Minimising the impact of visual impairmentBMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7197.1504 (Published 05 June 1999) Cite this as: BMJ 1999;318:1504
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EDITOR - While agreeing with Margrain (1) that many people with
poor vision are not benefiting from low vision aids his article under-
emphasised the importance of training in their use. Without this, many are
likely to be under-utilised and reading ability in the clinic situation
may not be maintained in the home.
Traditionally, hospital low vision clinics have been run by
optometrists on a relatively infrequent basis, with the emphasis on
dispensing optical aids including more complex spectacle-mounted devices,
with relatively little time available for training. In a recent postal
survey I found that half the clinics in North-West England are run
solely by visiting optometrists on a monthly basis, and in an audit of one
such clinic I found aids costing one third of the annual budget of £11
000 were never used and the proportion of patients able to read newsprint
only rose from 16 to 23 % ( un-published data ). In a review by Humphrey
and Thompson (2) only 23% of patients found their aids useful at home and
McIlwaine et al (3) reported 33% never used the aids provided.
In contrast, detailed analysis of a more integrated approach in
Scandinavia (4) found that 80% of age-related macular degeneration
patients were still able to read newsprint 5 years after LVA training
(which amounted to several hours with a special teacher). Less intensive
training provided by orthoptists in Torbay (5) (on average 84 minutes per
patient) produced good functional results and significantly higher levels
of patient satisfaction than in McIlwaine's study, and appeared cost-
effective due to emphasis on simpler and cheaper aids which offset
Further study is warranted to establish the best form of integrated
cost-effective low vision service and how it might replace the relatively
ineffective and wasteful service still provided in many hospitals.
Wayne Birchall Senior House Officer
Royal Eye Hospital
Manchester M13 9WH
1 Margrain TH. Minimising the impact of visual impairment.BMJ 1999;
2 Humphrey RC, Thompson gm. Low vision aids - evaluation in a general eye
department. Trans Ophthalmol Soc UK 1986; 105: 296-303
3 McIlwaine GG, Bell JA, Dutton GN. Low vision aids - is our service cost
effective? Eye 1991; 5: 607-11
4 Nillson UL, Nillson SEG. Rehabilitation of the visually handicapped
with advanced macular degeneration. Doc Ophthalmol 1986; 62:345-67
5 Shuttleworth GN, Dunlop A, Collins JK, James CRH. How effective is an
integrated approach to low vision rehabilitation? Two year follow-up
results from South Devon. Br J Ophthalmol 1995; 79: 719-23
Competing interests: No competing interests
The recent editorial (1) on minimising the impact of visual
impairment is firmly based on the medical model of disability, which
locates disability in individuals. Disabled people have developed the
social model as an accurate description of their life experience and the
World Health Organisation is revising its definition of disability, to
take this into account (2). The social model locates disability in
society, therefore it is society that
cases 'much individual suffering and economic hardship', not visual
For example, the editorial refers to the percentage of visually
impaired people who could read 'normal print' before and after the
provision of a 'suitable low vision aid and some training'. However, if
anyone who produced, for example, information in print, took into account
that the size of the print (or the use of print) can exclude some people
from gaining access to the information, there would be no such thing
as'normal print', only fully accessible information.
Under the terms of the Disability Discrimination Act 1995, from
October 1999, service providers which offer or provide goods, facilities,
or services to members of the public are required to take such steps as
are reasonable to ensure that disabled people can make use of their
services. In relation to this Act, the Code of Practice which is
currently before Parliament makes specific reference to the provision of
'documents in larger or clear print, Moon or Braille; information on
computer diskette; information on audiotape;
and telephone services to supplement other information' (3). This is
particularly relevant to the health sector and means, amongst other
things, that hospital and primary care information must be available in
formats that are accessible to everyone. The data given in the editorial
(1) about the
number of people who are visually impaired, gives an idea of how many
people potentially face discrimination if providers of goods, facilities,
and services do not take into account the need to produce information that
is fully accessible, not just in 'normal print'.
Last year the Royal National Institue for the Blind reported on a
major survey of Health Authorities and NHS Trusts in Great Britain (4).
Of the 326 Trusts which responded to the questionnaire, 35% offered
general patient information in large print, but only 4% were able to
provide test results for patients in that format.
The Royal College of Physicians 'Charter for disabled people using
hospitals' states that 'every disabled patient, visitor, or hospital
employee has the right to relevant and accessible information, especially
about the hospital's
provision for disabled people' (5).
The principle of removing society's barriers so that disabled people
are not marginalised can be applied not only to the provision of
information, but also to other aspects of minimising the impact of visual
impairment and indeed the impact of any impairment. From October 1999,
this will no longer be merely about good practice practice and equity, but
about conforming to the law.
Dr Joyce M Carter
Consultant in Public Health Medicine
Liverpool Health Authority
24 Pall Mall
Liverpool L3 6AL
Ms Natalie Markham
Disability Equality Officer
Liverpool City Council & Liverpool Health Authority
26 Hatton Garden
Liverpool L3 2AW
1 Margrain TM. Minimising the impact of visual impairment. BMJ
1999;318;1504 (5 June 1999)
2 Oliver M. Theories of disability in health practice and research.
*3 Disability Discrimination Act 1995: Code of practice. Right of
Access. Goods, facilities, services and premises. DfEE, 1999.
4 Royal National Institute for the Blind. Campaign report 7. Ill
informed - the provision of accessible health and medical information.
5 Royal College of Physicians. Disabled people using hospitals - a
charter and guidelines. London:RCP, 1998.
* Note to Editor: The Code of Practice, to which reference is made at
3. above was laid before Parliament as a draft on 27 April 1999, where it
will lie for 40 days, during which time either House of Parliament may
resolve that no further steps be taken in relation thereto. Therefore, if
letter is published, by the time it comes to press, the draft Code will
probably no longer be a draft.
Competing interests: No competing interests