Low Vision Module for Ophthalmology Curriculum

Preface

The National Focal Persons Courses in Low Vision (held in Hong Kong, Durban, Cairo and Sao Paolo) were used as opportunities for consultation with participating ophthalmologists regarding curriculum needs for low vision in ophthalmology training programmes in order to make it relevant and practical to both developed and developing countries. Also, the International Council of Ophthalmology guidelines on low vision rehabilitation in the residency guidelines, the American Academy of Ophthalmology Preferred Practice Patterns for Vision Rehabilitation, VISION 2020 – the Right to Sight, WHO Global Action Plan for Universal Eye Health, and Sustainable Development Goals were used to provide a comprehensive global reference.

The curriculum guidelines as the name suggests are a guide that can be adapted according to local circumstances. It is envisaged that it shall have the following intended application and would be useful for:

  • Ophthalmology residency programme directors planning to update the low vision modules
  • Ophthalmology training centres already running or planning to conduct low vision training for qualified ophthalmologists in low vision
  • Ophthalmology training centres planning to offer accredited certificate level training of ophthalmologists in low vision
  • Multi-specialty training centres planning on offering distance learning courses in low vision for ophthalmologists with the practical component undertaken at the parent or nearby hospital with a well-established low vision clinic or low vision centre

The authorship for this curriculum was conceived primarily by the IAPB Low Vision Working Group. The development of the ophthalmology curriculum was led by:

  • Dr HaroonAwan (lead writer)
  • Dr Pararajasegaram
  • Dr Rosario Espinoza Carrillo
  • Dr Filippo M. Amore.
  • Contributions were provided by:
  • Professor Jill Keeffe
  • Mr HasanMinto
  • Mr Joseph Cho
  • Ms SumranaYasmin.

Cover photo: Rajeev Karki, Nepal (from the #EyeCareForAll Photo Competition)

Outline ofLow Vision Modulefor Ophthalmology Curriculum

Session No. / Session Title / Duration
Introduction to the Course and Low Vision / 2 hours
Global, National, and Local Policies / 2 hours
Epidemiology / 2 hours
Anatomy and Function of the Eye / 2 hours
Causes and Implications of Visual Impairment and Prevention / 3 hours
Psychosocial Impact of Low Vision / 3 hours
Clinical Low Vision Assessment / 38 hours
Understanding Optical and Non-optical Low Vision Devices / 15 hours
Paediatric Low Vision Care / 26 hours
Accessibility and Environmental Modification / 3 hours
Models of Low Vision Care / 6 hours
Research in Low Vision / 3 hours

Total Length of Course - 105 hours (3 weeks)

Session Plan 1

Introduction to the Course and Low Vision

Time:2 hours

Outcomes:At the end of the session participants will know the overall objectives of this course, be familiar with one another and have an overview of the significance of low vision

Objectives:

  • Understand the objectives of this course
  • Understand the effects of low vision

Session Plan:

Stage / Content / Method / Material
Stage-1 / Introduction of participants / Discussion in pairs
Stage-2 / Objectives of the course / Discussion
Stage-3 / Assess expectations / Discussion
Stage-4 / Develop an understanding of low vision through simulation / Practical / Materials for low vision simulators

Process:

Stage-1: Introduction

Introduction of course leader

Prepare an orientation exercise to have participants work in pairs to get to know one another. Select participants to work in pairs. Give participants five minutes to introduce themselves to their partners. After the time is up, have them introduce their partner to the group.

Stage-2: Course Objectives

Share the objectives of the course with the participants and follow this with a question and answer session about the overall course. Use the objectives of the curriculum as a guide.

Stage-3: Assess expectations

Ask the participants about their expectations of this course and write these on a board or flip chart for the entirety of the course.

If there are any expectations that are relevant to the subject matter and have not been included as part of the training curriculum/schedule, consider adding them where appropriate.

The flip chart with the expectations should remain hanging on the wall during the entire course. At intervals during the course check that the listed expectations have been met.

Stage-4: Develop an understanding of low vision through simulation

Provide instruction on the creation of low vision simulators and have the participants create their own simulators.

Once the participants have completed their low vision simulators provide them with exercises to complete while wearing the low vision simulators.

