case study for visual impairment

Information

• Author Services

Initiatives

You are accessing a machine-readable page. In order to be human-readable, please install an RSS reader.

All articles published by MDPI are made immediately available worldwide under an open access license. No special permission is required to reuse all or part of the article published by MDPI, including figures and tables. For articles published under an open access Creative Common CC BY license, any part of the article may be reused without permission provided that the original article is clearly cited. For more information, please refer to https://www.mdpi.com/openaccess .

Feature papers represent the most advanced research with significant potential for high impact in the field. A Feature Paper should be a substantial original Article that involves several techniques or approaches, provides an outlook for future research directions and describes possible research applications.

Feature papers are submitted upon individual invitation or recommendation by the scientific editors and must receive positive feedback from the reviewers.

Editor’s Choice articles are based on recommendations by the scientific editors of MDPI journals from around the world. Editors select a small number of articles recently published in the journal that they believe will be particularly interesting to readers, or important in the respective research area. The aim is to provide a snapshot of some of the most exciting work published in the various research areas of the journal.

Original Submission Date Received: .

• Active Journals
• Find a Journal
• Proceedings Series
• For Authors
• For Reviewers
• For Editors
• For Librarians
• For Publishers
• For Societies
• For Conference Organizers
• Open Access Policy
• Institutional Open Access Program
• Special Issues Guidelines
• Editorial Process
• Research and Publication Ethics
• Article Processing Charges
• Testimonials
• Preprints.org
• SciProfiles
• Encyclopedia

Article Menu

• Subscribe SciFeed
• Recommended Articles
• Google Scholar
• on Google Scholar
• Table of Contents

Find support for a specific problem in the support section of our website.

Please let us know what you think of our products and services.

Visit our dedicated information section to learn more about MDPI.

JSmol Viewer

A systematic review on inclusive education of students with visual impairment.

1. Introduction

• What are the perceptions of general education teachers toward the inclusion of students with visual impairment?
• What factors impact attitudes of general education teachers toward inclusion?
• What are the challenges in accessing academic subjects for students with visual impairment in inclusive settings?
• What elements increase accessibility to academic subjects?

2.1. Steps 1 through 4

• The articles must have been published in English in a peer-reviewed journal between 1980 and September 2018.
• The articles must be related to students in a compulsory education program (that is, first grade to twelfth grade) with visual impairment (blind or low vision) and learning in general education classrooms/inclusive settings.
• The articles must be related only to students with visual impairment, with no other disabilities.

2.2. Steps 5 and 6

3.1. general education teachers’ perception toward the inclusion of students with visual impairment, 3.2. factors that impact attitudes of general education teachers, 3.2.1. teacher-related factors, 3.2.2. student-related factors, 3.2.3. environment-related factors, 3.3. challenges pertaining to access to academic subjects for students with visual impairment, 3.4. the elements that increase accessibility in academic subjects, 3.4.1. general education teachers possessing a generic set of effective pedagogical strategies, 3.4.2. effective teaching-learning tools, 3.4.3. external support, 4. discussion, 4.1. overview of findings, 4.2. salient suggestions to improve current inclusive education, 4.2.1. teacher training, 4.2.2. holistic support system with external specialist support, 5. conclusions, 6. limitations, conflicts of interest.

• Miyauchi, H.; Peter, P. Perceptions of students with visual impairment on inclusive dducation: A narrative meta-analysis. Hum. Res. Rehabil. 2020 , 10 , 4–25. [ Google Scholar ]
• United Nations. Convention on The Rights of Persons with Disabilities and Optional Protocol . 2006. Available online: https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities.html#Fulltext (accessed on 1 August 2020).
• Baker, E.T.; Wang, M.C.; Walber, H.J. The effects of inclusion on learning. Synth. Res. 1995 , 52 , 33–35. [ Google Scholar ]
• Jessup, G.; Bundy, A.C.; Broom, A.; Hancock, N. The social experiences of high school students with visual impairments. J. Vis. Impair. Blind. 2017 , 111 , 5–19. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Chang, S.C.H.; Schaller, J. The views of students with visual impairments on the support they received from teachers. J. Vis. Impair. Blind. 2002 , 96 , 558–575. [ Google Scholar ] [ CrossRef ]
• Brydges, C.; Mkandawire, P. Perceptions and concerns about inclusive education among students with visual impairments in Lagos, Nigeria. Int. J. Disabil. Dev. Educ. 2017 , 64 , 211–225. [ Google Scholar ] [ CrossRef ]
• Haegele, J.A.; Porretta, D. Physical activity and school-age individuals with visual impairments: A literature review. Adapt. Phys. Act. Q. 2015 , 32 , 68–82. [ Google Scholar ] [ CrossRef ]
• Haegele, A.; Zhu, X. Experiences of individuals with visual impairments in integrated physical education: A retrospective study. Res. Q. Exerc. Sport 2017 , 88 , 425–435. [ Google Scholar ] [ CrossRef ]
• Ronal National Institute for the Blind. Children and Young People-England ; RNIB Evidence-Based Review: London, UK, 2017. [ Google Scholar ]
• Lieberman, L.J.; Lepore, M.; Lepore-Stevens, M.; Ball, L. Physical education for children. Am. Phys. Educ. Rev. 2019 , 90 , 30–38. [ Google Scholar ]
• Ahsan, T.; Sharma, U. Pre-service teachers’ attitudes towards inclusion of students with high support needs in regular classrooms in Bangladesh. Br. J. Spec. Educ. 2018 , 45 , 81–97. [ Google Scholar ] [ CrossRef ]
• Ministry of Education New Zealand. Criteria and Definitions for Ongoing Resourcing Scheme (ORS). Available online: https://www.education.govt.nz/school/student-support/special-education/ors/criteria-for-ors/ (accessed on 1 August 2020).
• Spungin, S.J.; Huebner, K.M. Historical Perspectives. In Foundations of Education, History and Theory of Teaching Children and Youths with Visual Impairments , 3rd ed.; Holbrook, M.C., McCarthy, T., Kamei-Hannan, C., Eds.; American Foundation for the Blind: Arlington County, VA, USA, 2017; Chapter 1; pp. 3–49. [ Google Scholar ]
• Kalloniatis, M.; Johnston, A.W. Visual environmental adaptation problems of partially sighted children. J. Vis. Impair. Blind. 1994 , 88 , 234–243. [ Google Scholar ] [ CrossRef ]
• Opie, J.; Deppeler, J.; Southcott, J. You have to be like everyone else: Support for students with vision impairment in mainstream secondary schools. Support Learn. 2017 , 32 , 267–287. [ Google Scholar ] [ CrossRef ]
• Finkelstein, S.; Sharma, U.; Furlonger, B. The inclusive practices of classroom teachers: A scoping review and thematic analysis. Int. J. Incl. Educ. 2019 , 0 , 1–28. [ Google Scholar ] [ CrossRef ]
• Monsen, J.J.; Ewing, D.L.; Kwoka, M. Teachers’ attitudes towards inclusion, perceived adequacy of support and classroom learning environment. Learn. Environ. Res. 2014 , 17 , 113–126. [ Google Scholar ] [ CrossRef ]
• de Boer, A.; Pijl, S.J.; Minnaert, A. Regular primary schoolteachers’ attitudes towards inclusive education: A review of the literature. Int. J. Incl. Educ. 2011 , 15 , 331–353. [ Google Scholar ] [ CrossRef ]
• Wall, R. Teachers’ exposure to people with visual impairments and the effect on attitudes toward Inclusion. RE View 2002 , 34 , 111–119. [ Google Scholar ]
• George, A.L.; Duquette, C. The psychosocial experiences of a student with low vision. J. Vis. Impair. Blind. 2006 , 100 , 152–163. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Lieberman, L.J.; Robinson, B.L.; Rollheiser, H. Youth with visual impairments: Experiences in general physical education. RE View 2006 , 38 , 152–163. [ Google Scholar ] [ CrossRef ]
• de Verdier, K.; Ek, U. A longitudinal study of reading development, academic achievement, and support in Swedish inclusive education for students with blindness or severe visual impairment. J. Vis. Impair. Blind. 2014 , 108 , 461–472. [ Google Scholar ] [ CrossRef ]
• Hatlen, P. A personal odyssey on schools for blind children. J. Vis. Impair. Blind. 1993 , 87 , 171–173. [ Google Scholar ] [ CrossRef ]
• Sapp, W.; Hatlen, P. The expanded core curriculum: Where we have been, where we are going, and how we can get there. J. Vis. Impair. Blind. 2010 , 104 , 338–348. [ Google Scholar ] [ CrossRef ]
• Jessup, G.M.; Bundy, A.C.; Hancock, N.; Broom, A. Being noticed for the way you are: Social inclusion and high school students with vision impairment. Br. J. Vis. Impair. 2018 , 36 , 90–103. [ Google Scholar ] [ CrossRef ]
• Hess, I. Visually impaired pupils in mainstream schools in Israel: Quality of life and other associated factors. Br. J. Vis. Impair. 2010 , 28 , 19–33. [ Google Scholar ] [ CrossRef ]
• Ravenscroft, J.; Davis, J.; Bilgin, M.; Wazni, K. Factors that influence elementary school teachers’ attitudes towards inclusion of visually impaired children in Turkey. Disabil. Soc. 2019 , 34 , 629–656. [ Google Scholar ] [ CrossRef ]
• Selickaitė, D.; Hutzler, Y.; Pukėnas, K.; Block, M.E.; Rėklaitienė, D. The analysis of the structure, validity, and reliability of an Inclusive Physical Education Self-Efficacy Instrument for Lithuanian physical education teachers. SAGE Open 2019 , 9 , 215824401985247. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Mushoriwa, T. Research Section: A study of the attitudes of primary school teachers in Harare towards the inclusion of blind children in regular classes. Br. J. Spec. Educ. 2001 , 28 , 142–147. [ Google Scholar ] [ CrossRef ]
• Pliner, S.; Hannah, M. The role of achievement in teachers’ attitudes toward handicapped children. Acad. Psychol. Bull. 1958 , 7 , 327–335. [ Google Scholar ]
• Bardin, J.A.; Lewis, S. A survey of the academic engagement of students with visual impairments in general education classes. J. Vis. Impair. Blind. 2008 , 102 , 472–483. [ Google Scholar ] [ CrossRef ]
• Bandura, A. Self-efficacy: Toward a unifying theory of behavioral change. Adv. Behav. Res. Ther. 1978 , 1 , 139–161. [ Google Scholar ] [ CrossRef ]
• Haegele, J.A. Inclusion illusion: Questioning the inclusiveness of integrated physical education. Quest 2019 , 71 , 387–397. [ Google Scholar ] [ CrossRef ]
• Abrahamson, D.; Flood, V.J.; Miele, J.A.; Siu, Y.T. Enactivism and ethnomethodological conversation analysis as tools for expanding Universal Design for Learning: The case of visually impaired mathematics students. ZDM Math. Educ. 2019 , 51 , 291–303. [ Google Scholar ] [ CrossRef ]
• Klingenberg, O.G.; Holkesvik, A.H.; Augestad, L.B. Digital learning in mathematics for students with severe visual impairment: A systematic review. Br. J. Vis. Impair. 2020 , 38 , 38–57. [ Google Scholar ] [ CrossRef ]
• Klingenberg, O.G.; Holkesvik, A.H.; Augestad, L.B.; Erdem, E. Research evidence for mathematics education for students with visual impairment: A systematic review. Cogent Educ. 2019 , 6 . [ Google Scholar ] [ CrossRef ]
• Koehler, K.; Wild, T. Students with visual impairments’ access and participation in the science curriculum: Views of teachers of students with visual ompairments. J. Sci. Educ. Stud. Disabil. 2019 , 22 , 1–17. [ Google Scholar ] [ CrossRef ]
• Teke, D.; Sozbilir, M. Teaching energy in living systems to a blind student in an inclusive classroom environment. Chem. Educ. Res. Pract. 2019 , 20 , 890–901. [ Google Scholar ] [ CrossRef ]
• Pino, A.; Viladot, L. Teaching-Learning resources and supports in the music classroom: Key aspects for the inclusion of visually impaired students. Br. J. Vis. Impair. 2019 , 37 , 17–28. [ Google Scholar ] [ CrossRef ]
• Rogers, S. Learning braille and print together—The mainstream issues. Br. J. Vis. Impair. 2007 , 25 , 120–132. [ Google Scholar ] [ CrossRef ]
• West, J.; Houghton, S.; Taylor, M.; Ling, P.K. The perspectives of Singapore secondary school students with vision impairments towards their inclusion in mainstream education. Australas. J. Spec. Educ. 2004 , 28 , 18–27. [ Google Scholar ] [ CrossRef ]
• Haegele, J.A.; Lieberman, L.J. The current experiences of physical dducation teachers at schools for blind students in the United States. J. Vis. Impair. Blind. 2016 , 110 , 323–334. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Brody, L.E.; Mills, C.J. Gifted children with learning disabilities: A Review of the Issues. J. Learn. Disabil. 1997 , 30 , 282–296. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Whitmore, J.; Maker, C.J. Intellectual Giftedness in Disabled Persons ; Aspen Publication: New York, NY, USA, 1985. [ Google Scholar ]
• Besnoy, K.D.; Manning, S.; Karnes, F.A. Screening students with visual impairments for intellectual giftedness—A pilot study. RE view Rehabil. Educ. Blind. Vis. Impair. 2006 , 37 , 134–141. [ Google Scholar ] [ CrossRef ]
• Johnson, L. Teaching the visually impaired gifted youngster. J. Vis. Impair. Blind. 1987 , 81 , 51–52. [ Google Scholar ] [ CrossRef ]
• Porter, J.; Lacey, P. Safeguarding the needs of children with a visual impairment in non-VI special schools. Int. J. Disabil. Dev. Educ. 2014 , 65 , 108–118. [ Google Scholar ] [ CrossRef ]
• Morris, C.; Sharma, U. Facilitating the inclusion of children with vision impairment: Perspectives of itinerant support teachers. Australas. J. Spec. Educ. 2011 , 35 , 191–203. [ Google Scholar ] [ CrossRef ]
• Ben-Yehuda, S.; Leyser, Y.; Last, U. The inclusive practices of classroom teachers: A scoping review and thematic analysis. Int. J. Incl. Educ. 2011 , 15 , 17–34. [ Google Scholar ]
• Sirriyeh, R.; Lawton, R.; Gardner, P.; Armitage, G. Reviewing studies with diverse designs: The development and evaluation of a new tool. J. Eval. Clin. Pract. 2012 , 18 , 746–752. [ Google Scholar ] [ CrossRef ] [ PubMed ]

Click here to enlarge figure

Share and Cite

Miyauchi, H. A Systematic Review on Inclusive Education of Students with Visual Impairment. Educ. Sci. 2020 , 10 , 346. https://doi.org/10.3390/educsci10110346

Miyauchi H. A Systematic Review on Inclusive Education of Students with Visual Impairment. Education Sciences . 2020; 10(11):346. https://doi.org/10.3390/educsci10110346

Miyauchi, Hisae. 2020. "A Systematic Review on Inclusive Education of Students with Visual Impairment" Education Sciences 10, no. 11: 346. https://doi.org/10.3390/educsci10110346

Article Metrics

Article access statistics, further information, mdpi initiatives, follow mdpi.

Subscribe to receive issue release notifications and newsletters from MDPI journals

Emerging Technologies for Blind and Visually Impaired Learners: A Case Study

• First Online: 31 May 2023

Cite this chapter

• Regina Kaplan-Rakowski 9 &
• Tania Heap 9  

Part of the book series: Educational Communications and Technology: Issues and Innovations ((ECTII))

266 Accesses

Blind and visually impaired (BVI) people frequently encounter challenges in their daily lives. With the COVID-19 pandemic, some of those challenges decreased, but some became more evident. The goal of this chapter is two-fold. First, we present the findings of a qualitative case study of a blind student sharing reflections of his daily barriers with online learning during the COVID-19 pandemic, his success strategies, and his impressions of using emerging technologies. Second, we discuss guidelines on using traditional and innovative technologies to assist BVI individuals. The chapter has practical implications not only for the BVI population but also for all students, applying principles of Universal Design for Learning (UDL) and illustrating the responsibility of stakeholders for inclusive policies on the implementation of assistive technologies and accessible learning experiences.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save.

• Get 10 units per month
• Download Article/Chapter or eBook
• 1 Unit = 1 Article or 1 Chapter
• Cancel anytime
• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Available as EPUB and PDF
• Compact, lightweight edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info
• Durable hardcover edition

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Throughout this chapter, the authors will use both person-first language, which places the person before their characteristic (e.g., people with disabilities) and identity-first language, which leads with the person’s characteristic (e.g., blind user). There are pros and cons to using either approach, but when the opportunity presents, a good practice is to ask each individual which language they prefer.

Aisami, R. S. (2015). Learning styles and visual literacy for learning and performance. Procedia-Social and Behavioral Sciences, 176 , 538–545.

Article   Google Scholar  

Alobaid, A. (2021). ICT multimedia learning affordances: Role and impact on ESL learners' writing accuracy development. Heliyon, 7 (7), e07517.

