Baseline traits of patients presenting at a low vision clinic in Shanghai, China
Gao et al. BMC Ophthalmology
Baseline traits of patients presenting at a low vision clinic in Shanghai, China
Guohong Gao 0 1
Chaohu Ouyang 2
Jinhui Dai 0 1
Feng Xue 0 1
Xiaoying Wang 0 1
Leilei Zou 0 1
Minjie Chen 0 1
Fei Ma 0 1
Manrong Yu 0 1
0 Key Laboratory of Myopia, Ministry of Health PR China , Shanghai , China
1 Department of Ophthalmology, Eye and ENT Hospital Affiliated with Fudan University , Shanghai , China
2 Department of Ophthalmology, Shanghai Peace Eye Hospital , Shanghai , China
Background: Low vision, along with cataract, trachoma, onchocerciasis, childhood blindness and refractive error, is one of the priorities in the global initiative, VISION 2020-The Right to Sight. The purpose of this study was to characterize the traits of patients presenting at a low vision clinic in China. Methods: A retrospective study was conducted of the records of 299 patients who visited the Low Vision Clinic of Eye and ENT Hospital Affiliated to Fudan University from January 2009 to May 2014. Reviewed parameters included age, gender, education, occupation, cause of visual impairment and types of low vision aids (LVAs) dispensed. Results: Of all the patients (193 male; aged from 3 to 96 years, with a mean of 29.74 25.23 years), 43.48% experienced moderate visual impairment, 25.42% had severe visual impairment and 21.07% were blind. The four major causes of visual impairment were congenital cataract (14.38%), degenerative myopia (13.71%), juvenile macular degeneration (9.36%) and retinitis pigmentosa (9.36%). The most common causes of visual impairment were congenital cataract (22.67%) in 0-19-year-olds, retinitis pigmentosa (20.62%) in 20-59-year-olds, and age-related macular degeneration (36.54%) in the 60+ group. With the help of LVAs, a significant improvement of distance and/ or near vision or visual field was observed in 243 patients, of whom 185 accepted LVAs and 58 patients refused due to high price, inconvenience, young age (6 y), clumsy appearance and ignorance. The most commonly dispensed LVAs were stand magnifiers (21.57%) followed by spectacle-type LVAs (19.21%). Conclusions: The majority of the patients in our low vision clinic were young, the main causes of visual impairment were congenital and hereditary diseases. Stand magnifiers were the most commonly dispensed LVAs. High price was the major reason for refusing LVAs.
Low vision clinic; Visual impairment; Patient characteristics; Low vision aids; Rehabilitation
The World Health organization (WHO) reported in
2004 that 314 million people had visual impairment in
the world, of whom 45 million were blind, 124 million
were classified as having low vision after best correction,
and 145 million worldwide were visually impaired due to
uncorrected refractive errors . These figures have
been reduced with the effective implementation of the
program entitled Vision 2020: The Right to Sight and
the appropriate interventions. Globally, 285 million people
in the world were visually impaired in 2010, of whom 39
million were blind and 246 million had low vision. About
80% of visual impairment can be avoided or cured .
Approximately 90% of people with visual impairment
live in the developing countries with more than half of
them live in Asia and a vast majority in rural
communities . Based on surveys conducted in the rural areas
combined with data from urban settings, an estimated
75 million Chinese are visually impaired, with 8 million
being blind and 67 million having low vision [3-5].
Vision impairment is strongly associated with reduced
quality of life [6,7]. It is a common cause of reading
difficulty, loss of driving ability, mobility problems, and loss
of personal independence [8-11]. It also exerts a significant
impact on the socioeconomic development of individuals
and societies. Reduced vision brings about significant
consequences in relation to the individual, public health, and
community, such as increased cost of education, reduced
personal income and loss of productivity for those caring
for the visually impaired [12,13].
Through the use of low vision aids (LVAs) and
rehabilitation therapy, low vision rehabilitation is the
primary intervention for visual impairment to improve
daily function, seeking to maximize the patients ability
to perform daily activities, thereby improving quality of
life [14-16]. It has been estimated that very few people
with visual impairment, possibly only 5-10%, actually use
low vision rehabilitation services. Among the established
reasons are poor utilization of services, lack of awareness
of low vision services among patients, ignorance of
rehabilitation services, and low vision referral rates among
eye care practitioners [17,18].
