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Palestra de Dr. Laércio na Itália


Dear friends and colleagues, Ladies and Gentlemen, I am very happy to be with all of you sharing may experience along almost thirty years as an eye doctor. I am indebted to all the patients from whom I have learned about sub-normal vision.

It´s a privilege to be part of such an heterogenous audience composed by eye doctors, ocular therapists, optometrists, psychologists and to all those interested in helping people to mantain, recover and cure patients’ life problems.

I would like particulary to thank Mauricio Cagnoli ans Silvya Lakeland for the invitation to come to such an important event in a beautiful city like Genoa.

The purpose of my work as a low vision practitioner is to emphasize the role of the opthalmologist and the multidisciplinary team to help these people with residual vision to cope with their limitations. Such caring is an integral and essential component of the work. Encouraging patients to use whatever vision they have to enhance the quality of their daily lives is, of course, time consuming, but to watch a person move from hopelessness and dependence to self respect and autonomy is inspiring... Patients primarily need to feel that the people who help them are directing toward them “sensitivity to the human condition perspective on the relation of the person to the illness, and confidence in their capacity to overcome the illness in any possible way. The “clinician” involved needs to provide more guidance than therapy. It is the doctor´s responsability to furnish certain skills such as listening, interviewing, examining, diagnosing. It is ultimately the patiens who must become more aware of their own changes, strenghts, growth to a more salutary relationship with life´s challenges. Caring means collaboration with respect and confidence in the person.

LOW VISION PATIENT

People who cannot read, drive or travel alone, normally look for treatment. If their eye condition cannot be cured medically ou surgically, they are often told that nothing can be done and they should not waste their money coming back for examination. Patients feel abandoned at the most crucial moment, which may delay their obtaining a low vision evaluation and further optical and non optical treatment... Sometimes what occurs is that the dilemma of the visual impaired person is that a doctor may not necessarily associate acquired eye disease with loss of visual function; the doctor may be more concerned about treatment than with rehabilitation and the patient may be hesitant to express a need for more efficient visual function. Patiens receiving treatment for chronic eye disease find that the disease gets more attention, than their vision. They may not complain because they are expecting some treatment to restore sight to its former level without realizing or being told that they will never see normally again. They are often told “ to learn to live with it “ and are left to manage with reduced vision as well as they can, when they could be benefited from a low vision aid and natural therapies.

Reduced visual function whether present at birth or appearing later in life affects strongly one’s perception of useful existence. While trying to adjust both physically and psychologically to a sensory loss that upsets every aspect of daily life, a person may feel helpless and frustrated.

DEFINITION

Low Vision, Partial Sight , Residual Vision, Visual limitation, are terms to describe sight loss . The reality is that, there is an are irreversible damage, a visual loss that is potentially handicaping.

It can be described as bilateral sub normal visual acuity or abnormal visual field resulting from a disorder in the visual system. The defect may be in the globe (cornea, íris, lens, vitreous or retina), the optic pathways or the visual córtex. It may be hereditary congenital or acquired. Inborn or acquired disease my affect visual acuity or visual field and a variety of other ocular functions such as color perception, contrast sensitivity, dark adaptation, ocular motility and visual perception or awareness.

The visual acuity cannot be corrected to normal performance levels with conventional spectacles, intraocular on contact lenses. The patiens who have normal acuity, the visual field must be sufficiently impaired to prevent normal performance.

Sub Normal Vision is a statement of the relationship between visual acuity and visual function. It may be defined clinically as the point at which the patient becomes aware that his poor acuity hás affected his performance so that he sees himself as handicapped. It cannot be defined numerically.

Low Vision is a functional state rather than a mathematic notation. (This dramatic variability is characteristic of the capricious nature of eye disease and its random effect on the eyes and visual system.

PSYCHOSOCIAL ASPECTS

A low vision person considers himself a sighted person and functions usually far beyond his limits when others would consider him blind, have more difficulties to adjust himself to his residual visual rather than a person who has lost his vision and doesn´t have any possibility of recovering, as for example the congenital blind who doesn´t have any idea whatsoever what to be sighted is like.

