MAY 2021 1

MAY 2021 Dear Colleague,

I have been privileged to visit several “boutique” establishments in our country during this time when

international tourists are absent, and these lodges/hotels are forced to rebuild their South African

market.

A few issues stuck me, and somehow, I could relate them to our own profession.

First and foremost are the people who work at this “top end” of the market. My overall impression was

that they are resilient, innovative, benefitted from good training and above all, presented with people

skills that are often lacking elsewhere. In other words, they refused to let customer service standards

drop, even when their income has halved.

It is heartening to see this trend, but it also makes me question why we as a nation cannot perform like

this when it comes to the delivery of basic services. What happened to Ubuntu or is it just a slogan for

authorities to hide behind? Or does it have to have a monetary value?

It is also notable that Zimbabweans are often part of these resilient teams. They are a remarkable

people, and it remains a mystery why some political leaders take the very people who elected them, for

granted. In Africa we seem to want to share failures instead of successes.

Another issue that I noticed was the fact that most of these places, especially the older ones, needed

some TLC that would have happened in better times. Yet, “things” worked and there was someone

who could make it work if there was a problem. Compare this to our state of municipalities who, by the

way, benefit from selling essentials like water and electricity and receive State subsidies yet cannot

maintain the very lifeline they are responsible for.

It all comes down to basics not so. Take the example of a spectacle prescription that does not work in

the chosen frame, no matter how many times you adjust/change nose pads, pantoscopic angle or temple

fit, it just does not work, and nobody is satisfied with the outcome until someone takes the bull by the

horns and starts from scratch, with a smile.

So that is the obvious lesson, a well-run establishment sees to the basics first so they can avoid the

negative outcomes and/or reputational damage with the subsequent socio-economic hardship.

Enough of my COVID paranoia. On the positive side, Discovery Health will soon embark on a drive to

better “manage” those who live with Diabetes and Optometry is included in this at two levels, those

who just want to capture data and those who wish to play a broader role in the interdisciplinary team.

The GIO will therefor offer a repeat of the Diabetes course soon. This time mostly virtual and at two

levels in synergy with the Discovery program and reimbursement proposal.

The new ruling from the HPCSA that requires all Health Professionals to upload proof of CPD

activities, has caused a bit of a panic and we have decided to speed up the publications of this

newsletter to assist those who are short of points. Feel free to talk to Ingrid or Fiona if experiencing

difficulty.

I trust you will enjoy the spread of topics the May issue has to offer.

Stef

MAY 2021 2

MAY NEWSLETTER 2021

CONTENTS:

INTRODUCTION………………………………………………………………………1

LIGHT, REFRACTION & LENS DESIGN, DISPENSING………….…Next issue

CORNEA & CONTACT LENS……………………………………………………..3

ANTERIOR SEGMENT……………………………………………………………...3

POSTERIOR SEGMENT…………………………………………………………… 5

NUTRITION & SYSTEMIC DISEASE………………………………………..5

PATHWAYS………………………………………………………………………………Next issue

TECHNOLOGY/ LOW VISION……………………………………………………..9

ETHICS……………………………………………..………………………………………20

MAY 2021 3

MAY NEWSLETTER 2021

Since acne vulgaris is a disease of the sebaceous glands, it may have potential

effects on the ocular surface and tear homoeostasis, which are essential for good

vision. Optometrists should be aware of ocular surface pathologies when prescribing

glasses or contact lenses for the visual rehabilitation of these young patients. To

evaluate the ocular surface features, meibomian glands and tear parameters of

patients with acne vulgaris, the right eyes of 70 individuals (34 patients with acne vulgaris, 36 healthy volunteers) were

evaluated.

The tear break-up time of participants was

measured, and the Schirmer’s test was performed. To determine ocular surface

characteristics, samples were taken from the conjunctiva for impression cytology.

Finally, the loss rates of the upper and lower eyelid meibomian glands were

determined by taking meibography.

Tear break-up time was significantly lower in the study group compared to the control

group. No statistically significant difference was determined between the groups with

respect to Nelson grade in the conjunctival impression cytology. Grade 3 cytological

changes were not observed in either group. The median value of the loss rate in the

meibomian glands in the upper eyelid of patients with acne vulgaris was 19.10%

(IQR: 18%), while it was 8.75% (IQR: 9.53%) in the control group. The median

value of the loss rate in the meibomian glands in the lower eyelid was 15.70%

(IQR: 15.13%) and 7.70% (IQR: 6.53%) in the acne vulgaris and control groups,

respectively.

This study showed that patients with acne vulgaris may have a predisposition to meibomian gland damage and tear

instability. Researchers suggested that a more detailed ophthalmologic examination

should be performed in patients with acne vulgaris.

Still, further investigation into the

safety and efficacy of the method on human eyes is warranted.

Corneal collagen crosslinking (CXL) with riboflavin and UVA has been successful in

preventing keratoconus progression and corneal warpage, and new research

suggests this technique also shows promise in myopia. Through animal studies, an

investigative team from China found that the modified CXL procedure may potentially help control the pathologic process of

myopia, even though further investigation into its safety is necessary.

CXL with riboflavin-UVA is a minimally invasive procedure without allograft

material implantation, which makes it possible to reduce complications such as

infection and rejection, the researchers explained. “Its effectiveness, stability and

safety make it hopeful to arrest progressive myopia or to inhibit the over-expansion of

the sclera,” they wrote in their paper.

One study in the review used white rabbits

as a model. The right eyes underwent CXL using riboflavin and UVA radiation, and

every quadrant had either two or six scleral irradiation zones. The eyelids of the right

https://www.reviewofoptometry.com/news

letter/op/optometric-physician-march-29-2021

CXL May Also Help Halt Myopia Progression

Ocular Surface Characteristics in Acne

Vulgaris

In this Newsletter

1. Ocular Surface Characteristics in Acne

Vulgaris

2. CXL May Also Help Halt Myopia

Progression

3. Update and Guidance on Management

of Myopia

4. Prescribing Supplements for AMD

5. The evolving standard of care in AMD

6. A Common Approach to Low Vision:

Examination and Rehabilitation of the

Patient with Low Vision

7.

MAY 2021 4

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eyes were sutured after therapy to establish myopia. Outcomes showed that

CXL with riboflavin and UVA effectively prevented occlusion-induced axial

elongation and that the size of the treatment area was effective.

Another investigation established a lens-induced myopia model in guinea pigs to

develop methods of CXL for the treatment of progressive myopia. The results

indicated that CXL using riboflavin and UVA irradiation effectively prevented the progression of myopia by increasing scleral

biomechanical strength. Additionally, scleral collagen fiber arrangements of the

crosslinked eyes were denser and more regularly distributed than the myopic eyes.

More recent studies have investigated the effect of oral administration of riboflavin

combined with whole-body UVA irradiation on the biochemical and biomechanical

properties of the sclera in a lens-induced myopic guinea pig model. This technique

appeared to increase the strength and stiffness of the sclera by altering the

biochemical and biomechanical properties and resulted in greater decreases in axial

elongation and myopic diopter in the treatment group.

As for the technique being used to prevent myopia, the appropriate timeline for

interventional treatment should be further investigated, the investigators said. Scleral CXL has not yet been done on human

eyes in vivo, so potential problems should be investigated further, including long-term

safety and stability of CXL, proper parameters such as exact position and

suitable area of the eye to be treated, amount of energy needed and exposure

time, they concluded.

