A world class event

Trumpets sounded through Parliament Square to signal the opening of Vision 2005 and the start of a major international conference boasting a host of lectures, presentations, posters, CET events and seminars. Spread over four days, the conference attracted around 1,200 delegates of whom some 175 were optometrists or opticians. The scope of the event was ambitious to say the least, with six main strands based on different themes. This review represents just a snapshot of proceedings.
The line up of well-known and internationally renowned speakers remained consistent throughout the whole event, but the opening ceremony saw some faces famous outside the scientific community. Rosie Winterton (Minister of State for Health) introduced the conference with a show of support for the eye care pathways. She suggested that the visual impairment pathway was to be extended with further pilot schemes in the coming months, ensuring that a viable programme may be offered in future by primary care trusts in an effort to standardise the approach to visual impairment management.
BBC correspondent for disability Peter White made a strong argument for full involvement of the visually impaired in any strategy or management plans. He was later available for signings of his book in the exhibition area where an excellent band made up of visual, sensory and learning-impaired musicians played.
Perhaps the best received of the opening presentations, however, was that of Dr Krister Inde (Lund University, Sweden) who managed a sequence of blindness and impairment puns in his talk entitled 'See bad, feel good and the impact of rock 'n' roll on low vision' which the Now Show would have been proud of. He made the important point that all low vision professionals should remember to keep people with sight problems at the heart of their work. Using the example of his own misgivings at trying to help a good friend who was finding it difficult to come to terms with his recent loss of vision, he said he had come to realise that 'rehabilitation' was, in effect, 'learning to live with it'. Rehabilitation ends at the point when someone is able to adapt to their new visual environment and cope.

Childhood vision loss
Many presentations throughout the conference related to issues concerning childhood vision loss. An interesting study by social scientist Mary Boulton (Oxford Brookes University) looked at quality of life among visually impaired children and their parents and examined the impact of the child's vision condition, additional disabilities and behaviour problems.
Parents of children aged three to nine years with a visual impairment were contacted through health, education and social services and voluntary organisations in four areas of England. The parent with main caring responsibilities was asked to complete a questionnaire on their child's health-related quality of life, behaviour problems, vision condition and other disabilities, as well as on their own health-related quality of life. Children with a visual pathway condition were significantly more likely to have an additional severe disorder and to have a behaviour problem. Those with a visual pathway condition and an additional severe disorder had significantly lower utility scores than other visually impaired children.
Although almost all the children were free from emotional problems, their parents were found to have poorer scores for emotional, mental health and vitality measures than UK norms. Parents whose child had a behaviour problem and those with severe additional disorders also had significantly lower scores for these measures than other parents of visually impaired children.
Based on these findings, Dr Boulton's co-author, ophthalmologist Alistair Fielder (City University), proposed a 'Charter for families of young children with vision impairment'. The aim was to give families, parents and children greater confidence in working with professionals and organisations by setting out what they have a right to expect in relation to health, education and social services.
Tanuja Britto (Joseph Eye Hospital, India) was one of several presenters who had looked at the impact of educating children in either integrated mainstream schools or specialised 'blind schools'. Looking at 125 children with vision better than perception of light in two specialised schools in Tamil Nadu, Britto and her team monitored outcomes of low vision intervention throughout an integration into mainstream schooling and noted that several problems of education were overcome by the process of integration. The research was among several other studies reflecting benefits of an integrated approach. Paediatric visual impairment is clearly a major issue in India, with another speaker, Sanjiv Desai (Tarabai Desai Eye Hospital) noting that there are an estimated eight to nine million paediatric low vision cases. Compare this with the estimates of around 25,000 visually impaired under 17 years of age in the UK.
One of many presentations discussing the importance of an integrated care approach looked at the management of 10 children with congenital glaucoma. Maria Neves (Hospital Santa Maria, Portugal) described how visual outcomes post surgery were excellent in terms of acuity, but other factors such as mobility and autonomy were only improved after a significant period of rehabilitation, indicating the importance of a multidisciplinary approach as opposed to purely surgical/medical.
A UK-integrated programme of care was described by Dr Gillian Rudduck (Wirral Hospital NHS Trust) where children were prescribed aids, with training and follow-up with a rehabilitation officer. Previous work had suggested that only 5 per cent of a sample of visually impaired children had successfully incorporated LVAs into their lives. Reasons for not doing so included self-awareness and peer pressure. After the introduction of training and a support network, this figure had risen impressively to around 80 per cent.
Illustrating the great scope of the conference, a poster by Mirjana Vukoja (Low Vision Clinic Gteborg) aimed to design a play space useful to the visually impaired child. Quoting architect and designer Naum Gabo, that 'a room which requires movement in order to have a complete experience constantly "opens" new rooms', the poster described how an indoor playground had been constructed at the centre with integrated sculptures such that a child moving through the space might 'develop their own experiences in order to increase their curiosity, fantasy and perception of space and body'.