An, Y., Kaplan-Rakowski, R., Yang, J., Conan, J., Kinard, W., & Daughrity, L. (2021). Examining K-12 teachers’ feelings, experiences, and perspectives regarding online teaching during the early stage of the COVID-19 pandemic. Educational Technology Research and Development, 69 (2), 2589–2613. https://doi.org/10.1007/s11423-021-10008-5

Bartolic, S., Matzat, U., Tai, J., Burgess, J. L., Boud, D., Craig, H., Archibald, A., De Jaeger, A., Kaplan-Rakowski, R., Lutze-Mann, L., Polly, P., Roth, M., Heap, T., Agapito, J., & Guppy, N. (2022). Student vulnerabilities and confidence in learning in the context of the COVID-19 pandemic. Studies in Higher Education, 47 , 1–13.

Baumgartner, E., Hartshorne, R., Kaplan-Rakowski, R., Mouza, C., & Ferdig, R. E. (Eds.). (2022). A Retrospective of teaching, technology, and teacher education during the COVID-19 pandemic . Association for the Advancement of Computing in Education (AACE).

Google Scholar  

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3 , 77–101.

Brown, S. E. (2008). Breaking barriers: The pioneering disability students services program at the University of Illinois, 1948–1960. In The history of discrimination in US education (pp. 165–192). Palgrave Macmillan.

Buetow, S. (2010). Thematic analysis and its reconceptualization as saliency analysis. Journal of Health Services Research and Policy, 15 (2), 123–125.

Burgstahler, S. (2020). Creating inclusive learning opportunities in higher education: A universal design toolkit (pp. 47–48). Harvard Education Press.

Burgstahler, S., & Crawford, L. (2020). The development of accessibility recommendations for online learning researchers. In S. Burgstahler (Ed.), Universal design in higher education: Promising practices . DO-IT, University of Washington. Retrieved from: www.uw.edu/doit/UDHE-promisingpractices/preface.html

Caldwell, B., Cooper, M., Reid, L. G., Vanderheiden, G., Chisholm, W., Slatin, J., & White, J. (2008). Web content accessibility guidelines (WCAG) 2.0. WWW Consortium (W3C), 290, 1–34.

CAST. (2018). Universal design for learning guidelines version 2.2 . Retrieved from: http://udlguidelines.cast.org

Crossland, M. D., Starke, S. D., Wolffsohn, J. S., & Webster, A. R. (2019). Benefit of an electronic head-mounted low vision aid. Ophthalmic & Physiological Optics, 39 (6), 422–431.

Crutchfield, B., & Haugh, J. (2018). Accessibility in the virtual/augmented reality space. CSUN 2018 Assistive Technology Conference, San Diego, CA, March 22.

Enoch, J., McDonald, L., Jones, L., Jones, P. R., & Crabb, D. P. (2019). Evaluating whether sight is the most valued sense. JAMA Ophthalmology, 137 (11), 1317–1320.

Ferdig, R. E., Baumgartner, E., Hartshorne, R., Kaplan-Rakowski, R., & Mouza, C. (2020). Teaching, technology, and teacher education during the COVID-19 pandemic: Stories from the field . Association for the Advancement of Computing in Education (AACE). Retrieved from: https://www.learntechlib.org/p/216903/

Ferdig, R. E., Baumgartner, E., Mouza, C., Kaplan-Rakowski, R., & Hartshorne, R. (2021). Editorial: Rapid publishing in a time of COVID-19: How a pandemic might change our academic writing practices. Contemporary Issues in Technology and Teacher Education, 21 (1).

Hartshorne, R., Baumgartner, E., Kaplan-Rakowski, R., Mouza, C., & Ferdig, R. E. (2020). Special issue editorial: Preservice and inservice professional development during the COVID-19 pandemic. Journal of Technology and Teacher Education, 28 (2), 137–147. https://www.learntechlib.org/primary/p/216910/

Huber, E., Chang, K., Alvarez, I., Hundle, A., Bridge, H., & Fine, I. (2019). Early blindness shapes cortical representations of auditory frequency within auditory cortex. Journal of Neuroscience, 39 (26), 5143–5152.

Kaplan-Rakowski, R. (2021). Addressing students’ emotional needs during the COVID-19 pandemic: A perspective on text versus video feedback in online environments. Educational Technology Research and Development, 69 (1), 133–136. https://doi.org/10.1007/s11423-020-09897-9

Kent, M., Ellis, K., Latter, N., & Peaty, G. (2018). The case for captioned lectures in Australian higher education. TechTrends, 62 (2), 158–165.

King, A. J. (2014). What happens to your hearing if you are born blind? Brain, 137 (1), 6–8.

Kriemeier, J., & Götzelmann, T. (2020). Two decades of touchable and walkable virtual reality for blind and visually impaired people: A high-level taxonomy. Multimodal Technologies and Interaction, 4 (4), 79. https://doi.org/10.3390/mti4040079

Kuri, N. P., & Truzzi, O. M. S. (2002). Learning styles of freshmen engineering students. In Proceedings of the International Conference on Engineering Education (ICEE 2002).

Lavrakas, P. J. (2008). Encyclopedia of survey research methods . Sage Publications.

Book   Google Scholar  

Lee, D., & Cho, J. (2022). Automatic object detection algorithm-based braille image generation system for the recognition of real-life obstacles for visually impaired people. Sensors (Basel), 22 (4), 1601, 1–22. Retrieved from:. https://doi.org/10.3390/s22041601

Longhurst, G. J. (2021). Teaching a blind student anatomy during the Covid-19 pandemic. Anatomical Sciences Education, 14 (5), 586–589.

Lueders, K., Perla, F., Maffit, J., Vasile, E., Jay, N., Kaplan, J., & Hanuschock, W. E., III. (2020). Remote instruction for students who are blind or visually impaired: Experiences of preservice interns. In R. E. Ferdig, E. Baumgartner, R. Hartshorne, R. Kaplan-Rakowski, & C. Mouza (Eds.), Teaching, technology, and teacher education during the COVID-19 pandemic: Stories from the field . Association for the Advancement of Computing in Education (AACE).

Mayer, R. E. (2009). Multimedia learning (2nd ed.). Cambridge University Press.

McBride, C. R. (2020). Critical issues in education for students with visual impairments: Access to mathematics and the impact of the Covid-19 pandemic [Unpublished doctoral dissertation] University of Georgia.

McDonnall, M. C., & Sui, Z. (2019). Employment and unemployment rates of people who are blind or visually impaired: Estimates from multiple sources. Journal of Visual Impairment & Blindness, 113 (6), 481–492.

Mills, A. J., Durepos, G., & Wiebe, E. (2010). Reflexivity. Encyclopediaof case study research. SAGE Publications, Inc. https://doi.org/10.4135/9781412957397

Morgan, H. (2022). Alleviating the challenges with remote learning during a pandemic. Education Sciences, 12 (2), 109, 1–12, Retrieved from:. https://doi.org/10.3390/educsci12020109

Mouza, C., Hartshorne, R., Baumgartner, E., & Kaplan-Rakowski, R. (2022). Special issue editorial: A 2025 vision for technology and teacher education. Journal of Technology and Teacher Education, 30 (2), 107–115.

Paivio, A. (1986). Mental representations: A dual-coding approach . Oxford University Press.

Rodríguez, A., Boada, I., & Sbert, M. (2018). An Arduino-based device for visually impaired people to play videogames. Multimedia Tools and Applications, 77 (15), 19591.

Rose, D. (2000). Universal design for learning. Journal of Special Education Technology, 15 (3), 45–49.

Russ, S., & Hamidi, F. (2021, April). Online learning accessibility during the COVID-19 pandemic. In Proceedings of the 18th International Web for All Conference (pp. 1–7).

Siu, A. F., Sinclair, M., Kovacs, R., Ofek, E., Holz, C., & Cutrell, E. (2020). Virtual reality without vision: A haptic and auditory white cane to navigate complex virtual worlds. In Proceedings of the 2020 CHI Conference on Human Factors in Computing Systems, Honolulu, HI, April 25–30 .

Sooraj, V. S., Magadum, H. J., & Alluri, L. (2021, December). iTouch–blind assistance smart glove. In 2021 10th International Conference on System Modeling & Advancement in Research Trends (SMART) (pp. 172–175). IEEE.

Tellis, W. (1997). Introduction to case study. The Qualitative Report, 3 (2).

U.S. Bureau of Labor Statistics. (2022). Persons with a disability: Labor force characteristics summary . Retrieved from: https://bit.ly/2Rt9rgm

WHO. (n.d.). Assistive technology . World Health Organization : Health Topics. Retrieved from: https://www.who.int/health-topics/assistive-technology#tab=tab_1

Zhao, Y., Bennett, C. L., Benko, H., Cutrell, E., Holz, C., Morris, M. R., & Sinclair, M. (2018, April). Enabling people with visual impairments to navigate virtual reality with a haptic and auditory cane simulation. In Proceedings of the 2018 CHI conference on human factors in computing systems (pp. 1–14).

Download references

Author information

Authors and affiliations.

University of North Texas, Denton, TX, USA

Regina Kaplan-Rakowski & Tania Heap

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Regina Kaplan-Rakowski .

Editor information

Editors and affiliations.

Deborah Cockerham

Regina Kaplan-Rakowski

Wellesley Foshay

Michael J. Spector

Interview Questions to Jarrod

Online learning

What aspects of online learning work well for you?

What aspects of online learning do not work well for you?

How did the shift to online learning due to the COVID-19 pandemic impacted you?

How did the shift to online learning due to the COVID-19 pandemic impacted your community?

What support did you receive?

What support did you wish you had received?

How has the shift to online learning due to COVID-19 informed your opinion about the future of digital accessibility?

What does not work well for you? How accurate is dictation? Do you feel it is improving?

What can be done differently or better?

What technologies have you been using that are helpful to you?

What innovative technologies are you aware of that you think could be helpful to you?

What about screen readers?

What about smart speakers?

As an assistive technology user and an experienced gamer, what advice do you have for game designers and professors using gaming in their courses?

An additional question:

How much understanding of your situation do you think the sighted people have?

Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Kaplan-Rakowski, R., Heap, T. (2023). Emerging Technologies for Blind and Visually Impaired Learners: A Case Study. In: Cockerham, D., Kaplan-Rakowski, R., Foshay, W., Spector, M.J. (eds) Reimagining Education: Studies and Stories for Effective Learning in an Evolving Digital Environment. Educational Communications and Technology: Issues and Innovations. Springer, Cham. https://doi.org/10.1007/978-3-031-25102-3_16

Download citation

DOI : https://doi.org/10.1007/978-3-031-25102-3_16

Published : 31 May 2023

Publisher Name : Springer, Cham

Print ISBN : 978-3-031-25101-6

Online ISBN : 978-3-031-25102-3

eBook Packages : Education Education (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

Academia.edu no longer supports Internet Explorer.

To browse Academia.edu and the wider internet faster and more securely, please take a few seconds to  upgrade your browser .

Enter the email address you signed up with and we'll email you a reset link.

• We're Hiring!
• Help Center

Identifying and minimising barriers to Iearning for children with visual impairment: four case study scenarios

In my role as QTVI, using a qualitative case study design (Cohen et al., 2011) with some element of Ethnography (Coffey, 1999), I unpicked barriers to learning for four children with visual impairment on my caseload. My specialist teacher role provided a professional ‘identity dimension’ (Coffey, 1999:1) for undertaking ethnographic fieldwork and therefore, as researcher, I became an integral part of the research process. According to Coffey (1999:1), ‘In writing, remembering and representing our fieldwork experiences we are involved in processes of self presentation’ and this use of my ‘insiders perspective’ (Taylor, 2002:2) led to further professional identity construction. Choosing an explorative case-study design helped me to develop an in-depth understanding of the learning barriers for CYPVI (McMillan and Schumacher, 2006). Pseudonyms were used to protect children’s real identity (Appiah, 2005) whilst employer authorisation permitted me to share documented information. My aim with this paper was to share new insights on the identification and minimisation of barriers during learning experiences, and in doing so, contribute to solid evidence-based VI practice and inclusive education. My paper outlined the holistic needs of four very different cases, discussed intrinsic biological and extrinsic systemic barriers that influence full participation and engagement in classrooms. Theoretical and conceptual frameworks underpinned my thinking and decision processes and has been weaved through discussions.

Related Papers

Dr Benita McLachlan

Working in a new specialist teaching role within visual impairment education can be complex. Using ethnographic data and the author’s own reflexivity from reflective teaching journals, this paper demonstrates a new teacher’s knowledge and understanding on assessment processes for children and young people with visual impairment. Reflective and active learning are the cornerstones within practitioner research and whilst this paper aims to support other new specialist teachers of children and young people with assessments it additionally aims to enter an academic debate on visual impairment practice.

International Journal of Educational Development

Steve Njoroge

Local Education Authorities (LEAs) in Britain traditionally employ Visual Impairment (VI) Teams as integrative statutory Special Educational Needs and Inclusion (SENI)

My theoretical essay aims to bring a critical professional voice to the already much-debated ‘inclusive education’ arena. The focus is on teachers and their acceptance of constant political change, their ability to develop a conceptual understanding for change and self-learning. It argues a brief synopsis of historical and political developments that has been crucial for sustained and meaningful education for children with special educational needs and disabilities. The author’s inner perspective and reflexivity draw from ethnographical experiences as a specialist teacher, relevant literature and up-to-date disability research.

Bronwen Scott

European Journal of Special Needs Education

Danielle Hinton

This paper reports on work undertaken within phase 2 of a research study concerned with the use of online problem‐based learning (PBL) resources with teachers studying for a specialist qualification through distance education. The principal aim of this phase was to explore how pilot online PBL resources could be effectively embedded within two modules of a restructured programme of study in visual impairment. Following participation in the online components, participants completed a questionnaire designed to collect information on various aspects of their engagement in the activities. The findings presented in this paper relate to the format and design of the online PBL case scenarios, and, in particular, to the role of these in helping to develop participants’ self‐reported knowledge and understanding in relation to the module learning outcomes. Findings suggest that these resources can be used to develop knowledge and understanding in relation to selected module learning outcomes, and through further research could have an important role to play in the future professional development of practitioners supporting children with special needs.

Study of an inclusive intervention programme in pictorial perception with blind and sighted students.

Carmen Carpio de los Pinos

Abstract: This study evaluates the effectiveness of an intervention programme administered to blind and sighted school students. The students were given information concerning style, author and technique of three paintings from three different artistic periods, as well as guidelines to assess the overall aesthetics of each image. This programme was administered to 28 participants: 7 totally blind (the entire population of blind students in Castilla-La Mancha) and 21 sighted peers. Several methods of accessibility, such as verbal description of the content, sounds from the scenes and music from the artistic period, were implemented. Blind students were provided with tactile diagrams instead of reproductions of the paintings. A performance test was designed to assess qualitative and quantitative aspects and the collected data were analysed. Learning outcomes of blind and sighted students were compared after intervention and one month later. We found no significant differences between blind and sighted peers in content acquisition or aesthetic appreciation of the images. These results support the suitability of common accessible instructional strategies for the inclusion of blind students.

Research in Developmental Disabilities

Konstantinos Papadopoulos

The present study explored the total adaptive behavior of children and adolescents with visual impairments, as well as their adaptive behavior in each of the domains of Communication, Daily Living Skills, and Socialization. Moreover, the predictors of the performance and developmental delay in adaptive behavior were investigated. Instrumentation included an informal questionnaire and the Vineland Adaptive Behavior Scales (Survey Form). Forty-six children and adolescents with visual impairments participated. The results reveal the effect of age on total adaptive behavior and on each of the domains of Communication, Daily Living Skills, and Socialization; the older individuals with visual impairments present better performance but also a higher rate of delay in comparison with younger individuals. Moreover, the ability of independent movement is a predictor of performance and developmental delay on the Daily Living Skills and Socialization. The more independent the mobility of individuals with visual impairments is the better the performance and the lower the level of developmental delay. Moreover, the educational level of parents is a predictor of performance and developmental delay on the Communication and Socialization. The higher the educational level of parents the better the performance and the lower the developmental delay.

British Journal of Visual Impairment, 28 (3), 244-259.

David Preece

Loading Preview

Sorry, preview is currently unavailable. You can download the paper by clicking the button above.

RELATED PAPERS

Manuela Francisco

Carolyn Blackburn

International Journal of Early Childhood

Alfredo J. Artiles

Maha Khochen-Bagshaw PhD

III International Council for Education of People with Visual Impairment (ICEVI) Balkan Conference: “Transition of education and rehabilitation” (pp. 329-340). University of Belgrade, Faculty for Special Education and Rehabilitation.

