Approaching rehabilitation in patients with advanced glaucoma

Vision loss from advanced glaucoma is currently irreversible and impairs functional visual ability to effectively perform everyday tasks in a number of distinct functional domains. Vision rehabilitation strategies have been demonstrated to be effective in low vision populations and should be utilized in persons with advanced glaucoma to reduce disability and improve quality of life. Initial challenges to rehabilitation include an incomplete understanding of vision rehabilitation by the physician and patient, motivation to integrate rehabilitation into the plan of care, and availability of suitable providers to deliver this care. Physicians, working with well-trained vision rehabilitation providers can maximize function in important visual domains customized to the patient based on their needs, specific complaints, severity/pattern of visual damage, and comorbidities. Potential rehabilitative strategies to be considered for reading impairment include spectacle correction, visual assistive equipment, and sensory substitution, while potential strategies to facilitate driving in those deemed safe to do so include refractive correction, lens design, building confidence, restriction of driving to safer conditions, and avoiding situations where cognitive load is high. Mobility is frequently disrupted in advanced glaucoma, and can be addressed through careful distance refraction, behavior modification, home modification, mobility aids, walking assistance (i.e., sighted guide techniques), and smartphone/wearable technologies. Visual motor complaints are best addressed through optimization of lighting/contrast, sensory substitution, IADL training, and education. Special rehabilitative concerns may arise in children, where plans must be coordinated with schools, and working adults, where patients should be aware of their rights to accommodations to facilitate specific job tasks.