Low vision rehabilitation for better quality of life in visually impaired adults

What was the aim of the review?
The aim of this review was to find out if low vision rehabilitation can improve quality of life (QOL) for vision impaired people. Cochrane Review authors collected and analysed all relevant studies to answer this question and found 44 studies.

Key messages
Low vision rehabilitation does not appear to have an important impact on health-related QOL however the evidence is very low-certainty. There is low-certainty evidence that some low vision rehabilitation interventions, particularly psychological therapies and methods of enhancing vision, may improve vision-related QOL in people with sight loss compared to usual care.

What was studied in the review?
A person who is vision impaired has problems with their eyesight. If the vision loss cannot be corrected by glasses or contact lenses, or otherwise treated, then low vision rehabilitation may help to improve quality of life for people with vision impairment.

There are different types of low vision rehabilitation and these include:

• Psychological therapies and group programmes to help people adapt to permanent vision loss and improve well-being.
• Methods of enhancing vision such as teaching the use of magnifying devices, or other technologies, or teaching skills to improve the use of residual vision in daily life.
• Multidisciplinary rehabilitation programmes, which may include the use of magnifying devices and psychological therapies, as well as other services, including at patients’ homes.
• Other less common types of rehabilitation services such as balance training or home safety programs.

What were the main results of the review?
Cochrane Review authors identified 44 studies of low vision rehabilitation and QOL.

Most of these studies took place in vision rehabilitation services in high-income countries. Many of the participants in these studies were older and had a diagnosis of macular degeneration. The studies considered psychological therapies and group programmes, methods of enhancing vision as well as multidisciplinary rehabilitation programmes. In these studies, vision impaired people completed questionnaires about their general health, their vision, or other aspects of well-being.

Compared to people with vision loss who received no low vision rehabilitation:

• People with vision loss receiving psychological therapies and/or group programmes may experience:

⇒ no improvement in health-related QOL (very low-certainty);
⇒ some improvement in vision-related QOL (low-certainty).

• People with vision loss receiving methods of enhancing vision may experience:

⇒ some improvement in vision-related QOL (very low-certainty);
⇒ (there were no data available on health-related QOL).

• People with vision loss receiving a multidisciplinary rehabilitation programme may experience:

⇒ little or no improvement in health-related QOL (very low-certainty);
⇒ some improvement in vision-related QOL, particularly if an intensive programme is used (very low-certainty).

Compared to people with vision loss who received usual care:

• People with vision loss receiving psychological therapies and/or group programmes may experience:

⇒ little or no improvement in either health-related QOL (very low-certainty) or vision-related QOL (low-certainty).

• people with vision loss receiving methods of enhancing vision may experience:

⇒ little or no improvement in health-related QOL (very low-certainty);
⇒ some improvement in vision-related QOL (moderate-certainty).

• People with vision loss receiving a multidisciplinary rehabilitation programme may experience:

⇒ little or no improvement in either health-related QOL (very low-certainty) or vision-related QOL (low-certainty).

There was some evidence that psychological therapies had a positive impact on self-esteem (very low-certainty) and depression (moderate-certainty evidence)

There was no evidence to suggest any harms (adverse effects) of rehabilitation but data were limited.

How up-to-date is the review?
Cochrane Review authors searched for studies published up to 18 September 2019.

Authors' conclusions: 

In this Cochrane Review, no evidence of benefit was found of diverse types of low vision rehabilitation interventions on HRQOL. We found low- and moderate-certainty evidence, respectively, of a small benefit on VRQOL in studies comparing psychological therapies or methods for enhancing vision with active comparators.

The type of rehabilitation varied among studies, even within intervention groups, but benefits were detected even if compared to active control groups. Studies were conducted on adults with visual impairment mainly of older age, living in high-income countries and often having AMD. Most of the included studies on low vision rehabilitation had a short follow-up,

Despite these limitations, the consistent direction of the effects in this review towards benefit justifies further research activities of better methodological quality including longer maintenance effects and costs of several types of low vision rehabilitation. Research on the working mechanisms of components of rehabilitation interventions in different settings, including low-income countries, is also needed.

Read the full abstract...
Background: 

Low vision rehabilitation aims to optimise the use of residual vision after severe vision loss, but also aims to teach skills in order to improve visual functioning in daily life. Other aims include helping people to adapt to permanent vision loss and improving psychosocial functioning. These skills promote independence and active participation in society. Low vision rehabilitation should ultimately improve quality of life (QOL) for people who have visual impairment.