The terms blind and sighted represent stereotyped well-defined groups, and behavioral rules accepted culturally.

The role of the partial-sighted is usually less clearer, due to plenty of variables of this kind of vision . Generally, society considers the partial sighted as sighted and expects him to act like that.

The low vision patients would like to be included in any group, need and look for some kind of identity and behave according to other people´s expectations.

If they are expected to behave like sighted they act this way, and if expected to act like blind, they would act the same.

Therefore, people believe to know how to treat the low vision person and he himself knows now to behave.

Concerning the partial sighted people, the effective use of vision depends on physical and emotional state of being, influenced by environmental factors such as the size of the printed letters, the light, the contrast, the shape drawings, layouts, these variables make the patient see inconsistencies of images at certain moments. Unfortunatelly, parents, institutions who provide these services, think that if they once in a while can see normally, why not most of the time. When the low vision person cannot see properly is not necessarily due to lack of attention, incapacity or insufficient coordination. There are some apparent contradictions: he is able to ride a bike but cannot read the ads, behavior compatible with people with loss of central vision. On the other hand there are people who can read the ads on the other side of the room, but they stumble on a stool beside them, behavior compatible with serious loss of peripheral vision. These two situations may confound people in general.

The partial sighted people, whose vision acuity varies, is not able to recognize the tons of colours at certains moments and not at others, they put into practice certain behavioral changes such as they blink their eyes, bend their heads, move slowly and involuntarily, use their fingers to read, emit some sounds in order to compensate their visual limitations. To these people this behavior is absolutely normal necessary, but confound themselves and make them feel depressed.

The alterations of the optic nerve and its ramifications are due to several causes (atrophia, infection, tumor, degenerations and pre-natal troubles). The location of the problem is the most important factor to determine the visual function.

The vision handicapped people have to be recomended how to develop the capacity to comunicate their experiences.

If the loss occurs in the inferior quadrant of the visual field, mobility is affected. If the loss is in the right visual field, reading is affected, because the printed letter requires a progression from left to right of the ocular movements and exploration. If the loss is in central vision, studying becomes a problem.

The appearence of the eye may deceive: if the person doesn´t say anything this may lead to false conclusions, and if the person mentions his problems, people will think they give excuses not to perform certain tasks. That´s why these people need the cooperation of their families, close friends, teachers and employees of the institutions.

The patiens who have been sucessful in their rehabilitation are those with a high selfesteem, very intense relationships and a very good partnership with people responsible for them.

There are three personality types among low vision people:

  1. Those who use there condition to obtain certain advantages;
  2. Those who see themselves as sighted people;
  3. Those who learn how to make use of their residual visual as much as they can.

INFLUENCES IN VISUAL PEFORMANCE

Visual impairment is often associated with limitations in other systems particularly in people more than age 65 in whom sensory and physical disorders as a consequence os aging are predictable events.

Medical factors affecting performance are severe illness, reaction to medications, organic brain damage from various causes and neurologic or orthopedics handicaps.

Psychological factors are anxiety caused by loss of vision depression and apathy, and mental illness.

The visual performance of a person with low vision can be enhanced some ways:

  • Conventional refraction (glasses) contact and intraocular lenses, absorptive lenses and other corrective devices;
  • Low Vision – Magnifying aids and visual aids;
  • Help the patient psychologically in order to adjust to visual handicap;
  • Natural Therapies.

NATURAL THERAPIES

Since the beginning of my work as a low vision practitioner I have had the opportunity to travel abroad and by chance I could read some books such as:

  • Art of Seeing by Aldous Huxley;
  • Perfect Sight Without Glasses by W. Bates;
  • Help Yourself to Better Sight by Margaret Corbett.

After reading all these books, I met Meir Schneider who created the Self-Healing Method, in São Paulo, in a workshop of “Vision Problems” on the weekend.

From that time on, I have practiced the eye exercises for a while and recommended them to my patients on an ordinary basis. For those with poor vision the exercises have been used simultaneously with the optical and non-optical aids when absolutely necessary.

According to personal needs based on the posture, social behavior, motivation and the vision itself, I have established a program and discussed it with the visual therapist and other colleagues.

