Blindness Classification and external resources
A white cane, the international symbol of blindness
ICD-10 H54.0, H54.1, H54.4 ICD-9 369 DiseasesDB 28256
Various scales have been developed to describe the extent of vision loss and define blindness. Total blindness is the complete lack of form and visual light perception and is clinically recorded as NLP, an abbreviation for "no light perception." 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. 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.
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.
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.
- 1 Classification
- 2 Causes
- 3 Comorbidities
- 4 Management
- 5 Adaptive techniques and aids
- 6 Epidemiology
- 7 Society and culture
- 8 In other animals
- 9 See also
- 10 References
- 11 External links
In 1934, the American Medical Association adopted the following definition of blindness:
Central visual acuity of 20/200 or less in the better eye with corrective glasses or central visual acuity of more than 20/200 if there is a visual field defect in which the peripheral field is contracted to such an extent that the widest diameter of the visual field subtends an angular distance no greater than 20 degrees in the better eye.
The United States Congress included this definition as part of the Aid to the Blind program in the Social Security Act passed in 1935. In 1972, the Aid to the Blind program and two others combined under Title XVI of the Social Security Act to form the Supplemental Security Income program which currently states:
An individual shall be considered to be blind for purposes of this title if he has central visual acuity of 20/200 or less in the better eye with the use of a correcting lens. An eye which is accompanied by a limitation in the fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered for purposes of the first sentence of this subsection as having a central visual acuity of 20/200 or less. An individual shall also be considered to be blind for purposes of this title if he is blind as defined under a State plan approved under title X or XVI as in effect for October 1972 and received aid under such plan (on the basis of blindness) for December 1973, so long as he is continuously blind as so defined.
In the United States, legal blindness due to acuity loss is most often measured by a regular eye doctor with an eye chart.
Legal blindness due to visual field being less than 20 degrees is measured by a visual field test using a number IV target size. If the doctor or facility performing the test is approved by the Social Security Administration, this is the official US determination for legal blindness due to field loss in conditions like retinitis pigmentosa.
In the UK, the Certificate of Vision Impairment (CVI) is used to certify patients as severely sight impaired or sight impaired. The accompanying guidance for clinical staff states:
The National Assistance Act 1948 states that a person can be certified as severely sight impaired if they are “so blind as to be unable to perform any work for which eye sight is essential” (National Assistance Act Section 64(1)). The test is whether a person cannot do any work for which eyesight is essential, not just his or her normal job or one particular job.
In practice, the definition depends on individuals' visual acuity and the extent to which their field of vision is restricted. The Department of Health identifies three groups of patients who may be classified as severely visually impaired.
- Those below 3/60 Snellen (most people below 3/60 are severely sight impaired),
- Those better than 3/60 but below 6/60 Snellen (people who have a very contracted field of vision only),
- Those 6/60 Snellen or above (people in this group who have a contracted field of vision especially if the contraction is in the lower part of the field),
The Department of Health also state that a person is more likely to be classified as severely visually impaired if their eyesight has failed recently or if they are an older individual, both groups being perceived as less able to adapt to their vision loss.
Serious visual impairment has a variety of causes:
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%).
In terms of the worldwide prevalence of blindness, the vastly greater number of people in the developing world and the greater likelihood of their being affected mean that the causes of blindness in those areas are numerically more important. Cataract is responsible for more than 22 million cases of blindness and glaucoma 6 million, while leprosy and onchocerciasis each blind approximately 1 million individuals worldwide. The number of individuals blind from trachoma has dropped dramatically in the past 10 years from 6 million to 1.3 million, putting it in seventh place on the list of causes of blindness worldwide. Xerophthalmia is estimated to affect 5 million children each year; 500,000 develop active corneal involvement, and half of these go blind. Central corneal ulceration is also a significant cause of monocular blindness worldwide, accounting for an estimated 850,000 cases of corneal blindness every year in the Indian subcontinent alone. As a result, corneal scarring from all causes now is the fourth greatest cause of global blindness (Vaughan & Asbury's General Ophthalmology, 17e)
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.
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.
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 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.
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. 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.
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.
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. The same sentence was given in 2009 for the man who blinded Ameneh Bahrami.
Blindness can occur in combination with such conditions as mental retardation, autism spectrum disorders, cerebral palsy, hearing impairments, and epilepsy. In a study of 228 visually impaired children in metropolitan Atlanta between 1991 and 1993, 154 (68%) had an additional disability besides visual impairment. Blindness in combination with hearing loss is known as deafblindness.
A 2008 study published in the New England Journal of Medicine 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.
Adaptive techniques and aids
Many people with serious visual impairments can travel independently, using a wide range of tools and techniques. Orientation and mobility specialists are professionals who are specifically trained to teach people with visual impairments how to travel safely, confidently, and independently in the home and the community. These professionals can also help blind people to practice travelling on specific routes which they may use often, such as the route from one's house to a convenience store. Becoming familiar with an environment or route can make it much easier for a blind person to navigate successfully.