Philippos Katsoulis , panos Kokkotas , Maria Chatzi

Jaqueline Naidoo

Education in Practice

Jane Sjoberg

Asian Journal of Environment- Behavior Studies

Hazreena Hussein

Autism and Child Psychopathology Series

Sathiyaprakash Ramdoss , Cindy Gevarter

British Journal of Visual Impairment

Chemistry Teacher International

Mustafa SOZBILIR

International Conference on Education (ICEdu 2014)

Nor Jannah Hassan

Gelly Manousou

Heather Haynes Smith

Australasian Journal of Special Education

umesh sharma

Journal of Special Education and Rehabilitation

Daniela Dimitrova-Radojichikj

Alison O'Mara-Eves

Ophthalmic and Physiological Optics

Frank Eperjesi , Graeme Douglas

SDU International Journal of Educational Studies

Aydın Kızılaslan

Colette Gray

Assistive Technology Outcomes and Benefits

Emily Bouck , Aman Yadav

International Journal of Education, Psychology and Counseling (IJEPC)

Dr Kyra Pollitt

Carmen Hernandez-Ojeda

Amaal Farra

kunnathodi abdul gafoor

Children's Literature in Education

Jen Scott Curwood

Science Park Research Organization & Counselling

Norshidah Salleh

Philippos Katsoulis , Nikos Vaitsis

RELATED TOPICS

•   We're Hiring!
•   Help Center
• Find new research papers in:
• Health Sciences
• Earth Sciences
• Cognitive Science
• Mathematics
• Computer Science
• Academia ©2024

Fact sheets

• Facts in pictures
• Publications
• Questions and answers
• Tools and toolkits
• Endometriosis
• Excessive heat
• Mental disorders
• Polycystic ovary syndrome
• All countries
• Eastern Mediterranean
• South-East Asia
• Western Pacific
• Data by country
• Country presence 
• Country strengthening 
• Country cooperation strategies 
• News releases
• Feature stories
• Press conferences
• Commentaries
• Photo library
• Afghanistan
• Cholera 
• Coronavirus disease (COVID-19)
• Greater Horn of Africa
• Israel and occupied Palestinian territory
• Disease Outbreak News
• Situation reports
• Weekly Epidemiological Record
• Surveillance
• Health emergency appeal
• International Health Regulations
• Independent Oversight and Advisory Committee
• Classifications
• Data collections
• Global Health Observatory
• Global Health Estimates
• Mortality Database
• Sustainable Development Goals
• Health Inequality Monitor
• Global Progress
• World Health Statistics
• Partnerships
• Committees and advisory groups
• Collaborating centres
• Technical teams
• Organizational structure
• Initiatives
• General Programme of Work
• WHO Academy
• Investment in WHO
• WHO Foundation
• External audit
• Financial statements
• Internal audit and investigations 
• Programme Budget
• Results reports
• Governing bodies
• World Health Assembly
• Executive Board
• Member States Portal
• Fact sheets /

Blindness and vision impairment

• Globally, at least 2.2 billion people have a near or distance vision impairment. In at least 1 billion of these, vision impairment could have been prevented or is yet to be addressed.
• The leading causes of vision impairment and blindness at a global level are refractive errors and cataracts.
• It is estimated that globally only 36% of people with a distance vision impairment due to refractive error and only 17% of people with vision impairment due to cataract have received access to an appropriate intervention.
• Vision impairment poses an enormous global financial burden, with the annual global cost of productivity estimated to be US$ 411 billion.
• Vision loss can affect people of all ages; however, most people with vision impairment and blindness are over the age of 50 years.

Vision, the most dominant of our senses, plays a critical role in every facet and stage of our lives. We take vision for granted, but without vision, we struggle to learn, to walk, to read, to participate in school and to work.

Vision impairment occurs when an eye condition affects the visual system and its vision functions. Everyone, if they live long enough, will experience at least one eye condition in their lifetime that will require appropriate care.

Vision impairment has serious consequences for the individual across the life course. Many of these consequences can be mitigated by timely access to quality eye care. Eye conditions that can cause vision impairment and blindness – such as cataract or refractive error – are, for good reasons, the main focus of eye care strategies; nevertheless, the importance of eye conditions that do not typically cause vision impairment – such as dry eye or conjunctivitis – must not be overlooked. These conditions are frequently among the leading reasons for presentation to eye care services.

Globally, the leading causes of vision impairment and blindness are:

• refractive errors
• diabetic retinopathy
• age-related macular degeneration.

There is substantial variation in the causes of vision impairment between and within countries according to the availability of eye care services, their affordability, and the education of the population. For example, the proportion of vision impairment attributable to unoperated cataract is higher in low- and middle-income countries. In high income countries, diseases such as glaucoma and age-related macular degeneration are more common.

Among children, congenital cataract is a leading cause of vision impairment in low-income countries, whereas in middle-income countries it is more likely to be retinopathy of prematurity.

Uncorrected refractive error remains a leading cause of vision impairment in all countries amongst children and adult populations.

Globally, at least 2.2 billion people have a near or distance vision impairment. In at least 1 billion – or almost half – of these cases, vision impairment could have been prevented or has yet to be addressed.

Among this 1 billion people, the main conditions causing distance vision impairment or blindness are cataract (94 million), refractive error (88.4 million), age-related macular degeneration (8 million), glaucoma (7.7 million), diabetic retinopathy (3.9 million) (1) . The main condition causing near vision impairment is presbyopia (826 million)  (2) .

In terms of regional differences, the prevalence of distance vision impairment in low- and middle-income regions is estimated to be 4 times higher than in high-income regions (1) . With regards to near vision, rates of unaddressed near vision impairment are estimated to be greater than 80% in western, eastern and central sub-Saharan Africa, while comparative rates in high-income regions of North America, Australasia, western Europe, and of Asia-Pacific are reported to be lower than 10% (2) .

Population growth and ageing are expected to increase the risk that more people acquire vision impairment.

Impact of vision impairment

Personal impact.

Young children with early onset irreversible severe vision impairment can experience delayed motor, language, emotional, social and cognitive development, with lifelong consequences. School-age children with vision impairment can also experience lower levels of educational achievement.

Vision impairment severely impacts quality of life among adult populations. Adults with vision impairment can experience lower rates of employment and higher rates of depression and anxiety.

In the case of older adults, vision impairment can contribute to social isolation, difficulty walking, a higher risk of falls and fractures, and a greater likelihood of early entry into nursing or care homes.

Economic impact

Vision impairment poses an enormous global financial burden with an estimate annual global productivity loss of about US$ 411 billion purchasing power parity (3) . This figure far outweighs the estimated cost gap of addressing the unmet need of vision impairment ( estimated at about US$ 25 billion ).

Strategies to address eye conditions to avoid vision impairment

There are effective interventions covering promotion, prevention, treatment and rehabilitation which address the needs associated with eye conditions and vision impairment. While many vision loss cases can be prevented (such as those due to infections, trauma, unsafe traditional medicines, perinatal diseases, nutrition-related diseases, unsafe use or self-administration of topical treatment), this is not possible for all. For many eye conditions, e.g. diabetic retinopathy, early detection and timely treatment are crucial to avoid irreversible vision loss. Spectacle correction for refractive error and surgery for cataract are among the most cost-effective of all health-care interventions. Yet, globally only 36% of people with a distance vision impairment due to refractive error have received access to an appropriate pair of spectacles and only 17% of people with vision impairment or blindness due to cataract have received access to quality surgery.

Treatment is also available for many eye conditions that do not typically cause vision impairment, such as dry eye, conjunctivitis and blepharitis, but generate discomfort and pain. Treatment of these conditions is directed at alleviating the symptoms and preventing the evolution towards more severe stages of those diseases.

Vision rehabilitation is very effective in improving functioning for people with an irreversible vision loss that can be caused by eye conditions such as diabetic retinopathy, glaucoma, consequences of trauma, and age-related macular degeneration.

WHO response

WHO’s work is guided by the recommendations of the  WHO World report on vision (2019)  and the resolution on  "integrated, people-centred eye care, including preventable blindness and vision impairment"  adopted at the Seventy-third World Health Assembly in 2020. The key proposal is to make integrated people-centred eye care (IPEC) the care model of choice and to ensure its widespread implementation. It is expected that by shaping the global agenda on vision and eye care, the report and resolution will assist Member States and their partners in their efforts to reduce the burden of eye conditions and vision.

Some of WHO’s key areas of work and activities in the prevention of blindness include:

• Developing reports of the effective coverage of eye care indicators to monitor progress towards the 2030 global targets .
• Developing resources and technical tools to support the integration of eye care into health information systems .
• Observing and promoting World Sight Day as an annual advocacy event.
• The Eye care in health systems: Guide for action .
• The Package of eye care interventions (PECI) .
• The Eye care competency framework (ECCF) .
• The Eye care situation analysis tool
• The Tool for the assessment of diabetic retinopathy and diabetes management services.
• The Tool for the assessment of glaucoma services.
• The Tool for the assessment of refractive services.
• The Tool for the assessment of rehabilitation services and systems.
• The MyopiaEd: a mobile health toolkit for myopia to increase health literacy .
• A population-facing app for near and distance visual acuity testing.
• Graphics promoting healthy eye habits .

1. GBD 2019 Blindness and Vision Impairment Collaborators; Vision Loss Expert Group of the Global Burden of Disease Study. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: the Right to Sight: an analysis for the Global Burden of Disease Study. Lancet Glob Health. 2021 Feb;9(2):e144-e160. doi: 10.1016/S2214-109X(20)30489-7.

2. Fricke, TR, Tahhan N, Resnikoff S, Papas E, Burnett A, Suit MH, Naduvilath T, Naidoo K, Global Prevalence of Presbyopia and Vision Impairment from Uncorrected Presbyopia: Systematic Review, Meta-analysis, and Modelling, Ophthalmology. 2018 May 9.

3. Burton MJ, Ramke J, Marques AP, Bourne RR, Congdon N, Jones I, et al. The Lancet Global Health commission on Global Eye Health: vision beyond 2020. Lancet Glob Health. 2021; 9(4):e489–e551.

Health topic page

• WHO’s work on eye care, vision impairment and blindness (who.int)

Related links

• Report of the 2030 targets on effective coverage of eye care (who.int) 
• Eye care in health systems: guide for action (who.int) 
• World report on vision (who.int) 

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Clin Ophthalmol

Visual Impairment and Mental Health: Unmet Needs and Treatment Options

Docia l demmin.

1 Department of Psychology, Rutgers University, Piscataway, NJ, USA

Steven M Silverstein

2 Departments of Psychiatry, Neuroscience, and Ophthalmology, University of Rochester, Rochester, NY, USA

An estimated 2.2 billion people are visually impaired worldwide. Given that age-related vision loss is a primary cause of vision impairment, this number is projected to rise with increases in average lifespan. Vision loss often results in significant disability and is associated with a substantial economic burden, reduced quality-of-life, concurrent medical issues, and mental health problems. In this review, the mental health needs of people with vision impairment are examined.

Patients and methods

A review of recent literature on mental health outcomes and current treatments in people with visual impairment was conducted.

Considerable data indicate that rates of depression and anxiety are elevated among people with visual impairments. Moreover, individuals of lower socioeconomic status may be at increased risk for vision impairment and subsequent mental health problems. Existing psychosocial interventions for improving mental health in people with visual impairment show some promise, but are limited by low adherence and lack generalizability.

In order to improve outcomes, a better understanding of the mechanisms linking visual impairment and poor mental health is needed. It will also be essential to develop more effective interventions and expand access to services to improve the detection and treatment of mental health problems in this population.

Introduction

Impairments in vision are highly prevalent, affecting roughly 2.2 billion people worldwide. 1 Of these individuals, approximately 36 million are blind, and an estimated 217 million have marked (ie, moderate-to-severe) visual impairment. 2 In the US, age-related vision loss is a leading cause of disability among aging adults, primarily resulting from eye diseases such as macular degeneration, cataracts, glaucoma, and diabetic retinopathy. 3 Consequently, as increases in longevity raise the average age of the population, the incidence of visual impairment is also projected to grow, with global rates of blindness tripling and moderate-to-severe vision impairment doubling over the next 30 years. 2 As the prevalence of vision impairments continues to rise, so does the need to better understand the wide-ranging impact of these impairments on an individual’s mental health, quality-of-life, and overall well-being.

Vision impairments often result in significant disability and are associated with a substantial economic burden (estimated at more than $3 trillion globally) attributable to both direct and indirect (eg, productivity loss) costs. 4 In addition to the economic impact of blindness and vision loss, vision impairment is associated with reduced quality-of-life, 5 unintentional injuries, 6 and loneliness. 7 Moreover, individuals with visual impairment may be at greater risk for developing mental health problems, such as depression and anxiety. 8 However, because vision loss is conceptualized as a physical problem, the psychological sequelae of vision impairment may be under-recognized. In this review we examine the prevalence, development, and treatment of mental health problems in visually impaired populations.

Part I: Vision Loss and Mental Health

Depression in visually impaired populations.

A sizable body of literature suggests that people with vision impairment are at increased risk for specific mental health problems. In particular, a number of studies have demonstrated a link between vision impairment and depression (eg, 9–11 ). Nearly one third of individuals with visual impairments and disabling eye diseases experience mild depressive symptoms, 12 while 10.7–45.2% of study samples report clinically significant (ie, moderate-to-severe) depressive symptoms. 10–14 In one study of adults aged 20 and older, 10.7% of individuals with visual acuity impairment (ie, worse than 20/40, but not including complete blindness) endorsed clinically significant levels of depression, as opposed to 6.8% of people without acuity impairment. 11 In a study of adults with more severe visual impairment (acuity worse than 20/60 or blindness), 45.2% of the sample reported moderate depressive symptoms as compared to 16.6% in the normal to near-normal vision group. 10 Additionally, data from community samples indicates that people with low vision and/or blindness are 1.6–2.8-times more likely to develop depression compared to those without vision impairment, 10 , 11 even after controlling for demographic variables (but not after accounting for socioeconomic and health characteristics 11 ). However, visual impairment has been shown to increase the risk of depression (hazard ratio=1.22), even after adjusting for demographic, socioeconomic, and health factors. 9 Subjective evaluations of vision loss also appear to be linked with depression. In several studies, individuals with reported loss of visual function (eg, difficulty reading newsprint, going down steps) endorsed higher levels of depressive symptoms, with 11.3–20.8% experiencing moderate-to-severe depression, 11 , 15 as compared to 4.8% of people with no impairment in visual function. 11 Moreover, in one of these studies a relationship between depressive symptom severity and number of reported visual function problems was observed. 11 These findings indicate that rates of depression are significantly increased in people with varying degrees of vision loss.

Importantly, elevated rates of depressive symptoms have been observed in a range of different visually impaired populations. For example, in a study of retinitis pigmentosa, approximately 26% of the sample reported clinically significant depressive symptoms, despite relatively normal (central) visual acuity. 16 Similarly, nearly 30% of individuals with non-infectious ocular inflammatory disease but normal to near normal acuity endorsed mild-to-severe levels of depression. 17 However, other findings indicate that certain eye conditions may confer a relatively greater risk for depression. In a study by Cumurcu et al, 18 depression scores were significantly higher among people with pseudoexfoliative glaucoma, which has been associated with faster rates of progression and poorer treatment response, compared with primary open-angle glaucoma and age-matched controls, although groups did not differ significantly in rates of depressive disorder diagnoses. In another study, patients with primary angle-closure glaucoma, where vision loss occurs rapidly, reported higher levels of depressive symptoms than did patients with primary open-angle glaucoma, where vision loss is progressive, and normal-vision controls. 19 Some data also suggest that depression severity may depend on the nature and onset of vision loss. For example, Koenes and Karshmer 20 reported that depression scores were significantly higher in a sample of adolescents who were legally blind since birth relative to their sighted peers (though still within the mild range). However, in another study there was no significant difference between adolescents with congenital blindness and peers without visual impairment in terms of depression scores, 21 and a third study found rates of psychiatric comorbidity were lower among blind children and adolescents (approximately 9%) when compared with community prevalence estimates (approximately 13%). 22 Thus, while depression is a significant problem for many people with vision impairment, vision loss very early in life may be associated with less severe depression, perhaps due to a lesser need to relearn life skills compared to people who lose vision later in life.

Anxiety in Visually Impaired Populations

Fewer studies have investigated rates of anxiety among visually impaired populations. However, there is some evidence for increased prevalence. Donoyama and Takeda 23 found that massage practitioners with visual impairment reported higher levels of anxiety in comparison to same-age individuals in the general population. In newly-diagnosed glaucoma patients, roughly 35% of the study sample reported experiencing nervousness, anxiety, or stress; however, none of these patients had significant visual impairment (acuity 20/40 or better) and anxiety symptom severity did not correlated with degree of vision impairment. 24 This suggests that concern about having to live with vision loss in the future, and/or having to cope with knowledge that one has a progressive condition, can contribute to anxiety, even in the absence of reduced visual abilities. In another study of adolescents, endorsements of symptoms related to anxiety, tension, and general distress (eg, obsessive-compulsive related symptoms, paranoid symptoms, hostility, total symptoms) were significantly higher in those with vision impairment compared to those without. 25 Additionally, Bolat et al 21 reported that anxiety levels among adolescents with congenital blindness were elevated relative to their sighted peers. In a small sample of female veterans with significant vision loss (ie, acuity 6/60 or worse) or blindness, 11.1% endorsed elevated levels of PTSD-related symptoms, while one in five met criteria for a probable anxiety disorder diagnosis. 14 In another study, patients with primary angle-closure (rapid progression) and primary open-angle (gradual progression) glaucoma reported greater levels of anxiety symptoms than did controls, but prevalence was highest among those with primary angle-closure glaucoma. 19 However, Cumurcu et al 18 found no significant differences in anxiety symptom scores or diagnoses among individuals with pseudoexfoliative glaucoma, primary open-angle glaucoma, and normal vision controls. Therefore, in contrast to a robust association between vision impairment and depression, anxiety may be less pervasive among individuals with vision loss, and its emergence may be significantly mediated by other factors.