Due to the urgency of the increasing prevalence

of myopia worldwide, the European Society of

Ophthalmology, in cooperation with the

International Myopia Institute, published a review article to

increase awareness among eye care professionals and provide

recommendations to prevent the development and progression of myopia in children and adolescents.

Based on the IMI White Papers, this review paper makes several specific conclusions

regarding interventions for controlling myopia:

• Environmental influences: Indoor near work and outdoor activity play

important roles in developing myopia and preventing myopia, respectively.

There is strong evidence that less near work and more outdoor activity protect

against myopia development in the human eye. Time outdoors itself, rather

than physical activity, has been suggested to be the protective factor.

The link between time outdoors in the prevention of myopia is stronger than

the link between time outdoors and slowing the progression of existing

myopia. • Contact lenses: Ineffective—rigid gas

permeable contact lenses showed

inconsistent results in myopia progression (very low-certainty

evidence). Comparing spherical aberration SCLs with single vision SCLs

reported no difference in myopia (refractive) progression nor axial length

elongation (low-certainty evidence).

• Contact lenses: Effective—axial elongation was slightly less for bifocal

SCL wearers than for single vision SCL wearers (low-certainty evidence).

Orthokeratology contact lenses were more effective than SVLs in slowing

axial elongation (moderate-certainty evidence). There is evidence of myopia

control with soft multifocal contact

https://www.reviewofoptometry.com/news/a

rticle/cxl-may-also-help-halt-myopia-progression

Update and Guidance on Management of

Myopia

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MAY NEWSLETTER 2021

lenses (low-certainty evidence), specific

myopia control soft lens designs (moderate-

certainty evidence), and orthokeratology

(moderate-certainty evidence).

• Pharmaceutical agents: Antimuscarinic

eye drugs such as atropine eye drop or pirenzepine eye gel may

slow the progression of myopia (moderate-

certainty evidence). Axial elongation was

lower for children treated with atropine

than those treated with placebo (moderate-

certainty evidence) in studies using higher

doses. However, there is a weaker association

between refractive error and axial length

changes than optical studies. According to

Cochrane summary, systematic seven-methylxanthine had a small effect on

myopic progression and axial elongation compared with placebo in one study (moderate-certainty evidence). One

study did not find slowed myopia progression when comparing timolol eye

drops with no drops (low-certainty evidence).

• Combination therapies: Myopia progression was slower in children

treated with combinations of atropine eye drops and multifocal spectacles

than in children treated with placebo eye drops and single vision lenses

(moderate-certainty evidence). Orthokeratology with low-dose atropine

improved myopia control by the synergistic effect compared with

orthokeratology treatment alone. Further studies are needed to fully

assess the efficacy and safety of

atropine and orthokeratology or

bi- or multifocal soft contact lens

combination therapy.

The authors

conclude by reminding eye

care professionals that myopia information is

continually evolving, so it is

essential to stay abreast of studies

published in the peer-reviewed

literature

A look at the research and

patient considerations Conversion from dry

AMD to wet AMD is not necessarily

inevitable, in that several modifiable risk factors can impact

the risk of disease progression. These include smoking status, cardiovascular

disease, diet and systemic antioxidant levels. Studies also have suggested that

healthy macular pigment optical density (MPOD) can play a role. As a brief

refresher, the macular pigment is comprised of three carotenoids: (1) lutein,

(2) zeaxanthin and (3) meso-zeaxanthin. Together, they protect the macula from

Prescribing Supplements for

AMD

Abstract

Update and guidance on management of myopia. European Society of Ophthalmology

in cooperation with International Myopia

Institute

The prevalence of myopia is increasing extensively worldwide. The number of people with

myopia in 2020 is predicted to be 2.6 billion

globally, which is expected to rise up to 4.9 billion

by 2050 unless preventive actions and interventions are taken. The number of

individuals with high myopia is also increasing

substantially, and pathological myopia is predicted

to become the most common cause of irreversible vision impairment and blindness worldwide, and

also in Europe. These prevalence estimates

indicate the importance of reducing the burden of

myopia by means of myopia control interventions to prevent myopia onset and to slow myopia

progression. Due to the urgency of the situation,

the European Society of Ophthalmology decided

to publish this update of the current information and guidance on management of myopia. The

pathogenesis and genetics of myopia are also

summarized and epidemiology, risk factors,

preventive and treatment options are discussed in detail. Update and guidance on management of myopia.

European Society of Ophthalmology in cooperation with

International Myopia Institute. European Journal of

Ophthalmology, 1120672121998960.

Click here for the article:

DOI: https://doi.org/10.1177/1120672121

998960

https://reviewofmm.c

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guidance-on-

management-of-

myopia/?utm_campaig

n=Research&utm_me

dium=email&utm_sou

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ntent=Update and

Guidance on

Management of

Myopia&utm_term=3.

20&utm_source=What

CountsEmail&utm_me

dium=Review of

Myopia Management

2019&utm_campaign

=RMM_Research_Marc

h2021_v2

MAY 2021 6

MAY NEWSLETTER 2021

oxidative stress and blue light. (On the heels of this finding, office-based devices

have been created to measure MPOD to aid optometrists in their management

decisions).

This article discusses the research and

patient considerations associated with the treatment used to increase MPOD and the

vitamins shown to reduce the risk of AMD progression: ocular nutritional

supplementation. Optometrists can use this information to make prescribing decisions.

THE RESEARCH

The foundational evidence for the role

of ocular nutrition in age-related eye

disease was provided by AREDS (Age-

Related Eye Disease Study) and AREDS2.

AREDS shows that a supplement

formulation comprised of vitamin C, vitamin

E, beta-carotene, zinc and copper led to a 25% risk reduction of progressing to late

AMD over five years in patients who had intermediate or advanced AMD.

Additionally, for those who had advanced AMD in one eye, this risk reduction applied

to the fellow eye. Finally, no significant benefit was seen in patients without AMD or early AMD.

AREDS2 studied the addition of lutein, zeaxanthin and omega-3 and the

elimination of beta-carotene and a reduced level of zinc to the AREDS ocular nutritional

supplement. Results show that the combination of lutein and zeaxanthin had a

small beneficial effect in patients who had intermediate or advanced disease,

especially in those patients who had the lowest levels of dietary intake of the

carotenoids, and that omega-3 had no beneficial effect. Additionally, as beta-

carotene increases the risk of lung cancer

in current and former smokers, AREDS2 researchers concluded that substituting

lutein and zeaxanthin for beta-carotene in an ocular nutritional supplement was

advised.

Both foundational studies received criticism

for the following:

• Study subjects. The patients enrolled

in the AREDS studies differ from the average American socioeconomically, in

that these patients tended to have higher levels of education and better baseline nutrition.

• Other supplementation use. Some of the patients were

taking antioxidant vitamin supplementation prior to the

initiation of the trial.

• A missing carotenoid. The

AREDS2 ocular nutritional supplement did not contain meso-

zeaxanthin. Some research shows that an ocular nutritional

supplement that contains all three carotenoids benefits AMD

patients.

• Not enough omega-3. It has been

questioned whether the formulation of omega-3 used in AREDS2 was optimal,

as other research shows dietary oily fish and seafood consumption was

substantially lower in AMD patients, and serum red blood cell EPA and EPA and DHA were linked with a substantially

reduced risk of wet AMD. (See “Supplementation and Dark

Adaptation,” below.)

