Various scales have been developed to describe the extent of vision loss and define blindness.[1] Total blindness is the complete lack of form and visual light perception and is clinically recorded as NLP, an abbreviation for "no light perception."[1] Blindness is frequently used to describe severe visual impairment with residual vision. Those described as having only light perception have no more sight than the ability to tell light from dark and the general direction of a light source.
In order to determine which people may need special assistance because of their visual disabilities, various governmental jurisdictions have formulated more complex definitions referred to as legal blindness.[2] In North America and most of Europe, legal blindness is defined as visual acuity (vision) of 20/200 (6/60) or less in the better eye with best correction possible. This means that a legally blind individual would have to stand 20 feet (6.1 m) from an object to see it—with corrective lenses—with the same degree of clarity as a normally sighted person could from 200 feet (61 m). In many areas, people with average acuity who nonetheless have a visual field of less than 20 degrees (the norm being 180 degrees) are also classified as being legally blind. Approximately ten percent of those deemed legally blind, by any measure, have no vision. The rest have some vision, from light perception alone to relatively good acuity. Low vision is sometimes used to describe visual acuities from 20/70 to 20/200.[3]
By the 10th Revision of the WHO International Statistical Classification of Diseases, Injuries and Causes of Death, low vision is defined as visual acuity of less than 20/60 (6/18), but equal to or better than 20/200 (6/60), or corresponding visual field loss to less than 20 degrees, in the better eye with best possible correction. Blindness is defined as visual acuity of less than 20/400 (6/120), or corresponding visual field loss to less than 10 degrees, in the better eye with best possible correction.[4][5]
Blind people with undamaged eyes may still register light non-visually for the purpose of circadian entrainment to the 24-hour light/dark cycle. Light signals for this purpose travel through the retinohypothalamic tract, so a damaged optic nerve beyond where the retinohypothalamic tract exits it is no hindrance.
Serious visual impairment has a variety of causes:
Diseases
According to WHO estimates, the most common causes of blindness around the world in 2002 were:- cataracts (47.9%),
- glaucoma (12.3%),
- age-related macular degeneration (8.7%),
- corneal opacity (5.1%), and
- diabetic retinopathy (4.8%),
- childhood blindness (3.9%),
- trachoma (3.6%)
- onchocerciasis (0.8%).[13]
People in developing countries are significantly more likely to experience visual impairment as a consequence of treatable or preventable conditions than are their counterparts in the developed world. While vision impairment is most common in people over age 60 across all regions, children in poorer communities are more likely to be affected by blinding diseases than are their more affluent peers.
The link between poverty and treatable visual impairment is most obvious when conducting regional comparisons of cause. Most adult visual impairment in North America and Western Europe is related to age-related macular degeneration and diabetic retinopathy. While both of these conditions are subject to treatment, neither can be cured.
In developing countries, wherein people have shorter life expectancies, cataracts and water-borne parasites—both of which can be treated effectively—are most often the culprits (see river blindness, for example). Of the estimated 40 million blind people located around the world, 70–80% can have some or all of their sight restored through treatment.[citation needed]
In developed countries where parasitic diseases are less common and cataract surgery is more available, age-related macular degeneration, glaucoma, and diabetic retinopathy are usually the leading causes of blindness.[14]
Childhood blindness can be caused by conditions related to pregnancy, such as congenital rubella syndrome and retinopathy of prematurity.
Abnormalities and injuries
Eye injuries, most often occurring in people under 30, are the leading cause of monocular blindness (vision loss in one eye) throughout the United States. Injuries and cataracts affect the eye itself, while abnormalities such as optic nerve hypoplasia affect the nerve bundle that sends signals from the eye to the back of the brain, which can lead to decreased visual acuity.People with injuries to the occipital lobe of the brain can, despite having undamaged eyes and optic nerves, still be legally or totally blind.
Genetic defects
People with albinism often have vision loss to the extent that many are legally blind, though few of them actually cannot see. Leber's congenital amaurosis can cause total blindness or severe sight loss from birth or early childhood.Recent advances in mapping of the human genome have identified other genetic causes of low vision or blindness. One such example is Bardet-Biedl syndrome.
Poisoning
Rarely, blindness is caused by the intake of certain chemicals. A well-known example is methanol, which is only mildly toxic and minimally intoxicating, but when not competing with ethanol for metabolism, methanol breaks down into the substances formaldehyde and formic acid which in turn can cause blindness, an array of other health complications, and death.[15] Methanol is commonly found in methylated spirits, denatured ethyl alcohol, to avoid paying taxes on selling ethanol intended for human consumption. Methylated spirits are sometimes used by alcoholics as a desperate and cheap substitute for regular ethanol alcoholic beverages.Willful actions
Blinding has been used as an act of vengeance and torture in some instances, to deprive a person of a major sense by which they can navigate or interact within the world, act fully independently, and be aware of events surrounding them. An example from the classical realm is Oedipus, who gouges out his own eyes after realizing that he fulfilled the awful prophecy spoken of him. Having crushed the Bulgarians, the Byzantine Emperor Basil II blinded as many as 15,000 prisoners taken in the battle, before releasing them.[16]In 2003, a Pakistani anti-terrorism court sentenced a man to be blinded after he carried out an acid attack against his fiancee that resulted in her blinding.[17] The same sentence was given in 2009 for the man who blinded Ameneh Bahrami.