The burden of visual impairment is huge; therefore,
data on provision of low vision services has become
necessary for planning appropriate low vision care and
providing quality care to people with visual impairment
so that they can restore as much visual function as
possible. This paper reports the findings of a retrospective
study of low vision clinic population. It is hoped that
information obtained would help in policy formulation
and funds allocation for low vision services.
A retrospective review was conducted of the records of
299 consecutive patients seen at the low vision clinic of
Department of Ophthalmology, Eye and ENT Hospital
Affiliated to Fudan University between January 2009 and
May 2014. Almost all patients were referred from other
hospitals. Hospitals of surrounding provinces (e.g. Jiangsu,
Zhejiang and Anhui province) preferred to refer people
with ocular diseases to a hospital-based low-vision service.
The patients had been treated for various diseases for
about 6 months but their visual demands were not
adequately met by conventional methods. The information
extracted from the clinical records of all patients included
age, sex, education level, work status, cause of visual
impairment, chief visual demand, visual acuity and types of
The study was carried out with approval from the Ethics
Committee of the Eye and ENT Hospital of Fudan
University in accordance with the tenets of the Helsinki
Declaration. All patients gave their informed consent prior to
inclusion in this study.
The definitions of visual impairment used for the
estimates in this study followed the categories of the
International Classification of Diseases Update and Revision
The causes of visual impairment were determined by
ophthalmologists. In cases where two or more disorders
might be responsible for the visual impairment, the
primary was recorded.
Each patient, based on his or her test results and the
daily activity that he or she wanted to achieve in the
future, was prescribed more than two LVAs for distance
and near vision. LVAs decision was made together by
the ophthalmologist, Low-vision therapist, the patient
and/or the guardian. Telephone interviews were
conducted by the primary author about the ease in using
the LVAs 3 months post-intervention.
Data were entered into a database in Microsoft Excel
and analyzed using SPSS V.21.0 (Chicago, IL, USA)
Records of 299 patients (193 or 64.55% male) were
reviewed. Their ages ranged from 3 to 96 years with a
mean of 29.74 25.23. The majority of patients were
young with 191 (63.88%) under 30 and 108 (36.12%) over
30. The distribution of age and sex is shown in Table 1.
The education level, work status and visual demands
are summarized in Table 2. The majority of the patients
had received school level education at the time of
presentation. Most (89.33%) of the young patients (19 years)
were receiving school education and most (92.31%) of
the elderly patients (60 years) were retired.
With regards to the main visual demands, 131(43.81%)
patients complained of poor distant and near vision at
the same time, indicating that both were of equal
importance to them. Among the patients reporting poor
distance vision as their main problem, 68.63% were
young patients and 5.88% were elderly patients. The
patients complained that they could not read books or
newspapers, see the contents on a blackboard, watch TV,
recognize a person or tell traffic lights at a distance, and
other problems because of vision loss.
Of the 299 patients, 30 (10.03%) were classified as with
mild visual impairment (6/18), 130 (43.48%) moderate
Table 1 Age and sex distribution
Table 2 Education level, work status and visual demands
College or higher
Unemployed or Dropout
Distance and Near vision
Visual field expansion
(6/18 to 6/60) and 76 (25.42%) severe (6/60 to 3/60),
and 63 (21.07%) as blind (<3/60).
The causes of visual impairment are shown in Table 3,
with the most common being congenital cataract
(22.67%) in 0-19-year-olds, retinitis pigmentosa (20.62%)
in 20-59-year-olds, and age-related macular
degeneration (AMD, 36.54%) in the 60+ group. Two elderly
patients with cataract did not undergo operation because
of the poor general health and advanced age.
The LVAs (255 for 185 patients) dispensed are listed
in Table 4, near LVAs (177, 69.41%) outnumbering
distance LVAs (74, 29.02%) and prisms (4, 1.57%).