• No benefit for early

AMD. Observational studies demonstrate an association between

increased macular pigment levels and de-creased prevalence of macular

disease. Additional studies demonstrate the ability of nutritional

supplementation to increase the macular pigment level of an individual

patient. Therefore, one may draw the

A few notes from Dr.Ed Jervis about guidelines for AMD supplementation.

1. Patients must have intermediate dry AMD

(large drusen (bigger than the width of the retinal vein as it enters the optic nerve)

and/or retinal pigment changes (hyper-reflective foci on the OCT) 2. The patient needs to quit smoking

3. A balanced diet(including no processed food) and being close to your “goal weight” is

more important than simply taking a vitamin supplements.

5. Every patient should leave with an Amsler Grid (to be performed weekly, one eye at a

time- eg. every Friday) 6. Any distortions or drop in vision should be

scanned to determine the need for Avastin etc.

For more information, click here.

MAY 2021 7

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conclusion that supplementation has the potential to decrease risk for AMD in

individuals who have low levels of macular pigment, especially in those

who have a positive family history of AMD.

PATIENT CONSIDERATIONS

Optometrists should assess the following

information prior to prescribing an ocular nutritional supplement:

• Smoking. In patients who smoke, research shows that supplementation with high-dose beta-carotene can

increase the risk of lung cancer. As a result, Optometrists should

turn to formulations that do not contain beta-carotene.

• Genetics. A subgroup analysis of the AREDS data

suggests that different genotypes respond

differently to supplementation.

Specifically, patients who have one or two CFH

(complement factor H) risk alleles but no ARMS2 (age-related maculopathy

sensitivity 2) risk alleles were at an increased risk for progression to

advanced AMD with zinc supplementation. As a result, some

clinicians and researchers advocate for the routine use of genetic testing before beginning supplementation.

An independent study published in the British Journal of

Ophthalmology corroborated these results, but NEI researchers did not

reach the same conclusion. In the absence of a prospective clinical trial to

assess the value of genotyping, controversy remains regarding the role

of routine genotyping in supplement choice.

• Anticoagulants. Patients using anticoagulants, such as warfarin sodium

(Coumadin, Bristol-Meyers Squibb),

may experience complications from supplementation. Specifically, high

doses of vitamin E may inhibit platelet aggregation, interacting with this

medication. In addition, omega-3s may increase the risk of bleeding in those

using anticoagulant therapy. Due to these findings, O.D.s should

communicate with patients’ other medical providers before prescribing

supplements that contain vitamin E or omega-3. For those patients who cannot use

supplementation, Optometrists should tell them to avoid smoking and second-

hand smoke and eat a diet rich in omega-3 long-chain polyunsaturated

fatty acids (such as fish), and low in saturated fats and

cholesterol, among other risk-decreasing information.

AT THE READY. Our patients intuitively understand that diet is

one of the most important modifiable risk factors for

various diseases, including AMD. Some of them are even

reminded of their mothers telling them, “You are what you eat.” This tees

us up nicely to discuss the role of ocular nutritional supplements in AMD. But, to

be able to provide a prescription for a specific supplement and answer related patient questions, we must be

knowledgeable of the available research and patient considerations. Patients

depend on us. The pharmacy's supplement section has a dizzying array

of options.

Apply lessons learned in glaucoma to treating macular degeneration

Impaired dark adaptation occurs several years before clinically evident damage to

https://www.optometricmanagement.com/issues/2020/may-2020/prescribing-

supplements-for-amd

SUPPLEMENTATION AND

DARK ADAPTATION. Recently, impaired dark

adaptation has been proposed

as an early biomarker of AMD.

There is evidence that these

patients may benefit from the

early use of supplementation.

Currently, the NEI is recruiting

subjects for a clinical trial to

investigate; the role of vitamin A supplementation in AMD

patients and delayed dark

adaptation.

The evolving standard of care in AMD

MAY 2021 8

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the eye has occurred in AMD. Technological advances have revolutionized dark

adaptation testing, allowing it to be carried out easily in virtually any setting.

When new technology can impact an entire

generation of patients, optometrists have an opportunity to change. Such was the

case a generation ago in glaucoma with functional testing

(automated perimetry), and we are witnessing this same change now with age-related

macular degeneration (AMD).

Prior to automated perimetry,

glaucoma diagnoses were based on structural changes of the optic nerve along

with intraocular pressure (IOP) and documented with fundus photography. In

many cases, subtle optic-disc changes were questioned or ignored. All of this changed

with the advent of automated perimetry, which provided eyecare professionals a

means to support glaucoma diagnoses by assessing early functional changes. Indeed,

automated perimetry had a dramatic influence on the diagnosis, monitoring, and

care of glaucoma patients, and it became the standard of care.

When glaucoma’s sea change occurred, I remember the impact it had on our

profession. Optometry appears to be witnessing another paradigm shift—this time in how we approach AMD.

Missing the diagnosis

AMD is more prevalent than glaucoma and

diabetic retinopathy combined, yet very few optometrists can say they have three

times as many AMD patients as they do glaucoma patients. Why might this be the

case? Put simply, optometrists are not diagnosing it as often or as early as they

could be.

Historically, the failure to diagnose was

largely due to a lack of diagnostics. After all, Optometrists are great clinicians, but

research demonstrates that even stereoscopic macular observation and

evaluating fundus photos for subtle drusen and pigmentary changes can be tedious. A

study published in JAMA Ophthalmology showed just how often

diagnoses are missed by optometrists and ophthalmologists alike—even when the

doctors were aware that their findings would be double-checked

by trained graders.

This cross-sectional study, which included 1,288 eyes (644 adults)

from patients enrolled in the Alabama Study on Early Age-

Related Macular Degeneration (ALSTAR), revealed that eyecare practitioners are

missing AMD about 25 percent of the time. Also quite concerning is that 30 percent of

the undiagnosed eyes in the study had large drusen, a well-known risk factor for

progression to advanced disease.

Shifting our understanding of

diagnostic standards

Much like glaucoma, subtle functional

changes are present in AMD prior to the earliest clinical indicators of the condition.

Also, like glaucoma care before automated perimetry became the standard of care and

subsequently software advances aided in earlier diagnosis, AMD screening and

disease classification was—until recently—based exclusively on structural changes.

However, functional changes presenting as

impaired dark adaptation take place several years before clinically evident damage to

the eye has occurred. As a result of not diagnosing AMD early and not actively

monitoring disease progression, up to 78 percent of wet AMD patients are seeking

their first treatment after experiencing substantial, irreversible vision loss—

including 37 percent who are legally blind in at least one eye. Identifying early AMD

before significant visual impairment is the goal, yet the condition is difficult to observe

MAY 2021 9

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with clinical examination or even advanced imaging technologies.

Eyecare practitioners are able to use dark adaptation to identify patients with

subclinical disease. Delayed dark adaptation is the first clinical biomarker for

AMD and precedes visible presentation of drusen. Based on the preferred practice

patterns of the American Academy of Ophthalmology, dark adaptation functional

testing may overcome the practical challenges associated with diagnosing AMD using only traditional objective clinical

assessment.

Dark adaptation screening for AMD

generally is being applied to patients over age 50 years because this was the earliest

inclusion age in the Age-Related Eye Disease Study (AREDS). Careful probing for

subtle low-light vision impairment will likely lower this threshold and also reveal this

change in patients who may consider visual changes as “age appropriate.”

As more eyecare practitioners incorporate dark adaptation testing into their practices,

they are likely to see a trend similar to that of glaucoma with older patients having

higher rates of AMD than currently document in their charts.