Objectives: 

To assess the effectiveness of low vision rehabilitation interventions on health-related QOL (HRQOL), vision-related QOL (VRQOL) or visual functioning and other closely related patient-reported outcomes in visually impaired adults.

Search strategy: 

We searched relevant electronic databases and trials registers up to 18 September 2019.

Selection criteria: 

We included randomised controlled trials (RCTs) investigating HRQOL, VRQOL and related outcomes of adults, with an irreversible visual impairment (World Health Organization criteria). We included studies that compared rehabilitation interventions with active or inactive control.

Data collection and analysis: 

We used standard methods expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach.

Main results: 

We included 44 studies (73 reports) conducted in North America, Australia, Europe and Asia. Considering the clinical diversity of low vision rehabilitation interventions, the studies were categorised into four groups of related intervention types (and by comparator): (1) psychological therapies and/or group programmes, (2) methods of enhancing vision, (3) multidisciplinary rehabilitation programmes, (4) other programmes. Comparators were no care or waiting list as an inactive control group, usual care or other active control group. Participants included in the reported studies were mainly older adults with visual impairment or blindness, often as a result of age-related macular degeneration (AMD). Study settings were often hospitals or low vision rehabilitation services. Effects were measured at the short-term (six months or less) in most studies. Not all studies reported on funding, but those who did were supported by public or non-profit funders (N = 31), except for two studies.

Compared to inactive comparators, we found very low-certainty evidence of no beneficial effects on HRQOL that was imprecisely estimated for psychological therapies and/or group programmes (SMD 0.26, 95% CI -0.28 to 0.80; participants = 183; studies = 1) and an imprecise estimate suggesting little or no effect of multidisciplinary rehabilitation programmes (SMD -0.08, 95% CI -0.37 to 0.21; participants = 183; studies = 2; I2 = 0%); no data were available for methods of enhancing vision or other programmes. Regarding VRQOL, we found low- or very low-certainty evidence of imprecisely estimated benefit with psychological therapies and/or group programmes (SMD -0.23, 95% CI -0.53 to 0.08; studies = 2; I2 = 24%) and methods of enhancing vision (SMD -0.19, 95% CI -0.54 to 0.15; participants = 262; studies = 5; I2 = 34%). Two studies using multidisciplinary rehabilitation programmes showed beneficial but inconsistent results, of which one study, which was at low risk of bias and used intensive rehabilitation, recorded a very large and significant effect (SMD: -1.64, 95% CI -2.05 to -1.24), and the other a small and uncertain effect (SMD -0.42, 95%: -0.90 to 0.07).

Compared to active comparators, we found very low-certainty evidence of small or no beneficial effects on HRQOL that were imprecisely estimated with psychological therapies and/or group programmes including no difference (SMD -0.09, 95% CI -0.39 to 0.20; participants = 600; studies = 4; I2 = 67%). We also found very low-certainty evidence of small or no beneficial effects with methods of enhancing vision, that were imprecisely estimated (SMD -0.09, 95% CI -0.28 to 0.09; participants = 443; studies = 2; I2 = 0%) and multidisciplinary rehabilitation programmes (SMD -0.10, 95% CI -0.31 to 0.12; participants = 375; studies = 2; I2 = 0%). Concerning VRQOL, low-certainty evidence of small or no beneficial effects that were imprecisely estimated, was found with psychological therapies and/or group programmes (SMD -0.11, 95% CI -0.24 to 0.01; participants = 1245; studies = 7; I2 = 19%) and moderate-certainty evidence of small effects with methods of enhancing vision (SMD -0.24, 95% CI -0.40 to -0.08; participants = 660; studies = 7; I2 = 16%). No additional benefit was found with multidisciplinary rehabilitation programmes (SMD 0.01, 95% CI -0.18 to 0.20; participants = 464; studies = 3; I2 = 0%; low-certainty evidence).

Among secondary outcomes, very low-certainty evidence of a significant and large, but imprecisely estimated benefit on self-efficacy or self-esteem was found for psychological therapies and/or group programmes versus waiting list or no care (SMD -0.85, 95% CI -1.48 to -0.22; participants = 456; studies = 5; I2 = 91%). In addition, very low-certainty evidence of a significant and large estimated benefit on depression was found for psychological therapies and/or group programmes versus waiting list or no care (SMD -1.23, 95% CI -2.18 to -0.28; participants = 456; studies = 5; I2 = 94%), and moderate-certainty evidence of a small benefit versus usual care (SMD -0.14, 95% CI -0.25 to -0.04; participants = 1334; studies = 9; I2 = 0%). ln the few studies in which (serious) adverse events were reported, these seemed unrelated to low vision rehabilitation.

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