Low vision service outcomes: a systematic review
Executive Summary
Alison Binns, Catey Bunce, Chris Dickinson, Robert Harper,
Rhiannon Tudor-Edwards, Maggie Woodhouse, Pat Linck, Alan
Suttie, Jonathan Jackson, Jennifer Lindsay, James Wolffsohn,
Lindsey Hughes, Tom Margrain
Advisory Panel:
Mary Bairstow, Andy Fisher, Lisa Hughes, Marek Karas, Robert
W Massof, Anita Morrison-Fokken, Joan A Stelmack, Gaynor
Tromans.
September 2009
This review has been prepared for RNIB as part of the Low
Vision Service Model Evaluation (LOVSME) project.
Executive Summary
Visual impairment is a global concern, which is likely to become more
significant, on a social, economic and personal level, as the standard of
medical care improves, and the average lifespan increases. Low vision
rehabilitation aims to improve functional ability, and possibly wider
aspects, such as quality of life and psychosocial status, in those with
visual impairment. Different service models have been developed to
meet these goals, and there is need for a strong evidence base
regarding the ability of these different strategies to achieve positive
outcomes in various patient groups. This report is a systematic review of
the literature on the effectiveness of different models of vision
rehabilitation.
The primary objective of the review was to assess the effects of low
vision service provision on rehabilitation outcomes in people with a visual
impairment.
Secondary objectives:
1) To assess the relative effects of different service models on
rehabilitation outcomes in people with a visual impairment.
2) To assess the impact of timing of outcome assessment on
rehabilitation outcomes in people with a visual impairment.
3) To assess the evidence for a dose effect on rehabilitation outcomes in
people with a visual impairment.
4) To assess the effect of low vision service provision on special groups
of service users, e.g. people with learning disabilities, children and
people of working age.
5) To assess the costs associated with low vision service provision.
Literature was identified by searching the following databases: Web of
Science, EMBASE, Medline, Cochrane CENTRAL, PsychINFO, and
CRD databases. Additional literature was identified via hand searching of
relevant reviews [82, 115, 131-134], and by asking experts in the field for
additional sources of information.
Of 7,800 potential articles identified by the literature searching strategies,
forty-six of the studies were found to be relevant to the general
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effectiveness of low vision services, 4 were relevant to children and
minority groups, and 2 were relevant to the cost-effectiveness of low
vision services.
The findings of the report were as follows:
Quality of Evidence
Whilst there have been many publications on low vision rehabilitation
outcomes the quality of these reports has not always been good. That
is, many studies fail to report in sufficient detail the study design, the
nature of the intervention or indeed their findings (e.g. “p values” are
reported but no data is presented). In addition, few studies control for
any underlying deterioration in visual function during the follow-up period,
which may have masked benefits associated with the rehabilitation.
There is only 1 waiting list controlled randomised controlled trial of low
vision service outcomes. There are 2 randomised low vision service
comparison trials [75, 86-88] and 1 low quality randomised rehabilitation
training comparison trial [142]. Because of the absence of high quality
evidence (RCT) this review also included other types of study (e.g.
‘before and after comparisons’) but we excluded those having the
weakest study design (i.e. ‘case reports’ and ‘case series’).
In this review we use the terms: ‘very good evidence’ when referring to
the results of well designed randomised controlled trials; ‘good evidence’
when referring to consistent results from at least two robust studies that
are not randomised controlled trials and ‘evidence’ when referring to the
results from at least one robust study.
Does rehabilitation improve outcomes for service users?
The results reported by studies are dependent on: 1) the nature of the
rehabilitation programme (content and dose), 2) the outcome measures
used (larger effects are observed with functional ability measures,
smaller effects with QOL measures), 3) the characteristics of the people
studied, 4) when outcomes are measured, 5) study methodology.
There is good evidence that low vision rehabilitation has a large effect on
clinical reading ability (size of print read and reading speed) e.g. [70, 94,
96, 97, 145].