Examples

Viewing PowerPoint slides, reading notes, moving around the room in pairs.

REFERENCES

Focus on Low Vision

Article for ophthalmologist to recognise and refer: Minto H, Gilbert C. Low Vision: We Can All Do More. Journal of Community Eye Health 2012;25:1.

Session Plan 2

Global, National and Local Policies

Title:Global, national and local policies

Time:2 hours

Outcomes :At the end of the session participants will have a better understanding of global, national and local policies and statutory benefits for people with vision impairment

Objectives:

  • To introduce major global programmes and policies relevant to people with vision impairment
  • To discuss regional and local programmes and their benefits for people with vision impairment

Session Plan:

Stage / Content / Method / Material
Stage-1 / Global programmes and policies / Discussion / Websites (see references)
Stage-2 / National and local policies / Discussion / Websites (see references)
Stage-3 / Preparing submissions and applications / Practical / Sample forms

Process:

Stage-1: Global programmes and policies

Share the global programmes and policies (that have relevance to low vision) with the participants and explain the rationale:

  • UN Universal Declaration of Human Rights 1948
  • UN Convention onthe Rights of the Child 1989
  • UN Convention on the Rights of Persons with Disabilities 2006
  • UN Sustainable Development Goals 2015
  • VISION 2020 – IAPB & WHO Global Action Plan – Towards Universal Eye Health
  • EFA –VI - ICEVI, WBU

Discuss the current status of these agreements and their implementation in the context of the local country and implications for the country and region.

Stage-2: National and local policies

Outline national welfare schemes, education support, employment opportunities, pensions, and other benefits provided for people with disabilities. Also discuss funding and benefits provided to non-government organizations working to support people with disabilities.

Discuss the roles, responsibilities and activities of disabled persons’organizations.

Describe the responsibility and advocacy roles of a Teacher for a child with low vision and effective ways to advocate for their access to appropriate education.

Stage-3: Preparing submissions and applications

Case Study

Present a case study outlining a national or local situation where a teacher has gained support for a student with vision impairment.

Practical

Select submission forms and applications from available sources of support and funding. Discuss the process of completing these forms and have the participants complete a sample form.

REFERENCES

Universal Declaration of Human Rights.

UN Convention on the Rights of the Child.

UN Convention on the Rights of Persons with Disabilities.

Sustainable Development Goals.

Vision 2020 – The Right to Sight.

WHO Global Action Plan – Towards Universal Eye Health 2014-2019.

International Council for Education of People with Visual Impairment.

Nordstrom, K. (2007). Convention on the rights of persons with disabilities. The

Educator, 20 (2).

UNESCO. (1994). The Salamanca Statement and Framework for Action on Special

Needs Education. Salamanca, Spain: UNESCO and Ministry of Education and

Science Spain.

World Blind Union.

Marrakesh Treatyto Facilitate Access to Published Works for Persons Who Are Blind, Visually Impaired, or Otherwise Print Disabled (2013) treaties/en/ip/marrakesh

UNESCO. (2015) Education for All

Session Plan 3

Epidemiology

Title:Epidemiology

Time:2 hours

Outcome:Participants will have an understanding of the World Health Organization (WHO) terminology of visual impairment, and the prevalence and causes of visual impairment

Objectives:

  • Understand the definitions and classification of visual impairment, low vision and blindness
  • Understand the sources of data and their limitations
  • Able to present data on global epidemiology of visual impairment
  • Able to present data on national epidemiology of visual impairment

Session Plan:

Stage / Content / Method / Material
Stage-1 / Describe and compare the ICD-10 and ICF / Instruction, Discussion / ICD-10, ICF handouts
Stage-2 / Definitions and classification of visual impairment, low vision and blindness / Instruction, Discussion / WHO website
Stage-3 / Global epidemiology of visual impairment / Instruction, Discussion / IAPB website
Stage-4 / National epidemiology of visual impairment / Instruction, Discussion / Publications, National websites
Stage-5 / Sources of epidemiological data and their limitations / Instruction, Discussion

Process:

Stage-1: Describe and compare the ICD-10 and ICF

Describe and explain the epidemiological and functional definitions of visual impairment as stated by the World Health Organization (WHO).

Describe the ICF and compare the implications of the medical and social models of health for the assessment and understanding of low vision.

