A Hearing Expert’s Guide to Hearing Care for People With Vision Loss

According to the 2019 world report on vision, there are over 2.2 billion people worldwide with vision loss ¹, of whom many also have hearing loss. Most older adults will experience age-related changes in vision, most of which are not amenable to correction. Aging is also the primary risk factor for many eye conditions, but—as with hearing loss—genetics, lifestyle, infections, and other health conditions also play an important role. With the aging of the population, the prevalence of vision loss will increase dramatically over the coming decades. Age is also the biggest risk factor for hearing loss, thus an increasingly large proportion of individuals visiting hearing care services will have a visual impairment.

Figure 1: Summary of adaptation to practice.

Figure 2: The teach-back technique.

Table 1: Visual Acuity Levels and Their Impact on Vision.

Table 2a: Age-Related Eye Conditions and Their Implications for Daily Function.

Table 2b: Common Eye Diseases and Conditions and Their Implications for Daily Function.

A recent workshop with older people, carers, and health professionals emphasized the importance of optimizing health and social care services to effectively meet the needs of older adults with multimorbidity. ² Similarly, international practice recommendations aimed at clinicians working across the fields of hearing, vision, and cognitive health advise multidisciplinary working and joint learning. They state: “Professionals assessing hearing should take into account the impact of vision on evaluations of hearing.” ³ Presumably, this recommendation arose because individuals with impaired vision may have difficulty accessing and negotiating hearing care, completing tests that require vision, managing their hearing aids, and seeing informational materials provided in a print format. ^4,5

In this article, we introduce hearing specialists to clinical terms and definitions of vision loss, some common eye conditions and their functional impacts, and outline strategies to use when evaluating hearing and providing audiological rehabilitation to people with vision loss.

VISUAL ACUITY AND VISUAL FUNCTION

Vision is the ability to resolve fine visual detail and is typically defined as acuity for high-contrast targets presented at a fixed distance (typically 6 meters or 20 feet) as assessed -using a Snellen chart. Having 20/20 vision means an individual can see clearly at 20 feet, while 20/100 vision would mean they must be as close as 20 feet to see what a person with normal vision can see at 100 feet. ⁶ However, acuity is just one metric of vision. Visual field, color discrimination, and contrast sensitivity (discrimination of subtle differences in shading) are more functionally informative than high-contrast acuity. ⁷ Table 1 shows the terms used to describe vision loss and the difficulties an individual will likely encounter with each degree of acuity.

Unlike hearing, visual status is defined based on “best corrected” vision in the better eye. This means that recorded acuity is the best vision that can be achieved.

In Tables 2a, and 2b we describe some specific age-related changes in vision, eye conditions, their functional impacts, and implications for hearing care. Tips for clinical practice are below. Note that these tables do not include the secondary impacts of vision loss (e.g., financial, emotional, psychosocial, etc.) because these are much more difficult to quantify and are dependent on other factors. Again, as with hearing loss, vision loss is associated with increased risks of depression, isolation, falls, and cognitive decline. ^8–11 Further, the combined impact of both vision loss and hearing loss further increases the odds of developing these, and of developing them sooner. ^8,12–14

“Normative” age-related changes to vision are extremely common (Table 2a), many of which are not amenable to correction. Although eye diseases (Table 2b) affect far fewer people, they cause greater visual impairment. Some types of vision loss can be treated or managed, although depending on individual circumstance and location, treatments have varying effectiveness and are not always readily available. For example, in some cases, refractive errors can usually be fully compensated by spectacles; cataracts may be removed by lens replacement surgery; the progression of glaucoma can be managed with medication and surgery; although progressive, some forms of age-related macular degeneration can be treated with injections and light treatment (photodynamic therapy); and good diabetic control can limit diabetic retinopathy. ¹⁵

HEARING CARE/AUDIOLOGY: CONSIDERATIONS FOR PEOPLE WITH VISUAL IMPAIRMENT

There are several aspects of the hearing care process that can be adapted for individuals with vision loss. Below we describe each and provide tips for how you might change your practice. ^4,5,15–20 This information is shown in summary form in Figure 1

Awareness of Vision Loss. Adapting hearing care provision for people with vision loss is as important as adapting vision care for people with hearing loss. There are many overlaps in what should be considered. Like hearing loss, patients do not necessarily reveal their vision difficulties unless asked and it is not outwardly visible unless the patient presents with assistive devices.

Tips for practice:

• Routinely ask, “Do you have difficulty with eyesight?”, as this may help guide you in how you conduct the rest of the appointment.
• Be aware of the subtle signs of vision loss. These include not making eye contact when conversing, squinting, or straining when looking at written materials, not responding to a physical gesture like a handshake, bumping into furniture, or partially completing forms.