Introduction

According to World Health Organization (WHO) data from 2010, there were an

estimated 285 million people living with visual impairment worldwide. Of these, 39

million were reported as blind and 246 million as having low vision. The most

common causes (80%) of these visual impairments are treatable conditions such

as uncorrected refractive errors and

cataract. These are followed by age-related macular degeneration (AMD), glaucoma,

and diabetic retinopathy. It has been reported that 65% of visually impaired and

82% of blind people are 50 years of age or older. Considering that the population is

aging, this suggests that more people will be at risk in the future. Definitions of low

vision and blindness may vary between countries. According to the definition

accepted in the USA, best corrected visual acuity less than or equal to 6/60 in the better eye or a visual field less than or

equal to 20° in the better eye is considered

legal blindness. In the 2016 version of the

International Classification of Disease (ICF)-10, visual impairment is classified in

5 categories based on presenting visual acuity. While older definitions were based

on best corrected visual acuity of the better eye, the current definition is based on

presenting visual acuity (with glasses if any, without glasses if not) in order to

emphasize the burden of uncorrected refractive errors (Table 1). According to

this, presenting visual acuity in the better eye equal to or better than 6/18 is defined

as mild or no visual impairment; equal to

https://www.optometrytimes.com/view/the-evolving-standard-of-care-in-amd

Table 1. Classification of visual

impairments according to the International

Classification of Disease-10 2016 revision

A Common Approach to Low Vision:

Examination and Rehabilitation of the

Patient with Low Vision

MAY 2021 10

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or better than 6/60 and worse than 6/18 as moderate visual impairment (category 1);

equal to or better than 3/60 and worse than 6/60 as severe visual impairment

(category 2); and worse than 3/60 as blindness. Blindness is also separated into

3 categories: visual acuity worse than 3/60 (category 3), worse than 1/60 (or counting

fingers at 1 meter) (category 4), and no light perception (category 5). According to

this classification, those with moderate and severe visual impairment (visual acuity worse than 6/18 and equal to or

better than 3/60) and those with a visual field less than or equal to 20° are

defined as having “low vision” and require rehabilitation. Functionally, low

vision can be regarded as a level of vision that prevents someone from

performing their everyday activities. Having a presenting visual acuity worse

than 3/60 and a corresponding visual field smaller than 10° is defined as

blindness. Because this new definition also includes uncorrected refractive

errors which were previously unaccounted for, the prevalence of

blindness in various countries increases to 15% in all age groups and 25-30%

among older adults. Studies have shown that the prevalence of low vision is up to

60% among older adults.

The prevalence and causes of blindness and low vision in different societies vary based on their level of development.

According to WHO data, the prevalence of blindness is 7.3/1000 in Africa, 3.5/1000 in

the USA, 8.5/1000 in the Eastern Mediterranean Region, 3.0/1000 in Europe,

6.9/1000 in Southeast Asia except India, and 5.3/1000 in the Western Pacific Region except China. Global data indicate there

are 3 people with low vision for each blind person; in the USA and Europe, which have

the lowest rates of blindness, the prevalence of low vision is 25.6 and 28.7

per 1000, respectively. This rate is 25.4/1000 in Africa and 32/1000 in

Southeast Asia.

According to data from 2000, it was estimated that there were 937,000

(0.78%) blind and 2.4 million (1.98%) people with low vision over 40 years of age

in the USA. Age-related macular degeneration (AMD) is the most common

cause of blindness among Caucasians, accounting for 54.4% of cases. By 2020,

the prevalence of blindness in the USA is predicted to increase by 70% to reach 1.6

million, and a similar increase is expected

in the low vision population.

Globally, 42% of visual impairment is due

to uncorrected refractive errors, while 33% is caused by cataract. Other major causes

include glaucoma, diabetic retinopathy (DR), trachoma, AMD, and corneal

opacities. The primary cause of blindness is cataract (51%) (Figures 1 and and22). In

North America and other developed countries, the main causes of vision loss are AMD, DR, and glaucoma. Other causes

include herpes simplex keratitis, retinal detachment, retinal vascular diseases, and

hereditary retinal degenerative diseases. In developing countries, the primary causes of

vision loss are uncorrected refractive errors and cataract, followed by glaucoma,

infectious diseases, injuries, and xerophthalmia. In short, visual impairment

Figure 1 ;Distribution of global causes of visual impairment (taken from WHO report entitled Global

Data on Visual Impairments 2010)RE: Refractive errors,

AMD: Age-related macular degeneration, CO: Corneal opacity, DR: Diabetic retinopathy

MAY 2021 11

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in developed countries is a result of unpreventable and/or currently untreatable

causes, whereas preventable (infectious, e.g. trachoma, or nutritional, e.g. vitamin A

deficiency) and/or treatable (e.g. cataracts) causes still play a major role in developing

countries. The fact that most of the diseases that cause blindness and low

vision are preventable or treatable has

prompted many organizations to take action, especially WHO. According to the VISION 2020 report from WHO, low vision

prevention and rehabilitation are among

the primary global goals.

A person’s ability to perform important

sight-based tasks is defined as “visual functioning”. Reduced visual functioning

due to disorders of the eye or visual system results in low vision. In addition to visual acuity, visual functioning should be

assessed using parameters such as visual field, contrast sensitivity,

electrophysiological tests, adequacy of preferred retinal locus, color vision,

binocularity, and stereopsis.

Low vision rehabilitation aims to increase quality of life by enabling patients to live independently, have a vocation or skill with

which they can financially support themselves, and enjoy life. The stages of

modern low vision rehabilitation include the intake, assessment of residual visual

function, assessment of residual functional vision, interventions and recommendations,

and vision rehabilitation therapy.

1. The Intake

The purpose of low vision assistance and rehabilitation is to enable

individuals to perform the sight-based activities they want to do but

currently cannot, using special

methods and/or equipment.

The initial interview is of key

importance, as it will influence the entire rehabilitation process. The patient’s family members should also

be involved in some parts of this process, and it is imperative that

sufficient time be allocated. History-taking from a patient with low vision

differs from that in the classical ophthalmologic examination. The

patient’s sociocultural characteristics, medical and ocular history, priorities,

and goals must be questioned in detail and recorded. A patient is

asked which tasks are difficult or impossible for them to perform in order to

gain insight into their visual functioning. In particular, they should be asked about

which activities they are limited in and wish to continue doing. It should be determined

whether they use any methods to help them perform the activities that they have difficulty with. The environmental

conditions in locations such as their home, school, and workplace should be

questioned, as well as what provisions are needed to increase their visual functioning

in these places.

It must be kept in mind that patients may have different needs, and each patient should be offered personalized solutions.

Visual needs important to the patient may include reading, doing crafts, watching

television, seeing the board in school, or reading road signs or bus numbers. Some

Figure 2 : Distribution of global causes of blindness (taken

from WHO report entitled Global Data on Visual Impairments

2010)

RE: Refractive errors, AMD: Age-related macular degeneration, CO:

Corneal opacity, DR: Diabetic retinopathy

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patients can have unrealistic expectations of low vision rehabilitation, such as being

able to drive. Although rehabilitation has a high success rate in regaining abilities such

as reading, patients with low vision are not eligible to receive a driver’s license in

Turkey. It may be necessary to inform patients what expectations are realistic

without being discouraging. In cases where the patient and their family cannot adapt to

their current situation and are pessimistic, the negatives of the patient’s visual impairment and disease should not be

emphasized during the interview; instead, they should be guided and encouraged

about what they can do.