Low Vision Provision
Three studies from around the world looked at different modes of low vision service delivery for elderly patients and the methods of measuring outcomes.
Ger van Rens (Free University Amsterdam) assessed the long-term outcome of low vision services on vision-related quality of life among patients referred to optometrists and those seen in 23 regional multidisciplinary low vision centres in the Netherlands. The study involved 296 patients aged over 50 years who had had no previous contact with low vision services.
Patients completed two questionnaires before their first visit and one year later: the Vision Quality of Life Core Measure (VCM1), which assesses feelings and perceptions associated with visual impairment, and a Low Vision Quality of Life questionnaire developed by the group after looking at around 35 surveys that were available.
As many as 81 patients were lost to follow-up, but of the patients who completed the one-year study, those referred to optometric services showed less deterioration in mobility than patients referred to multidisciplinary low vision centres. No other differences in vision-related quality of life were found between the two groups. In contrast to shorter studies, the results indicated a small decline in vision-related functioning and a small improvement in adjustment to vision loss at one year.
Joan Stelmack (Hines VA Hospital, US) described the Low Vision Intervention Trial (LOVIT) to evaluate outcomes of optometry-based low vision rehabilitation for 122 legally blind veterans with macular diseases. Veterans were randomised to treatment from a low vision outpatient programme or a usual care (waiting list) control group. Those in the treatment group received five (2 to 2.5 hour) therapy sessions and one home visit to evaluate the home environment and set up prescribed devices.
Outcome was measured at baseline and at four months by a 48-item telephone questionnaire where patients reported their difficulty performing daily living activities. Other measures included the instructor's rating of the veteran's visual skills and use of low vision devices after rehabilitation, visual skills for reading (PEPPER VSRT), health status (SF-36), and symptoms of depression.
The LOVIT study was ongoing and the aim was to evaluate the cost and cost-effectiveness of low vision rehabilitation. Delegates were invited to follow the results at www.lowvisionproject.org.
Sonya Girdler (Curtin University of Technology; Australia) reported on the Confident Living Programme (CLP) for adults aged 55 and over with age-related vision loss. This was a structured, eight-week, self-management programme conducted in a group environment and had been developed jointly by low vision rehabilitation specialists and patients.
A total of 75 subjects with best corrected VA of 6/12 or less underwent either the CLP and usual case management or case management only. General health and vision-specific outcomes were measured pre and post intervention and at four months. CLP participants showed increased occupational engagement, fewer symptoms of depression and some positive changes in relation to adapting to visual loss. The results suggested that the CLP could significantly improve rehabilitation and overall quality of life for older adults with age-related vision loss.
These studies highlighted the wide variety of tests used to assess vision-related quality of life. Evidence of the effectiveness of these tests was needed if the worldwide problem of under-funding of low vision services was to be overcome.

Eccentric Viewing and PRL
Bearing in mind the significant proportion of visually impaired who have a central scotoma, the adaptation through eccentric viewing and developing a preferred retinal location was a theme throughout the conference. Vision therapy encouraging the adoption of a suitable PRL, the problems of assessing the size of a scotoma when fixation is variable and the need for a standardised measurement approach such that any improvement in vision usage might be accurately monitored, were some of the subject areas discussed. On occasion, at some of the scientific seminars, debate became quite heated.
Most of the studies monitoring eccentric viewing and alternative retinal location in recent years has been carried out using the Rodenstock Scanning Laser Ophthalmoscope (SLO) which has been shown to effectively track fixation. The newer Nidek MP1 (see page 28) has added to the armoury. One presentation by Samuel Markowitz (Toronto Western Hospital, Canada) described how the Heidelberg Retina Tomograph II had been used with a fixation target and macular perimetry to effectively monitor eccentric viewing.
An example of the use of the SLO in such research was described by Dr Angela Rees (Institute of Ophthalmology, Moorfields). She described how most patients with AMD and bilateral dense central scotomas adopt a preferred retinal locus (PRL) for eccentric viewing. She suggested that the optimal PRL position is in the inferior visual field as it provides a larger uninterrupted visual span for reading and mobility. However, the majority of patients appear to place their PRL to the left or right of their scotoma. Her team had tried to decide what factors determined PRL location and, specifically, whether the PRL developed in the area of peripheral retina with best visual acuity and contrast sensitivity. She used the SLO to determine the PRL of 21 patients with AMD and also an eye tracker to assess peripheral acuity and contrast sensitivity. It was found that acuity was best near the PRL, but this was not the case for contrast sensitivity. She could not distinguish whether the PRL developed at the area of best VA or if it improved at the PRL through practice. However it appears that either VA is more important than CS in determining PRL location, or VA improves more with practice than CS, even when that location may not be optimal for everyday visual tasks.
As the accuracy with which PRLs may be identified improves, several presentations showed how this information may be exploited in vision therapy strategies. David Logan (Visibility UK, Glasgow), for example, gave an excellent presentation showing how low vision assessment had been used on subjects to identify a PRL as well as required magnification and eye preference. Training was then given to encourage subjects to use their PRL for reading and other tasks and great strides in performance had been achieved.
Jrgen Gustafsson (Lund University, Sweden) had used a Hartmann-Shack aberrometer to measure off-axis aberrations in patients with absolute central scotomas. He had found that correction of these errors led to better use of an eccentric viewing point.
The conference had its moments of controversy and conflict. Jelena Jovacevic (Rochester, US) reported on work using a high-tech approach to identify PRL use in Stargardt's patients. He showed how a computer-generated virtual world allowed a simulation of a busy 'sidewalk' with large animated figures representing passers-by. Fixation points of normal sighted and Stargardt's patients had been mapped throughout and in both groups they had found that fixation had been concentrated on the torso area of the passers-by. The conclusion was drawn that this was evidence of an absence of eccentric viewing in the Stargardt's group.
This was, however, hotly contended by the audience, many of whom were leading researchers in this field. The sample may have been using eccentric viewing of the facial area by fixating on the torso area such that the face of the passer-by, the obvious reference point for many visually impaired, fell outside the scotoma.