Age-Related Vision Loss and Mental Health

Impairments in vision are closely linked with age, and rates of blindness and vision loss increase dramatically with each decade of life over 40 years of age. 26 , 27 Among older adults, age-related macular degeneration (AMD) is a primary cause of vision loss, affecting an estimated 196 million people globally in 2020. 28 As opposed to complete blindness, age-related causes of vision loss often result in partial sight or low vision. However, impairments are generally not correctable by usual means (ie, glasses, contacts, surgical procedures), and individuals commonly experience gradual and continued deterioration. 3 Thus, people with age-related vision loss constitute a large percentage of the visual impairment population. 26 , 28

As mental health conditions are already fairly prevalent among older adults, with estimates of major depression ranging from 1–5% in community samples, 29 older adults with vision impairments may be at even greater risk for mental health problems. Indeed, visual disability has been identified as a strong indicator of depression in older adults. 30 In studies of older adults with vision loss a high prevalence of several mental health conditions, but particularly depression, has been observed. 31–34 Data indicate that up to 8.6% of older adults with vision loss meet criteria for a depressive disorder, 33 , 35 a notably higher percentage than found in the general aging population 29 , and 10.9–43% report clinically significant levels of depressive symptoms. 32 ,– 33 ,– 36–41 Seniors with comorbid depression and vision impairment have higher rates of smoking, obesity, physical inactivity, 42 and poorer evaluations of health, 37 potentially resulting from depressive symptomatology. Nevertheless, even after controlling for socio-economic and health-related factors, vision loss has been identified as a significant predictor of depression in aging adults, both cross-sectionally and longitudinally. 34 , 39 , 43 In AMD, the prevalence of depression may be even higher. In studies of AMD, 10.5–44.4% of participants report moderate-to-severe symptoms of depression, 44–48 and up to 32.5% meet major depressive disorder criteria. 49 Notably, depression rates are similarly elevated in both non-neovascular (ie, dry) AMD, whereby layers of the macula progressively deteriorate, and neovascular (ie, wet) AMD, which involves more rapid and severe vision loss. 50 While AMD is always bilateral, disease progression is not necessarily equilateral; however, data indicate that nearly 30% of patients develop a depressive disorder within a few months of acquiring AMD in their second eye. 47 Increased AMD severity has also been linked with more severe depressive symptoms, 44 , 51 and in some studies a relationship between depressive symptom severity and degree of visual impairment has been observed, 44 but not all. 48 Therefore, depression is a significant issue in visually impaired older adults, and particularly among those with AMD.

Anxiety is also problematic in older adults with visual impairment, although findings have been somewhat mixed. Aging adults with vision impairment have a much higher prevalence of anxiety disorders in comparison to elderly general population samples, between 7.5–8.6%. 33 , 35 Reported estimates of clinically significant anxiety symptoms range from 8.7–15.6% of visually impaired older adults. 33 , 38 , 40 , 45 Additionally, in comparison to elderly adults with other conditions (ie, diabetes, cardiovascular problems), seniors with vision loss endorse a greater number of anxiety symptoms. 52 In AMD, elevated levels of anxiety symptoms have been reported in 9.6–30.1% of study samples. 44 , 45 However, other studies have not observed increased rates of anxiety among visually impaired older adults relative to normal-vision peers, after controlling for age, gender, and other potential confounders (eg, health behaviors, life events, etc.). 36 Some data indicate the risk for anxiety symptoms may be dependent upon the form of ocular pathology in elderly adults. For example, Eramudugolla et al 45 observed a relationship between anxiety symptoms and self-reported cataracts in aging adults, but not other eye diseases (eg, AMD, glaucoma) after controlling for demographic, health, and clinical (eg, treatment, disability) characteristics. Similarly, Augustin et al 44 found no association between anxiety symptom severity and visual acuity in patients with AMD after adjusting for demographic variables. Further supporting a weaker relationship with visual disability than in depression, vision loss predicted anxiety cross-sectionally but not longitudinally in a sample of aging adults. 34 However, while anxiety may not be as strongly related to vision loss as is depression, it is still a significant symptom for many people, and it may emerge even before significant visual disability becomes evident. It is also important to note that there are additional factors that may contribute to anxiety and that need further study, including loss of visual acuity and reductions in night vision, which can occur in the absence of eye disease.

Other Psychological Problems

An increased risk of suicide has also been documented in visually impaired populations. Suicidal ideation has been linked with vision impairment in elderly adults, 53–55 and risk increases with severity of impairment. 53 Vision loss has also been identified as an independent risk factor for suicide among aging adults, and its associated risk is greater than that associated with malignant disease and neurological disorders. 56 In a general population sample, visual acuity was negatively correlated with suicidal ideation and attempts, and individuals with the poorest acuity were 2–3-times more likely to report suicidal ideation or suicide attempts than were those with near-normal vision, even after adjusting for socioeconomic variables. 57 Interestingly, no association between visual acuity and depressive symptoms was observed in this study. 57 Notably, an increased risk of suicide has not been reported in all studies. Stensman et al 58 reported no association between visual impairment and rates of suicide, and Meyer-Rochow et al 59 found elevated rates of suicide only among males with vision loss. In a longitudinal study of adults in the US, individuals with vision impairment were reported to be at elevated risk for suicide after a mean follow-up of 11 years, but completed suicide was not significantly more likely for those with visual impairment as compared to those without, after controlling for other demographic and health factors. 60 However, visual impairment was found to significantly increase suicide risk by 18% indirectly, through effects on reported health (eg, quality of health, number of nonocular health conditions). 60 Together, these data indicate that vision impairment may heighten risk for suicide, by means of both direct and indirect effects.

Interestingly, visual hallucinations may be quite prevalent among individuals with visual impairment (see Menon et al 61 for a review). About 41–59% of patients with visual impairment report experiencing elementary visual hallucinations (eg, colored lights, flashes; 61–64 ). According to reviews, complex visual hallucinations (eg, formed objects/people) are experienced by 5–17.5% of individuals with vision impairment, 61 , 65 and this is referred to as Charles Bonnet Syndrome (CBS). While CBS is most prevalent in older adults with vision impairment, particularly AMD, it has also been reported in children 66 and has been linked with sudden vision loss. 67 The experience of visual hallucinations among visually impaired populations is sometimes reported to be neutral and non-distressing. 61 , 65 However, an estimated one quarter of patients display anger, anxiety, or mild paranoia as a result of these experiences. 61 Depression, 68 social isolation, 69 and cognitive impairment 69 , 70 have also been reported in association with CBS. Though diagnostically CBS requires that insight regarding hallucinations remain intact, patients may nevertheless become confused by these experiences initially and may react accordingly. 61 , 65 Visual hallucinations may also be under-reported by people with visual impairments for fear of being perceived as clinically unstable or psychotic. 61 , 65 Indeed, CBS is often not recognized by medical providers and can be incorrectly identified as a primary psychiatric disorder. 61 Health professionals must be aware of the wide range of symptoms associated with vision impairment.

The Nature of the Relationship Between Vision Impairment and Mental Health

People with vision impairment may experience mental health difficulties for a variety of reasons. Included among these is the emotional distress that is associated with losing one’s sight. Blindness is reported to be one of the most feared health problems; survey data indicate that a greater proportion of individuals fear blindness than fear cancer or paralysis. 71 Self-reported reactions to vision loss include anxiety, 72 worry, 73 frustration, 74 social withdrawal, 75 and embarrassment. 74 Additionally, for individuals with progressive vision loss, substantial fear and anxiety may be experienced in anticipation of further reductions in sight. 72 Qualitative data indicate that people with vision loss and blindness may develop negative self-perceptions as a result of societal stigma and experience feelings of loss, similar to bereavement. 76 Vision-specific distress (ie, emotional reactions to vision loss) has been identified as a robust predictor of depressive symptom severity, 12 , 77 independent of degree and duration of vision impairment. 12 Importantly, while vision-specific distress and depression may be strongly related, they are also distinct in their associated risk factors. 77 Thus, distress that is associated with vision loss may be a mechanism by which depression risk is increased in some people with visual impairment.

Vision-specific distress may also account for the association between subjective evaluations of visual function and depressive symptom severity. 17 , 78 In a national sample of adults with vision loss, subjective reports of visual function were predictive of depression even after controlling for demographic, socioeconomic, and health factors, whereas ophthalmologist-measured impairments were not. 11 Similarly, among people with newly-diagnosed glaucoma (with acuity of 20/40 or better), perceptions of difficulty with vision-related tasks was associated with depressive symptom severity, but objective measures of visual function (eg, acuity) were not correlated with depression scores. 24 In patients with retinitis pigmentosa, Hahm et al 16 also observed that subjective evaluations of visual function were lower among those who reported elevated levels of depressive symptoms, as compared to those without significant mood problems. These studies indicate that even the perceived loss of vision may generate significant distress and result in mental health problems.

Depression may also stem from impairments in functioning related to vision loss. As mentioned previously, individuals with vision loss experience a variety of functional limitations, 76 , 79 such as difficulty walking, reading, and driving. 80 Older adults with vision impairment report greater difficulty performing activities of daily living (ADLs) than do aging adults with respiratory, cardiovascular, and metabolic conditions. 52 Moreover, research indicates that people with subjective and objective difficulties performing necessary ADLs are at elevated risk for depression. 81–84 Qualitative interviews indicate that individuals with visual impairments may experience negative emotions when they are no longer able to engage in work or meaningful activities that are central to their identity. 74 While both vision impairment and depression are independently associated with functional decline, together these conditions may result in even greater disability than either condition alone. For example, Bookwala and Lawson 85 found that poorer self-reported visual function predicted greater depression in a sample of aging adults; however, a significant indirect effect of vision impairment on depressive symptom severity was also observed, via increased functional limitations and social isolation. In another study, older adults with both vision loss and depression reported greater difficulty performing a number of ADLs as compared to those with either condition alone. 86 Thus, for some individuals with vision impairment, the development of mood problems may be a consequence of functional impairment.

Age is another factor that may contribute towards an increased risk for mental health problems in people with visual impairment. As stated above, rates of visual impairment increase substantially with age, 26 and 6.6% of adults over 65 are visually impaired in the US. 87 Depressive symptoms are commonly experienced by aging adults in the general population, and often go untreated. 88 Furthermore, factors associated with the onset of depression later in life include functional impairment and poor health. 89 , 90 Therefore, age may be a confounding variable in the high prevalence of depression in people with visual impairments. However, in a population-based study of older adults with vision loss, younger age was identified as a significant predictor of depressive symptoms, after controlling for additional health factors, 78 suggesting that individuals with vision impairment may be at heightened risk for mental health problems in the transition into later adulthood, possibly because of negative expectations about the future. Depression risk may also depend on type and severity of visual impairment, as shown in a 10-year follow-up study of people aged 65 and older. Older adults with a recent decline in distance visual function were at a 3-fold risk of developing depressive symptoms over the follow-up period. Conversely, older adults reporting depressive symptoms at baseline had a 62% increased likelihood of having visual function loss after 10 years, even after controlling for sociodemographic variables, medical comorbidity, cognitive impairment, antidepressant use, and past depressive episodes. 91 These data demonstrate that multiple variables, including pre-vision loss tendencies towards depression, attitudes and expectations about aging, age-related vision loss, and age and severity of vision loss may contribute to increases in depression in older adults.

Individuals with vision impairment may also experience distress with regards to treatment. For example, injections, directly into the eye, of vascular endothelial growth factor inhibitors (anti-VEGF) are an available treatment for people with neovascular (ie, wet) AMD. 92 Anti-VEGF treatment may be perceived as stressful due to anticipatory anxiety about pain or discomfort. 93 However, one study observed that 56% of patients with neovascular AMD had anxiety regarding anti-VEGF treatment, but only 3.3% of patients reported anxiety related to injection pain; rather most patients reported concern regarding potential complications and treatment efficacy. 94 Additionally, anxiety surrounding anti-VEGF treatment did not change with the number of injections received, indicating that these symptoms may be somewhat enduring. 94 Treatment providers must be aware that visually impaired populations may experience anxiety concerning their health, healthcare, and treatment options.

Overall, the relationship between mental health and vision impairment may be bidirectional (see Figure 1 ). 11 For instance, depression might elevate risk for ocular disease through a number of poor health behaviors, such as an unhealthy diet, tobacco and other substance use, and treatment non-compliance. 42 , 95 , 96 Antidepressant medications may also have ocular effects. Both tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) have been associated with an increased risk for mydriasis (pupil dilation) which in turn increases the risk of angle-closure glaucoma. 97 Additionally, known neurotransmitter dysfunction (eg, dopamine, GABA) in the brain in people with depression may have implications for the visual system overall, including for ocular function (eg, reduced retinal sensitivity 98 , 99 ) and visual processing (eg, reduced contrast sensitivity 100 , 101 ). However, while at times mental health problems may be an antecedent to vision loss, the literature reviewed above indicates that often mental health problems are a consequence of vision impairment. Distress and functional impairment that are associated with vision loss may elicit a variety of psychological problems, and, in particular, affect one’s mood. 85 , 86 , 102 As noted above, knowing that one has a disorder of vision can have psychological consequences, even in the absence of obvious visual impairment. Furthermore, among visually impaired and visually disabled individuals, depression and anxiety may be worsened as a result of social isolation or an inability to work. 74 , 85 However, the effects of each of these factors may be intertwined. In a study of adults with vision loss, reduced activity participation due to vision impairment was related to depression, however, vision-specific distress was identified as a mediator of this effect. 12 The relationship between age, mental health, and vision loss also appears to be bidirectional. In a longitudinal study of older adults, Frank et al 34 found that self-reported vision status was a significant predictor of future depression, whereas baseline depression and anxiety were associated with future self-reported vision impairment, even after adjusting for sociodemographic and other health characteristics. Thus, more longitudinal studies are needed, in individuals across the lifespan, in order to clarify the direct and indirect effects of vision impairment on mental health.

Bidirectional interaction between visual impairment and mental health problems.

Socioeconomic and Demographic Considerations

Low socioeconomic status is a risk factor for vision impairment (see 103 for review). Globally, low vision has been associated with economic disadvantage. 104 , 105 Rates of visual impairment are higher in low income countries as compared to high income countries, and the prevalence of blindness has been inversely correlated with nations’ gross domestic product (GDP). 105 Across many nations, visual impairment has been linked with household income, 106 and people living in impoverished neighborhoods have been reported to be at increased risk of vision impairment or blindness. 107–111 A relationship between visual impairment and education has also been widely observed, where lower education attainment is associated with higher rates of visual impairment. 106 , 112 , 113 For example, a study in the US reported that rates of visual impairment were highest among individuals who did not graduate from high school. 114 In addition, social class may be a factor in visual impairment risk. Among middle-aged working adults in England, the prevalence of vision impairment was reported to be 1.9% among professionals (Class I) and 5% among unskilled manual workers (Class V), and risk for visual impairment increased by 28% with each descent in social grade. 115 Individuals with lower socioeconomic position are more likely than those of higher socioeconomic position to develop vision impairment, in both developed and developing nations. 109 , 111 , 112 , 116 Furthermore, in a British longitudinal birth cohort study an association between low socioeconomic position in childhood and earlier adulthood and risk for visual impairment in mid-adulthood was observed. 115 Results from an annual household survey administered to nearly 70,000 adults in the US over a 3-year period indicated that lower levels of education and household income were associated with vision impairment, even after adjusting for demographic characteristics, health behaviors (eg, smoking), health conditions (eg, diabetes, hypertension), and healthcare access (eg, medical insurance). 114 However, another study found that substance use mediated the relationship between low socioeconomic status and vision impairment. 117 Nevertheless, together these data indicate that socioeconomic disadvantage increases the likelihood of vision impairment, directly and/or indirectly.

Certain demographic variables have also been linked with heightened risk of vision impairment. 103 Some data indicate that race and ethnicity are not related to the prevalence of visual impairments, after controlling for age, socioeconomic variables, and refractive error. 118 However, in a study of visual impairment in a Latino/Hispanic population, the prevalence of vision impairment was much higher than rates reported in non-Hispanic White samples and other population-based studies in the US. 119 Additionally, in a study of older adults with vision loss, non-White ethnicity was associated with a greater risk for depression, even after controlling for age, gender, and health. 120 Data also indicate that African-Americans experience the highest prevalence of visual impairment, 27 and may be at especially high risk for conditions such as open-angle glaucoma. 121 Still, it is uncertain whether an increased prevalence of vision impairment in certain racial or ethnic groups might be a function of low socioeconomic status and/or marginalization, particularly as these variables are not always controlled for (eg, Rahi et al 115 ). Gender is another factor that has been associated with visual impairment risk. 122 , 123 According to recent estimates, the prevalence of vision impairment in women is 1.3-times that of men. 27 One potential explanation for the relationship between vision loss and gender is that the average lifespan of women is longer than that of men, and as rates of vision impairment increase significantly with age it might be expected that women would experience a higher prevalence of visual impairment and eye disease. 123 , 124 Nonetheless, even after controlling for age, higher rates of vision impairment in women have been observed. 125 Other studies, however, report that rates of vision loss are fairly equal among men and women after age adjustments. 26 Importantly, among older adults with vision loss, female gender has been identified as a unique predictor of subthreshold depression, after adjusting for age, psychiatric history, and health status. 126 These data are consistent with findings of higher rates of depression and anxiety among women as compared to men in the general population (potentially resulting from gender (eg, symptom manifestation) and sex differences (eg, hormonal effects, genetic predisposition) 127 , 128 ); and suggests that women with vision impairment may be at increased risk for developing mental health problems. Thus, the risk for visual impairment and related outcomes may be influenced by demographic characteristics, such as ethnicity and gender.