Patient-Provider Communication. Effective patient-provider communication underpins all aspects of a successful medical consultation but may be more challenging with people who have both vison and hearing loss.

Tips for practice:

• Use large high-contrast font if using an electronic display board in the waiting area.
• Always face the patient to introduce yourself and any others who are in the room. Even if you have seen the person before, do not assume they will recognize you by your voice.
• Do not expect eye contact or assume that lack of direct eye contact means lack of attention to what you are saying.
• Supplement all gestures (e.g., nodding, pointing) with verbal information.
• Use accurate and specific language when giving directions or instructions.
• Offer to read written materials aloud, and physically identify -exactly where signatures or consent are required using a signature guide.

The Environment. The environment should be optimized to enhance visual and auditory communication. Note that variable light levels can affect vision, and bright sunlight may be a greater problem for some than dark corridors.

Tips for practice:

• Keep the environment well-lit.
• Keep all walkways free from clutter.
• Use simple contrasting signage for wayfinding, plain decor, and furniture in colors that contrast with the equipment and walls.

Note that electronic “push-to-release” doors may pose a problem for people with vision loss as they may not be able to identify signs or buttons to open them. A solution is to have doors that allow for manual as well as automatic opening.

Navigating the Hearing Consultation. Clear and accurate verbal communication is always important but might be more so when working with people with vision loss because they might not see where you are or what you are doing.

Tips for practice:

• Ask clients if they would like to be guided to the appointment room. Merely walking ahead and expecting them to follow is not appropriate. Likewise, offer to guide the client between the office area and the sound booth. The basics for sighted guide can be found here: bit.ly/3Zwl3Me. Offer assistance, rather than assume assistance is necessary.
• Give detailed verbal instructions rather than pointing or gesturing, e.g., “Take the gray door to your immediate right, and sit on the red chair.”
• Draw attention to obstacles, steps, or changes in levels ahead.
• If the booth area is darker than the office area, use a lamp with dimmer switch to help with acclimatization.
• Describe in detail what you are going to do and where you are in relation to your client, so they are not taken by surprise. For example, “I am going to stand behind you to put on the headphones.”

Selecting Rehabilitation Strategies and Devices.

Tips for practice:

• Provide automated hearing aid settings and rechargeable hearing aids if appropriate for the client’s hearing needs.
• Select hearing aids that can be controlled via a mobile phone app–providing that the app uses large high-contrast font and large controls.
• Emphasise the value of including a communication partner in hearing aid appointments.
• Consider alternatives to a traditional hearing aid (e.g., pocket talker or Apple ear buds) and/or supplement with assistive technology designed for dual sensory loss such as such as alarm clocks with raised markings and vibrating pads, amplified doorbells and fire alarms, which flash and vibrate, and amplified telephones with large buttons and vibratory ringers.

Providing Instructions and Information. Audiologists often emphasise written information for their clients with hearing loss, but this cannot be relied on when an individual also has vision loss.

Tips for practice:

• Use tactile demonstrations to provide hearing aid instructions. For example, have the patient feel where the on/off switch is in relation to other controls, point out physical differences in the positive/negative faces of a hearing aid battery, and use raised tactile stickers and/or bold color coding to distinguish right and left aids.
• Have available a lighted magnifier or a CCTV in your clinic. Magnifiers can be acquired at a reasonable cost and provide both good lighting and magnification simultaneously.
• Use the teach-back technique to ensure the patient has understood what you told them (i.e., following your explanation, ask the patient to tell you in their own words what they understood, clarify where needed, then ask the patient again what they now understand.) This technique has been shown to increase patient understanding, confidence, and recall (see Fig. 2 for more details).
• Ask the patient which format they prefer for written information (printed, electronic, braille, etc.).
• Printed materials should be provided in 16 or 14 pt. font, sans serif font (e.g., Arial or Calibri). Use bolded or underlined text for emphasis (avoid all capitals and italics). Write numbers in word form, left align text, use 1.5 spacing, and have a ragged right margin. Use columns rather than long lines of text, use consistent rather than variable layouts, and leave ample white space between text and images. Print documents in black on white paper with a matte finish.

SUMMARY

To summarize, vision loss is common in the population but comes in many different forms. As with hearing loss, its prevalence dramatically increases with age. Typical management of hearing loss often relies on using vision to compensate for hearing loss. This cannot be relied on for people with vision loss. The extent, and functional impacts of vision loss will vary considerably so adaptations to your hearing care need to be modified to each patient’s needs.