Visual impairment

Encyclopedia of Medicine, Apr 06, 2001 by J. Ricker Polsdorfer

Total blindness is the inability to tell light from dark, or the total inability to see. Visual impairment or low vision is a severe reduction in vision that can't be corrected with standard glasses or contact lenses and reduces a person's ability to function at certain or all tasks. Legal blindness (which is actually a severe visual impairment) refers to a best-corrected central vision of 20/200 or worse in the better eye or a visual acuity of better than 20/200 but with a visual field no greater than 20° (e.g., side vision that is so reduced that it appears as if the person is looking through a tunnel).

Vision is normally measured using a Snellen chart. A Snellen chart has letters of different sizes that are read, one eye at a time, from a distance of 20 ft. People with normal vision are able to read the 20 ft line at 20 ft--20/20 vision--or the 40 ft line at 40 ft, the 100 ft line at 100 ft, and so forth. If at 20 ft the smallest readable letter is larger, vision is designated as the distance from the chart over the size of the smallest letter that can be read.

Eye care professionals measure vision in many ways. Clarity (sharpness) of vision indicates how well a person's central visual status is. The diopter is the unit of measure for refractive errors such as nearsightedness, farsightedness, and astigmatism and indicates the strength of corrective lenses needed. People do not just see straight ahead; the entire area of vision is called the visual field. Some people have good vision (e.g., see clearly) but have areas of reduced or no vision (blind spots) in parts of their visual field. Others have good vision in the center but poor vision around the edges (peripheral visual field). People with very poor vision may be able only to count fingers at a given distance from their eyes. This distance becomes the measure of their ability to see.

The World Health Organization (WHO) defines impaired vision in five categories:

• Low vision 1 is a best corrected visual acuity of 20/70.
• Low vision 2 starts at 20/200.
• Blindness 3 is below 20/400.
• Blindness 4 is worse than 5/300
• Blindness 5 is no light perception at all
• A visual field between 5° and 10° (compared with a normal visual field of about 120°) goes into category 3; less than 5° into category 4, even if the tiny spot of central vision is perfect.

Color blindness is the reduced ability to perceive certain colors, usually red and green. It is a hereditary defect and affects very few tasks. Contrast sensitivity describes the ability to distinguish one object from another. A person with reduced contrast sensitivity may have problems seeing things in the fog because of the decrease in contrast between the object and the fog.

According to the WHO there are over forty million people worldwide whose vision is category 3 or worse, 80% of whom live in developing countries. Half of the blind population in the United States is over 65 years of age.

The leading causes of blindness include:

• Macular degeneration
• Glaucoma
• Cataracts
• Diabetes mellitus.

Other possible causes include infections, injury, or nutrition.

Most infectious eye diseases have been eliminated in the industrialized nations by sanitation, medication, and public health measures. Viral infections are the main exception to this statement. Some infections that may lead to visual impairment include:

• Herpes simplex keratitis. A viral infection of the cornea. Repeated occurrences may lead to corneal scarring.
• Trachoma. This disease is responsible for six to nine million cases of blindness around the world, of the third of a billion who have the disease. Trachoma is caused by an incomplete bacterium, Chlamydia trachomatis, that is easily treated with standard antibiotics. It is transmitted directly from eye to eye, mostly by flies. The chlamydia gradually destroy the cornea.
• Leprosy (Hansen's disease). This is another bacterial disease that has a high affinity for the eyes. It, too, can be effectively treated with medicines.
• River blindness. Much of the tropics of the Eastern Hemisphere are infested with Onchocerca volvulus, a worm that causes "river blindness." This worm is transmitted by fly bites and can be treated with a drug called ivermectin. Nevertheless, twenty-eight million people have the disease, and 40% of them are blind from it.

Exposure of a pregnant woman to certain diseases (e.g., rubella or toxoplasmosis) can cause congenital eye problems. Injuries to the eyes can result in blindness. Very little blindness is due to disease in the brain or the optic nerves. Multiple sclerosis and similar nervous system diseases, brain tumors, diseases of the eye sockets, and head injuries are rare causes of blindness.

Vitamin A deficiency is a widespread cause of corneal degeneration in children in developing nations. As many as five million children develop xerophthalmia from this deficiency each year. Five percent end up blind.

A low vision exam is slightly different from a general exam. While a case history, visual status, and eye health evaluation are common to both exams, some things do differ. Eye charts other than a Snellen eye chart will be used. Testing distance will vary. A trial frame worn by the patient is usually used instead of the instrument containing the lenses the patient sits behind (phoropter). Because the low vision exam is slightly more goal oriented than a general exam, for example, what specifically is the patient having trouble with (reading, seeing street signs, etc.) different optical and nonoptical aids will generally be tried. Eye health is the last thing to be checked so that the lights necessary to examine the eyes won't interfere with the rest of the testing.