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- Maya Al Meer
Some patients suffer from eye diseases such as cataract or glaucoma and many others that cause a decrease in their level of vision making it impossible for them to regain their normal eyesight; this is known as visual impairment. Low vision is a mix of severe visual impairment and moderate visual impairment. The patient shows a decrease in the visual acuity less than (6/18) 20/60 and equal to or better than 3/60 in better eye with the best correction or visual field less than 20 degrees in diameter. Low vision could be a cause of injury, age, disease or present from birth. The patient with low vision would feel isolated from the world, live home independently and stop getting engaged in social activities. Denial, anger, anxiety, depression and grief are some psychological effects that low vision patients feel as a result of their visual impairment.
Psychological Effects of Low Vision on Patients
Data analysis have estimated that approximately ten to eleven million people in North America are blind and visually impaired (American Foundation of the blind [AFB], ND) and women represent two thirds of world’s vision impaired (Connor & keeffe, 2007). The term visual impairment includes vision with all its stages starting from blindness, and lack of functional light to low vision (AFB, ND). Around 124 million people in the world suffer from low vision that cannot be corrected neither by contact lenses nor eyeglasses (Connor & Keeffe, 2007). You may feel scared or worried once you get informed from the doctor that you have partially lost your vision, especially if you are an older adult. You will face some complications while adapting to vision loss rather than other health problems that you may be facing. For example, you will not be able to get engaged in social activities like before; you would prefer to stay home independently (Optelec, 2012).
A patient is considered to suffer from low vision if his visual acuity does not reach more than 20/70 or have peripheral vision loss with loss of light sensitivity. Some patients have refractive errors that can be corrected with eyeglasses, contact lenses or surgery however it is not the case in low vision (Goldstein, 2013). Low vision is defined by the World Health Organization (WHO) from two different sides: From an epidemiological perspective and from service provision perspective. The epidemiological perspective states that low vision is determined by depending on the visual acuity and visual field (Connor & Keeffe, 2007).
“Visual acuity less than 6/18 (20/60) and equal to or better than 3/60 in the better eye with best correction or visual fields less than 20 degrees in diameter. From a service provision perspective, low vision is defined in functional terms: a person who has impairment of visual functioning even after treatment and/or standard refractive correction, and has a visual acuity of less than 6/18 to light perception, or a visual field less than 10 degrees from the point of fixation, but who uses, or is potentially able to use, vision for the planning and/or execution of a task” (Connor & Keeffe, 2007).
Low vision may be the result of age related macular degeneration, glaucoma and diabetic retinopathy. The causes of low vision vary between countries. In countries with middle to high income, low vision is due to genetics or may be present at birth and retinopathy of prematurity. However in countries with low income, the causes refer to vitamin A deficiency, measles and cataract (Connor & Keeffe, 2007). People suffering from low vision face difficulties in differentiating between colors, objects and recognizing faces (Goldstein, 2013). Some devices may be used to decrease the impact of low vision on patients which may be categorized into optical and non optical devices. The optical devices include hand held or stand magnifiers, telescopes and glare control devices, however; the non optical devices include task lightning devices such as lamps, reading stands, and high contrast watches (Minto & Butt, 2004). Low vision is defined as a visual impairment that cannot be corrected by contact lenses, glasses or surgery with a decrease in the visual acuity (AFB, ND). Denial, anger, anxiety, depression and grief are some psychological effects that low vision patients feel as a result of their visual impairment.
Depression is a common reaction seen within low vision patients. According to the American Psychiatric Association and World Health Association, depression could be defined as a mental disorder that is pointed out by showing loss of interests in hobbies and low mood. The phenomenon of depression is obvious within people suffering from low vision recently more than people having normal sight. As the visual impairment gets worse, the patient would feel more depressed and that would reflect negatively on him especially when it is considered one of the stages of the grief process. In some people, depression may last for four years after the beginning of vision loss this means that the patient hasn’t accepted the idea that his visual acuity has decreased (Tabrett & Latham, 2009).
The patient would know that he is passing through a depression stage when he seems unhappy, he shows an attitude of resentment, lack of interest in daily activities, and drift away from the society. The reason behind why we feel depressed is controversial; however depression usually results from a dramatic event that happened in the past such as the death of a person, illness or vision loss. Generally, there is a solution for getting rid of depression once you relief all the pressure, however that is not the case in low vision since it is untreatable. Depression is considered to be one of the highest causes of disease in improved countries by 2020 as it has been stated by the World Health Organization. In older communities 1-2% of people are affected by depression, 30-40% of older patients suffering from the visual impairment have higher percentage of depression which is 2. 3 to 4. 6 times higher than that of people having normal vision (Tabrett & Latham, 2009).
There are three factors that regulate the level of depression within low vision patients which are level of vision, general health, and social support. The level of depression is indirectly proportional to the level of vision which means people who have total visual loss with no perception of light suffer from less level of depression than those people with impaired visual loss. Those people who still have remaining vision feel more depressed since they always feel afraid that at any time or day they may lose their vision totally. Unlike level of vision, general health and depression are related to each other. Whether the individual suffer from low vision or not, but have poor health condition he is still going to feel depressed. Social support acts like a barrier that decrease levels of depression in low vision patients. Low vision patients need support to make them accept their situation better. The support given to them may be functional or structural . Functional which means it depends on the type of support which can be emotional, instrumental, informational, and recreational support. However structural support depends on the size, quality and proximity of the support given to them. (Tabrett and Laham , 2009).