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There is good evidence that low vision aids provided by rehabilitation
services are valued by service users and used at home e.g.[75, 79]
There is very good evidence that Veterans’ Affairs rehabilitation
programmes (both inpatient and outpatient) have a very large positive
effect on self reported functional ability e.g. [61, 121, 130].
There is evidence that other rehabilitation programmes have a medium
effect on functional ability e.g. [122].
There is contradictory evidence about the ability of rehabilitation
programmes to improve “vision related quality-of-life”. For example,
whilst Kuyk et al (2008) and Stelmack et al., 2002 showed medium/small
effects from the inpatient Veterans’ Affairs rehabilitation programme [90]
and Scott et al, (1999) showed a medium effect for a more modest
programme (60-90 min) [147], Lamoureux et al, (2007) showed only a
small effect [58] and DeBoer et al, (2006) and Reeves et al, (2004) no
change (before – after) [75, 83].
There is no evidence that even the comprehensive Veterans’ Affairs
rehabilitation programme can improve generic health related quality-oflife (e.g. SF-36) [61]. Similarly, less intense, multidisciplinary
rehabilitation programmes and hospital based programmes have been
unable to demonstrate a positive effect on the SF-36 and its derivatives
e.g.[58, 75, 147].
Despite reports of small improvements in mood / reduction in depression
after low vision service intervention e.g. [42, 100, 150], there is no
evidence that an intensive rehabilitation programme can reduce
depressive symptoms [61]. However, there is some evidence that
“Independent Living Programmes” and group instruction in “Adaptive
Skills Training” can have a small to medium effect on adjustment to
visual loss respectively [64, 69].
Is there evidence that some services are better than
others?
A well conducted study provided no evidence that “enhanced” services
were better at improving vision related quality-of-life than good hospital
services [75]. And, there is no evidence that multidisciplinary services
are better at improving vision related quality-of-life than optometric
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services [83, 129]. However, there is evidence that a group based
“problem solving health education programme” is more effective than an
“individual intervention” [86-88].
Do rehabilitation outcomes deteriorate with time?
Only a few studies have followed rehabilitation outcomes over time.
Effects at 2 months are slightly larger than at 6 months [90] and effects
at 3 months are larger than at 12 months [130]. There is some evidence
that the effects of intense programmes (e.g. Veterans’ Affairs Hines)
‘wash out’ at 3 years [72], although caution is needed because of the
significant number of participants ‘lost to follow up’. However, the decline
in outcomes with time is not a universal finding. For example, there is
evidence that positive outcomes reported for ADLs following a “problem
solving skills” based health education programme do not deteriorate over
28 months [86-88].
Is more rehabilitation better?
There is conflicting evidence regarding a ‘dose effect’. For example,
Stelmack et al, (2006) found a very large effect using the VA LV VFQ-48
following an intensive inpatient Veterans’Affairs rehabilitation programme
(42 days) but only a small effect following a Veterans’ Affairs outpatient
programme (2-4 visits) [121]. The larger effects reported in the literature
tend to come from intensive rehabilitation programmes e.g. [61, 148],
however, other studies have shown that it is possible to obtain a medium
or large effect size with a relatively low dose intervention [70, 122].
Studies on children, those of working age and minority
groups
There is very little evidence on rehabilitation outcomes in children. The
only evidence relates to reading ability and use of aids [68, 156].
Most studies only involve older adults, and many of the more robust
studies only older males (e.g. from Veterans’ Affairs rehabilitation
programmes). Although several studies include ‘people of working age’
there are no specific studies on this group of people.
There is no evidence on outcomes in ethnic minority groups or those with
learning disabilities.
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How cost-effective is low vision service provision?
When considering the wider question of the ability of interventions to
deliver a cost effective service to people with low vision, little evidence
was found. The available evidence was of a variable quality. Only 2
relevant studies were identified and both recruited older people rather
than the wider population of people with low vision [140, 141]. Eklund et
al (2005) demonstrated a Health Education Programme delivered in
groups was less costly than individual treatment [140]. Another study
showed that in-patient rehabilitation was more costly and more effective
than out-patient rehabilitation [141]. Neither study included incremental
cost effectiveness ratios, therefore it is not possible to conclude that
either were cost effective. We were unable to find any economic
evaluations that included children with low vision.
