对老年性黄斑变性低视力患者进行视功能康复教育训练的研究评价
http://www.100md.com
37c医学网
作者：Serge VETTARD,Thierry CAILLAT,Martine MAUGET
单位：
关键词：
眼视光学杂志990401 摘 要 目的：本研究通过使用光学助视器，对老年性黄斑变性(ARMD)低视力患者进行视觉功能训练的再教育，研究教育对低视力患者视觉康复的重要程度，同时评价低视力康复的各项指标和助视器的作用。方法：对139位ARMD低视力患者的最佳视力眼进行该项目的研究和跟踪，平均年龄79岁(56～95岁)，各患者根据个人需要,分别使用单眼望远镜、放大眼镜、显微镜、视屏放大器等；再教育训练项目：①视动刺激练习、空间定位练习、手眼协调练习；②各种阅读方法识别和训练；③认知功能，如视觉记忆或逻辑推理等诱发训练；结果：教育和训练后，95例视力增加了一行以上(67.6%)，67例(48.2%)能借助助视器进行有效的阅读工作；训练前的平均单字视力为1.50/10，训练后平均为2.14/10；对比敏感度视力曲线发生了改善性变化；50%阅读速度增加，35.6%保持不变，14.4%有所下降，平均阅读速度为47.08字/分(训练前为36.51字/分)；生活自理能力评分显著性增加；58%能书写帐单和信件。结论：可以通过开发低视力患者周边的视觉视功能进行视觉功能康复；使用助视器同时结合患者教育和训练在视功能康复中起至关重要作用；ARMD低视力患者可以通过上述方法康复部分视觉，以获得日常生活所需的最低视觉和阅读能力。
, 百拇医药
Results of functional vision re-education in 139 patients suffering from age related macular degeneration
Serge VETTARD Thierry CAILLAT Martine MAUGET
The authors try to assess the result of low vision re-education in an age related macular degeneration(ARMD) population suffering from loss of central vision,which in turn leads to handicap and lack of autonomy in daily life.Between 1993 and 1996,240 patients with ARMD systematically underwent an examination of their low vision.101 patients were excluded from the study because they did not follow the re-education program for more than 4 months.
, 百拇医药
The 139 other patients benefited from the same procedures,trainning in visuo-motor strategies,spatial orientation,eye-hand co-ordination and development of discrimination involved in the use of vision.
Visual acuity,contrast sensitivity,reading performances,drawing and writing abilities as well as the degree of autonomy in daily life were compared before and after rehabilitation.
Objective
This study aims at assessing the results of re-educating functional vision when combined with an optical aid in a population suffering from ARMD,when the loss of central vision of the second eye has lead to a handicap in everyday life and,in particular,a difficulty in or a loss of reading and writing capacity.
, 百拇医药
Visual acuity sensitivity to contrast,the extent of autonomy in daily life and reading and writing capacities are compared at the beginning and the end of the re-education program.The use threshold of optical aids in daily life is also assessed.
Methods
Between 1993 and 1996,246 patients suffering from ARMD underwent an assessment their visual function.This assessment was carried out according to a protocol divided into of two parts:
, http://www.100md.com
①a subjective assessment of the visual handicap,the requirements of the patient and their psychological state.
②an objective assessment of residual visual capaci-ties and the strategies of use of these capacities.
58 patients were excluded from the study when the medical,psychological,social or geographical context was too problematic to undertake a re-education project with a probable chance of improvement (20 patients) or when a simple,appropriate,optical correction was sufficient for their requirements (38 patients).A group of 182 patients were included in a re-education protocol,but 43 patients dropped out in the first 4 months and were not selected for this study.
, 百拇医药
139 patients (40 men and 99 women) therefore followed a functional vision re-education program for the best eye (67 RE/72 LE),during which a magnifying optical aid was prescribed to enable training in reading and writing.
36 atrophic forms were observed,103 forms with neo-vessels,treated with photocoagulation using a laser (88 cases) or radio therapy (15 cases).The re-education was undertaken when the retina had healed up.
The average age was 79 years old (youngest 56～oldest 95).116 patients were equipped with a monocular telescopic optical system(83.5%).
, 百拇医药
18 patients had another optical aid(microscopic glasses,magnifying glasses,video agrandisseurs)(12.9%).