With the help of LVAs, a significant improvement of
distance and/or near vision or visual field was observed
in 243 patients, of whom 185 patients accepted LVAs
and 58 refused due to high cost (36.11%), inconvenience
(20.83%), young age (6 y, 18.06%), clumsy appearance
(12.50%), ignorance (6.94%) and discomfort (5.56%).
Amongst those who refused LVAs, 17.24% gave two or
more reasons. The remaining 56 (18.73%) patients
refused to accept LVAs because LVAs did not lead to
significant improvement in vision or visual field.
Of all the patients responding to the telephone
interviews, 41 (22.16%) reported the use of the aids as
easy, 55 (29.73%) relatively easy, 38 (20.54%) a little
difficult, 27 (14.59%) very hard, and 24 (12.97%) extremely
The distribution of age and sex in our study is different
from previous reports in the developed countries but
similar to those from other developing countries. In this
study, a large proportion (73.91%) of patients was below
50 years old, most of the young patients being students
who are more likely to seek rehabilitation services
because poor vision is a big burden in continuing
education. This population composition is similar to the
findings from the developing countries [20-25] in which
the patients aged below 50 ranged between 57.01% and
73.82% and those aged 60 and above between 18.54%
and 31.09%. The high ratio between the male to female
in our study is similar to that of other studies conducted
in the developing countries (1.83:1 to 2.63:1). In
contrast, the majority (>60%) of the patients were aged 60
and above and more females were found to present for
low vision services in studies from the developed
countries [26-30]. The differences probably suggest the
reduced access and utilization of low vision rehabilitation
services by females and the older population in the
developing countries .
Visual impairment could affect work, study and social
activities, as mainly evidenced by the premature
retirement and unemployment in adults and school dropouts
in children. The majority of our patients considered near
and distance vision to be of equal importance. The
elderly patients were chiefly concerned with reading,
while children were more likely to deem distance vision
as being their major problem. To meet the visual needs,
it is very important to consider a patients working
distance and the desired outcome when prescribing LVAs.
The most common causes of visual impairment in our
study population as a whole differed markedly from the
studies in Korea (optic atrophy) , India (retinitis
pigmentosa)  and Malaysia (structural defects) . Two
studies in Nepal [23,25] reported the most common
Table 4 Low vision aids dispensed in relation to age
Aid dispensed Age (years)
0-9 10-19 20-29
causes in the country were diabetic retinopathy and
retinitis pigmentosa. In contrast, studies in the developed
countries [26-30] found AMD as the most common cause.
The possible reasons for lower prevalence of AMD in the
developing countries may include age and nutrition, less
cigarette smoking, and lower body mass index [24,31]. In
our study, the most common causes of visual impairment
among children were congenital and hereditary diseases,
which is similar to other reports [22-24,27]. Retinitis
pigmentos was found to be a the leading cause among
the adults aged 2059 years. Both in our study and the
studies in Malaysia  and Nigeria . AMD was
identified as the most common cause of visual
impairment among those over 60 in our study and in other
studies [20,22-24,26-30]. Different from other studies,
degenerative myopia was the the second leading cause
of visual impairment in our study and also the first
cause of visual impairment in patients aged 20 and
above. Considering the high prevalence of myopia in
China, the visual impairment caused by myopia deserves
more attention. In our study, the majority of the patients
with congenital cataract, who unresponsive to
therapeutic training for amblyopia, were companied by
nystagmus, strabismus and secondary glaucoma. These
findings suggest that great emphasis should be placed
on the rehabilitation in the patients with congenital
cataract combined with other eye diseases.
Spectacle-type LVAs came second in our study in
contrast to the findings of India  and Nepal  in which
spectacle magnifiers were the most commonly dispensed
devices. Handheld magnifiers were dispensed less
frequently in our clinic than in others [20,22,23,27-30]. Stand
magnifiers and spectacle-type LVAs were the most
commonly used LVAs for near vision, while binocular
telescopes were the most popular devices for distance vision.