Health Inequity as a Result of Socioeconomic Disadvantage in Visually Impaired Populations

In visually impaired populations a number of individual and societal factors may interact to restrict access to services. Both physical and mental healthcare may be limited by financial barriers. 129 , 130 For example, in one study of older adults with visual impairment, those who reported severe levels of depressive symptoms had less education, lower income, and were more likely to be a racial or ethnic minority, 42 and these populations may have less access to quality eye care and lower quality health insurance. Relatedly, many mental health providers may not offer a sliding scale or accept Medicare/Medicaid insurance. 129 As an example, among AMD patients, depression scores were significantly improved in older adults who received four to 12 anti-VEGF treatments as compared to those who received three or less injections. 94 However, these treatments can be quite costly, and so the full course of treatment may not be accessible to a portion of individuals with AMD. As another example, cataract surgery is a cost-effective intervention 131 and has been shown to ameliorate hallucinations and depression among people with vision impairment. 61 , 132 Nevertheless, these vision problems may remain untreated in many individuals with visual impairment, as many people of low socioeconomic status are less likely to receive even basic eye care services (eg, spectacle coverage). 107 Therefore, people with vision impairment, many of whom are socioeconomically disadvantaged, may encounter a variety of obstacles to accessing adequate healthcare, and this can contribute to both poorer vision and mental health outcomes.

Part II: Mental Health Assessment and Treatment in People Visual Impairment

Although data demonstrate an elevated prevalence of mental health issues in people with visual impairments, these problems remain largely untreated. 39 , 133 For example, a high prevalence of clinically significant anxiety and depression are reported by individuals with AMD, yet studies indicate that up to 91% are not receiving treatment for these mental health issues. 94 Similarly, in a large sample of visually impaired older adults, 34% who met criteria for a mood or anxiety disorder reported not receiving any mental health services over the previous 6 months. 35 Most strikingly, in a study of 143 adults with vision impairment, 14.7% qualified as moderately depressed and 27.3% met the cut-off for mild depression, however, only 12% of the study sample was prescribed antidepressant medication and none were currently receiving any counseling or mental health support. 12 Treatment of mental health problems in visually impaired populations may be lacking for numerous reasons, but one issue may be the tendency of both patients and providers to focus on the physical aspects of vision loss, or the need to re-learn practical skills, rather than the psychological and emotional impact, 133 perhaps based on the misguided assumption that mood will necessarily improve after new skills are learned. Another contributor to lack of mental health treatment is that people who experience vision loss may be more inclined to rely on personal resources (ie, to attempt to maintain their independence), rather than to seek help. 35 , 134 Additionally, a shortage of knowledgeable mental health providers with training or experience in treating individuals with vision impairment may create a barrier to receiving services. In a survey that assessed a range of disabilities, mental health clinicians rated visual impairment as one of the most difficult populations to serve for reasons such as a lack of funding, accessibility, and expertise. 129 Lack of integrated care (eg, lack of mental health screening, and the presence of mental health professionals co-located at ophthalmology clinics) also contributes to suboptimal identification and treatment of mental health issues among people with eye conditions. Finally, although antidepressants have been associated with improvements in both depressive symptom severity and visual function in people with AMD, some people may be disinclined to take psychotropic medication for a number of reasons (eg, side-effects, drug interactions, etc.). 42 Additionally, antidepressant medications may be less effective for those with milder or treatment-resistant depression. 135 Therefore, effective psychological interventions that can be widely disseminated are needed in order to address the mental health concerns of people with vision impairment.

Below, we review current approaches to treating mental health problems in people with vision impairment. To identify articles to include in this review a literature search was conducted. Selection criteria included peer-reviewed studies of interventions aimed at improving mental health (ie, psychological well-being) in people with visual impairment. Electronic databases (eg, PubMed; Google Scholar) were searched using combinations of these keywords: “vision impairment”, “visual impairment”, “treatment”, “intervention”, “mental health”, “depression”, and “anxiety”, and reference lists of the identified studies were examined for potentially relevant articles. As the overarching goal of this review is to promote a greater understanding of the mental health needs of people with vision impairment, an exhaustive review of the treatment literature is not presented here. Rather, only those articles which were determined to be most representative and informative of the current status of behavioral treatments were included in the review.

Self-Management Interventions

Early approaches to improving mental health in people with vision impairment focused on self-management techniques. Self-management interventions have been found to be effective in improving a range of health outcomes among individuals with chronic conditions, including asthma, arthritis, and diabetes. 136 Individuals learn to monitor their condition (ie, disease progression), and to manage any physical and psychosocial consequences that may have an impact on their quality-of-life. 136 Several studies have investigated the outcomes of self-management interventions delivered in group format to individuals with AMD. 137 In these studies, self-management was significantly more effective than were control conditions at reducing psychological distress and improving self-efficacy and functioning in patients with AMD. 137 , 138 Furthermore, these effects were sustained up to six months after intervention end. 139 , 140 Self-management has also been shown to bolster the effects of usual care in people with age-related vision loss. In one study, self-management combined with usual care led to greater participation in life situations and adaptation to vision loss, fewer depressive symptoms, better physical and mental quality-of-life, and increased self-efficacy in comparison to usual care alone, and many of these effects were maintained up to 12-weeks post-treatment. 141 However, these positive outcomes were not replicated in a sample of older adults with a broader range of eye conditions (ie, a less specific disease-related focus) and fewer baseline psychological symptoms. 142 Thus, self-management approaches may be most beneficial for individuals who are experiencing significant psychological distress, and perhaps who can identify a specific cause of their visual changes ( Table 1 ).

Self-Management (SM) Interventions

Notes: a Effect size is calculated as ([intervention group mean change] – [control group mean change])/(preintervention SD); b Partial eta squared where small=0.10, medium=0.30 and large=0.50.

Abbreviations: ACS, Activity Card Sort; AMD, age-related macular degeneration; AMD-SEQ, Macular Degeneration Self-Efficacy Scale; AVLS, Adaptation to Vision Loss Scale, Adaptation to Vision Loss Scale – 12 item; DASS, Depression, Anxiety, Stress Scale; DSSI-11, Duke Social Support Index 11 item; GDS-125, Geriatric Depression Scale; GSES, Generalized Self-Efficacy Scale; IVI, Impact of Vision Impairment Questionnaire, LOT-R, Life Orientation Test–Revised; NEI-VFQ, National Eye Institute Visual Function Questionnaire; POMS, Profile of Mood States; QWB, Quality of Well-Being Scale; SF-35, Short Form-36 Health Survey; SM, self-management.

Problem-Solving Interventions

Problem-solving treatment (PST) may also be beneficial for individuals with vision impairment. PST is a manualized intervention that involves learning skills such as how to define problems, establish realistic goals, generate, choose, and implement solutions, and, finally, evaluate outcomes. 143 , 144 PST is a brief intervention that can be delivered by non-specialists (ie, general practitioners, nurses) and thus has applicability for primary care settings. 143 , 145 Randomized controlled trials in general psychiatric samples indicate that PST is equally as effective as antidepressant medication alone, and the combination of PST and antidepressant medication in managing depressive symptoms. 146 In a randomized control trial comparing the effects of PST to usual care, PST was more effective in preventing depression in older adults with AMD after two months, but the difference between the interventions was no longer significant after six months. 144 , 147 Thus, PST may delay the onset of depression in people with AMD, however, additional sessions or booster treatments may be necessary in order to prevent the emergence of depression as time goes on and the condition worsens. 144 , 147 Additionally, another study found that 6–8 sessions of PST delivered to older adults with vision loss and significant (ie, moderate-to-severe) depressive symptoms led to a reduction in depressive symptom scores, but the change was not clinically significant. 120 Nevertheless, PST may offer several advantages over other treatment approaches. For example, in many cases PST is delivered by Master’s or Bachelor’s level clinicians or nurses (eg, 48 , 102 , 144 ), thereby expanding patient access to treatment. More recently, PST was delivered to individuals with vision impairment and significant depressive symptoms via phone (ie, telehealth). 148 After three months, participants reported significant improvement in depressive symptom severity, health-related quality-of-life, and confidence in using problem-focused coping skills. 148 Additionally, one mechanism by which PST may be effective is by encouraging continuation of valued activities. 144 This is an important aspect of treatment given the association between functional decline and depression in people with vision loss. 36 , 42 , 102 In comparison to supportive therapy, PST demonstrated similar outcomes in terms of activity engagement, self-reported visual function, physical health status, and depressive symptom severity in people with AMD. However, PST has led to greater improvements in vision-related quality-of-life and increased use of adaptive coping strategies at 3- and 6-months post-treatment. 149 Notably, while PST and supportive therapy are similar, PST is unique in its incorporation of problem-solving skills training. Thus, learning effective methods for solving problems may be especially beneficial for people with vision loss ( Table 2 ).

Problem-Solving Treatment (PST)

Abbreviations: AMD, age-related macular degeneration; AMD-SEQ, AMD Self-Efficacy Questionnaire; BDI-II, Beck Depression Inventory; CDS, Chronic Disease Score; CSE, Coping Self-Efficacy Scale; DSSI-11, Duke Social Support Index-11 item; EQ-5D, EuroQol Five Dimensions Questionnaire; GDS‐15, Geriatric Depression Scale; HDRS, Hamilton Depression Rating Scale; LOT-R, Life Orientation Test–Revised; NEI-VFQ, National Eye Institute Visual Function Questionnaire; OPS, Optimization in Primary and Secondary Control Scale; PHQ-9, Patient Heath Questionnaire; PST, problem-solving treatment; VFQ-48, Visual Function Questionnaire; AQoL-7D, Vision-Related Assessment of Quality-of-Life.

Vision Rehabilitation

Another behavioral intervention that may hold promise for improving psychiatric symptoms in visually impaired populations is vision rehabilitation. These programs typically involve a combination of low vision clinical services (eg, prescription of adaptive devices and instruction on use), rehabilitation training (eg, skills of daily living), orientation and mobility training (eg, safe travel procedures), and counseling and support groups to help with adaptation to disability and improve quality-of-life. 150 The primary aim of vision rehabilitation programs is to maintain or improve an individual’s current level of functioning. However, by promoting self-efficacy, vision rehabilitation may also lessen depression risk in people with visual impairment. 151 Importantly, studies have found that specific treatment components of low vision clinical services, counseling, and the use of optical devices were associated with significant change in depression scores, whereas skills training and the use of adaptive devices were not. 151 , 152 Despite these findings, counseling services are typically only offered as a supplement to functional rehabilitation, and, in one study, were received by as few as 16% of participants. 151 Thus, while targeting visual functioning may also have an impact on psychological functioning in elderly adults with vision loss, directly addressing the emotional aspects of vision loss is a necessary part of treatment that may lead to more robust improvements in mental health ( Table 3 ).

Vision Rehabilitation Interventions

Abbreviations: CES-D, Center for Epidemiological Studies Depression Scale; IADL, instrumental activities of daily living; OMFAQ, Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire.

Cognitive Behavioral Interventions

Among individuals with AMD, modified cognitive-behavioral interventions have been used to improve depression and anxiety symptoms, with some success. In one study, a single component of cognitive behavioral treatment, behavioral activation, in conjunction with low vision rehabilitation was significantly more effective in preventing depression in patients with AMD compared with supportive therapy combined with low vision rehabilitation. 153 A follow-up mediation analysis demonstrated that improvement in depression scores following behavioral activation and low vision rehabilitation was explained by an increase in social engagement. 153 Self-guided CBT has also led to a significantly greater reduction in depressive symptoms among patients with AMD relative to usual care, although improvements in other outcomes, including anxiety and self-efficacy, were not observed. 154 Cognitive and behavioral approaches have also been tested in other visually impaired populations, such as people with blindness. In one study, individuals with blindness receiving Rational Emotive Behavior Therapy (REBT), a type of cognitive therapy, reported significant reductions in irrational beliefs, depression, anxiety, and stress and improvements in self-esteem, while these same changes were not observed in the control group. 113 Moreover, these mental health effects were maintained in the REBT group up to 1-month post-treatment. 113 Together, these findings suggest that cognitive behavioral interventions may be effective in improving psychological functioning of adults with varying degrees of vision loss ( Table 4 ).

Cognitive Behavioral Therapy (CBT) Interventions

Notes: a Cohen’s d estimate of effect size where small=0.20, medium=0.50 and large=0.80.

Abbreviations: AMD, age-related macular degeneration; BA+LVR, behavioral activation + low vision rehabilitation; BADS, Behavioral Activation for Depression Scale; CBT, cognitive behavioral therapy; CDS, Chronic Disease Score; DASS-21, Depression, Anxiety, Stress Scale – 21 item; DMSES, Diabetes Self-Care Self-Efficacy Scale; ESEI, Eysenck’s Self Esteem Inventory; GAD-7, Generalized Anxiety Disorder inventory; IBT, Jones Irrational Beliefs Questionnaire; LSA, Life-Space Assessment; MOS-6, Medical Outcomes Study-6; NEI-VFQ, National Eye Institute Visual Function Questionnaire; NEO-PI-R, Revised Neuroticism, Extroversion, Openness Five Factor Inventory; PHQ-9, PHQ-9 Patient Heath; REBT, rational emotive behavior therapy; ST+LVR, supportive therapy + low vision rehabilitation.

Stepped Care Interventions

In the last decade, stepped care has been a recommended approach to treating individuals with mild-to-moderate levels of depression and anxiety. 155 Stepped care has also demonstrated success in reducing the incidence of depressive and anxiety disorders among older adults in the general population who experience subthreshold symptoms. 156 Stepped care increases efficiency of behavioral health care delivery by initially providing patients with the least intensive interventions and then moving to more intensive services as required (ie, if symptoms remain near baseline levels). 157 In a multi-site randomized control trial, van der Aa et al 157 tested the effectiveness of stepped care in ameliorating depression and anxiety in older adults with vision loss. Compared to individuals receiving usual care, those in the stepped care group reported significantly greater improvements in depressive and anxiety symptoms and vision-related quality-of-life at treatment end. 157 Older adults receiving stepped care were also less likely than controls to develop depressive or anxiety disorder over a 2-year follow-up period. However, 25–30% of elderly patients in the stepped care group that qualified for guided self-help or PST were either non-compliant or not fully adherent to treatment protocols and reported finding these steps to be unnecessary or too burdensome. 157 Additionally, a considerable number (~30%) of older adults receiving stepped care developed depression, though half of these individuals reported a history of depressive or anxiety disorders. 157 Thus, while stepped care may be effective in preventing the onset of mental health problems in older adults with vision impairment, it may be less effective in preventing the recurrence of depression in those with preexisting or past symptoms. As anxiety and depression are relatively common in the population at large, and may be especially prevalent among individuals with vision impairment (reviewed above), this signifies a significant limitation of this approach, although it is a limitation shared with many other interventions for many other health conditions. Nevertheless, stepped care has demonstrated superiority to usual care in terms of cost-effectiveness. 158 Therefore, stepped care models may offer some advantage over traditional approaches in targeting mental health problems in older adults with vision impairment ( Table 5 ).

Abbreviations: AVL, Adaptation to Vision Loss scale; CBT, cognitive behavioral therapy; CES-D, Center for Epidemiological Studies Depression Scale; EQ-5D, EuroQol Five Dimensions Questionnaire; HADS-A, Hospital Anxiety and Depression Scale–Anxiety Subscale; LVQoL, low vision quality-of-life; PST, problem-solving treatment.

Additional Considerations

Although studies of behavioral interventions for the prevention and treatment of mental health problems in people with vision impairment have reported some positive results, these treatments are lacking in several ways. Many of these interventions are focused almost exclusively on improving functionality through skills training. 144 , 151 Though functional impairment has been linked to depressive symptoms in individuals with vision impairment, 36 , 102 vision-specific distress has also been identified as an important contributor to depression in this population. 12 Therefore, more targeted interventions for psychological and emotional difficulties associated with vision loss may be needed. Indeed, Wahl et al 159 compared the effects of an emotion-focused treatment with a problem-focused approach in patients with AMD and found that, while problem-solving therapy was associated with an increase in active problem orientation and adaptation to vision loss, only those in the emotion-focused therapy group experienced a significant decrease in depressive symptoms (though the effect size was small). Additionally, many current treatments for mental health problems in people with vision impairment are severely limited in their effectiveness. Findings from a meta-analysis indicate that, overall, psychosocial interventions have a small significant effect on improving depression in people with vision impairment, and this effect is linked with age, whereby lower age was associated with better outcomes. 160 However, after removing a study outlier with a small sample size, younger age of participants, and shorter follow-up period, the effect of the included interventions on depressive symptoms was no longer significant. 160 Similarly negligible results were obtained for anxiety symptoms, with psychosocial interventions leading to a medium-sized reduction in anxiety symptoms in comparison to control conditions, without statistical significance. 160 Likewise, the assessed psychosocial interventions did not appear to have a significant impact on psychological stress or well-being, but again a relationship was observed between younger age and better outcomes. 160 Outcomes of these interventions may also depend largely on the age of the individual. While prior studies of psychosocial interventions demonstrate some degree of efficacy in older adults with vision loss, and particularly AMD, 161 meta-analytic findings indicate that improvements are less robust in elderly samples. 160 Related to this finding, risk and protective factors for mental health problems in older adults may be different from those of younger people, 29 and therefore treatment may need to be adapted to fit the individual needs of the consumer. 160 One issue relevant to this point is that with increasing age there is more likely to be failure of other bodily systems, and other situations (eg, loss of a spouse) that promote depression. Therefore, interventions that are associated with a significant reduction in depression in younger patients may appear to have reduced benefit in older patients, even if the absolute level of change is the same in both populations (owing to increased baseline depression levels in the latter group). Finally, the relatively high rates of treatment non-adherence and attrition reported in some studies 41 , 137 , 148 is problematic and limits the interpretation of results, especially their generalizability. In short, overall, there is evidence of mild-to-moderate effects of existing approaches for treating mental health problems in people with visual impairment broadly. Further efforts are needed to develop novel interventions that can be applied to a wider range of individuals with vision impairment, and to develop interventions for people with more severe depression and/or who are nonadherent with recommended treatment.

