week before admission to the rehabilitation center and 3 months and 1 year after discharge from the rehabilitation center. A total of 178 consecutive patients from the Hines Blind Rehabilitation Center participated in development of the 48-item Veterans Affairs Low Vision Visual Functioning Questionnaire (VA LV VFQ-48). Data were analyzed for 95 who participated in all 3 administrations of the questionnaire. Comprehensive blind rehabilitation program (mean hospital admission, 40 d). The self-report ratings of patients' difficulty performing 48 activities on the VA LV VFQ-48. The increase in visual ability +/- standard deviation of .981+/-.482 logits (equivalent to an 8-line improvement in visual acuity on an Early Treatment of Diabetic Retinopathy Study chart) at 3 months postrehabilitation decreased to .682+/-.485 logits (equivalent to a loss of 2.5 lines of visual acuity on the same chart) 1 year postrehabilitation. The effect sizes measured at 3 months (2.035) and 1 year (1.495) indicate large treatment effects corresponding to statistically significant differences for the increase in visual ability at 3 months and 1 year postrehabilitation (paired 2-tailed t tests, P<.001) relative to pretreatment measures. The difference in visual abilities measured at 3 months and 1 year posttreatment also is statistically significant (P<.001). Treatment effects decreased over the 12-month follow-up period. However, the group of patients whose data were analyzed was still statistically and clinically significantly better at their 1-year follow-up than before beginning treatment.Archives of Physical Medicine and Rehabilitation 06/2007; 88(6):691-5. · 2.44 Impact Factor
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ABSTRACT: To evaluate the effectiveness of a low-vision rehabilitation program. A multicenter randomized clinical trial was conducted from November 2004 to November 2006 with a 4-month follow-up. A total of 126 patients were included, 98% of whom were white and male. The patients were referred from eye or low-vision clinics and blind rehabilitation centers with a visual acuity in the better-seeing eye worse than 20/100 and better than 20/500 and were eligible for Veterans Affairs (VA) services. Telephone interviews of patients were conducted in their homes before and after participation in an outpatient low-vision program at a VA medical care facility or a (waiting list) control group. The interviewer administering questionnaires by telephone was masked to patients' assignments. Interventions included low-vision examination, counseling, and prescription and provision of low-vision devices and 6 weekly sessions provided by a low-vision therapist to teach use of assistive devices and adaptive strategies to perform daily living tasks independently. Change in patients' visual reading ability estimated from participant responses to the Veterans Affairs Low-Vision Visual Functioning Questionnaire (LV VFQ-48) reading items completed at baseline compared with 4 months after enrollment for the treatment and control groups. The secondary outcomes were changes in other visual ability domains (mobility, visual information processing, visual motor skills) and overall visual ability from baseline to 4 months estimated from VA LV VFQ-48 difficulty ratings for subsets of items. The treatment group demonstrated significant improvement in all aspects of visual function compared with the control group. The difference in mean changes was 2.43 logits (95% confidence interval [CI], 2.07-2.77; P < .001; effect size, 2.51) for visual reading ability; 0.84 logit (95% CI, 0.58-1.10; P < .001; effect size, 1.14) for mobility; 1.38 logits (95% CI, 1.15-1.62; P < .001; effect size, 2.03) for visual information processing; 1.51 logits (95% CI, 1.22-1.80; P < .001; effect size, 1.82) for visual motor skills; and 1.63 logits (95% CI, 1.40-1.86; P < .001; effect size, 2.51) for overall visual function. The program effectively provided low-vision rehabilitation for patients with macular diseases. APPLICATIONS TO CLINICAL PRACTICE: At least 10 hours of low-vision therapy, including a home visit and assigned homework to encourage practice, is justified for patients with moderate and severe vision loss from macular diseases. Because the waiting-list control patients demonstrated a decline in functional ability, low-vision services should be offered as early as possible. clinicaltrials.gov Identifier: NCT00223756.Archives of ophthalmology 06/2008; 126(5):608-17. · 3.86 Impact Factor
Vision Rehabilitation and Intra-Ocular Telescopes – shortened
As ophthalmologists involved in vision rehabilitation we feel compelled to let our voice be heard
on the issue of intra-ocular telescopes. Our reaction was triggered by a recent paper1, but is
directed at a growing list of related papers. Our intention is not to stifle innovation, but to ask for
adequate, comparative studies.
Macular degeneration is a significant and growing problem across the world. We are frustrated
that we cannot change the condition of the retina. It is understandable that surgeons seek
remediation through surgery. It is encouraging that surgical techniques have progressed to a
point where complex devices can be implanted without major additional risks. Yet, since all
surgery carries risks, more complex surgery is bound to carry more risks.
All papers on this subject report that the patients saw better and felt better after surgery than
they did before. However, they fail to separate the factors that contribute to this improvement:
Removal of a cataractous lens.
Insertion of a telescopic device.
Rehabilitation training following surgery.
By not separating these factors, it is impossible to estimate how much improvement can be
attributed to each of them.
The contribution of lens extraction cannot be known precisely, but clinicians can estimate it from
ophthalmoscopy or by PAM and interferometry.