5 patients could not be equipped because they were unable to read words in spite of a magnified image.
figure 1 The re-education procedure was identical for all the patients
The re-education procedure was identical for all the patients and included,in the form of workshops (figure 1),the stimuation of visuo-motor strategies,of spatial orientation,of hand-eye co-ordination (pointing,drawing) and the development of discrimination capacities.
, 百拇医药
Different methods of reading training were used.
The cognitive functions such as those involved in the process of visual memory or logical reasoning were systematically called upon.
Results
Morphoscopic Visual Acuity
This was measured using separate letters (from identification) and groups of letters or words (reading capacity).
, 百拇医药
Visual Acuity With Separate Letters
We observed after re-education,and with optical correction,an improvement in visual acuity with a gain of at least one line in 95 cases (67.6%).The visual acuity was stable or diminished in 1/3 of the cases,increased by 1 to 2 lines in 1/3 of the cases and by more than 2 lines in 1/3 of the cases.The population whose visual acuity is less than 1/10 decreased whilst that whose acuity is greater than 2/10 increased (table 1).
, 百拇医药
table 1 Visual acuity for single letters, population
before and after re-education
Visual acuity called upon in reading (reading threshhold)
The visual acuity called upon during reading increased in 67 cases by at least one line (48.2%).It is identical in the other half of the cases.Overall,it is still difficult to read printed characters and it is only possible to do so with the help of an optical aid (figure 2,table 2).
, 百拇医药
figure 2 It is only possible to read characters with the help of an opticalaid
table 2 Reading capacitty,population before and after re-education
It is interesting to note that the improvement is more significant for very low levels of acuity (table 3).
table 3 Average gain in lines of VA
, http://www.100md.com
The average visual acuity in separate letters for all the patients is 1.50/10 before re-education and 2.14/10 after re-education,that is an average gain of 42%.The average visual acuity called upon during reading is 1.78/10 (P8-910) before re-education and 2.04/10 (P7/P8) after re-education,that is an average gain of 14.6% (table 4).
table 4 average value of the visual acuity in minutes/of are
, http://www.100md.com
Group I:VA for separate letters with optical correction.
Group II:maximum erading threshoid with optical correction.
Group III :VA using separate letters with an optical aid.
Group IV :maximum erading threshoid using an optical aid.
Visual acuity obtained using an optical aid is proportional to magnification.
Sensitivity to contrasts
, 百拇医药
This was measured in 48 patients,using a spatial frequency network au Mentor,for 3 levels of contrast.The curve's appearance is slightly modified after re-education with an improved sensitivity for the higher contrasts (figure 3，table 5).
figure 3 The curve's appearance was improved sensitivity for higher contrasts
table 5 Sensitivity to contrasts, average 48 patients
, 百拇医药
Reading speed
This was assessed using an optical aid in words/minute on a text of a size equivalent to standard sized print in 118 patients.
It is increased in 50% of cases,stable in 35.6% of cases and slowed down in 14.4% of cases.The average reading speed remains rather slow because it is of 36.51 words per minute before re-education as compared with 47.08 words per minute after.
Autonomy in daily life
, 百拇医药
A score was determined measuring the ability to move around,to perform daily tasks and enjoy leisure activities.The majority of patients we considered sufficiently autonomous after re-education (table 6).
table 6 Autonomy in daily life
Reading capacities…in daily life
Reading became possible using an optical aid in 56.8% of cases,possible but only from time to time in 34.5% of cases and impossible in 8.7% of cases (table 7).
, 百拇医药
table 7 Reading capacities in daily life
Writing capacity
This was determined by a score given on the basis of legibility,linearity of the writing and the possible re-reading using an optical aid.Around 58% of patients are able to write their own cheques or letters (table 8).
table 8 writing capacities
The use of optical aids
, 百拇医药
They are used in 70% of cases (reading,writing,T.V.),occasionally in 26% of cases (T.V. and reading from time to time) and never in 4%.
Discussion
The improvement in visual acuity of separate letters is probably due to a better use of peripheral vision (eccentric scotoma) and an improved capacity for form identification.
The reading of words is difficult even if the visual acuity threshold for separate letters is very much improved.This difference in perception can certainly be put down to phenomena like the completion described by SAFRAN or by metamorphopsias,which are still active.
, http://www.100md.com
The decrease in the handicap in everyday life results from a combination of improvement of different factors such as visual acuity or sensitivity to contrast,but also from an improved use of perceptive strategies.It can also be supposed that the development of cognitive mechanisms helps the patient to make a better assessment of his limits and capacities and therefore acquire improved self confidence.