Comorbidities
Blindness can occur in combination with such conditions as mental retardation, autism spectrum disorders, cerebral palsy, hearing impairments, and epilepsy.[18][19] In a study of 228 visually impaired children in metropolitan Atlanta between 1991 and 1993, 154 (68%) had an additional disability besides visual impairment.[18] Blindness in combination with hearing loss is known as deafblindness.Management
A 2008 study published in the New England Journal of Medicine[20] tested the effect of using gene therapy to help restore the sight of patients with a rare form of inherited blindness, known as Leber Congenital Amaurosis or LCA. Leber Congenital Amaurosis damages the light receptors in the retina and usually begins affecting sight in early childhood, with worsening vision until complete blindness around the age of 30.The study used a common cold virus to deliver a normal version of the gene called RPE65 directly into the eyes of affected patients. Remarkably all 3 patients aged 19, 22 and 25 responded well to the treatment and reported improved vision following the procedure. Due to the age of the patients and the degenerative nature of LCA the improvement of vision in gene therapy patients is encouraging for researchers. It is hoped that gene therapy may be even more effective in younger LCA patients who have experienced limited vision loss as well as in other blind or partially blind individuals.
Two experimental treatments for retinal problems include a cybernetic replacement and transplant of fetal retinal cells.[21]
Adaptive techniques and aids
Mobility
Tools such as the white cane with a red tip - the international symbol of blindness - may also be used to improve mobility. A long cane is used to extend the user's range of touch sensation. It is usually swung in a low sweeping motion, across the intended path of travel, to detect obstacles. However, techniques for cane travel can vary depending on the user and/or the situation. Some visually impaired persons do not carry these kinds of canes, opting instead for the shorter, lighter identification (ID) cane. Still others require a support cane. The choice depends on the individual's vision, motivation, and other factors.
A small number of people employ guide dogs to assist in mobility. These dogs are trained to navigate around various obstacles, and to indicate when it becomes necessary to go up or down a step. However, the helpfulness of guide dogs is limited by the inability of dogs to understand complex directions. The human half of the guide dog team does the directing, based upon skills acquired through previous mobility training. In this sense, the handler might be likened to an aircraft's navigator, who must know how to get from one place to another, and the dog to the pilot, who gets them there safely.
Some blind people use GPS for the visually impaired as a mobility aid. Such software can assist blind people with orientation and navigation, but it is not a replacement for traditional mobility tools such as white canes and guide dogs.
Technology to allow blind people to drive motor vehicles is currently being developed.[22]
Government actions are sometimes taken to make public places more accessible to blind people. Public transportation is freely available to the blind in many cities. Tactile paving and audible traffic signals can make it easier and safer for visually impaired pedestrians to cross streets. In addition to making rules about who can and cannot use a cane, some governments mandate the right-of-way be given to users of white canes or guide dogs.
Reading and magnification
Most visually impaired people who are not totally blind read print, either of a regular size or enlarged by magnification devices. Many also read large-print, which is easier for them to read without such devices. A variety of magnifying glasses, some handheld, and some on desktops, can make reading easier for them.
Others read Braille (or the infrequently used Moon type), or rely on talking books and readers or reading machines, which convert printed text to speech or Braille. They use computers with special hardware such as scanners and refreshable Braille displays as well as software written specifically for the blind, such as optical character recognition applications and screen readers.
Some people access these materials through agencies for the blind, such as the National Library Service for the Blind and Physically Handicapped in the United States, the National Library for the Blind or the RNIB in the United Kingdom.
Closed-circuit televisions, equipment that enlarges and contrasts textual items, are a more high-tech alternative to traditional magnification devices.
There are also over 100 radio reading services throughout the world that provide people with vision impairments with readings from periodicals over the radio. The International Association of Audio Information Services provides links to all of these organizations.
Computers
Access technology such as screen readers, screen magnifiers and refreshable Braille displays enable the blind to use mainstream computer applications and mobile phones. The availability of assistive technology is increasing, accompanied by concerted efforts to ensure the accessibility of information technology to all potential users, including the blind. Later versions of Microsoft Windows include an Accessibility Wizard & Magnifier for those with partial vision, and Microsoft Narrator, a simple screen reader. Linux distributions (as live CDs) for the blind include Oralux and Adriane Knoppix, the latter developed in part by Adriane Knopper who has a visual impairment. Mac OS also comes with a built-in screen reader, called VoiceOver.The movement towards greater web accessibility is opening a far wider number of websites to adaptive technology, making the web a more inviting place for visually impaired surfers.
Experimental approaches in sensory substitution are beginning to provide access to arbitrary live views from a camera.
Modified visual output that includes large print and/or clear simple graphics can be of benefit to users with some residual vision.[23]
Other aids and techniques
Blind people may use talking equipment such as thermometers, watches, clocks, scales, calculators, and compasses. They may also enlarge or mark dials on devices such as ovens and thermostats to make them usable. Other techniques used by blind people to assist them in daily activities include:
- Adaptations of coins and banknotes so that the value can be determined by touch. For example:
- In some currencies, such as the euro, the pound sterling and the Indian rupee, the size of a note increases with its value.
- On US coins, pennies and dimes, and nickels and quarters are similar in size. The larger denominations (dimes and quarters) have ridges along the sides (historically used to prevent the "shaving" of precious metals from the coins), which can now be used for identification.
- Some currencies' banknotes have a tactile feature to indicate denomination. For example, the Canadian currency tactile feature is a system of raised dots in one corner, based on Braille cells but not standard Braille.[24]
- It is also possible to fold notes in different ways to assist recognition.
- Labeling and tagging clothing and other personal items
- Placing different types of food at different positions on a dinner plate
- Marking controls of household appliances
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