When planning the rehabilitation program, questionnaires and scales about activities

of daily living can be used to determine in detail what difficulties the patient faces in daily life. These scales are also used to

evaluate the effectiveness of low vision rehabilitation. One of these scales is the

Low Vision Quality of Life Questionnaire (LVQOL), developed by Wolffsohn and

adapted to Turkish by Idil et al. and another is the National Eye Institute Visual

Functioning Questionnaire (NEI-VFQ 25), which was adapted to Turkish by Toprak et

al. The purpose of these scales is to characterize and determine the impact of

visual impairment in daily life. The Turkish version of the LVQOL consists of a total of

24 items in 5 dimensions, including 12 items about distance vision, mobility, and

lighting, 3 items about adjustment, 5 items about reading and fine skills, and 4 items

on activities of daily living. The NEI-VFQ 25 comprises 25 items in 11 subgroups and 12

optional items. This scale includes items assessing general vision, difficulty in activities requiring near and distance

vision, limitations of peripheral and color vision, ocular pain, vision-related limitation

of social functions, role limitations, dependency, mental health symptoms, and

driving difficulties, and general health. Higher scores in these scales correspond to

better quality of life. When evaluating the patient with low vision, quality of life scales

are useful for assessing the patient’s perceptions of their disease and whether

rehabilitation has resolved their vision-

related problems.

2. Assessment of Residual Visual

Functions

Determining visual function is essential

when examining the patient with low vision. Low vision examination differs from routine ophthalmologic examination in

some respects. Distance and near visual acuity are assessed in detail. Best visual

acuity should be determined with the most appropriate correction, because the

patient’s residual vision will inform the

selection of rehabilitation methods.

Measurement of Distance Visual Acuity

Visual acuity measurement is the easiest and most useful method of assessing visual

functioning, although it does not fully reflect a low vision patient’s performance in daily life. At this stage, it is essential to use

charts that a person with low vision can see and place them at an appropriate test

distance. A person with low vision gaining the ability to read some letters on a

suitable and correctly applied chart when they could not read any letters in previous

examinations is an important positive initial experience in the rehabilitation process.

Accurate determination of visual acuity in a patient with low vision is also important to

monitor disease, determine the amount of magnification needed for glasses or other

optical device, evaluate response to therapy if provided, and to create disability

reports if required. Examination should be performed under standard conditions (e.g.,

fixed chart distance and lighting) and with suitable charts. The Snellen chart is not

appropriate for examination of the low vision patient because it has low sensitivity in the 6/10-6/24 range due to its irregular

geometric arrangement and because the top lines are easier to read due to the

crowding phenomenon. Instead, the logMAR-based Bailey-Lowie or Early

treatment diabetic retinopathy study charts

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are preferred. Advantages of these charts are that they use logarithmic scales and

the lines include equal numbers of letters of similar legibility. The spacing between

the letters and lines is determined based on the size of the letters in each line. More

lines are included at the low vision levels. Visual acuity is scored as 0.1 logMAR for

each line and 0.02 logMAR for each correctly read letter. Better visual acuity

corresponds to a lower logMAR score. Depending on visual acuity, measurement can be performed by adjusting the distance

between the patient and chart to 2 meters or even 1 meter. It is suitable for use in

low vision examination because it provides more sensitive measurement at low vision

levels, facilitates refraction examination,

and is preferred for academic purposes.

Measurement of Near Visual Acuity

For patients with low vision, charts that include text samples are better for

assessing near vision than charts that use optotypes. This enables the evaluation of

reading performance, detection of any scotomas, and assessment of the effectiveness of therapy or rehabilitation.

During examination, it must be ensured that the distance between the individual

and the near vision chart is appropriate and fixed. The patient’s near vision is measured

monocularly and binocularly using an addition suitable for the working distance of

the reading chart. The metric M-unit is used for letter size. Near vision acuity is

recorded as reading distance in meters divided by letter size in M-units. The

Minnesota Low Vision Reading Chart (MNREAD), which can be applied using a

computer screen or printed cards, is one of the charts frequently used in patients with

normal or low vision, especially for

international comparisons.

Refraction Test-Retinoscopy

Refraction testing must be performed more carefully in a patient with low vision. When examining low vision patients with

abnormal head position, eccentric gaze, or nystagmus, the use of trial frames and

lenses should be preferred over phoropter.

For patients with eccentric fixation or

nystagmus and for uncooperative patients, cycloplegia and dynamic retinoscopy should

be performed when measuring refractive error. Although refractive error can be

measured using an autorefractometer in patients with low vision, determining

refractive error by retinoscopy is ideal. When a clear reflection cannot be obtained,

the patient should be approached until a reflection is seen, and necessary

adjustments should be made based on this distance. After retinoscopy, the patient’s

refractive error is confirmed using subjective methods such as fogging and

cross-cylinder.

Remarkably, for approximately 15% of

patients referred for low vision rehabilitation, functional vision can be

restored by simply prescribing appropriate

distance and/or near vision spectacles.

Visual Field

Visual field is one of the most important parameters of visual function in the low vision patient. Diseases involving the

macula, such as AMD, hereditary macular dystrophies, and macular edema, lead to

scotomas that significantly impact visual functioning and reading performance. The

Amsler Grid test is especially useful for identifying the location and size of central

scotomas. However, this test is inadequate for small scotomas and conditions such as

macular diseases in which fixation is commonly extrafoveal and unstable. These

types of visual field defects are best evaluated by scanning laser

ophthalmoscope (SLO). Because SLO provides instant retinal images, visual field defects and the related area of the retina

can be evaluated simultaneously. Microperimetry using SLO technology

enables the detection of important parameters such as preferred retinal locus

and fixation stability in low vision patients

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with central scotoma, and trained retinal

locus training can be provided.

Peripheral visual field loss adversely affects an individual’s orientation in unfamiliar

environments, mobility, and hazard perception. These defects are often seen in

patients with advanced glaucoma and retinitis pigmentosa. Kinetic (Goldman) and

static (Humprey, Octopus) perimetries can

be used to evaluate such defects.

High-power prism designs are used for hemianopias and quadrantanopias of

neurological origin and cases of tunnel vision due to diseases such as retinitis

pigmentosa.

Assessment of Contrast Sensitivity

Contrast sensitivity is the power to distinguish differences in shade between two regions. Although contrast sensitivity

tests are not used in clinical practice for every patient with low vision, they can be performed for patients whose visual

functioning is poorer than expected based on their measured visual acuity. Clinically,

deficits in contrast sensitivity are especially common in corneal edema, cataract, optic

nerve diseases, and some retinal diseases. Patients with low contrast sensitivity might

require more magnification than expected for their visual acuity and may benefit from

increased ambient light. Closed-circuit television systems that increase contrast

and broaden the visual field can be recommended to these patients. Many

contrast sensitivity charts are used in clinical practice to measure perceived

contrast, such as the Vistech VCTS test, Pelli-Robson Letter chart, Arden chart,

CSV-1000 chart, and Regan chart. For patients with low vision, contrast sensitivity

tests designed specifically for low vision should be used, such as the CSV-1000LV,

ELCT, and CSV-1000 1.5 cycles/degree.

Color Vision

Hereditary and acquired color vision disorders have several distinguishing

features. Hereditary color blindness (protanopia and deuteranopia) is a stable,

binocular, usually red-green color vision deficiency that preferentially affects males.