Improving Mental Health Treatment in People with Vision Impairment

Vision loss affects all aspects of one’s life. The findings reviewed indicate that mental health problems are a significant burden for many people with vision impairment., 9–11 However, despite the widespread prevalence of these issues, screening and treatment remain inadequate. Better outcomes may be achieved if several changes are made. First, more rigorous evaluation of current treatment approaches is warranted. In addition to measuring long-term outcomes, treatment efficacy needs to be tested in a broader sample of people with vision impairment, including children and individuals with complete blindness. More work is also needed to identify mechanisms of change (eg, reductions in vision-specific distress, 12 maintaining valued activities, 144 recovery of self-esteem, increased hope for the future, etc.). 162 Related to this, in addition to screening for level of issues such as depression and anxiety, screening should adequately capture the patient’s stage of emotional adjustment to vision loss 162 so that the treatment approach matches the patient’s perspective on his/her condition. In addition to targeting mental health problems, it is critical to focus on poor adherence, especially for people who could be receiving an effective intervention. Dismantling studies are also needed to identify important treatment components, as was done in a study of AMD when the effects of a single cognitive-behavioral component, behavioral activation, was examined in combination with vision rehabilitation, and results were positive. 153 Additionally, client characteristics that may influence treatment outcomes, such as age, 89 , 90 , 120 severity and duration of vision loss, 19 , 20 , 22 , 24 and prognosis of the disease 18 , 94 need to be recognized. It is also important that these factors, and other potentially confounding variables (eg, functioning, social support, psychiatric history, family history of eye disease), are controlled for in studies of treatment effectiveness. Finally, at least some subpopulations (eg, AMD patients with low income and with psychological denial of disability) may require a greater focus on issues that interfere with treatment adherence, as poor adherence may affect outcomes more than the disease in cases where effective treatments are available.

In order to improve access to care, structural changes may be required. This may include integrating services, such as behavioral health and ophthalmology, or even general healthcare given high rates of medical comorbidity in this population. 31 , 86 Relatedly, routine screening for mental health problems in eye care settings may be beneficial, and has high acceptability among patients (ie, considered a “good idea”). 39 A discussion between patients and their providers regarding the relationship between visual impairment and mental health, and factors that may increase risk for mental health problems, may improve access and engagement in mental health services. Furthermore, providing information and educating patients and their families on the potential effects of vision loss on functioning over time may facilitate the development of self-supportive strategies that allow patients to better manage future challenges. An expansion of current treatment options is also needed in order to serve a wider range of individuals with vision loss. Though data are limited, there is some evidence that peer support groups for people with vision impairment have positive effects on mental health, 163 and in qualitative studies patients report benefiting from their peers in a multitude of ways (eg, providing role models of success, allowing comparison with those more unfortunate). 164 In addition, delivering therapy by phone 148 or through mobile applications may increase treatment accessibility, particularly among individuals with mild or moderate symptom levels that may be undetected by general health providers. Further introduction of established mental health interventions to visually impaired populations is also essential, especially regarding treatments that have demonstrated efficacy in general depression populations, as mood symptoms may be especially problematic in people with vision impairment. 9 , 11 For instance, acceptance and commitment therapy (ACT) is a “third wave” form of cognitive therapy that encourages acceptance of events (vs experiential avoidance) and behavior change that is guided by goals and values, and has demonstrated superiority over other treatments in improving depression, anxiety, and other mental health problems among people with physical health conditions, 165 such as chronic pain. 166 In older adults with vision impairment, a relationship between lower acceptance of vision loss and subthreshold depression has been reported 126 and avoidant coping has been identified as a unique predictor of both vision-specific distress and depressive symptoms. 77 Thus, an intervention aimed at enhancing psychological adjustment and coping, such as ACT, may have a positive effect in people with vision loss. In summary, implementing a variety of changes to improve the detection and treatment of mental health problems in people with vision impairment may lessen health inequity and improve outcomes in this population.

Summary and Conclusions

Vision impairment has a substantial personal and global impact. 4 , 5 , 31 Besides high rates of physical comorbidity, people with visual impairments are at risk for poor mental health outcomes. 9–11 Importantly, approximately 68% of vision impairment is avoidable. 167 While blindness as a result of age-related disease (eg, AMD, diabetic retinopathy, glaucoma) is not reversible at this point, many impairments can be corrected or altogether avoided 131 with better attention to eye health, and doing so should prevent development of some mental health problems. However, better screening for mental health changes and greater availability of effective treatments, and of adequately trained (with regard to understand the psychological consequences of vision loss) mental health professionals, are necessary as well. It is also critical to increase our understanding of the range of psychological and psychosocial effects associated with visual disability (and anticipation of it) and the mechanisms that contribute to the onset and maintenance of mental health problems in this population. While it is important to address both the emotional and practical needs of people with visual impairment, historically, mental health concerns have been largely overlooked in these individuals. Proper attention to mental health issues is likely to be a complex endeavor, however, as it requires widespread screening, careful attention to the patient’s stage of emotional adjustment to living with vision loss, development of novel interventions, availability of trained practitioners, and addressing health disparities related to socio-economic status.

The authors report no conflicts of interest in this work.

• Research article
• Open access
• Published: 12 November 2015

Visual impairment, coping strategies and impact on daily life: a qualitative study among working-age UK ex-service personnel

• Sharon A. M. Stevelink 1 ,
• Estelle M. Malcolm 1 &
• Nicola T. Fear 1 , 2  

BMC Public Health volume  15 , Article number:  1118 ( 2015 ) Cite this article

25k Accesses

29 Citations

4 Altmetric

Metrics details

Sustaining a visual impairment may have a substantial impact on various life domains such as work, interpersonal relations, mobility and social and mental well-being. How to adjust to the loss of vision and its consequences might be a challenge for the visually impaired person. The purpose of the current study was to explore how younger male ex-Service personnel cope with becoming visually impaired and how this affects their daily life.

Semi-structured interviews with 30 visually impaired male ex-Service personnel, all under the age of 55, were conducted. All participants are members of the charity organisation Blind Veterans UK. Interviews were analysed thematically.

Younger ex-Service personnel applied a number of different strategies to overcome their loss of vision and its associated consequences. Coping strategies varied from learning new skills, goal setting, integrating the use of low vision aids in their daily routine, to social withdrawal and substance misuse. Vision loss affected on all aspects of daily life and ex-Service personnel experienced an on-going struggle to accept and adjust to becoming visually impaired.

Conclusions

Health care professionals, family and friends of the person with the visual impairment need to be aware that coping with a visual impairment is a continuous struggle; even after a considerable amount of time has passed, needs for emotional, social, practical and physical support may still be present.

Peer Review reports

Becoming visually impaired can be a life changing experience and is likely to have far reaching consequences for the person affected [ 1 – 3 ]. Persons acquiring a visual impairment express a variety of emotional, cognitive, behavioural and social responses to this significant loss. The model of grief proposed by Kübler-Ross, originally used to describe coping in terminally ill persons, has shown to be useful in a variety of settings in which persons face a significant crisis, change or loss, such as acquiring a visual impairment [ 4 , 5 ]. People affected will mourn their loss of vision and associated losses including their job, leisure activities and independence and may go through various phases of grief, which include denial, anger, depression, bargaining and acceptance [ 6 ]. Positive or negative mechanisms of adjustment, also termed coping strategies, can help individuals to master their impairment. Broadly speaking, we can distinguish between adaptive coping strategies such as seeing a counsellor and goal setting or maladaptive coping strategies including social withdrawal and substance misuse [ 7 , 8 ].

Service personnel are at a higher risk of becoming visually impaired than civilians as a result of deployment experiences. A decrease in combat-related mortality has been reported during the recent deployments to Iraq and Afghanistan compared to other conflicts; this can be explained by technological and medical advances in medical care, body armour and casualty evacuation [ 9 ]. However, more Service personnel return home with combat-related trauma such as shrapnel wounds, extremity amputations, head injury and vision loss [ 9 – 12 ].

Recently, a study reviewing the prevalence of mental health problems among (ex-) service personnel with an irreversible impairment (e.g. hearing, vision, but predominantly physical) concluded that common mental health disorders such as post-traumatic stress disorder, anxiety, psychological distress and depression, were frequently reported, but levels varied widely across study populations. Nevertheless these levels appeared to be higher than found in comparable samples of civilian and military populations without an impairment [ 13 ].

This study utilised a sample of younger (ex-) Service personnel who are members of Blind Veterans UK (55 years of age or below). Blind Veterans UK is a charity organisation, formerly known as St Dunstan’s, which provides support and care for (ex-) Service personnel who have a visual impairment in both eyes, regardless of the cause. The majority of the members of Blind Veterans UK are 65 years and older, however, due to military operations in Iraq and Afghanistan, the charity has seen an influx in younger members over the last decade. Therefore Blind Veterans UK commissioned the King’s Centre for Military Health Research at King’s College London to examine the mental health and social well-being of their younger members. We explored how ex-Service men adjust to their loss of vision, which coping strategies they use and how their loss of vision and its consequences has impacted on their daily life.

Setting and design

A cross-sectional study was conducted using a mixed methods approach. Phase 1 of the study consisted of telephone interviews with male and female (ex-) Service personnel whereby clinical screening measures for mental health were used. A subsample of the phase 1 participants was invited to join phase 2 of the study. Phase 2 consisted of semi-structured in-depth face to face interviews, covering various topics including the impact of becoming visually impaired on various domains of life and coping strategies. The current paper will report on male participants included in phase 2 of the study.

Participants

All participants were members of Blind Veterans UK and were under 55 years of age at recruitment. Male participants who took part in phase 1 of this study ( n  = 74) were asked if they would be interested in taking part in a qualitative interview. Sixty-six participants indicated their willingness to do the face-to-face interview. We were especially interested in those who became visually impaired due to their deployment to Iraq or Afghanistan ( n  = 10). They were prioritised in the selection process for phase 2 after which other participants were invited. Thirty male ex-Service personnel were approached and two declined. Therefore, an additional two male members were invited and they agreed to participate. We deemed 30 face-to-face interviews sufficient to reach data saturation based on previous experiences and the literature [ 14 ]. The data collection period was closely monitored to ensure that the data collected was rich and descriptive and no new information seemed to emerge whilst approaching the set interview target.

A semi-structured interview schedule was used consisting of 11 open-ended questions covering different aspects of how a visual impairment can have an impact on life, difficulties experienced because of being visually impaired and how ex-Service men adjusted to life with a visual impairment (Additional file 1 ). These questions were developed in collaboration with Blind Veterans UK, to ensure they met the remit of the work commissioned and were appropriate for use in the target population. The draft interview guide was piloted by E.M.M. and S.A.M.S. among two members of Blind who just exceeded the age threshold off 55 years. Feedback from the participants suggested that the questions were received well, easy to follow and comprehensive. Therefore no changes were made to the interview guide. Socio-demographic data obtained during phase 1 were linked to the participants who were included in phase 2 of the study.

Interviews took place between December 2012 and May 2013. Prior to the interview, participants received an information package explaining the study and a detailed signposting booklet (in accessible formats) providing information about various sources of help and advice that might be useful for the participant, such as the Veterans UK helpline.

Participants were interviewed by two researchers (E.M.M. and S.A.M.S.) who were trained and experienced in using the qualitative interview schedule. The majority of the interviews took place in the participant’s home environment after verbal informed consent was given. Procedures were in place for participants who were distressed or at risk and required a call back from a Community Psychiatric Nurse. All interviews were recorded with a Dictaphone. Interviews lasted 35–105 min. At the end of the interview participants were thanked for their time and received £20 in cash.

The interviews were transcribed in full to include all spoken words and non-verbal utterances such as sighs and laughter. Recordings were listened to and transcripts were read and re-read by E.M.M. and S.A.M.S. Both independently coded five different transcripts each using NVivo as an organisational tool. Once five transcripts were independently coded, E.M.M. and S.A.M.S. met to compare and discuss. The initial coding framework was grounded in the content of the data (inductive). Data were analysed thematically [ 15 ]. Throughout the first stages of the analysis process the coding framework was revised and further developed. E.M.M. and S.A.M.S. independently read and coded three additional transcripts to ensure the coding framework reflected the data. Any disagreement about codes between the two researchers were discussed and resolved. Once the coding frame was finalised, E.M.M. independently coded all of the transcripts (Additional file 2 ). Intra-coder agreement was established by E.M.M. by coding three interviews at two time points which were one month apart. An intra-coder agreement of 84.5 % was found, indicating good agreement. Once all transcripts were coded, the codes were put into broader themes and associated sub-themes. The main themes identified for the current paper were coping (strategies) and the impact of vision loss on daily life. Pseudonyms are used when presenting the data.

Ethical approval

Ethical approval for this study was granted by the Social Care Research Ethics Committee (12-IEC08-0032).

Out of the 30 younger ex-Service men, 27 were below 45 years of age; 15 were employed at the time of the interview; four were still serving but were waiting to be medically discharged. Of those who had left the Armed Forces, 13 out of 30 had left over 10 years ago and just over half (17 out of 30) were married or in a long term relationship. The great majority (26 out of 30) had served in the Army.

Twelve men had a combat-related visual impairment, of which 10 sustained the impairment during deployment to Iraq or Afghanistan. 12 out of the 30 sustained their impairment less than 5 years ago. Genetic causes of visual impairment were the most common causes of visual impairment ( n  = 7) among those with a non-combat-related visual impairment followed by ocular medical conditions (e.g. age-related macular degeneration, glaucoma) ( n  = 4) and environmental causes ( n  = 4) (e.g. toxic or injury related). The overwhelming majority of ex-Service personnel used low vision aids (28 out of 30); four had a guide dog, 17 used talking books and 19 used a white stick. Approximately one in three participants screened positive for probable depression, probable anxiety or probable Post-Traumatic Stress Disorder (Stevelink et al., (2015) http://bjo.bmj.com/content/early/2015/04/23/bjophthalmol-2014-305986.full .

In the next section the findings of the two themes identified for the current paper, specifically ‘coping (strategies)’ and ‘impact of vision loss on daily life’, are combined to describe how vision loss affected the person from the time directly after becoming visually impaired and how this changed subsequently.

Coping with a visual impairment and impact on daily life

Directly after becoming visually impaired, younger male ex-Service personnel thought “life is over” and they “ [didn’t] want to carry on” . Their confidence was undermined, they felt sorry for themselves and had the feeling there was no way out.

Phil (non-combat-related visual impairment, age 35–44 years) : “Well initially straightaway it [loss of vision] stopped me from going out straightaway. I went in for the first two years, first year and a half at least, I was very depressed. Very sorry for myself and thought that was it (…). (…) I didn’t think there was anything I could do so yeah, dread, full of dread and fear and all that lot did come into it.”

These feelings and experiences were reinforced by other losses that were experienced as a result of their loss of vision such as losing their job, experiencing relationship difficulties and an increased dependence on others.

In most cases, if personnel suffered a deterioration of their sight whilst in Service, they were medically discharged and as a result had to confront the issue of changing their career. This was similar amongst those who had left the Service and had started a civilian job. This forced change of career was generally experienced as a “regression” leading into a cascade of accompanying consequences such as experiencing financial hardship if living on benefits, different family dynamics due to for example family members taking on the role of carer and, above all, impaired self-esteem. Ex-Service men felt that by no longer being the breadwinner in the household and a highly trained professional, they were set back to square one as said by Alan (combat-related visual impairment, age 25–34 years):

“(…) it’s like all that experience, all that knowledge… shoved right back in your face (…). (…) You’re a broken toy now. What happens to broken toys… goes to the tip doesn’t it? (…). You know you’re a broken toy they don’t want to know you.”

Denial of the consequences of vision loss resulted in ex-Service men trying to do the things they were used to do; this resulted in feelings of frustration and irritation as illustrated by Richard (non-combat-related visual impairment, age 45–54 years):

“(…) at first it [loss of vision] made me really down and depressed and … . Because I’d known for quite a while before that there was something wrong. And I went through not accepting it. So at first I wouldn’t accept it and then when I first finished work obviously I had to walk everywhere. I got quite narky with people. If I was out with my stick and they’d bump into me. I’d get quite angry with them… because it was everybody else’s fault for getting in my way. So I went through like a stage of denial, I suppose and then being angry.”