media exposure
One of the real coups of this conference was the way the organisers (the RNIB) had managed to arouse national interest including media exposure. The Guardian ran a special pull-out supplement and many other nationals ran stories related to the conference. Most interest was given over to the so-called 'bionic eye' which allowed a light transducer to reproduce a perceivable image in those with no sight previously.
Much controversy exists over whether vision therapy interventions actually lead to a recovery of sight or merely reflect either artefacts of the technique or the process of re-adaptation to the sight loss. The choice by the organisers to use Professor Bernhard Sabel (University of Magdeburg, Germany) to chair this session was interesting, as his work on the use of such interventions was somewhat at odds with that of one of the speakers he was to introduce and this difference in viewpoint led to a somewhat heated exchange of ideas.
Several of the early speakers at this event suggested that the 'plastic period' which indicates that amblyopia therapy may only be valuable during the first eight years of life, may actually be present for much longer. Yuzo Chino (University of Houston, US) described how an increasing body of evidence suggested that the functional connections in our visual brain may mature later and show substantial plasticity for much longer periods of time, even in adults. They found that extensive vision training among adult strabismus patients over a two year period showed improvements in stereoacuity of two minutes of arc on average. This may give further confidence to those advocates of IPS-type treatments (see page 26).
Krystel Huxlin (Rochester, US) showed evidence that subjects with severe neurological field loss following visual cortex lesions who had undertaken a two-alternative, forced-choice, global direction discrimination task within their blind fields had shown improvement. She stated 'all patients progressed from no conscious perception of the random dot stimulus and severely abnormal discrimination thresholds to conscious perception and near-normal thresholds'. Concerns about the research included fixation control, but she maintained that an improvement of 5 to 10 degrees of field appeared realisable with training.
Susanne Trauzettel-Klosinski (University Eye Hospital, Tbingen, Germany a major centre in the world of low vision research) had always had concerns about the accuracy of tracking when attempting to show improvements with therapy to those with field loss. If, for example, someone with a hemianopia undergoes therapy, might the apparent improvement in their field merely reflect their ability to fixate with another retinal locus and not an improvement of the blind area. She and her team had assessed such patients using the SLO which is able to accurately monitor fixation (unlike, for example, the Humphrey). She used a triplet of stimuli presented at 0.5 degrees eccentricity to 17 patients with homonymous hemianopic field loss. The number of dots seen before and after periods of vision training were then measured and she was allowing an improvement of just 1 degree of field to represent evidence of improvement. Such an improvement only occurred in one eye of one patient and so it was concluded that accurate fixation tracking was able to show that no improvement actually occurs with vision therapy. This was in direct conflict with research carried out using perimetry without fixation tracking, such as that of the chairman Sabel who just happened to present his work next.
Sabel asked, forcefully, whether the SLO should replace perimetry in optometry world wide. He explained how his work had concentrated on the boundary area between the sighted and blind field. Here, he argued, was an area of 'residual vision' which, after intensive training, could be shown to improve (a third of the sample he studied). It has to be said, however, that difficulties in tracking highlighted by earlier presenters left much of the audience a little sceptical when it became clear that there had been a heavy use of subjective questionnaires.
Dr Robert Harper (Manchester Royal Eye Hospital) presented work from his team, including Claire Chandler, on an autofocus bioptic telescopic device among a low vision sample. The Bioptic is widely used in the US but has yet to be taken up here significantly. It is a four-times distance Keplerian telescopic unit (allowing about a 12-degree field) mounted on the upper optic of a spectacle such that a distance magnification may be achieved when the head is tilted down. The autofocus allows continuity of vision quality. The team used a battery of optical and questionnaire assessments to suggest that the aid improved quality of life and was better for prolonged viewing tasks.
This is just a flavour of what was a very extensive conference which certainly establishes the UK as a major player in the global scientific vision research community.