Other visual functions are normal. Acquired color vision deficiencies can be monocular

and asymmetrical, are often progressive, and usually involve blue-yellow color

blindness. Most color vision disorders in patients with low vision are blue-yellow

dischromatopsia. Pseudoisochromatic plates are the most commonly used color vision tests. They are simple and can be

performed quickly. They comprise colored numbers or paths on a background of equal

saturation. The Ishihara test, the most well-known pseudoisochromatic table, only

tests red-green vision. For blue-yellow dischromatopsia, which is more common

among patients with low vision, color arrangement tests such as the Farnsworth

100 Hue and D 15 tests or the Wang & Wang color vision plates are more

appropriate than the Ishihara test. In addition, the reliability of

pseudoisochromatic tests decreases at visual acuity levels lower than 6/20. In

general, blue-yellow color blindness is considered to be associated with large

lesions involving the outer retina, while red-green color blindness occurs in lesions

involving the inner retina and optic nerve. Furthermore, blue-yellow color blindness is seen in cataract and glaucoma, while red-

green color blindness occurs in cone dystrophy. As part of rehabilitation,

patients can be advised to seek high color

and tone contrast.

Glare Test

Glare refers to excessive brightness in the visual field and can be accompanied by

asthenopia, headache, and squinting. Glare can be associated with media opacities

such as cataracts and corneal scar, or albinism, achromatopsia, or aniridia. It can be assessed simply during visual acuity

measurement by holding a light source near the fixation line and observing the

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reduction in the number of lines or letters

the patient can read.

3. Assessment of Residual Functional

Vision

Low vision patients with similar residual

visual functions may have very different performance when it comes to utilizing

their vision. Assessment of residual functional vision determines how and to what extent the low vision patient can use

their residual vision and the individual and environmental factors that affect this

ability. This also includes educational vision assessment to facilitate appropriate

education planning.

As explained in detail in ICF system, in addition to their visual functions, an individual’s activity and participation and

environmental factors must be evaluated in a rehabilitation program. In other words,

visual functions determine a person’s capacity, whereas functional vision refers

to their performance.

Therefore, functional vision assessment identifies how the patient uses their vision and

what visual skills and environmental adjustments

they need to better use their vision. It is based on the

patient’s actual performance in the target activity and

measurement of the adequacy of this performance. For

example, in a patient whose primary goal is to read,

residual visual function is determined using methods

such as visual acuity, refractive error, and visual

field, while residual functional vision is measured using a performance index such

as reading speed. Reading performance should be assessed using continuous text cards instead of solitary optotypes.

Continuous text cards must be representative of commonly read materials

and commonly used words in the population, be standardized in terms of

length and width, and be printed in the

native language of the population.

An objective measure of reading performance is maximum reading speed.

Other parameters that can be used in assessment include reading acuity, critical

print size, and Reading Accessibility Index. Maximum reading speed is the reading rate

that is not limited by print size. Reading acuity is the smallest print size that can be

read without making any errors; critical print size is the smallest print size that can

be read at maximum speed. The recently developed Reading Accessibility Index

indicates the visual accessibility of familiar printed material and is calculated as the

mean reading speed across the ten largest print sizes on an MNREAD chart. It

represents reading performance in daily life. MNREAD cards, developed at the University of Minnesota, can be used to

assess reading performance. They provide corresponding values for reading acuity in

Snellen, logMAR, and M-units from 40 cm. Although originally

in English, they have been validated

in various languages. A

Turkish version has also been

developed and validated and is of

equal difficulty to versions in other

languages to allow its use in

international

studies (Figure 3).

Quality of life scales can be used in the

subjective evaluation of functional vision. It is also possible to evaluate the

effectiveness of rehabilitation with these

scales.

Daily visual goals usually include reading, writing, watching television, dressing,

performing personal care, moving around, cooking, doing home maintenance,

Figure 3: Assessment of reading performance

using MNREAD cards

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cleaning, and working. A rehabilitation program is designed taking into account

the patient’s visual priorities and their distance, near, or intermediate distance

vision needs. This planning requires a multidisciplinary low vision team. In order

to increase the patient’s participation and motivation, their family should be involved

in planning and implementing the low

vision rehabilitation.

4. Interventions

The data obtained in the first three stages

are evaluated and an individualized intervention program is planned for each

low vision patient. This program encompasses the necessary techniques

and/or assistive technology.

Devices Used in Low Vision

Rehabilitation

Optical systems

I. Telescopes

Advantages of telescopes include being able

to magnify an image at long

working distances with hands-free

use; however, they also have

disadvantages such as being difficult and dangerous to use when moving

due to narrowing of the visual field, causing difficulty in achieving binocularity, and

being costly, and they can also cause esthetic concerns. They can be integrated

into the patient’s own prescription glasses, and some models are also focusable

(Figure 4). Their length increases with their magnifying power, and visual field narrows

as their length increases and diameter decreases. Bioptic telescopes can be used

at magnifications of up to 6x. When a

telescope is prescribed for a patient with

low vision, they must be trained in its use.

Telescopes are either Galilean or Keplerian depending on their optical principles. The

Galilean telescope consists of two lenses, a low-power plus objective lens and a high-

power minus eyepiece lens, and it gives an upright image. The Keplerian telescope also

consists of two lenses, a low-power plus objective lens and high-power plus

eyepiece lens. The inverted image obtained with Keplerian telescopes is corrected with

prisms. Although Galilean telescopes have certain advantages such as being shorter

and lighter and having a larger visual field, Keplerian telescopes have better image

quality because they use light more efficiently. Keplerian telescopes are more

complex with a wider range of focus. The telescopes used in low vision rehabilitation

are usually Keplerian.

Telescopes can be focusable or fixed-focus

depending on their focusing characteristics. In focusable telescopes, the patient’s

spherical error can be corrected and a base lens may be required for high astigmatism.

With fixed-focus telescopes, the patient’s refractive error (spherical + cylindrical)

must be given as the base lens.

Depending on the patient’s vision level,

telescopes can be prescribed monocularly or binocularly. For near vision, a +3.00 to

+12.00 D cap (reading cap) can be attached. Telescopes can be hand-held,

clip-on, or spectacle-mounted (large-scale, bioptic, mini-telescope). Spectacle-mounted telescopes are mostly used for

watching television or by school-aged children for looking at the board, whereas a

monocular hand telescope is hung around the neck and used only when needed,

allowing the user to continue their

everyday activities.

Although telescopes are not suitable for use when moving due to narrowing of the

visual field, various special designs have been developed in an effort to overcome

this limitation.

Figure 4: Some types of

telescopes used in our clinic

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These designs, which are used when in motion, are bioptic telescopes and

autofocus telescopes. In bioptic telescopes, a

compact, low-power magnifying telescope is

placed in an area in the patient’s visual field,

usually the superotemporal region.

When the patient looks through their glasses, the magnified image from the

telescope can be viewed when needed by

adjusting their head or eye position. With

autofocus telescopes, this process is modified with a

motorized focusing system so that the user

can easily follow objects at different distances

(Figure 5). Although bioptic telescopes are

useful for distance viewing, their use is

limited by their appearance and the ring

scotoma surrounding the magnified image. This led to the recent

development of ‘in-the-spectacle-lens’ telescopes, a design in which a wide-field

Keplerian telescope is built completely within the

spectacle lens. By simultaneously using the

magnified and nonmagnified view of the viewing area, the

vision multiplexing feature provided by these devices

facilitates the patient’s

orientation and navigation.