Dispensing LVAs reflected the visual demands of patients,
with the majority being dispensed to those under 60 years
of age. In most LVA holders, visual acuity (near and/or
distance) or visual field were much improved when using
the LVAs, suggesting that LVAs were very helpful devices
to patients with visual impairment. However, a
considerable number of patients would give up the long-term use
of the LVAs. The results of the telephone survey showed
that about half of LVAs holders could not utilize LVAs
effectively, which might be related to disease progression,
physical deterioration, poor compliance and mobility of
patients, and inadequate guidance and training in the use
In this study, we found that availability, portability,
durability and appearance of the LVAs, and affordability,
cognitive ability and age of the patients were the main
influencing factors in dispensing LVAs. Generally,
electronic magnifiers could improve visual function as
good as, even better than optical magnifiers. However,
electronic devices were dispensed less frequently mainly
because they were too expensive. Besides, the standby
time was short, and it was difficult to repair if they were
damaged. Some patients refused LVAs because their vision
was either too poor or too good. The majority of the LVAs
refused by patients because of high price were electronic
devices and binocular telescopes. Inconvenience of LVAs
was mainly reflected in poor portability and operation
difficulty. Most of the patients who refused to accept LVAs
for being too young were preschoolers, and they shared a
number of common characteristics such as poor
independence, noncompliance and less visual demand for
reading and seeing a blackboard. Some parents preferred
environmental modifications such as moving the children
closer to the chalkboard or asking them to hold the book
closer. For the cosmetic reasons, spectacle-type devices
and binocular telescope were primarily refused by patients.
The patients who accepted LVAs shared some of the
features such as definite visual demands, good affordability,
good cognitive ability and significant improvement in the
quality of life with the help of LVAs.
The present retrospective study has a number of
limitations that should be acknowledged. First, it had a low
response rate and lacked long-term follow-up data with
fewer than a third of the patients responding to the
interview after rehabilitation. Second, we used a
convenience sample, and as such they may not be
representative of all patients with visual impairment in China.
Third, the small sample size limited the significance of
the results. Despite these limitations, this study is among
the first to provide hospital-based data on visual
impairment in China. Such data, particularly the findings that
the subjects with visual impairment refused useful LVAs
in this setting, are of value in planning strategies to
improve the eye health in China, who has the largest
population in the world.
In summary, patients seeking low vision rehabilitation
services are predominantly young and male in our low
vision clinic. Congenital and hereditary diseases were the
main causes of visual impairment, while age related
diseases (e.g., AMD) were the most common causes among
the elderly. Screening in the communities and schools is
useful for early detection, diagnosis and treatment of these
diseases. The growing focus on visual impairment,
rehabilitation and education means that eye care/healthcare
providers need to take the lead in working with the
education and rehabilitation communities. Counselling, a critical
component of eye care, should be provided throughout
the program. In addition, great emphasis should be
focused on popularization, education and guidance of low
vision rehabilitation, which will heighten awareness of the
accessibility and availability of low vision care.
As we have discussed, LVAs can be of great help in the
daily lives, work and study of patients with visual
impairment; however, consistent effort and cooperation between
patients and doctors are required. The rehabilitation of
low vision is challenging, requiring a multidisciplinary
team of ophthalmologists, optometrist, consultants and
rehabilitation therapists. According to other studies
[16,32-34], patients with visual impairment should be
referred to multidisciplinary specialist centers and
encouraged to accomplish regular follow-up and training. The
key to the success of the LVAs is to keep them portable,
comfortable, aesthetic and inexpensive, according to the
study. It is, we propose, most important to revamp of the
medical insurance coverage in Low vision rehabilitation.
The authors declare that they have no competing interests.
Study concept and design (GHG, JHD, XYW, FX); data collection (GHG,
CHOY); analysis and interpretation of data (LLZ, FM, MRY); drafting of the
manuscript (GHG, CHOY); critical revision of the manuscript (XYW, FX, LLZ,
FM, MRY); statistical expertise (CHOY); obtained funding (JHD, GHG);
administrative, technical, or material support (CHOY); supervision (JHD).
All authors read and approved the final manuscript.
This paper was funded by the National Natural Science Foundation of China
(No.81070750 and 81271040) and the Ministry of Health of China
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