Estimation of cost-effectiveness is essential to support decision makers,
such as NICE, to make recommendations for resource allocation. This
requirement becomes increasingly important for an aging population and
in times of financial constraint. A significant problem in determining an
economic case is the lack of effectiveness evidence; and of the data that
does exist, even less is reported in a form that lends itself to inclusion in
an economic model which could demonstrate cost-effectiveness.
There is a need to investigate whether integrated low vision services
lead to improved, cost effective outcomes for people with low vision.
In summary this literature review shows:
 There is a lack of high quality evidence to support the effectiveness
of low vision service provision.
 The majority of studies use a relatively weak ‘before and after’
comparison design, many do not provide a full description of the
intervention studied and results are not always reported in full.
 There has been little agreement about how best to measure
outcomes and this frustrates study comparisons.
 Low vision aids improve reading ability and are valued by service
users.
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 Well resourced rehabilitation programmes (e.g. Veterans Affairs
programmes in USA) can produce large improvements in
‘functional ability’ but there is no evidence that they improve
‘generic health related quality-of-life’.
 There is contradictory evidence about the ability of services to
improve ‘vision related quality-of-life’.
 Despite several reports of small improvements in mood following
low vision rehabilitation there is no evidence that even the well
resourced Veterans Affairs programme can reduce depressive
symptoms in its client group. However, other types of programme
such as “Independent Living Programmes” and “Adaptive Skills
Training” may help people ‘adjust’ to vision loss.
 There is no evidence that ‘enhanced’ services are better at
improving ‘vision related quality of life’ than ‘standard’ hospital
based services in the UK.
 There is no evidence that ‘multidisciplinary services’ are better at
improving vision related quality of life than ‘optometric services’ in
Holland.
 There is evidence that a ‘group based health education
programme’ is more effective than an ‘individual intervention’.
 There is some evidence that rehabilitation outcomes peak at
around 2-3 months and decline thereafter but this is not a universal
finding.
 There is some evidence that rehabilitation outcomes are better
following more intense rehabilitation programmes but, the optimum
‘dose’ has not yet been established.
 There is very little information about rehabilitation outcomes in
children and none about outcomes in those of ‘working age’ and in
minority groups.
 Only 2 studies are directly relevant to the cost of low vision
rehabilitation but it is not possible to conclude that the programmes
studied were cost effective.
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 Robust research methods and high quality reporting are necessary
to advance our understanding of how rehabilitation services can
best help people with a visual impairment.
Copies of the full systematic review may be obtained from RNIB or Tom
Margrain, the corresponding author at, the Cardiff School of Optometry
and Vision Sciences, Cardiff University, Cardiff, Wales.
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Appendix 2: Affiliations
Authors:
Alison Binns, Cardiff University
Catey Bunce, Moorfields Eye Hospital
Chris Dickinson, University of Manchester
Robert Harper, Manchester Royal Eye Hospital
Rhiannon Tudor-Edwards, Bangor University
Maggie Woodhouse, Cardiff University
Pat Linck, Bangor University
Alan Suttie, Fife Society for the Blind
Jonathan Jackson, Royal Victorial Hospital
Jennifer Lindsay, Royal Victoria Hospital
James Wolffsohn, Aston University
Lindsey Hughes, British and Irish Orthoptic Society
Tom Margrain, Cardiff University
Advisory Panel:
Mary Bairstow, Vision 2020 UK
Andy Fisher, Focal Point UK
Lisa Hughes, Service User
Marek Karas, Optometric Advisor, RNIB
Robert W Massof, Hopkins University School of Medicine.
Anita Morrison-Fokken, FOCUS Birmingham
Joan A Stelmack, Edward E. Hines Jr VA Hospital, Illinois.
Gaynor Tromans, FOCUS Birmingham
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