Conclusion
Re-education combined with optical aids seems to play an active role in the development of existing visual capacities in peripherral vision.The difficulty of use of optical aids requires a training program to stimulate different mechanisms which are going to enable,in the majority of cases,the patient suffering from ARMD to regain their personal autonomy in daily life and an aptitude for usual reading.
, http://www.100md.com
At the end of the re-education program,we observed an improved psychological attitude,helping the patient to accept his visual deficit and overcome his handicap.
From:Centre Ophtalmologique d'imagerie Laser
Biographical references
1 Clenet MF.Orthoptique et basse vision.CEil en coin n special,SNAO,Paris,1991
2 Colenbrander A,Fletcher DC.Guest editors,Low vision and vision rehabilitation.Ophthalmology Clin North Am,1994
, 百拇医药
3 Corbe Ch,Menu JP,Chaine G.Trait
itique physiologique et clinique Ed.Doin-Paris,1993
4 Koenig F.D g n rescence maculaire et r ducation de la lecture.Protocole de Bellevue,institut ISPEN,1996
, http://www.100md.com
5 Larmande P,Larmande A.Abr g de neuro ophtalmologie Ed.Masson,Paris
6 Levy-Schoen A,O'Reagan JK.Le regard et la lecture La recherche,1989,211-20∶744～753
7 Mc Mahon T.T.Hausen M.Viana M.Fixation charracteristics in macular disease invest.Ophthalmol.Vis.Sci,1991,32-3∶567～574
8 Rubin GS，Legge G.E.Psychophysics of reading.VI,The role of contrast in low vision Vision Res，1989,29-1∶79～91
, 百拇医药
9 Safran A.B.Assimacopoulos A.Le d ficit visuel Ed.Masson,Paris,1995
10 Vettard S, Mauget M.D g n rescence maculaire li e 
lage:r sultats de la reeducation de la vision fonctionnelle chez 41 patients apr s photocoagulation de type p rifov olaire Bull.Soc.Ophtalmol.Fr.sous presse
11 Virtanen P，Laatikainen L. Primary success with low vision aids in age-related macular degeneration Acta Ophthalmologica,1991,69∶484～490
(收稿：1999-06-10), 百拇医药
单位：
关键词：
眼视光学杂志990401 摘 要 目的：本研究通过使用光学助视器，对老年性黄斑变性(ARMD)低视力患者进行视觉功能训练的再教育，研究教育对低视力患者视觉康复的重要程度，同时评价低视力康复的各项指标和助视器的作用。方法：对139位ARMD低视力患者的最佳视力眼进行该项目的研究和跟踪，平均年龄79岁(56～95岁)，各患者根据个人需要,分别使用单眼望远镜、放大眼镜、显微镜、视屏放大器等；再教育训练项目：①视动刺激练习、空间定位练习、手眼协调练习；②各种阅读方法识别和训练；③认知功能，如视觉记忆或逻辑推理等诱发训练；结果：教育和训练后，95例视力增加了一行以上(67.6%)，67例(48.2%)能借助助视器进行有效的阅读工作；训练前的平均单字视力为1.50/10，训练后平均为2.14/10；对比敏感度视力曲线发生了改善性变化；50%阅读速度增加，35.6%保持不变，14.4%有所下降，平均阅读速度为47.08字/分(训练前为36.51字/分)；生活自理能力评分显著性增加；58%能书写帐单和信件。结论：可以通过开发低视力患者周边的视觉视功能进行视觉功能康复；使用助视器同时结合患者教育和训练在视功能康复中起至关重要作用；ARMD低视力患者可以通过上述方法康复部分视觉，以获得日常生活所需的最低视觉和阅读能力。
, 百拇医药
Results of functional vision re-education in 139 patients suffering from age related macular degeneration
Serge VETTARD Thierry CAILLAT Martine MAUGET
The authors try to assess the result of low vision re-education in an age related macular degeneration(ARMD) population suffering from loss of central vision,which in turn leads to handicap and lack of autonomy in daily life.Between 1993 and 1996,240 patients with ARMD systematically underwent an examination of their low vision.101 patients were excluded from the study because they did not follow the re-education program for more than 4 months.
, 百拇医药
The 139 other patients benefited from the same procedures,trainning in visuo-motor strategies,spatial orientation,eye-hand co-ordination and development of discrimination involved in the use of vision.