Denial is one of the psychological effects of low vision on patients. The first reaction seen by patients once they know about their situation is denial. Patients would find difficulty in understanding what was going on, they would blame the doctor or think that he made a mistake. Patients would still believe that they will get different results when they repeat the test again (Royal National Institute of Blind People [RNIB], 2013). Denial is a defense mechanism in which individuals refer to when they are not capable of believing the truth or reality (Cherry, 2014). Passing through denial for a short period could be a good thing providing more time for the patient to accept his situation ;however, if the process of denial remained for a long period of time this will delay the treatment that requires action instantly. When patients are in denial they reject to admit that their visual acuity has decreased, avoid facing the facts and reduce the effects of the situation (Mayo Clinic Staff, 2011).
Denial works in such a way to protect the person’s ego from situations that he can’t deal with. In some cases, low vision patients will accept the idea that they have lost some of their vision however they will still hold on the responsibility to others (Cherry, 2014). In some circumstances, the denial process could be supportive since it gives your brain the chance to involuntarily absorb stunning or upsetting information at a pace that won’t send you into an emotional collapse (Mayo clinic staff, 2011).
Anger is one of the common feelings of sight loss. Anger is an expected response to unwanted changes. Low vision patients consider family and friends as their cause for making them feel angry. They think that they are not doing their role completely by making them feel better or they are not finding the convenient way to help them. We have to take into consideration also that those people are still new to the situation. According to the organizations and doctors, the patient might find that the services they have given them are not enough or may not be helpful. At times due to the absence of a target, patients start blaming themselves or ask why me what have I done to get this as a punishment. They would try to find answers for their questions everywhere even though they know that it wouldn’t change anything (RNIB, 2013).
Another effect seen within low vision patients is Anxiety. Anxiety comes after the feeling of anger, and it is considered being as a step where the patients somehow start to believe that their visual impairment is irreversible. They will be worried about how they will be able to manage things they got used to do since childhood. It feels embarrassing to ask from family or friends for their help. Anxiety is seen the most in individuals especially when they are not expecting what’s coming next. It is considered to be an internal signal to pay attention and take precautions until they find the right way for accepting their situation. With the increase of confidence, anxiety tends to decrease gradually (RNIB, 2013).
Anxiety shows some symptoms ranging between nervousness, sweating, light headiness, rapid heartbeat and breathing rate as identified by Cruse in 1999. Anxiety is also seen during the process of diagnosis where the patient may show some responses or reactions, therefore a specialist has to deal with the situation (Stephens, 2007). If the individual is the one who supports the family financially, then feeling anxious will be a big obstacle since it will cause a withdrawal and point of weakness for him (Cruse, 1999). Rovner and Casten (2002), cited in Tolman et al. (2005 p. 748) discovered that loss of acitivity interceded the relationship between visual acuity and levels of distress identified with vision loss, and that distress increased as individuals surrendered valued activities as a result of visual impairment. “Visual loss has been associated with hallucinations in Alzheimer’s patients (Chapman et al. , 1999) and identified as a predisposing factor in delirium in older hospital patients (Inouye et al. , 1993) – both studies cited in Burmedi et al. (2002)” (Stephen, 2007).
Grief has a big effect on the psychological life of low vision patients. Once patients realize that they have lost their sight partially, they will be living in an environment full of sadness and grief. And that feeling will increase with time according to the situation which affects them negatively. They wouldn’t notice a friend that is passing by on the street or they may drop something and wouldn’t be able to find it again. Patients would believe that if they admit that they are sad is self-pity and people would think they are weak (RNIB, 2013). Loss, grief and recovery are words that hold different meaning to people. Grief can show both physical and behavioral symptoms varying between loss of appetite, crying, anger, anxiety and difficult focusing. Karen Briskie, director of The Medical Team Journey Behavioral says that grief is a normal process, a strong emotion, and a worldwide experience that proves that we are human. Grief alone represents a normal reaction to loss. It is essential for the patient to admit the grief since it helps in speeding up the healing process (Searson, ND).
“Grief is not classified as a clinical depression and it is not necessary to use antidepressant as a treatment. Page Moss Fletcher, MD adds that grief and loss are a common human experience and can be helped with therapy” (Searson, ND). Clinical depression is described as being a health problem that can be cured by medication, therapy and support. Patients who undergo treatment would notice that they are happier than before and the percentage of individuals committing bad behavior will decrease (Searson, ND). In order for patients with sight loss to relief grief they have to undergo a long period of time and a slow and organized therapy. Patient suffering from grief passes through a process called the cycle of grief. The cycle includes denial, anger, bargaining, depression and finally acceptance. The third stage which is bargaining, in this stage the patient would be more conscious about his situation and he will notice some changes. He may begin to search for targets to get help from if there was anything to do to make things better. The final stage which is acceptance the patient will start to lose hope and accept their vision loss. They need to change their lifestyle to get used to the loss (Windsor, 2010).
In conclusion, vision loss doesn’t affect the patients only but also affects the people surrounding them. Family members and friends need to understand that low vision is dramatic and emotional. The loss of sight causes denial, anger, depression and anxiety which are all psychological effects. Family members play an important role in providing support for patients and help them find the right way to accept their situation. They have to convince them to attend low vision care organizations in order to overcome their loss.
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