The emotional turmoil personnel went through whilst adjusting, adversely affected their relationship with their partner. Those who were in a relationship at the time of becoming visually impaired suggested that their impairment put a strain on that relationship. Personnel experienced increased dependence on their partner resulting in changing relationship dynamics. Both the partner and the person affected needed time to adapt to this new situation. In a few cases, participants divorced or ended their relationship with their partner, but the dominant view was that the impairment was a contributing factor but not the main reason for breaking up.

Charlie (non-combat-related visual impairment, age 35–44 years): “ But it [loss of vision] very nearly I think cost us my wife and I our marriage, because I was quite unpleasant on more than one occasion. But thankfully we’re coming through the other side so yeah it’s been a difficult journey.”

Members who became visually impaired in combat were proud about the circumstances that led to their loss of vision ( “serving Queen and Country” ), whereas those with a non-combat-related visual impairment struggled with the question ‘why me?’ and even felt guilty, ashamed or embarrassed. Some personnel expressed the hope that their vision would improve over time or were looking into potential treatment options. Personnel were mourning about what they had lost and what they could have done if they had not sustained a visual impairment.

Harry (combat-related visual impairment, 35–44 years): “You know the doctors are going to say to you at some point you don’t need to come and see us anymore, and that’s when it will sink in and that’s what you’ve got for the rest of your life, that’s what you’re stuck with. And at that point you need to just accept it, just get on with it because the longer you kid yourself it’s going to get better, or there’s going to be some miracle surgery, the longer it ‘ll take you to adapt.”

The visual impairment not only affected the domain of work and interpersonal relationships but also other areas as illustrated by Nick (non-combat related, age 25–34 years):

“ (…) you do have a bad impact on your day to day life especially from washing up to having food or to prepare a meal. Then taking medication and also you know dress yourself, and also you can’t actually go out on your own all the time. So your movement is quite restricted although it can be done with some training outside, but there is the danger off (…) colliding with something or someone or some obstruction.”

As time passed, ex-Service personnel were able to “ change [their] head around ” and tried to adjust to their visual impairment and its consequences, by applying various coping strategies. The ‘military ethos’ of “crack on” and “adapt and overcome the situation” helped them to overcome any problems they experienced. However, for some personnel it acted as a barrier because they were reluctant to ask for help and struggled through with their visual impairment (defined by the researchers as coping at a cost).

Other reasons for coping at a cost were that younger ex-Service personnel felt ashamed, lacked confidence or were too proud to ask for help. They did not want to be seen as a burden on others. Coping at a cost was enforced by reactions from the public. For example, Max (non-combat-related visual impairment, 35–44 years) was assaulted when using his cane on public transport after accidently bumping into someone; they did not believe he was visually impaired so from that moment on he decided not to use a cane anymore.

The unavailability of support and resources influenced how younger members coped with their loss. Ex-Service personnel tried ‘to escape’ by, for example, substance abuse or made a non-fatal suicide attempt.

Tom (non-combat-related visual impairment, 25–34 years): “ When I first lost my eyesight I never had that emotional support. I never had it and I dealt with it on my own. My way was hitting the drinks and hitting the drugs and going crazy .”

Other examples of maladaptive behaviour included isolation and social withdrawal from family and friends, acting aggressively or in an unfriendly manner.

Besides the use of maladaptive coping strategies, several adaptive coping strategies were applied. One of these was termed by the researchers as ‘downward comparison’. Younger ex-Service personnel pointed out that they were aware of other people being worse off than themselves such as soldiers with serious brain injury, cancer patients or if they still had some vision left those who were completely blind. Others made a comparison with vision impaired members who managed to carry on successfully. By making a downward comparison or by comparing themselves with people who had faced the same problems, coping was facilitated as members got inspired and motivated to “crack on with life”.

Oliver (non-combat-related visual impairment, 35–44 years): “They [members of Blind Veterans UK] proved that there are other people in the same situation as me and even not worse, and that you know you can still do day to day tasks and you can still do a lot of varied things if you put your mind to it. You know and it’s just challenging your mind to being able to do these things.”

People’s favourite leisure activities and interests changed substantially because they were no longer able to undertake them due to their loss of vision. Driving a car was missed tremendously, followed by sporting activities and reading. Personnel tried to get around these barriers by adopting a problem-focused approach (e.g. use of low vision aids, retrain, find other activities they were able to do). Also accepting or asking for (social) support from family, friends, charities or seeking professional support, helped ex-Service personnel to adjust and carry on.

Just after becoming visually impaired, personnel needed a lot of help and relied heavily on others. Once they started to adapt, people learned new skills and strategies, resulting in increased confidence and less reliance on others. This had a positive impact on the mental well-being of the person with the visual impairment and facilitated the process of accepting their loss of vision and its consequences. Further personnel learned what they are still able to do and what not, thereby reflecting on and adapting to the restrictions their visual impairment imposed. However, the dependence on others played a limiting role and new activities such as taking up different hobbies like disability sports were not always experienced as that satisfying.

Andrew (combat-related visual impairment, 25–34 years): “You have to accept that sort of thing as part of the hard bit in the beginning. (…) once you’ve accepted it [loss of vision] you get used to it and just move on from then. Then obviously you have achievement from there and then you put yourself to whatever you need to achieve.”

Achievement was often mentioned as a next step. Younger ex-Service personnel decided to set a particular goal such as starting a new course or degree, or signed up for a sporting challenge. By working towards a particular goal, personnel got back in a daily routine, their confidence increased as well as their self-worth. This impacted positively on their mental well-being. Reflecting on the different experiences of the participants it becomes apparent that coping with loss of vision is a dynamic long-term process. Even after years, people may struggle as new situations, challenges or life events come by.

Jack (combat-related visual impairment, 25–34 years): “It’s been [amount of years] now and there was a time I thought I’d accepted what had happened to me, but you know that was temporary. And yeah I don’t think I’ve fully accepted what’s happened to me. There [are] good periods and bad periods and you know they come and go quite randomly and yeah they affect me for different amounts of time and I can get quite negative sometimes and quite self-deprecating.”

Younger ex-Service men suggested that becoming visually impaired had turned their life upside down; the accompanying consequences had adverse effects on a variety of life domains and adjusting was experienced as a tough journey. Personnel struggled with an increased level of dependence on others, a loss of freedom, a lack of confidence and impaired feelings of self-worth. Various coping strategies were applied by younger ex-Service men and these enabled them to adjust to their loss and overcome challenges they faced down the line. Coping was an on-going and dynamic process with ex-Service personnel experiencing good and bad times, even after many years since sustaining their impairment.

The Kübler-Ross model was initially developed to describe how people cope with death and dying following a distinct 5 stage model (denial, anger, depression, bargaining and acceptance) [ 6 ]. We used this model as an example in the introduction to describe how people may deal with facing a significant loss, such as sustaining a visual impairment. However, over the years this model has been critiqued widely [ 16 – 18 ].

When reflecting on our results, it became clear that ex-Service men experienced a far wider range of emotions and behaviours; in some cases these emotions occurred simultaneously. Instead of a stage like pattern of response, the data showed coping was more dynamic, highly interactive and a unique journey for every individual. Whereas the individual affected plays a central role in Kübler-Ross’ model, we found that other factors played an important role as well as to how people adjust, including the availability of social support, use of low vision aids, presence of public attitudes, family composition and other situational factors [ 19 ]. The variety of positive or negative mechanisms of adjustment helped the individual to master their impairment and should be referred to as forms of coping strategies [ 18 ]. Acceptance is described as the closing stage of the grief process by Kübler-Ross. However, as pointed out by Murray and colleagues (2010), and reflected in our data, we found coping to be a long-term process, whereby the person affected will apply different strategies depending on the changes or new situations they encounter [ 20 ]. Therefore, acceptance may occur temporarily but will interact with new periods of adjustment and the grief process can be characterised as ‘a chronic recurrent but episodic process’ [ 20 ]. This has been illustrated earlier with a quote from Jack (combat-related visual impairment, 25–34 years): he interchangeably experiences periods of acceptance vs. rejection, despite the fact that a considerable amount of time has passed by since he became visually impaired.

Personnel tried to adjust using various strategies, including a strategy termed by the researchers as ‘coping at a cost’. Underlying reasons such as feeling too embarrassed to ask for help, not wanting to burden others or wanting to ‘crack on’ alone. Participants suggested that asking for help would impede on their sense of self-pride and self-respect [ 19 , 21 – 24 ]. This attitude of ‘cracking on’ is a key element of the work ethic of the British Army and encourages pro-activity over passivity and contemplation [ 25 ]. A different strategy was comparing themselves with others they classified as worse off [ 26 , 27 ]. This downward comparison motivated and inspired people to life their live to the fullest. For ex-Service personnel with a combat-related visually impairment, feelings of being grateful to still be around were apparent. Analysis of the quantitative data of the current study suggested that the prevalence of mental health problems was not substantially different between personnel with a combat-related visual impairment (25.0 %) compared to those with a non-combat-related visual impairment (29.6 %) (Ref).

Impact of visual impairment on life domains

Various quantitative studies have examined the impact of vision loss on the psychological well-being of elderly populations [ 3 ]. A review summarizing qualitative evidence of seventeen studies on the impact of and coping with vision loss suggested that people relied more heavily on others to perform their daily activities [ 7 ]. Further, they reported the loss of leisure activities and hobbies. In addition, a negative impact on mental well-being was described such as the onset of depression, impaired self-esteem, being less socially active and experiencing challenges with regards to interpersonal relationships and communication [ 7 ]. Despite the review summarizing studies among the elderly, the findings correspond well with those from the current study. However, the researchers would like to highlight that while the actual barriers and changes due to the loss of vision and its related consequences may be unique for each person, they impede on the same highly valued core concepts of (in) dependence, autonomy, self-esteem, control, confidence, freedom and identity.

A different review synthesised the findings of quantitative studies about the psychosocial impact of vison loss in adults aged 18–59 years [ 2 ]. They concluded that the general mental health, social functioning and quality of life were adversely affected. However, this was not consistent for the impact of visual impairment on the prevalence of depression [ 2 ]. The association between depression and visual impairment appears to be more evident among elderly [ 1 , 24 ].

Limitations

This study had various limitations. First, all participants were members of the charity organisation Blind Veterans UK and had served in the UK Armed Forces. In what way these findings can be extrapolated to different visually impaired populations such as civilians, elderly, women and people who are not involved in a charity organisation remains uncertain. Second, the research team asked sensitive questions related to how personnel coped with their visual impairment. They could have given socially acceptable answers because they did not feel confident, did not trust the interviewer or did not want to appear as ‘weak’. This issue was addressed by informing them what to expect, building good rapport and providing the opportunity to ask the team questions. An important strength of this qualitative study is the substantial sample size ( n  = 30). Therefore, we are confident that we captured a wide range of views and experiences.

Implications

Clinicians, ophthalmologists and other health care providers as well as partners, the wider family and friends need to be aware that coping is an on-going process and that even after a considerable amount of time, needs for emotional, social, practical and physical support may still be present. Functional training and psychosocial support should be offered enabling personnel to regain their confidence, feelings of self-worth and independence.

Our findings suggest that sustaining a visual impairment is a life changing event that has important effects on various domains of life. Adjusting to loss of vision and its related consequences can be described as a long-term and difficult journey whereby ex-Service personnel apply various coping strategies to overcome the challenges they face later on in their lives. Future research should be directed into how positive coping can be facilitated and how factors such as the duration of the visual impairment and perceived social support, influence coping processes.

Horowitz A. The prevalence and consequences of vision impairment in later life. Top Geriatr Rehabil. 2004;20(3):185–95.

Article   Google Scholar  

Nyman SR, Gosney MA, Victor CR. Psychosocial impact of visual impairment in working-age adults. Br J Ophthalmol. 2010;94(11):1427–31.

Article   CAS   PubMed   Google Scholar  

Pinquart M, Pfeiffer JP. Psychological well-being in visually impaired and unimpaired individuals: a meta-analysis. Br J Vis Impair. 2011;29(1):27–45.

Schilling OK, Wahl HW. Modeling late-life adaptation in affective well-being under a severe chronic health condition: the case of age-related macular degeneration. Psychol Aging. 2006;21(4):703–14.

Article   PubMed   Google Scholar  

Bergeron CM, Wanet-Defalque M. Psychological adaptation to visual impairment: the traditional grief process revised. Br J Vis Impair. 2013;31(1):20–31.

Kübler-Ross E. On death & dying. New York: Scribner; 1969.

Google Scholar  

Nyman SR, Dibb B, Victor CR, Gosney MA. Emotional well-being and adjustment to vision loss in later life: a meta-synthesis of qualitative studies. Disabil Rehabil. 2012;34(12):971–81.

Hodge S, Barr W, Bowen L, Leeven M, Knox P. Exploring the role of an emotional support and counselling service for people with visual impairments. Br J Vis Impair. 2013;31(1):5–19.

Fazal TM. Dead wrong? Battle deaths, military medicine and exaggerated reports of war’s demise. Int Secur. 2014;39(1):95–125.

Blood CG, Puyana JC, Pitlyk PJ, Hoyt DB, Bjerke HS, Fridman J, et al. An assessment of the potential for reducing future combat deaths through medical technologies and training. J Trauma. 2002;53(6):1160–5.

Eastridge BJ, Jenkins D, Flaherty S, Schiller H, Holcomb JB. Trauma system development in a theater of war: Experiences from operation Iraqi freedom and operation enduring freedom. J Trauma. 2006;61(6):1366–72. discussion 1372–1363.

Bellamy RF. A note on American combat mortality in Iraq. Mil Med. 2007;172(10):1023.

Stevelink SA, Malcolm EM, Mason C, Jenkins S, Sundin J, Fear NT. The prevalence of mental health disorders in (ex-)military personnel with a physical impairment: a systematic review. Occup Environ Med. 2014;72:243–51.

Article   PubMed   PubMed Central   Google Scholar  

Fugard AJB, Potts HWW. Supporting thinking on sample sizes for thematic analyses: a quantitative tool. Int J Soc Res Methodol. 2015;18(6):669–84.

Ritchie J, Lewis J, McNaughton Nicholls C, Ormston R. Qualitative Research Practice: a guide for social science students & researchers. 2nd ed. London: SAGE; 2014.

Brewer BW. Review and critque of models of psychological adjustment to athletic injury. J Appl Sport Psychol. 1994;6(1):87–100.

Copp G. A review of current theories of death and dying. J Adv Nurs. 1998;28(2):382–90.

Corr CA. Coping with dying-lessons that we should and should not learn from the work of Kublerross, Elisabeth. Death Stud. 1993;17(1):69–83.

Weber JA, Wong KB. Older adults coping with vision loss. Home Health Care Serv Q. 2010;29(3):105–19.

Murray SA, McKay RC, Nieuwoudt JM. Grief and needs of adults with acquired visual impairments. Br J Vis Impair. 2010;28(2):78–89.

Wong EYH, Guymer RH, Hassell JB, Keeffe JE. The experience of age-related macular degeneration. J Vis Impair Blind. 2004;98(10):629–40.

Ivanoff SD, Sjostrand J, Klepp KI, Lind LA, Lindqvist BL. Planning a health education programme for the elderly visually impaired person—a focus group study. Disabil Rehabil. 1996;18(10):515–22.

Brouwer DM, Gaynor S, Winding K, Hanneman M. Limitations in mobility: experiences of visually impaired older people. Br J Occup Ther. 2008;71(10):414–21.

Mitchell J, Bradley C. Quality of life in age-related macular degeneration: a review of the literature. Health Qual Life Outcomes. 2006;4:97.

King A. Why we’re getting it wrong in Afghanistan. In: Prospect. 2009.

Teitelman J, Copolillo A. Psychosocial issues in older adults’ adjustment to vision loss: findings from qualitative interviews and focus groups. Am J Occup Ther. 2005;59(4):409–17.

Thurston M, Thurston A, McLeod J. Socio-economic effects of the transition from sight to blindness. Br J Vis Impair. 2010;28(2):90–112.

Download references

Acknowledgements

We would like to thank Professor Christopher Dandeker based at the Department of War Studies, King’s College London, for his useful comments on an earlier draft of the paper.

Author information

Authors and affiliations.

King’s Centre for Military Health Research, King’s College London, Weston Education Centre, 10 Cutcombe Road, SE5 9RJ, London, United Kingdom

Sharon A. M. Stevelink, Estelle M. Malcolm & Nicola T. Fear

Academic Department of Military Mental Health, King’s College London, Weston Education Centre, 10 Cutcombe Road, SE5 9RJ, London, United Kingdom

Nicola T. Fear

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Sharon A. M. Stevelink .

Additional information

Competing interests.

S.A.M.S., E.M.M. and N.T.F. are based at King’s College London, which receives funding from the UK Ministry of Defence (MoD). S.A.M.S. and E.M.M. receive funding from Blind Veterans UK to carry out the Blind Veterans UK study. The authors were not directed in any way by the charity or the MoD in relation to this publication.

Authors’ contribution

SAMS was involved in the planning of the study, in developing the data analysis strategy for this paper, participated in data collection, undertook the data analyses and wrote the paper. EMM was involved in developing the data analysis strategy for this paper, participated in data collection, undertook the data analyses, contributed to and commented on the paper. NTF was the principal investigator for this study, was involved in the design, planning and data analysis strategy development of the study and commented extensively on the paper. All authors read and approved the final manuscript.

Additional files

Additional file 1:.