The theoretical improvement due to the telescopic system can be calculated. It would be
worthwhile to also calculate how off-axis placement or tilt can reduce this. In the latest paper,
the theoretical magnification is given as 1.3x, equivalent to about one line (26%) on an ETDRS
chart. In cases where fundus photography is possible, the minification of the postoperative
image (the camera is looking through a reverse Galilean telescope) is an objective measure of
the actual magnification achieved. We are not aware that studies have reported this.
As Vision Rehabilitation professionals, we know first hand how much vision rehabilitation can
improve the patient’s performance of daily living skills, even with a defective macula2-4.
Unfortunately, many of our colleagues are not convinced, because letter chart testing does not
adequately measure these results.
Vision rehabilitation has three objectives.
(1) Improving the optical image. This can be achieved with various magnification devices, from
a low-tech hand magnifier to a high-tech video-magnifier, with improved illumination, use of
filters, etc. Intra-ocular telescopes address this magnification aspect, but they reduce the field
of view, which can be a risk factor for falls5.
(2) Improving the use of the eccentric Preferred Retinal Locus (PRL) or pseudo-fovea. Training
can improve search and fixation strategies as well as hand-eye coordination. In our offices we
see on a daily basis results such as improved reading speed, improved reading distance and
improved reading endurance, as reported in the latest paper. These effects often are greater
than the theoretical 1-line improvement provided by the telescope in the latest paper.
(3) Improving the patient’s safety, participation and well-being and the performance of Activities
of Daily Living (ADLs) through attention to non-visual cues, through adapted aids, through
environmental modifications and through improving the awareness of the patient’s condition
among family members and others.
We commend the authors for including a significant vision rehabilitation component. However,
since this training was done after surgery, its effect could not be separated from the other
In this age of evidence-based medicine, patients and the profession deserve sound insight into
the relative effects of various interventions. We therefore recommend that any study about the
implantation of telescopic devices contain the following.
As a minimum, estimates of the relative contributions of the three interventions.
Preferably, a comparison of matched groups: surgery vs. structured vision rehabilitation.
The gold standard would be a true Randomized Clinical Trial.
When such comparative studies are done, the benefits of intra-ocular telescopic devices can be
properly separated from the improvements that can be achieved with vision rehabilitation
training alone. However, unless journals and others insist that these comparisons be made, we
will never have definitive proof of their relative strengths.
We urge you and other journal editors to apply these suggestions as review criteria for any
paper that is sent for your review.
Original = 850 words Shortened = 682700 = limit for letters to the editor.
* August Colenbrander, MD Smith-Kettlewell Eye Research Institute, San Francisco, CA
* Donald C. Fletcher, MD California Pacific Medical Center, San Francisco, CA
Judith A. Bennington, MDAshland, WI
A. Jan Berlin, MDPortland, ME
* Ronald J. Cole, MD Sacramento, CA
* Robert M. Christiansen, MDUniversity of Utah, Salt Lake City, UT
Eleanor Faye, MDLighthouse International, New York, NY
* Joseph Fontenot, MDCommunity Services for Vision Rehabilitation, Daphne, AL
Bert M. Glaser, MD National Retina Institute, Birmingham, AL
* Paul Homer, MD,Boca Raton FL
* Mary Lou Jackson, MDMassachusetts Eye and Ear Infirmary, Boston, MA
Mary G. Lawrence, MD, MPH University of Minnesota, Minneapolis, MN
* Samuel N. Markowitz, MD University of Toronto, Toronto, Canada
* Lylas Mogk, MD Henry Ford Medical Center, Detroit, MI
* Rebecca Morgan, MD University of Oklahoma, Oklahoma City, OK
* Nelson Sabates, MDUniversity of Missouri, Kansas City, MO
Sheila Santos-Jimenez, MD St. Luke's Medical Center, Philippines
* John Shepherd, MDUniversity of Nebraska Medical Center; Omaha, NE
implant for visual rehabilitation of patients with macular disease. Ophthalmology. 114(5):860-5, 2007
Orzalesi N, Pierrottet CO, Zenoni S, Savaresi C. The IOL-Vip System: a double intraocular lens
Measuring Outcomes of Vision Rehabilitation with the Veterans Affairs Low Vision Visual Functioning
Questionnaire. IOVS, August 2006, Vol. 47, No. 8
Stelmack JA, Szlyk JP, Stelmack TR, Demers-Turco P, Williams TR, Moran D’A, Massof RW.
inpatient vision rehabilitation program. Arch Phys Med Rehabil 2007;88:691-5.
Stelmack JA, Moran D’A, Dean D, Massof RW. Short- and long-term effects of an intensive
Journal of the Society for Clinical Trials – in press.
The Veterans’ Affairs Low Vision Intervention Trial: Design and Methodology. Clinical Trials:
Adults: The Salisbury Eye Evaluation ;; IOVS, 2007;48:4445-4450.
Freeman EE, Muñoz B, Rubin G, West SK. Visual Field Loss Increases the Risk of Falls in Older
5 most relevant references = limit for “Ophthalmology”.