In cases involving vision injury, it is essential to obtain a functional vision loss assessment. This assessment will cover many areas that medical doctors will ignore. Here is a sample that I hope will be of use to you. Call me if you have questions. My number is 610 642 7676. Evan Aidman
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I met with Sol M. and her son, Rey M. on May 12, 2013. With her son’s assistance, we were able to communicate clearly in English. We met in order to discuss the functional ramifications of Mrs. M.’s monocular vision. I have also reviewed the ophthamologists’ reports for her incident of December 18, 2012 and the relevant portions of her deposition.
As a vision specialist, I am qualified to discuss psychosocial aspects of vision impairment, the effect of a visual impairment on daily life and treatment and support for people with visual impairments.
MEDICAL HISTORY
Mrs. M.’s most recent ophthalmologist visit documented a change of vision in her right eye from 20/200 to “light perception.” This is a significant decrease in usable vision, as was noted by Dr. Elliot Werner.
In an office setting Mrs. M. appeared tense. Her right eye shows some disfigurement around the eye, and the sclera appears red. Mrs. M. squinted frequently under fluorescent office lighting.
Since the incident, Mrs. M. has developed a marked degree of blepharospasm involving both eyes. Blepharospasm is a neurological disorder characterized by involuntary muscle contractions, which causes “uncontrollable blinking and lid squeezing.” It “involves both eyes and may result in temporary inability to see” during spasms. Dictionary of Eye Terminology, 3d Ed., Barbara Cassin, Sheila A. B. Solomon, Triad Publishing Co. Gainesville, FL, 1997. In addition to the functional vision loss this causes, it is very cosmetically displeasing, causing the eyes to squint and blink. During spasms the eyelids almost completely closed causing functional loss of vision.
Mrs. M. describes the vision loss in her right eye as having gotten worse, and indicates that she is only able to see using her left eye. She complains of pain in the orbital area of the eye, and in the tissue around the eye as far back as her ear. Mrs. M. describes hearing loss concurrent with the vision loss. This is undocumented in other medical findings. The discomfort is worse in cold weather.
With only light perception in her right eye, Mrs. M. functions with monocular vision. Monocular vision leaves her without depth perception. The lack of depth perception has an impact on all activities that require binocular vision. These extend across settings in activities of daily life, mobility, work and recreation.
Some activities that Mrs. M. has identified as difficult include: Reaching for items on a grocery store shelf, measuring ingredients, pouring liquids, laundry, walking up and down steps, accessing public transportation, childcare, and playing recreational Mah-jongg, and cards.
Mrs. M. indicates that she used to read for pleasure. She does not read since the incident, due to discomfort from the combined visual issues. She has also reduced her frequency of writing to family members. She uses the telephone in place of the letters she used to write to children and family in the Philippines and Italy.
Mrs. M.’s mobility patterns are typical for an individual with vision loss who has not received vision rehabilitation or orientation and mobility training.
She must protect her left eye by exercising caution in her activities, and by wearing protective eyewear, to retain her remaining vision. Monocular vision, and the depth perception problems it creates, makes it harder for individuals to judge distance, and increase the occurrence of small and more serious accidents.
I fabricated two sets of goggles to simulate Mrs. M.’s acuity deficit. The first set simulates 20/200 vision, which was Mrs. M.’s vision as of her March 16, 2004 visit with Elliot B. Werner, M.D. The second set of goggles simulates Mrs. M.’s vision as of her visit with Dr. Werner, which was light perception with no projection. These devices do not simulate blepharospasm.
MOBILITY ISSUES
In the area of mobility, Mrs. M. was observed walking, in an unfamiliar office setting, on steps and in an open parking lot. Mrs. M. uses an adapted trailing technique. Using her left hand she trails/feels along a wall until she reaches an open space. Mrs. M. negotiates open space with a tentative semi-shuffling gate. When walking through a doorway she grasps it with her left hand to guide herself through it.
Steps are negotiated with a non-alternating descent pattern, left foot first, and then right foot joining on the same step (the typical adult pattern is alternating feet on alternating steps). Mrs. M. used her right hand on the handrail after first standing at the left side as if she would prefer to use her left hand and descend on the left side. Ascent was similar.
In the sunny parking lot, Mrs. M. indicated discomfort from glare. She again traversed open space with a tentative gait. There was no evidence of protective posture at this time. She walked more comfortably when she was able to use her hand to trail a car, wall or other object.
Vision loss is a cause of mobility problems. Before the incident, Mrs. M. rode public transportation to work, as she was in the process of doing at the time of this incident. She is now unable to travel unassisted.