II. Microscopes (High-

Diopter Near Spectacles)

After correcting hyperopia, near addition and reading distance are calculated according to

Kestenbaum’s rule. For example, in a patient with a corrected visual acuity of

20/100, the near add is the inverse of visual

acuity, 100/20=5 D, and near reading distance is

1/5=20 cm. The add is gradually increased to the

dioptric power that allows the patient to comfortably

read a text size of 1 M. The actual value will be higher than the predicted

value in patients with low contrast sensitivity or

macular scotoma and those who want to read

letters smaller than 1 M. Binocular vision up to +10

D is possible. As the dioptric power increases,

reading distance is reduced accordingly. If

the reading distance is too short, it can be

increased with high-power plus lenses held away

from the eye with special clip-on systems. The

effect of additional illumination must also be assessed during

examination. The advantages of microscopes include their wide visual field, hands-free

operation, and pleasing esthetic appearance.

Negative aspects are their short working distance and

inability to tolerate values greater than 10 D binocularly

(Figure 6).

In patients whose binocular

vision is better than their monocular vision (i.e., with

similar visual acuity in both eyes), a base-in prism can

be added to facilitate accommodative convergence

(Figure 7). Although there are various formulas to calculate Δ

Figure 5

Various examples of bioptic telescopes

Figure 6: Some types of

microscopes used in the clinic

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addition, a base-in Δ roughly twice the D power addition can be added to both eyes.

If the patient’s reading performance is better

when their less sighted eye is closed

(i.e., the patient is functionally

monocular), a frosted lens can be prescribed

for the less sighted eye or the patient can be instructed to close

the weaker eye when

reading.

Because high D

(greater than +4.5 D) additions in bifocal

and progressive lenses are difficult to tolerate binocularly and the

likelihood of problems at intermediate and far distances increases

in parallel with D power, dedicated reading glasses should be recommended to patients

with low vision. Moreover, as the use of near vision spectacles provides a larger

visual field, it will enable eccentric viewing.

III. Magnifiers

Magnifiers can be used in addition to near vision spectacles in order to meet the needs of low vision patients when reading

and performing tasks requiring near vision. They can be used simultaneously with near vision spectacles, and do not require

myopic correction in most patients. Remember that with magnifiers, the

greater the working distance, the smaller the visual field. Magnifiers are available as

hand-held, stand, illuminated, fiberoptic,

and dome/bar magnifiers.

Advantages of hand-held magnifiers are that they are portable, can be used at

longer working distances than spectacles, and are inexpensive. Some have built-in

illumination. The virtual image can be brought closer to the focal plane at the

back of the eye by changing the object

distance. Aspheric magnifiers provide better image quality. They are useful when

looking at mobile phone screens and price tags while shopping.

However, they must be held steady at a fixed working

distance (Figure 8).

With stand magnifiers, the

object distance can be adjusted easily. They require a fixed, flat

surface and

usually include a

built-in light

source. This

increases contrast and

reduces the amount of

magnification needed, thus increasing reading speed. Stand magnifiers should be

used in conjunction with near vision spectacles of about +3.00 to +3.50 D in

older patients.

They may be preferable

for those who cannot

use hand-held

magnifiers due to

tremor, paralysis,

arthritis, or poor hand-eye

coordination, or those who

require more magnification than spectacles

provide (Figure 9).

IV. Filtering Lenses

These lenses filter certain wavelengths of light while allowing the passage of other

Figure 7. Microscopes with prism

additions

Figure 8. Hand-held

magnifiers

Figure 9. Stand magnifiers

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wavelengths. This reduces the patient’s photophobia and provides clearer vision by

increasing contrast sensitivity. According to the patient’s needs, different filtering

lenses can be prescribed for both indoors and outdoors. The lenses are different

colors based on the wavelength they filter. Although there are filters recommended for

certain diseases, it is more appropriate to

try a set of filtering lenses to identify the

filter the patient is most comfortable with

(Figure 10).

V. Electro-optical Systems

Closed-circuit television (CCTV) systems

are systems that project visuals such as written text or images to a screen and

enable adjustments such as magnifying the image and changing brightness and

contrast. They are so called because of the direct cable connection between the

camera imaging system and the display. Features such as variable magnification,

auto-focus, magnification without focusing, reverse contrast, voice-command controls,

and automatic forwarding have also been added to these systems. Electro-optical

systems mitigate or overcome many problems associated with magnifying

systems, such as narrow visual field, short working distance, reduced contrast,

aberrations, and illumination. The main problem with electro-optical systems is that

they are large and costly. However, with technological advances, systems now come

in portable sizes and have become

relatively less expensive (Figure 11).

Mouse magnifiers are devices that look like a computer

mouse and contain a

camera that is moved

over the material to

be viewed. They are

easy to carry,

cheaper than CCTV

systems, and can be

connected to most personal

computers. They can

have variable magnification, reverse contrast,

and focusing features. Their main disadvantage is limited viewing area

(Figure 12).

Today,

electronic tablets have

become more popular than

most optical systems due

to their many functions and

applications that assist

those with low vision,

especially school-age

children. Most individuals

with low vision can benefit from electronic reading devices such as the iPad (Apple,

Cupertino, CA, USA) and Kindle (Amazon, Seattle, WA, USA). A prospective study showed that these types of electronic

Figure 12. Mouse electronic

magnifier

Figure 11. Examples of electro-

optical systems

Figure 10. Filtering lenses

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devices increased reading performance in most patients. These devices include

applications that enable the user to increase the size and darkness of

characters, adjust the contrast, brightness, and color of the display background,

magnify and zoom, zoom by taking a photograph of an image, take spoken

commands, and read text aloud. Their advantages include ease of access,

relatively low cost, and combination of different functions that can be used for

both distant and near tasks.

Non-Optical Systems

Non-optical systems increase the patient’s residual visual function or use signals that

stimulate one of the other senses. Illumination, large-print books, increased

contrast, typoscope, reading stands, and sunglasses or spectacles with filtering

lenses to reduce glare can be used alone or in conjunction with optical systems in

patients with low vision.

Illumination reduces the need for

magnification and increases reading performance, particularly in macular

degeneration patients who have reduced contrast sensitivity. Patients must be

taught how to properly direct table lamps while reading. The built-in illumination in

hand-held and stand magnifiers increases reading performance for most patients. On

the other hand, patients complaining of excessive glare will benefit from reducing the light level and using hats, sunglasses,

filtering lenses, and light-blocking glasses. Patients can be advised to increase the

contrast when printing documents, try different contrasts such as a light-colored

object on a dark background, use glasses with contrast-enhancing yellow or orange

filtering lenses, and use a typoscope or

electro-optical system.

5. Recommendations and Vision

Rehabilitation Therapy

As visual impairment progresses, patients

can be offered alternate tools and

techniques such as white cane training, use of the Braille alphabet, audio books, and

voice recording devices. It is also very important to modify the patient’s living

conditions. Taking measures such as sitting students in the middle of the front row of

the classroom, organizing the kitchen and other home environments in a contrasting

and appropriate way, and accentuating steps and handrails will make daily life

easier. Vision loss can have a major impact on some quality of life and emotional state in some individuals. These people should

receive psychological counseling to help them adjust and overcome the emotional

problems they are experiencing.

Low vision rehabilitation is not just the prescription of a low vision aid. Training

programs consisting of habituation exercises practiced in the clinic or at home constitute one of the most important

stages of rehabilitation. Various training programs and courses are implemented in

vision rehabilitation therapy to develop related functions and improve performance.