Visual acuity,contrast sensitivity,reading performances,drawing and writing abilities as well as the degree of autonomy in daily life were compared before and after rehabilitation.
Objective
This study aims at assessing the results of re-educating functional vision when combined with an optical aid in a population suffering from ARMD,when the loss of central vision of the second eye has lead to a handicap in everyday life and,in particular,a difficulty in or a loss of reading and writing capacity.
, 百拇医药
Visual acuity sensitivity to contrast,the extent of autonomy in daily life and reading and writing capacities are compared at the beginning and the end of the re-education program.The use threshold of optical aids in daily life is also assessed.
Methods
Between 1993 and 1996,246 patients suffering from ARMD underwent an assessment their visual function.This assessment was carried out according to a protocol divided into of two parts:
, http://www.100md.com
①a subjective assessment of the visual handicap,the requirements of the patient and their psychological state.
②an objective assessment of residual visual capaci-ties and the strategies of use of these capacities.
58 patients were excluded from the study when the medical,psychological,social or geographical context was too problematic to undertake a re-education project with a probable chance of improvement (20 patients) or when a simple,appropriate,optical correction was sufficient for their requirements (38 patients).A group of 182 patients were included in a re-education protocol,but 43 patients dropped out in the first 4 months and were not selected for this study.
, 百拇医药
139 patients (40 men and 99 women) therefore followed a functional vision re-education program for the best eye (67 RE/72 LE),during which a magnifying optical aid was prescribed to enable training in reading and writing.
36 atrophic forms were observed,103 forms with neo-vessels,treated with photocoagulation using a laser (88 cases) or radio therapy (15 cases).The re-education was undertaken when the retina had healed up.
The average age was 79 years old (youngest 56～oldest 95).116 patients were equipped with a monocular telescopic optical system(83.5%).
, 百拇医药
18 patients had another optical aid(microscopic glasses,magnifying glasses,video agrandisseurs)(12.9%).
5 patients could not be equipped because they were unable to read words in spite of a magnified image.
figure 1 The re-education procedure was identical for all the patients
The re-education procedure was identical for all the patients and included,in the form of workshops (figure 1),the stimuation of visuo-motor strategies,of spatial orientation,of hand-eye co-ordination (pointing,drawing) and the development of discrimination capacities.
, 百拇医药
Different methods of reading training were used.
The cognitive functions such as those involved in the process of visual memory or logical reasoning were systematically called upon.
Results
Morphoscopic Visual Acuity
This was measured using separate letters (from identification) and groups of letters or words (reading capacity).
, 百拇医药
Visual Acuity With Separate Letters
We observed after re-education,and with optical correction,an improvement in visual acuity with a gain of at least one line in 95 cases (67.6%).The visual acuity was stable or diminished in 1/3 of the cases,increased by 1 to 2 lines in 1/3 of the cases and by more than 2 lines in 1/3 of the cases.The population whose visual acuity is less than 1/10 decreased whilst that whose acuity is greater than 2/10 increased (table 1).
, 百拇医药
table 1 Visual acuity for single letters, population
before and after re-education
Visual acuity called upon in reading (reading threshhold)
The visual acuity called upon during reading increased in 67 cases by at least one line (48.2%).It is identical in the other half of the cases.Overall,it is still difficult to read printed characters and it is only possible to do so with the help of an optical aid (figure 2,table 2).
, 百拇医药
figure 2 It is only possible to read characters with the help of an opticalaid
table 2 Reading capacitty,population before and after re-education
It is interesting to note that the improvement is more significant for very low levels of acuity (table 3).
table 3 Average gain in lines of VA
, http://www.100md.com
The average visual acuity in separate letters for all the patients is 1.50/10 before re-education and 2.14/10 after re-education,that is an average gain of 42%.The average visual acuity called upon during reading is 1.78/10 (P8-910) before re-education and 2.04/10 (P7/P8) after re-education,that is an average gain of 14.6% (table 4).
table 4 average value of the visual acuity in minutes/of are
, http://www.100md.com
Group I:VA for separate letters with optical correction.
Group II:maximum erading threshoid with optical correction.
Group III :VA using separate letters with an optical aid.
Group IV :maximum erading threshoid using an optical aid.
Visual acuity obtained using an optical aid is proportional to magnification.