Mrs. M.’s son reports that she has fallen several times since the incident. Outside, she encounters undetected curbs and bumps. Inside, she has bumped into tables and chairs. Her family is concerned about her safety when traveling, and in activities inside the home. A sister or friend accompanies her when she travels by bus. She has greatly reduced her travel for pleasure and for activities of daily life because of this.
OTHER FUNCTIONAL LIMITATIONS
Before the incident, Mrs. M. reported participating independently in a wide range of activities. In community life she went on day trips, to church and social gatherings, babysat her grandchildren, played Mah-jongg and cards with friends. She took public transportation to the grocery store, shopping and to babysitting jobs. At home, she cleaned her house, cooked, and took care of the laundry. She enjoyed reading, and also liked to put on makeup and get dressed up to attend social events. She led a very active, independent life and was active in the Filipino community.
Because of her vision loss, and her resulting mobility and perceptual problems, and other injuries, she requires assistance to shop. She has difficulty picking items off the shelf, as she “misses” what she reaches for at the grocery store. Because of her lack of depth perception, she sometimes misses the cup when she pours liquid from a pitcher. She is afraid to cut food for fear of injuring herself. She does not cook on the stove or with the microwave, after having some accidents and “making messes.” Overall she and her family feel that cooking is too dangerous.
She does not read due to visual discomfort. She no longer plays Mah–jongg. She has curtailed much of her social activity, and does not put on makeup anymore. Whether this is due to physical discomfort, social discomfort, or depression, I was not able to ascertain in the 45-minute interview.
Mrs. M. seemed distraught over her situation, and it was hard for her to talk about how her life has changed. She seemed to have enthusiasm for the things she used to do. When asked how she spends her time currently, she stated that she sits in her bedroom and plays solitaire all day after day (she indicates that she has to hold the cards close to her face to read them). Her husband now does all of the house cleaning, cooking and laundry. He also works 4-6 hours per day. Her son indicates that the husband is not accustomed to doing these chores, and that there is friction in the family due to the change in roles. The couple fights and argues more frequently due to this conflict.
Mrs. M. maintains her personal hygiene, such as showering, brushing her teeth, taking care of her hair and dressing.
She is less active with her grandchildren, and no longer baby-sits. Her five–year–old grandchild asks her what is wrong with her face.
RECOMMENDATIONS
Mrs. M. would benefit from a full assessment by a vision rehabilitation therapist or low vision therapist. I strongly recommend intensive rehabilitation training so that she can learn techniques to care for herself and to engage in activities of her choosing. She would benefit from a mobility evaluation by an orientation and mobility instructor, and orientation and mobility training for safe, independent indoor and outdoor travel.
The assessing professionals will determine a course of treatment. My conservative estimate for initial rehabilitation and follow up would be for 2 hour sessions of private rehabilitation training on a weekly basis for at least 4 months. This will cost approximately $90.00 an hour. Similarly in orientation and mobility, 2 hour sessions of orientation mobility training on a weekly basis for at least 4 months. This will also cost approximately $90.00 an hour. When that is completed, the professionals she works with will set up a schedule for follow-up and maintenance of skills. Again, my estimate is of monthly follow-up for 6 to 12 months of 2-hour sessions at $90.00 an hour.
Mrs. M. needs audiology testing for her hearing loss. Her hearing loss aggravates the functional problems and safety issues brought on by her vision loss, and increases communication problems.
A person with monocular vision has a substantially greater risk of becoming visually impaired in the good eye than a fully sighted person has of suffering damage in either eye. I recommend that Mrs. M. wear protective glasses, and exercise caution in activities.
I am sending her catalogues with various adaptive items for household tasks, such as telephones with large numbers, playing cards with large markings, stove and microwave controls for the visually impaired, etc. The cost of equipping her home with some of the items she needs is approximately $500.00. There may be other costs incurred for materials associated with her rehabilitation. These materials will help her to be more independent and to actively engage in activities in her home and community.
Mrs. M. is going through a period of grieving and loss associated with vision loss. I recommend that doctors and family members be aware of this, and monitor her for signs of depression. I recommend that she attend a support group for individuals with vision loss.
CONCLUSIONS
A person in her 60’s can work, play an active role in her grandchildren’s lives, run errands, do housework and lead a fulfilling life. Since the incident, instead of being a caregiver, Mrs. M. is now a care consumer. Mrs. M. has suffered a life-changing event. She has lost a great deal of confidence in her ability to function in daily life. Although she may never recover the function she had before the incident, rehabilitation training and orientation and mobility training will help her to be more independent with her residual vision.
All of the conditions and functional ramifications mentioned herein are a direct result of the visual impairment caused by Mrs. M.’s injury. All of my opinions are stated to a reasonable degree of professional and scientific certainty.
Very truly yours,
Alison (Ayala) Ballonoff, MS Ed.