Some of these programs are reading and writing skills, orientation and mobility, and

driving education in countries where it is legal. Occupational therapists conduct

assessments at the patient’s home, school, or workplace to improve orientation and

mobility and facilitate adaptation. If there are target activities in the patient’s real life

environments, they are also practiced using the auxiliary devices and the necessary

environmental adjustments are

recommended.

In South African society corruption, fraud

and accounting failure have become the norm, so much so that we barely react when the latest scandal hits the headlines.

We have become fatigued, but this doesn’t mean that we can give up the fight against

these scourges of society. To quote Edmund Burke, “The only thing necessary

https://www.ncbi.nlm.nih.gov/pmc/articl

es/PMC6517854/

Ethics

MAY 2021 21

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for the triumph of evil is for good men to do nothing.” We cannot turn a blind eye

when we see minor acts of unethical behaviours, as once someone has displayed

that he can “get away with it”, what will prevent him from further, more serious

unethical behaviours?

Looking at the likes of Steinhoff, the Guptas, Tongaat-Hulett, Bosasa and other

large corruption, fraud and accounting failure cases, we have to look to the leadership of these entities and, sadly, our

country.

Corruption and bribery cannot happen with only one-party present. It is trite to say “It

takes two to tango”.

So, why do so many people follow and support them?

There are three main reasons:

Position

By placing themselves in positions of

power, these people assume positions of leadership and respect. Most of us are

taught from a young age to respect and obey people in these positions. You defer to

the chairman of the board, you listen to your teachers, you do as the police ask, even when they are wrong. People who

question the system are considered troublemakers. This is leading through fear

and cannot continue forever. As has been seen in the Bosasa matter, once freed from

this leadership, people start speaking out and the house of cards will tumble.

Expertise

If someone knows more about a topic than

you do, you are more likely to take his advice or follow his instructions. It is

rational do so. Looking at Steinhoff, with senior Chartered Accountants telling the

accounting department how to account for transactions and values, why would they

not simply do as they were told?

Relationships and Charisma

Once you’ve known somebody for a period of time and have built a relationship with

him, you are more likely to want to assist him. If you like that person, the willingness

to assist increases exponentially. Most leaders are charismatic and likeable in their

professional personas. They are able to hide who they are from the outside world

and therefore it comes as a surprise when we discover a fraud or corruption matter. Bernie Maddoff is a case in point. He was

the former non-executive chairman of the NASDAQ stock market. He also ran the

largest Ponzi scheme in the world for over twenty years.

So, how do we lead ethically and ensure

that we are running ethical businesses?

As the saying goes, the fish rots from the head. It comes down to leadership. Do you

want a high-flying CFO, with a penchant for creative accounting or the CFO who is not

afraid to challenge accounting treatments or out of the ordinary transactions? Do you

want a CEO who leads by bullying subordinates into submission or the CEO

whom people genuinely respect because she always does the right thing for the

company given the circumstances? Do you really want to be fellow directors with the person who is having an affair? What

makes you think he would be loyal to the company and the board? You cannot simply

draw a line in the sand and state that the way people behave in their personal lives

does not impact on their professional lives. It does and it will. You may not know when

and how it will transpire, but it will.

Compliance with the King IV report on corporate governance is a statutory

requirement for entities listed on the JSE. Private entities are strongly encouraged to

adopt as much of King IV as is reasonably possible. The definition of ethics included in

King IV is as follows: “Considering what is good and right for the self and the other, it

can be expressed in terms of the golden

MAY 2021 22

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rule, namely, to treat others as you would like to be treated yourself. In the context of

organisations, ethics refers to ethical values applied to decision-making, conduct,

and the relationship between the organisation, its stakeholders and the

broader society.”

According to King IV, ethical leadership requires integrity, competence,

responsibility, accountability, fairness and transparency. It complements effective leadership, which is results-driven. Do you

live these principles outside of your professional environment, in your

relationships and in your communities? Being ethical may cost you a contract here

and there. However, being unethical can cost you your reputation. And that is a

much higher cost.

So, the question is - What is Ethical leadership? It’s definitely not about trying

to avoid a scandal!

The Oxford Dictionary defines ethics as: “Moral principles that govern a person’s

behaviour or the conducting of an activity.”

Ethical leadership is about acting responsibly and modelling the right

behaviours to be able to inspire and lead your employees into achieving more; and to create the most value for society. Ethical

leaders should always display ethical and appropriate behaviour in all facets of their

lives and should lead by example. In addition, they should always strive towards

creating an ethical work environment articulated by policies and rules best for the

business and its stakeholders and not by politics or personalities. Decisions and

outputs need to be value-based and in line with the organisation’s vision and mission.

This is in line with the King IV Code and

Principles (17 principles which include one extra for institutional investors) that

replaced King III. Mervyn King, chairperson of the King Committee, said that: “An

updated code became necessary because of

the international and local developments in corporate governance. In drafting the King

IV report, the committee revised the ‘apply or explain’ approach and replaced it with an

‘apply and explain’ approach. King IV advocates that the governing body must

disclose the means through which it is being held accountable to deliver. With the

code bringing to the forefront ethical and effective leadership, the first three

principles especially intensify the importance of ethics in an organisation.

Let us examine these a bit further:

Principle 1- The Governing Body Should Lead Ethically and Effectively:

This principle encompasses the six ethical

characteristics of integrity, competence, responsibility, accountability, fairness and

transparency. In any organisation, the Board of Directors must adhere to all its

duties by acting with due care and diligence. In addition, the Board must be

composed of competent individuals who can steer and set the tone for the

organisation, set the strategic direction, review and approve policies, be risk

adverse and, very importantly, ensure accountability.

Principle 2: The Governing Body Should Govern the Ethics of the

Organisation in a Way that Supports the Establishment of an Ethical

Culture:

This principle further exacerbates the need for ethics to be endorsed by organisations.

Ethical foundations must be established. A few examples of how this can be achieved

and managed is by way of documenting and implementing a Code of Ethics and

Conduct, endorsing policies around corruption and anti-bribery, Whistle

Blowers, gifts and the establishment of a Social and Ethics Committee.

Principle 3: The Governing Body

Should Ensure that an Organisation be

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a Responsible Corporate Citizen:

In order to become a good corporate citizen, the board must at minimum assess

its activities in the following areas: the workplace (health and safety of its

employees, fair and equal pay, the relevant labour legislation requirements, BBBEE

etc.), the economy (economic transformation, tax legislation etc.), society

and the environment. Overall, the King IV Code calls for leaders

to be ethical and to break away from results and compliance-based leadership

styles. Leaders should become more strategic by applying their minds to the

manner in which they conduct their day to day business, and to be held accountable

for their actions.

In an ever-changing world, as ethical leaders within our organisations, we need

to strive towards creating a culture in which people do the right thing. Leading

from the top is not always pleasant and it requires a demonstration of courage. You

are never going to please everyone and some of your decisions may leave you

questioning whether you have done the right thing. However, the running of an

organisation ethically and responsibly is never going to be an easy task.

We are at a time where the world is experiencing great difficulty and it is

becoming increasingly difficult for businesses to decipher between what is

right and what is wrong. Ethics, Integrity, Competence, Responsibility, Accountability,

Fairness and transparency have never been more important. Make the right choice!

Regards

Ingrid

https://www.moore-southafrica.com/news-

views/october-2020/leading-with-ethics