Sensitivity to contrasts
, 百拇医药
This was measured in 48 patients,using a spatial frequency network au Mentor,for 3 levels of contrast.The curve's appearance is slightly modified after re-education with an improved sensitivity for the higher contrasts (figure 3，table 5).
figure 3 The curve's appearance was improved sensitivity for higher contrasts
table 5 Sensitivity to contrasts, average 48 patients
, 百拇医药
Reading speed
This was assessed using an optical aid in words/minute on a text of a size equivalent to standard sized print in 118 patients.
It is increased in 50% of cases,stable in 35.6% of cases and slowed down in 14.4% of cases.The average reading speed remains rather slow because it is of 36.51 words per minute before re-education as compared with 47.08 words per minute after.
Autonomy in daily life
, 百拇医药
A score was determined measuring the ability to move around,to perform daily tasks and enjoy leisure activities.The majority of patients we considered sufficiently autonomous after re-education (table 6).
table 6 Autonomy in daily life
Reading capacities…in daily life
Reading became possible using an optical aid in 56.8% of cases,possible but only from time to time in 34.5% of cases and impossible in 8.7% of cases (table 7).
, 百拇医药
table 7 Reading capacities in daily life
Writing capacity
This was determined by a score given on the basis of legibility,linearity of the writing and the possible re-reading using an optical aid.Around 58% of patients are able to write their own cheques or letters (table 8).
table 8 writing capacities
The use of optical aids
, 百拇医药
They are used in 70% of cases (reading,writing,T.V.),occasionally in 26% of cases (T.V. and reading from time to time) and never in 4%.
Discussion
The improvement in visual acuity of separate letters is probably due to a better use of peripheral vision (eccentric scotoma) and an improved capacity for form identification.
The reading of words is difficult even if the visual acuity threshold for separate letters is very much improved.This difference in perception can certainly be put down to phenomena like the completion described by SAFRAN or by metamorphopsias,which are still active.
, http://www.100md.com
The decrease in the handicap in everyday life results from a combination of improvement of different factors such as visual acuity or sensitivity to contrast,but also from an improved use of perceptive strategies.It can also be supposed that the development of cognitive mechanisms helps the patient to make a better assessment of his limits and capacities and therefore acquire improved self confidence.
Conclusion
Re-education combined with optical aids seems to play an active role in the development of existing visual capacities in peripherral vision.The difficulty of use of optical aids requires a training program to stimulate different mechanisms which are going to enable,in the majority of cases,the patient suffering from ARMD to regain their personal autonomy in daily life and an aptitude for usual reading.
, http://www.100md.com
At the end of the re-education program,we observed an improved psychological attitude,helping the patient to accept his visual deficit and overcome his handicap.
From:Centre Ophtalmologique d'imagerie Laser
Biographical references
1 Clenet MF.Orthoptique et basse vision.CEil en coin n special,SNAO,Paris,1991
2 Colenbrander A,Fletcher DC.Guest editors,Low vision and vision rehabilitation.Ophthalmology Clin North Am,1994
, 百拇医药
3 Corbe Ch,Menu JP,Chaine G.Trait
itique physiologique et clinique Ed.Doin-Paris,19934 Koenig F.D
g n rescence maculaire et r ducation de la lecture.Protocole de Bellevue,institut ISPEN,1996, http://www.100md.com
5 Larmande P,Larmande A.Abr
g de neuro ophtalmologie Ed.Masson,Paris6 Levy-Schoen A,O'Reagan JK.Le regard et la lecture La recherche,1989,211-20∶744～753
7 Mc Mahon T.T.Hausen M.Viana M.Fixation charracteristics in macular disease invest.Ophthalmol.Vis.Sci,1991,32-3∶567～574
8 Rubin GS，Legge G.E.Psychophysics of reading.VI,The role of contrast in low vision Vision Res，1989,29-1∶79～91
, 百拇医药
9 Safran A.B.Assimacopoulos A.Le d
ficit visuel Ed.Masson,Paris,199510 Vettard S, Mauget M.D
g n rescence maculaire li e lage:r sultats de la reeducation de la vision fonctionnelle chez 41 patients apr s photocoagulation de type p rifov olaire Bull.Soc.Ophtalmol.Fr.sous presse11 Virtanen P，Laatikainen L. Primary success with low vision aids in age-related macular degeneration Acta Ophthalmologica,1991,69∶484～490
(收稿：1999-06-10), 百拇医药