Coding framework with the two main themes identified for the current paper. (DOCX 15 kb)

Additional file 2:

Semi-structured interview guideline. (DOCX 14 kb)

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Stevelink, S.A.M., Malcolm, E.M. & Fear, N.T. Visual impairment, coping strategies and impact on daily life: a qualitative study among working-age UK ex-service personnel. BMC Public Health 15 , 1118 (2015). https://doi.org/10.1186/s12889-015-2455-1

Download citation

Received : 27 October 2014

Accepted : 26 October 2015

Published : 12 November 2015

DOI : https://doi.org/10.1186/s12889-015-2455-1

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Health-related quality of life

BMC Public Health

ISSN: 1471-2458

• General enquiries: [email protected]

• Visual Impairment

A review of visual impairment

• January 2018
• African Vision and Eye Health 77(1)

• University of KwaZulu-Natal
• This person is not on ResearchGate, or hasn't claimed this research yet.

Discover the world's research

• 25+ million members
• 160+ million publication pages
• 2.3+ billion citations

• Sphamandla Josias Nkambule

• Nigist Legesse
• Bayisa Abdissa
• Zenabu Begna
• Dereje Lemma

• Maximus Monaheng Sefotho
• Ronél Ferreira
• Rania G.E. Zaki
• Reham F. Elshinawy
• Karim M. Naguib

• Paula Varaidzai Makondo
• Rutwik Mishra
• Suvasish Dalai
• Sudhansu Sekhar Lenka
• Satyajit Sundar Ray

• Daniel Sunkwa Quarcoo Dogbe

• H.S. Sacharowitz

• A. O. Oduntan
• O. A. Oduntan
• QUAL LIFE RES

• Ruth Marie Antoinette van Nispen

• CLIN EXP OPTOM

• Milind S. Manumali
• Mallikarjun M Heralgi

• GORDON JOHNSON
• ARCH OPHTHALMOL-CHIC
• Sheila K. West
• Recruit researchers
• Join for free
• Login Email Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google Welcome back! Please log in. Email · Hint Tip: Most researchers use their institutional email address as their ResearchGate login Password Forgot password? Keep me logged in Log in or Continue with Google No account? Sign up

• Open access
• Published: 15 September 2021

Visual impairment and medication safety: a protocol for a scoping review

• Sally J. Giles   ORCID: orcid.org/0000-0003-1623-6029 1 , 2 ,
• Maria Panagioti 1 , 2 ,
• Lisa Riste 1 ,
• Sudeh Cheraghi-Sohi 1 , 2 ,
• Penny Lewis 3 ,
• Isabel Adeyemi 1 ,
• Karen Davies 1 ,
• Rebecca Morris 1 , 2 ,
• Denham Phipps 3 ,
• Christine Dickenson 3 ,
• Darren Ashcroft 1 , 3 &
• Caroline Sanders 1 , 2  

Systematic Reviews volume  10 , Article number:  248 ( 2021 ) Cite this article

2743 Accesses

2 Citations

13 Altmetric

Metrics details

The number of individuals with a visual impairment in the UK was estimated a few years ago to be around 1.8 million. People can be visually impaired from birth, childhood, early adulthood or later in life. Those with visual impairment are subject to health inequities and increased risk for patient safety incidents in comparison to the general population. They are also known to be at an increased risk of experiencing medication errors compared to those without visual impairment. In view of this, this review aims to understand the issues of medication safety for VI people.

Methods/design

Four electronic bibliographic databases will be searched: MEDLINE, Embase, PsycInfo and CINAHL. Our search strategy will include search combinations of two key blocks of terms. Studies will not be excluded based on design. Included studies will be empirical studies. They will include studies that relate to both medication safety and visual impairment. Two reviewers (SG and LR) will screen all the titles and abstracts. SG, LR, RM, SCS and PL will perform study selection and data extraction using standard forms. Disagreements will be resolved through discussion or third party adjudication. Data to be collected will include study characteristics (year, objective, research method, setting, country), participant characteristics (number, age, gender, diagnoses), medication safety incident type and characteristics.

The review will summarise the literature relating to medication safety and visual impairment.

Peer Review reports

Visual impairment (VI) refers to a condition where the person has a reduction in their visual acuity or field of vision, which cannot be corrected by spectacles or contact lenses. It is estimated to affect 285 million people, 39 million of whom are blind [ 1 ]. The number of individuals with a visual impairment in the UK was estimated a few years ago to be around 1.93 million [ 2 ]: about 3% of the adult population [ 3 ]. People can be visually impaired from birth, childhood, early adulthood or later in life. People over 50 represent the largest group of blind and visually impaired people, which currently stands at 82% of the blind and visually impaired population worldwide [ 1 ]. Those with visual impairment or blindness are reported to be marginalised in terms of accessing healthcare information and facilities, and they are known to receive sub-optimal healthcare [ 4 ]. Marginalised patients, such as those with visual impairment, are subject to health inequities and increased risk for patient safety incidents in comparison to the general population [ 5 ]. Studies also suggest that people with VI are more at risk of social isolation [ 6 ], which could further perpetuate their increased risk of being affected by patient safety incidents. Those with visual impairment are known to be at an increased risk of experiencing medication errors [ 7 ] compared to those without visual impairment. This could be for a number of reasons, such as being unable to open medication containers, being unable to differentiate various types of medication containers, being unable to differentiate various types of tablets/capsule dosage forms, forgetting to take medication on time and taking the wrong medication [ 7 , 8 ]. Medicine-taking is complex and requires various and coordinated forms of work on the part of the patient and those in their networks. People with VI may not be able to perform their medicine work as easily as those without VI. The importance of supporting visually impaired patients to help improve their medication safety was further strengthened in 2016 when NHS England introduced the Accessible Information Standard (AIS), which required that the information and communication needs of disabled patients are proactively addressed in all aspects of NHS healthcare, including the dispensing of medicines [ 9 ]. Digital solutions are increasingly used to improve people’s safety and quality of life and VI people are frequent users of the Internet to support their wellbeing [ 10 , 11 ]. There are concerns about the cost and lack of universal availability of this technology [ 12 ], and it is less clear how digital technologies, managed by individuals, can not only empower visually impaired people, but also safeguard them from harm related to medication management [ 13 ].

To understand the issues of medication safety for VI people, it is essential to gather evidence from their experience and consider that alongside previous research. We have undertaken focus groups with VI people identifying a number of key themes, including the variation in VI and consequences for medication safety. We propose conducting a scoping review of existing research evidence to increase the understanding of VI and medication safety.

The issues of medication safety for people with VI depend on the nature/severity of the visual condition. Previous research conducted by the team [ 14 ] identified that health and social care practitioners lack knowledge and understanding of VI, but many people with VI feel confident to explain what works for them and find “work arounds” to maintain safety in medicine taking.

With an ageing population in many developing countries, the number of people with age-related vision loss is likely to increase. The scoping review aims to identify the specific medication safety issues for people with visual impairment and how these patients manage their medicines to mitigate against medication safety issues.

Objective of the scoping review

To identify and analyse the existing literature relating to the association between medication safety and visual impairment, including the main types of and contributory factors to medication safety issues.

Firstly, “to examine the extent, range and nature of research activity; this type of rapid review might not describe research findings in any detail but is a useful way of mapping fields of study where it is difficult to visualise the range of material that might be available.” The second common reason is determining whether a systematic review is feasible and of value. The third and fourth common reasons seem to describe scoping reviews that are not exploratory or preparatory, but done in their own right. Other authors similarly state that scoping reviews are used to synthesise research evidence and are often used to map existing literature in a given field in terms of its nature, features and volume. As such, scoping reviews have also been called “mapping” reviews. Finally, a map of the range of the available evidence can be undertaken as a preliminary exercise prior to the conduct of a systematic review. If we wish to conduct other more systematic reviews, then this review will allow us to see where and if that might be possible.

Search strategy

Four electronic bibliographic databases will be searched: MEDLINE, Embase, PsycInfo and CINAHL. We will also identify eligible studies by checking the reference lists of those studies identified in the search that meet our inclusion criteria. Our search strategy will include search combinations of two key blocks of terms: visual impairment and medication safety (Table 1 ), similar to those used in two previous reviews [ 15 , 16 ].

The proposed search terms are shown in Table 1 .

Eligibility criteria

Studies will be excluded if they fail to meet any of the 3 criteria (a “NO” choice). Studies will be eligible for full-text screening if they fully (a “YES” choice to each criterion) or partly (one or more “UNSURE” choice) meet criteria A1, A2 and A3.

A. For any study type (including review articles and opinion pieces):

Is it an empirical research?

YES, NO, UNSURE

Does it make reference to medication safety or medicines management?

The research has been conducted with visually impaired patients?

We will include:

Types of studies : We will include empirical studies which provide data on medication safety or medicines management for visually impaired patients. Study designs will not be restricted and will include both quantitative designs (that is, randomised controlled trials, quasi-experimental studies, cohort studies, cross-sectional studies) and qualitative studies including case studies. We will also include grey literature reports.

Types of participants: patients with visual impairment. We will not exclude participants on the basis of comorbidities

Phenomena of interest: medication safety/medicines management issues for visually impaired patients. On the basis of previous research, we anticipate that such issues may include being unable to open medication containers, being unable to differentiate various types of medication containers, being unable to differentiate various types of tablets/capsule dosage forms, forgetting to take medication on time and taking the wrong medication and polypharmacy (Zhi-Han, 2017: Cheraghi-Sohi et al, 2014.

Setting/context: Studies conducted in any setting. We will not restrict our search in specific geographical areas or date of publication.

We will exclude:

Non-empirical studies

Case studies reporting a new onset of visual impairment following medication use

Articles in non-English languages

Management of search outcomes and study eligibility screening

The results of the searches of each database will be exported to COVIDENCE [ 1 ] and duplicates deleted.

Using PRISMA guidelines (Moher et al, 2009), screening will be completed in two stages (see Fig. 1 ). Initially, the titles and abstracts of the identified studies will be screened for eligibility (see the “Eligibility criteria” section). A proportion of titles and abstracts (50%) will be screened by two researchers independently to assess reliability using the kappa statistic. Assuming reliability is confirmed, screening of the remaining titles and abstracts will be completed by one reviewer.

PRISMA flowchart

Next, the full texts of studies initially assessed as “relevant” for the review will be retrieved and checked against our inclusion/exclusion criteria. Full-text screening will be completed by two members of the research team independently, with disagreements resolved by discussion.

Methodological quality of the studies

As scoping reviews aim to provide a map of what evidence has been produced as opposed to seeking only the best available evidence to answer a particular question related to policy and practice, a formal assessment of methodological quality of the included studies of a scoping review will not be performed.

Data synthesis

A narrative synthesis will be conducted and the results will be organised according to the research aims. The first section of the results will present the research findings on the association between medication safety and visual impairment, the main types of patient safety issues encountered by people with visual impairment and the key contributory factors. The second section will focus on presenting the available evidence on the use of digital technologies for managing medication among people with visual impairment. In the third section, we will outline future research recommendations for designing and testing digital interventions to improve medication safety in people with visual impairment. We will take into consideration the present findings as well as the broader literature (from existing systematic reviews) on the use of digital technologies in improving medication safety.

This review will summarise the literature relating to visual impairment and medication safety. Four electronic bibliographic databases will be searched, using combinations of two key blocks of search terms: visual impairment and medication safety. The findings from this review will provide an evidence base for further work in this area. It will increase understanding of the issues that visually impaired people face in relation to medication safety and ultimately improve quality of health care.

Availability of data and materials

Not applicable

Abbreviations

• Visual impairment

Sally Giles

Rebecca Morris

Sudeh Cheraghi-Sohi

Penny Lewis

Accessible Information Standard

Pascolini D, Mariotti SP. Global estimates of visual impairment: 2010. British Journal of Ophthalmology. 2012;96(5):614–8. https://doi.org/10.1136/bjophthalmol-2011-300539 .

Article   Google Scholar  

Pezzullo L, Streatfeild J, Simkiss P, Shickle D. The economic impact of sight loss and blindness in the UK adult population. BMC Health Serv Res. 2018;18(1):63. https://doi.org/10.1186/s12913-018-2836-0 .

Office for Disability Issues, 2011. Life Opportunities Survey 2009-2011. HM Government, Crown

Cupples M.E, Hart P.M, Johnston A et al. Improving healthcare access for people with visual impairment and blindness. BMJ 2012; 344 doi: 4 (Published 30 January 2012)

Lecko C. Patient safety and nutrition and hydration in the elderly. The Health Foundation; 2013.

Sharts-Hopko, Smeltzer S, Ott B et al. Healthcare experiences of women with visual impairment. Clinical Nurse Specialist: May-June 2010 - Volume 24 - Issue 3 - p 149-153

Zhi-Han L, Hui-Yin Y, Makmor-Bakry M. Medication-handling challenges among visually impaired population. Archives of Pharmacy Practice. 2017;8(1):8–14.

Cheraghi-Sohi S, Jeffries M, Stevenson F, Ashcroft DM, Carr M, Oliver K, et al. The influence of personal communities on the self-management of medication taking: A wider exploration of medicine work. Chronic Illn. 2015 Jun;11(2):77–92. https://doi.org/10.1177/1742395314537841 Epub 2014 Jun 11. PMID: 24920009 .

NHS England. Making health and social care information accessible. July 2015. Available at: https://www.england.nhs.uk/wp-content/uploads/2015/07/access-info-upd-july-15.pdf ()

Miller Smedema, S and McKenzie, A.R. (2010) The relationship among frequency and type of internet use, perceived social support, and sense of well-being in individuals with visual impairments, Disability and Rehabilitation, 32:4, 317-325, DOI: https://doi.org/10.3109/09638280903095908

Meyer CH, Stanzel BV, Moqaddem S, Brohlburg D. [Healthcare “Apps” for smartphones: relief or toy for patients and the visual impaired?]. Der Ophthalmologe : Zeitschrift der Deutschen Ophthalmologischen Gesellschaft. 2012 Jan;109(1):21-29. DOI: https://doi.org/10.1007/s00347-011-2426-6 , Apps für Smartphones im Gesundheitsbereich.

Kim HN. Understanding of how older adults with low vision obtain, process, and understand health information and services. Informatics for Health and Social Care. 2017;44(1):70–8. https://doi.org/10.1080/17538157.2017.1363763 .

Article   PubMed   Google Scholar  

World Health Organisation (WHO). Medication without harm. https://www.who.int/patientsafety/medication-safety/campaign/en/ , accessed, May 2020

Giles, Sally J., Lewis, Penny J., Phipps, Denham L., Mann, Faith * , Avery Anthony J. and Ashcroft, Darren M. PhD *† Capturing Patients' Perspectives on Medication Safety. Journal of Patient Safety : March 11, 2019

Maaskant JM, Vermeulen H, Apampa B, Fernando B, Ghaleb M A, Neubert A, Thayyil S, Soe A. Interventions for reducing medication errors in children in hospital. Cochrane Database of Systematic Reviews, 10 th March 2015

Kentab BY, Barry HE, Al-Aqeel Sinaa A, Hughes CM. A systematic review of pharmacists’ interventions to support medicines optimisation in patients with visual impairment. International Journal of Clinical Pharmacy. 2019;41(6):1400–7. https://doi.org/10.1007/s11096-019 .

Download references

Acknowledgements

This research was funded by the National Institute for Health Research through the Greater Manchester Patient Safety Translational Research Centre (NIHR Greater Manchester PSTRC). The views expressed are those of the authors and not necessarily those of the NIHR or Department of Health and Social Care.

Author information

Authors and affiliations.

NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Suite 11, 7th floor, Williamson Building, Oxford Road M13 9PL, Manchester, UK

Sally J. Giles, Maria Panagioti, Lisa Riste, Sudeh Cheraghi-Sohi, Isabel Adeyemi, Karen Davies, Rebecca Morris, Darren Ashcroft & Caroline Sanders

Centre for Primary Care, University of Manchester, Oxford Road M13 9PL, Manchester, UK

Sally J. Giles, Maria Panagioti, Sudeh Cheraghi-Sohi, Rebecca Morris & Caroline Sanders

Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK

Penny Lewis, Denham Phipps, Christine Dickenson & Darren Ashcroft

You can also search for this author in PubMed   Google Scholar

Contributions

SG and MP designed the review and drafted the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Sally J. Giles .

Ethics declarations

Ethics approval and consent to participate, consent for publication, competing interests.

There are no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Giles, S.J., Panagioti, M., Riste, L. et al. Visual impairment and medication safety: a protocol for a scoping review. Syst Rev 10 , 248 (2021). https://doi.org/10.1186/s13643-021-01800-8

Download citation

Received : 26 October 2020

Accepted : 25 August 2021

Published : 15 September 2021

DOI : https://doi.org/10.1186/s13643-021-01800-8

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Medication safety

Systematic Reviews

ISSN: 2046-4053

• Submission enquiries: Access here and click Contact Us
• General enquiries: [email protected]

• Contact SCoTENS
• Privacy Policy

Special Educational Needs

Case study: visual impairment.

Declan wants to take part in everything and he has little or no fear.  If he is in a new situation he uses his hands to explore it (or him/her).  he is becoming quite strong and determined and does not like to be told what to do.  Because he cannot see things he wants to satisfy his curiosity by asking questions constantly.  Why? is his favourite word.  Sometimes Declan can be seen rocking backwards and forwards.  he does this when he has become confused and doesn’t know what is happening.