Stage-2: Definitions and classification of visual impairment, low vision and blindness

Refer to the 2008 WHO definition of visual impairment. Highlight the importance of presenting compared to best corrected vision. Outline and discuss the critical differences between:

  • visual impairment
  • low vision
  • blindness

Explain the differences between none, mild, moderate, severe, and profound visual impairment categories.

Stage-3: Global epidemiology of visual impairment

Share information regarding the global prevalence and causes of visual impairment. Highlight the regional differences and their importance for planning of prevention, treatment, correction, and rehabilitation programmes.

Explain the differences between avoidable, preventable and treatable causes of visual impairment.

Discuss the following standard references:

  • WHO Global Data on Visual Impairment 2010
  • Global magnitude of visual impairment caused by uncorrected refractive errors in 2004
  • Global Burden of Disease Study 2010 – Blindness and Visual Impairment
  • Global Vision Database Maps

Stage-4: National epidemiology of visual impairment

Explain how prevalence data can be applied to a country to establish the number of people with visual impairment and how this will vary across regions of a specific country.

Discuss the common problems related to lack of accurate and recent data on the causes of visual impairment. Discuss possible solutions, such as the use of regional data.

Exercise

Use the data on causes of vision impairment to plan the human resources needed for eye care within a country.

Stage-5: Sources of epidemiological data and their limitations

Discuss the following:

  • Sources of data need to be critically reviewed to establish if the data is truly representative of a region or country
  • Differences in the methodology of data collection that affect its accuracy
  • Categorization of vision
  • Age and location of the population studied.
  • The size of the sample studied
  • The sources of the sample (particularly in children)
  • Do the data give information on the disadvantaged and under-served populations

REFERENCES

Gilbert, C., & Foster, A. (2001). Childhood blindness in the context of VISION 2020 –

The Right to Sight.Bulletin of the World Health Organization, 79(3), 227-232.

Global Burden of Disease Study.

Global Vision Database Maps.

World Health Organization.Refractive error and low vision.

World Health Organization. (1992). Management of low vision in children.

WHO/PBL/93.27.

Bourne RRA, Stevens GA, White RA, Smith JL, Flaxman SR, Price H, Jonas JB, Keeffe J, Leasher J, Naidoo K, Pesudovs K, Resnikoff S, Taylor HR.Causes of Global Vision Loss: 1990-2010. The Lancet Global Health 2013.Open Access.

Cama A, Keeffe J. Childhood visual impairment in Fiji. Arch Ophthalmol 2010;128:608-612.

Gilbert CE, Ellwein L. Prevalence and causes of functional low vision in school-age children: results from standardized population surveys in Asia, Africa and Latin America. Invest Ophthalmol Vis Sci 2008;49:877-881.

Understanding Low Vision. Gilbert C. Journal of Community Eye Health 2012;25:2.

Session Plan 4

Anatomy and Function of the Eye

Time:1 hour

Outcome:At the end of this session the participants will able to describe the characteristics of the normal eye, and they will understand common visual defects.

Objectives:

  • Understand what vision is and the importance of vision
  • Understanding of at least six characteristics of the normal eye
  • Understanding of at least ten parts of the eye and their functions
  • Understanding of how the healthy eye functions
  • Knowledge of common visual defects

Session Plan:

Stage / Content / Method / Material
Stage-1 / Explanation of vision and the importance of vision for learning and functioning / Instruction, Discussion / Diagrams
Stage-2 / The parts of the eye and their functions / Instruction / Model eye, Handout, Websites
Stage-3 / Visual defects / Demonstration, Discussion / Handout, Websites

Process:

Stage-1: Explanation of vision and the importance of vision for learning and functioning

Explain the visual system referring to the eye, brain and the environment. Discuss how the visual system receives and interprets information. i.e.

visual mechanism,

image forming mechanism

Outline the importance of vision in functioning particularly during early learning.

Stage-2: Parts of the eye and their function

List the primary parts of the normal eye using the model eye. Use diagrams of the eye (external and internal components). Discuss the function of the anterior and posterior segments of the eye.

Discussion using simple questions such as: “How do you think the iris controls light?” or, “How does the lens help to see near and distant objects?”