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.
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.
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.
Modified visual output that includes large print and/or clear simple graphics can be of benefit to users with some residual vision.
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.
- 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
Most people, once they have been visually impaired for long enough, devise their own adaptive strategies in all areas of personal and professional management.
The WHO estimates that in 2002 there were 161 million visually impaired people in the world (about 2.6% of the total population). Of this number 124 million (about 2%) had low vision and 37 million (about 0.6%) were blind. In order of frequency the leading causes were cataract, uncorrected refractive errors (near sighted, far sighted, or an astigmatism), glaucoma, and age-related macular degeneration. In 1987, it was estimated that 598,000 people in the United States met the legal definition of blindness. Of this number, 58% were over the age of 65. In 1994-1995, 1.3 million Americans reported legal blindness.
Society and culture
In literature and the arts
In Greek myth, Tiresias was a prophet famous for his clairvoyance. According to one myth, he was blinded by the Gods as punishment for revealing their secrets, while another holds that he was blinded as punishment after he saw Athena naked while she was bathing. In the Odyssey, the one-eyed Cyclops Polyphemus captures Odysseus, who blinds Polyphemus in order to escape. In Norse mythology, Loki tricks the blind God Höðr into killing his brother Baldr, the God of happiness.
The New Testament contains numerous instances of Jesus performing miracles to heal the blind. According to the Gospels, Jesus healed the two blind men of Galilee, the blind man of Bethsaida, the blind man of Jericho and the man who was born blind.
The parable of the blind men and an elephant has crossed between many religious traditions and is part of Jain, Buddhist, Sufi and Hindu lore. In various versions of the tale, a group of blind men (or men in the dark) touch an elephant to learn what it is like. Each one feels a different part, but only one part, such as the side or the tusk. They then compare notes and learn that they are in complete disagreement.
The Dutch painter and engraver Rembrandt often depicted scenes from the apocryphal Book of Tobit, which tells the story of a blind patriarch who is healed by his son, Tobias, with the help of the archangel Raphael.
Slaver-turned-abolitionist John Newton composed the hymn Amazing Grace about a wretch who "once was lost, but now am found, Was blind, but now I see." Blindness, in this sense, is used both metaphorically (to refer to someone who was ignorant but later became knowledgeable) and literally, as a reference to those healed in the Bible. In the later years of his life, Newton himself would go blind.
"Three Blind Mice" is a medieval English nursery rhyme about three blind mice whose tails are cut off after chasing the farmer's wife. The work is explicitly incongruous, ending with the comment Did you ever see such a sight in your life, As three blind mice?
Bob Dylan's anti-war song "Blowin' in the Wind" twice alludes to metaphorical blindness: How many times can a man turn his head // and pretend that he just doesn't see... How many times must a man look up // Before he can see the sky?
Contemporary fiction contains numerous well-known blind characters. Some of these characters can "see" by means of fictitious devices, such as the Marvel Comics superhero Daredevil, who can "see" via his super-human hearing acuity, or Star Trek's Geordi La Forge, who can see with the aid of a VISOR, a fictitious device that transmits optical signals to his brain.
Blind and partially sighted people participate in sports such as swimming, snow skiing and athletics. Some sports have been invented or adapted for the blind such as goalball, association football, cricket, and golf. The worldwide authority on sports for the blind is the International Blind Sports Federation. People with vision impairments have participated in the Paralympic Games since the 1976 summer Paralympics in Toronto.
The word "blind" (adjective and verb) is often used to signify a lack of knowledge of something. For example, a blind date is a date in which the people involved have not previously met; a blind experiment is one in which information is kept from either the experimenter or the participant to mitigate the placebo effect or observer bias. The expression "blind leading the blind" refers to incapable people leading other incapable people. Being blind to something means not understanding or being aware of it. A "blind spot" is an area where someone cannot see, for example, where a car driver cannot see because parts of his car's bodywork are in the way.
In other animals
Statements that certain species of mammals are "born blind" refers to them being born with their eyes closed and their eyelids fused together; the eyes open later. One example is the rabbit. In humans the eyelids are fused for a while before birth, but open again before the normal birth time, but very premature babies are sometimes born with their eyes fused shut, and opening later. Other animals such as the blind mole rat are truly blind and rely on other senses.
The theme of blind animals has been a powerful one in literature. Peter Schaffer's Tony-Award winning play, Equus, tells the story of a boy who blinds six horses. Theodore Taylor's classic young adult novel, The Trouble With Tuck, is about a teenage girl, Helen, who trains her blind dog to follow and trust a seeing-eye dog.
- Blindness and education
- Color blindness
- Cortical blindness
- Eye disease
- List of blind people
- Tactile alphabets
- Tactile graphic
- Tangible symbol systems
- World Blind Union
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- Blindness Resource Center from The New York Institute for Special Education
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