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Visual impairment is an important public health problem and poses an enormous global financial burden due to productivity losses. Given the high financial burden of low vision and blindness in its own population, India has a great need to strengthen its low-vision services and better equip its eye specialists.
In a global initiative, the World Health Organization (WHO) launched VISION 2020: The Right to Sight, which prioritized preventable blindness. This initiative sought and still seeks to increase awareness of primarily preventable eye diseases; its large-scale aim is to fully eliminate avoidable blindness. Although awareness of low-vision services among ophthalmic professionals in India has increased, these services are not robust and strong programs have not yet materialized.
Globally, at least 2.2 billion people have a near vision or distant vision impairment. In at least one billion of these cases, vision impairment was preventable or remained untreated. The most common causes of low vision in adults are the following: age-related macular degeneration, glaucoma, cataracts, and diabetic retinopathy.
The International Classification of Diseases 11 (2018) classifies vision impairment into two groups: distance and near-presenting vision impairment.
Distant vision impairment is classified on the following scale:
- Mild—visual acuity worse than 6/12 to 6/18
- Moderate—visual acuity worse than 6/18 to 6/60
- Severe—visual acuity worse than 6/60 to 3/60
- Blindness—visual acuity worse than 3/60.
Near vision impairment is classified as near visual acuity worse than N6.
Despite progress in therapeutic approaches, many diseases of the eyes and visual pathways still cause persistent visual deficits that make everyday life for those suffering from visual impairment rife with challenges. Apart from direct functional impact on the sufferer, visual impairment increases the risk of injury and of contracting further miscellaneous disorders. Moreover, when vision loss coexists with other health problems such as hearing loss or cognitive deficiency, the resulting consequences are usually severe.
While the majority of people with vision impairment and blindness are over the age of 50 years, vision loss can affect people of all ages. In children, refractive errors and squinting are the most common expressions of visual impairment. In addition to affecting their health, children with visual impairments face many damaging social problems. These commonly include: being asked hurtful questions, being bullied by their peers, being pitied as a child with a disability, and being overprotected by parents, which can further hurt a child’s social development.
Research has found that 65% of the general population are visual learners, meaning they need to see information to retain it. Hence, reduced visual input resulting from vision impairment can present a significant barrier to a child’s development and thus to their future success.
It is clear that failing to win the global struggle against visual impairment creates financial and personal difficulties in the present. Worse, this issue is not stagnant. It is highly likely that the number of people living with low vision will increase over the coming decade.
While visual impairment is a complex issue, rehabilitation aims to compensate for these limitations by optimizing residual vision. Rehabilitation measures in blind or visually impaired patients include a wide array of options, including the following: vision aids, tactile aids, and acoustic aids. These aids are for reading impairment, obstacle detection, and electronic guidance systems for orientation impairment. Training given to visually impaired people typically centers on learning how to use aids, learning possible compensatory behaviors, orientation and mobility training, and saccade training.
Organizations and healthcare institutions, however, do not stop assisting visually impaired individuals at this stage of rehabilitation. Social counseling can be just as important as training visually impaired people on how to use these rehabilitation measures. Social counseling for visually impaired people can include managing visual impairment’s effect on life at school, at work, in leisure activities and independent living; for registering as disabled, in seeking state support due to blindness and in providing access to self-help groups.
In India, the state of Kerala has made commendable progress in the prevention of avoidable blindness over the past decade. However, accurate data on the accessibility and effectiveness of low-vision services from the state are currently lacking. The challenge of rehabilitating the increasing number of visually impaired is enormous and requires appropriate strategic planning and efficient use of available resources. Still, the Kerala Government, Kerala Society of Ophthalmic Surgeons (KSOS), and some NGOs have launched statewide projects to address visual impairment in the populations they serve.
The Kerala government launched the “Kazcha” project to empower visually impaired people. Most visually impaired people are unaware of technological advances, like screen reading, that can be of great help to them. Such technologies can help them overcome many difficulties. The “Kazcha” project will also teach visually impaired people how to use mobile applications that can be of help in their day-to-day lives and equip them with the latest technologies.
The KSOS envisages starting Low Vision Centers in all districts in Kerala as a part of its Low Vision Project, which was launched during Drishti 2018, the annual conference of KSOS at Kannur. KSOS will bear the expense of training optometrists at Aravind Eyecare Systems, Madurai, and help partner hospitals to set up Low Vision Centers. “Punarjyothi,” the low vision project is the brainchild of Professor P.S. Girijadevi, former Director of the Regional Institute of Ophthalmology (RIO), Trivandrum. It is being taken forward in a big way by the alumni of RIO.
The Society for the Rehabilitation of the Visually Challenged (SRVC), a registered NGO, has been working in the field of rehabilitation of the visually challenged (VC) since 2002. SRVC has taken a different approach by pursuing new avenues for employing the VC in non-conventional areas; taking advantage of existing technology; and offering the VC necessary training. Through empowering VC individuals and by creating public awareness, SRVC also aims to play an active role in creating an inclusive atmosphere and thus aid the VC in social integration. Projects and possible occupations identified for VC individuals under this project are orchestra, data entry, telemarketing, medical transcription, call center jobs, physiotherapy, counseling, foreign language assistance, tea tasting, wine tasting, assaying, and promoting sporting abilities in blind football, blind cricket, powerlifting, and other athletic disciplines. Tiffany Brar is an Indian community service worker who became blind as an infant due to oxygen toxicity. She is the founder of the Jyothirgamaya Foundation, a non-profit organization that teaches life skills to blind people of all ages.
As has been shown, the spectrum of visual rehabilitation has become much wider in recent years and is no longer limited to the eyes. It now includes a new understanding of functional compensatory cortical plasticity in the adult visual system. This understanding gives healthcare professionals a bigger toolkit for providing treatment and rehabilitation options. For example, electronic canes can help patients to detect nearby objects. More recently, optical character recognition devices translate visual information—such as text, monetary denominations, and faces—into spoken words. Unobtrusively designed, the device includes a miniature camera clipped onto the wearer’s eyeglass frame.
Further, several studies report promising results from repetitive trans-cranial stimulation, which is an example of a noninvasive method for restoring vision. Trans-cranial direct current stimulation is another technique to induce changes in cortical excitability. If repeated in daily sessions, it may modulate brain network plasticity, helping to restore impaired vision. Direct treatments, like retinal implants, appear to increase vision within acceptable safety profiles. Patients who have received retinal implants report significant improvement in their quality of life. Artificial vision has already shown efficacy in patients suffering from retinal photoreceptors degeneration.
After a thorough diagnostic evaluation of a person’s individual visual impairment and analysis of its effects, the chosen rehabilitative measures can usually restore reading ability and improve spatial orientation, thereby enhancing the patient’s independence and quality of life.
As the demand for visual rehabilitation is increasing, healthcare institutions and medical professionals must take steps to make treatment possibilities more widely available. Furthermore, as the scientific basis for visual rehabilitation is currently inadequate in some areas, more research in the field will be needed.
However, the field is ripe for advancement. Optometrists along with ophthalmologists and social therapists can effectively tackle these demands. We have paramedics posted even in Primary Health Centres, India’s state-owned healthcare facilities whose assistance is valuable. Efficient utilization of the potential of all the stakeholders can bring great changes in the lives of people with visual impairment and blindness.
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Conflicts of interest
There are no conflicts of interest.
