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At the Royal National Institute of the Blind, optometrist Sonal Rughani and rehabilitation worker for the visually impaired Sylvie Mackal work hard to prevent such situations. As two members of the RNIB's low vision clinic team - contracted to serve the areas of Islington and Camden - they develop strategies which allow their patients to manage their vision loss and, wherever possible, maintain a degree of independence.
Assessing the patient
Patients can be referred to the low vision clinic from their ophthalmologist, hospital consultant, GP or social services. They can also self-refer. On their first visit to the clinic, patients undergo a two-hour assessment which includes a thorough eye examination. However, the assessment differs from those taking place in other clinical settings. Both Rughani and Mackal spent time talking with the patient about their daily life, and how their eye condition has affected it. The pair look at four main areas: living skills, mobility, communication with the outside world and social inclusion. Following this assessment, Rughani will conduct an eye examination.
'I look at their visual status and the health of their eyes but I look at this in terms of any functional difficulties this might be causing them,' Rughani explains. 'It might be they cannot read small print, meaning they can't read the label on their medication. Or perhaps they can't judge depth well, so they could burn themselves when making a cup of tea. Essentially we look at the clinical findings and determine what they mean for the patient at an everyday level.'
Once the difficulties are determined, Rughani and Mackal put their problem-solving skills to use. 'In many cases a doctor will tell a patient that, medically, nothing more can be done. Hearing that can be devastating. However, it does not mean that nothing more can be done in terms of maximising the vision that is still there,' Rughani says.
The team have a vast array of tools to draw on. And while lamps, magnifiers and other low vision aids are regularly recommended, the team are often required to be quite inventive in devising solutions. 'One woman we saw was very upset at having difficulty seeing her dinner plates,' Rughani recalls. 'We discovered both her plates and her tablecloth was patterned. We recommended she turn her tablecloth over - so it was plain - and the plates then stood out against it. That solution really worked for her.'
And more than just living skills, the team aims to help their patients develop the means and confidence to remain an active part of society. 'A lot of the work we do is about building a person's confidence. Often we refer them to other services and social clubs for the visually impaired. For example, we once worked with a boxer and found a blind boxing association for him in London,' Rughani says.
The team also operates an 'open-door' policy, so after the initial assessment, patients can return for additional help at any point. This is crucial, says Rughani, as the journey to accepting and living with sight loss can be a long one, and patients may need continued support.
According to Mackal, the 'feel-good factor' of this job is huge. 'It is very rewarding, you are always leaving someone better off than when they first came in. Some people have given up on happiness, so when you make an improvement - however small - it can change their lives,' she says.
Signature guides, bank note measures or devices that beep to signal when a glass is almost full can make a big difference. Simple strategies such as moving furniture, installing fluorescent lighting or programming the telephone with important numbers are equally valuable, says Mackal. She recalls the case of an elderly man with glaucoma who no longer moved around his house for fear of banging into things, or treading on one of his visiting grandchildren. She taught him how to make tea for himself and how to use a cane to navigate the flat and, eventually, a route to the local store.
'I also helped him programme the telephone so he could call people. Two days after that his diabetic wife had a medical emergency, and he was able to use the telephone to call for help. Such a simple strategy, and it proved to be life saving.'
New horizons
Rughani says that becoming involved in this work has opened up a whole new area of optometric practice for her. She has worked in the area of low vision since qualifying in 2000, and currently splits her time between the RNIB low vision clinic and a hospital. 'What you can do in a half-hour appointment with a visual field chart compared to what you can do with two hours in a clinic setting is very different. I do appreciate that hospital services are stretched and they can't always take the time to talk or provide the services we do. My role at the clinic is incredibly stimulating as it is about problem-solving and also it requires you to learn what the world looks like to a person who is visually impaired.'
Mackal has worked in her role for the past six years, first employed by the RNIB and now by the Camden Primary Care Trust. 'I consider how much I rely on my sight, and how lucky I am to see all the beauty in the world. So I really enjoy helping people who can't see. I value my sight dearly and I just want to do something for those who no longer have theirs.'