The main point is to show the patient how the efficiency of the vision can be developed just like any other skills.

In the begining of my profession as an ophthalmologist it was necessary to learn the physiology of the eye and its implications the best possible way in order to prevent, how to diagnose and treat eye problems. When I specialized a few years later in Homeopathy the eyes became just part of the whole, and then I could understand the mental side of vision which makes use of the eyes to see with.

I have learned and I believe what Aldous Huxley wrote in his book “Art of seeing”.

“For the person whose sight is sub normal the correct mental attitude may be expressed in some such words as these. I know theoretically that defective vision can be improved. I feel certain that if I learn the art of seeing, I can improve my own defective vision. I am practicing the art of seeing as I look now, and it is likely that I shall see better than I did. If I don´t see as well as I hope, I shall not feel wretched or aggrieved, but go on, until better vision comes to me”.

We should culltivate an attitude of confidence combined with indifference, confidence in our capacity to do the job and indifference to possible failure.

The awareness of the importance of working on the body to help the eyes as for example, when you loose up the body, relieving the stress from the neck and the head improving the blood circulation in this area. We know how connected the body including the eyes, and emotions such as fear, anger, worry, grief, envy, status-seeking, lust, ambition make the mind and body suffer and consequentely vision can be impaired through direct action upon the nervous, glandular and circulatory systems, partly lowering the efficiency of the mind.

THE LOW VISION AIDS

A low vision aid is any device that enables the low vision patient to improve performance. There are two types of aids: optical and nonoptical.

OPTICAL AIDS

A low vision optical aid is a device that by virtue of its optical properties raise the level of visual performance of the low vision patient. It may be a convex lens, mirror, prism, or electronic device. A convex lens magnifies the image of the object to varying degrees depending on its dioptric strength. Eletronic devices transmit magnified images eletronically, while mirrors and prisms reflect or relocate images on the retina. All of the aids use healthy areas of the retina to substitute for damaged areas. No aid can ever replace all of the functions of the normal eye. Therefore, a person may need a number of optical aids for distance and near tasks. Aids are prescribed in relation to the eye diagnosis, the severity of the condition, the task requirements and the individual response of the low vision patient.

NONOPTICAL AIDS

Nonoptical aids are visual aids that do not use magnifying lenses to improve visual function. The following are examples of aids that enhance visual function by environmental conditions.

  1. Specific ilumination: improved room lighting, reading lamps, and flash-lights;
  2. Light transmission: absorptive lenses, filters, and lens coatings that reduce glare and increase contrast;
  3. Reflection control: typoscopes (reading, slits), visors, sideshields, otpical coatings, and polarizing lenses;
  4. Enhanced contrast: colors that improvise contrast as in the use of black ink on white paper, dark colors against a light background (or the reverse), and fluorescent or painted strips;
  5. Linear magnification: books with large-print letters and numerals.

NONVISUAL DEVICES

Nonvisual devices supplement low vision aids or, when there is a profound visual impairment, replace visual activity. They provide acess to information through the use of other senses.

Audiologic equipement ; Medical devices with signal or voice; Reading machines; Sonic travel devices; Talking book discs and cassettes; talking calculator; Talking clocks and watches; Tape cassetes; Typewriter (learning to type rather than to write; voice activated printing machines).

Conclusion

Our role as professionals of health is to make use of all resources available so that we can help our patients to recover, may it be for the quality of life, a healthier way to look at themselves, because we know that the development of an incapacity depends on the way people internalize their limitations as debilitating and indesirable.

If the focus is our patient and if we dedicate our efforts to him, putting aside our ego and our need of recognition, we will be able to make him use all his potencial, his physical, emotional and spiritual resources to succeed in his journey.

The multidisciplinary team should have the same goal and spirit to integrate the majority of their patients in the various roles in their lives and with themselves and for this, they should count on the help of their families, friends and professionals working in the area, and above, all with the constant supervision and continuous help from our Creator.

Fonte: CPVI - Palestra ministrada na Italia em 2005 pelo Dr. Laércio Motoryn