Ask the participants to label a diagram of the eye, identifying the parts of the eye and describing the function.

Stage-3: Visual Defects

Explain examples of how abnormal functioning of the different parts of the visual system lead to specific visual defects.

Examples

  • Blurred vision – refractive system, ocular media, central retinal function
  • Dark-Light adaptation – anterior segment (iris), retinal function
  • Visual Fields – retinal function, cortical function,
  • Central and para-central scotoma - retina
  • Generalized loss such as peripheral - retina
  • Hemianopia and quadrantanopia – cortical
  • Colour Vision – retina, ocular media
  • Eye movements – extra-ocular muscles, cortical, visual deprivation
  • Contrast sensitivity – everything

EYE DISEASE SIMULATIONS

National Eye Institute

CNIB

Perkins

Session Plan 5

Causes and Implications of Visual Impairment and Prevention

Time:3 hours

Outcomes:Participants will be able to describe the causes, symptoms and implications of visual impairment and will have knowledge of prevention strategies

Objectives:

  • Present the most common causes of visual impairment
  • Explain parts of the eye and symptoms associated with the causes of visual impairment
  • Outline prevention and interventions for common causes of vision impairment

Session Plan:

Stage / Content / Method / Material
Stage-1 / Common causes of visual impairment in children / Discussion, Demonstration / WHO website, Model of the eye
Stage-2 / Common causes of visual impairment in adults / Discussion, Demonstration / WHO website, Model of the eye
Stage-3 / Signs and symptoms of common causes of visual impairment / Discussion / ICEH and WHO posters, Model of the eye
Stage-4 / Treatment and prevention / Instruction, Discussion / Model of the eye

Process :

Stage-1: Common causes of visual impairment in children

  • Congenital
  • Hereditary
  • Later onset
  • Trauma

List congenital, hereditary and acquired diseases and disorders of the eye that commonly cause low vision in children, including:

  • Congenital and traumatic cataracts
  • Cornea degenerations/dystrophies
  • Albinism
  • Microphthalmos
  • Aniridia
  • Leber’s congenital amaurosis
  • Optic atrophy
  • Retinal disorders – retinoblastoma
  • Amblyopia
  • Retinopathy of prematurity
  • Rubella
  • Vitamin A deficiency – xerophthalmia
  • Trachoma – eye lids and corneal changes

Intervention measures for all of the relevant diseases should be discussed in detail during this session. Emphasize the diseases that are a treatment priority.

List the diseases that cannot be treated or cured, but can be easily prevented.

Stage-2: Common causes of visual impairment in adults

  • Hereditary
  • Acquired
  • Trauma

List hereditary and acquired diseases and disorders of the eye that commonly cause low vision in adults, including:

  • Cataracts – congenital and acquired
  • Age related macular degeneration (ARMD)
  • Diabetic retinopathy – vision loss from disease and consequent treatment (laser photocoagulation)
  • Glaucoma
  • Retinitis pigmentosa
  • Corneal degenerations/dystrophies
  • Trachoma – eye lids and corneal changes
  • Optic atrophy
  • Multiple sclerosis
  • Stroke and acquired brain injuries
  • Macular dystrophies/degenerations – Best’s disease, Stargardt’s disease
  • Myopic degeneration
  • Ocular colobomas

Intervention measures for all of the relevant diseases should be discussed in detail during this session. Emphasize the diseases that are a treatment priority.

List the diseases that cannot be treated or cured, but can be easily prevented.

Stage-3: Signs and symptoms of common causes of visual impairment

Conduct this session in the form of group work.

Group work

Divide the participants into 4 or 5 small groups and ask each group to draw and label a diagram of the eye. Ask the participants to work in groups and point out which parts of the eye are affected by each disease and what are the likely symptoms. They can use simulators for this exercise. This task should take around 25 minutes.

  • Eyelid
  • Cornea
  • Lens
  • Retina

Cataracts

Signs and Symptoms include:

  • Clouding of lens, opacities
  • vision may seem cloudy and blurry;
  • glare, where light sources appear too bright, and halos around lights
  • double vision
  • reduced contrast acuity
  • poor night vision
  • in the final stages, sight diminishes to the extent that the patient cannot see

Age Related Macular Degeneration (ARMD)