As society places increasing emphasis on mental health and access to technology increases, the structure and prioritisation within low vision appointments is evolving. These changes bring new challenges and demands in terms of our clinical support, requiring us to consider how our current clinical approach impacts the quality of life (QoL) of our patients.
In adult low vision clinics, the focus is on helping individuals maintain independence to improve their QoL. With teenagers, the challenge begins with achieving independence in the first place. A focus on this demographic therefore presents an important opportunity to assess whether our low vision models are effective, and whether the support provided truly meets the needs of our patients.
Across the NHS’ services, we are placing increased emphasis on the availability of wider support, including low vision appointments. It is crucial to remember that we operate within a multidisciplinary team and effective collaboration is key to ensuring that appropriate support is provided for our young patients and their families. In addition to low vision services, we also offer support through eye clinic liaison officers, family support officers and counsellors.
Given the wide range of available services, patients may find it difficult to identify the most appropriate point of contact and coordinate care with the relevant staff members. When striving for clinic efficiency, are we sufficiently engaging with patients to assess their specific needs? Furthermore, are we actively encouraging their progress as they receive care? A fundamental aspect of improving the referral process should be ensuring that we have a clear understanding of the scope and offerings of low vision services.
Adult low vision and paediatric low vision clinics both include refraction, management of low vision devices, signposting and general advice. Appointments typically last between 45 minutes and two hours, depending on the needs of the patient or family. This does not include mobility training, home assessments or the provision of electronic devices – although we can offer advice on electronic solutions.
Paediatric low vision clinics have additional considerations. More importance is placed on simple-to-use and less flimsy devices, e.g. a dome magnifier, or assisted technology. In some cases, we measure contrast and reading speed. Most importantly, we prepare a personalised letter to the school. This letter includes an explanation of the visual impairment and specifically how it impacts the child. It will also contain advice regarding contrast, lighting and glare, seating positions, and sometimes even the types of pencil that we would recommend they use (e.g. high contrast 4B pencils). These letters are not only essential for school support but also serve as a useful resource for parents, helping us to effectively signpost them to visual impairment clubs, charities or resources for their child.
While these appointments are comprehensive, we face a clear challenge with time constraints and the need to prioritise the most pressing concerns of the patient during clinic appointments. Often, there is a significant difference between the concerns of the patient and those of the parent or carer. This discrepancy is particularly evident in teenage patients, who do not always fit neatly into the framework of either paediatric or adult low vision care. At this stage, they are usually well-acquainted with their school setup, prefer to focus on technology and seek discreet ways to enhance their vision rather than relying on low vision devices. Additionally, they may be either indifferent to receiving a letter for school / college support, or very eager for a letter to secure specific accommodations.
Figure 1: Example of blindfolded game for parent's understanding.
This group of patients is beginning to step out into the world, a challenging experience for any teenager, but even more so for one living with visual impairment. It’s a crucial time for building confidence and establishing a sense of self and belonging. Parents, who are accustomed to advocating fiercely on their child’s behalf, are now concerned about how their teenager will navigate the world beyond school and how much they will need to fight to secure their right for equal access along their respective paths. The focus of these clinics must shift towards building confidence in children so that they can advocate for their own needs, helping them understand that their version of ‘normal’ is not only valid, but that there are multiple ways to engage with the world. This approach encourages a departure from the notion that conformity to a standardised model is required for true belonging.
Figure 2: Example of game to explain contrast and visual noise.
One of the most memorable interactions I had with a reluctant teenage patient occurred when his mother explained, “He doesn’t want to be different,” while repeatedly reassuring him that, “he’s just special.” I observed that this language, though well-intentioned, seemed to encourage further withdrawal in an already quiet and disengaged teenager. His growing annoyance made him increasingly reluctant to accept any advice. I finally turned to him and said, “You’re not special.” This direct statement was met with a fleeting, instinctive smirk, followed by lifting his head and a laugh. I then explained to both the patient and his mother that, in the waiting room, there are a group of patients who, like him, “don’t want to be different” – so who, in that group, could truly be considered ‘different’ or ‘special’? This reframing of the conversation, built on the rapport I had already established with his mother, helped shift their perspective. The simple change in mindset transformed the atmosphere in the room, and his mother with some relief saw his newfound engagement in the conversation. This moment of mutual understanding allowed us to then explore more subtle ways for him to express his needs and manage his visual and mental fatigue, which we found seemed to have been closely tied to the notion of being ‘special’. I reassured him that while these appointments can be draining, he was doing well under the circumstances. After all, what teenager wants to spend their morning with bright lights shone into their eyes, whilst talking about their deteriorating vision? I earned another smile.
This experience, among many others, has deepened my understanding of how crucial it is to build confidence in these clinics. I now make it a point to highlight a teenager’s strengths – whether it’s their communication skills during the appointment or their creative innovations for adapting their home environment to support their vision. I also take the time to reassure the parents, pointing out the things they are doing well and, when appropriate, informing them of the mental health support available for them as well. This approach has transformed the way my teenage patients engage with me and has made it easier for them to articulate what they’re experiencing. By shifting the focus from their vision impairment to who they are as individuals, we can finally work together to tackle their visual concerns as a team.
Figure 3: Family Support Officer, Jean Cavanagh discussing a
teenage low vision patient with Optometrist, Phoebe Withrington.
A common issue I encounter with many young visually impaired patients is poor posture, often linked to the tendency to lean forward when reading or focusing on tasks. Instead of only concentrating on visual techniques such as relative size magnification, we can also encourage activities that promote good posture. For instance, I frequently recommend touch typing, which not only improves posture but also helps alleviate eye fatigue and boosts social confidence, particularly in school settings. I have also found rowing to be an effective activity for promoting both physical posture and mental resilience. Rowing is a sport that doesn’t rely on vision and maintains proper posture while developing the mental strength needed to keep pushing forward. One of my fit and healthy low vision teenage patients started out with poor posture and an inability to make eye contact or lift their head during our appointments. Two years later, after working with her mother to motivate her to engage in sports, she now enjoys competing in rowing championships, giving talks to her local community about her visual impairment, and walks to her rowing club independently. Most importantly for me, when she walks into my clinic, she holds her head high and greets me with a smile.
We are currently developing a web link that will provide clinicians with a more holistic focus on advice and resources, such as the above, aimed at helping young people to build their confidence and become active, engaged members of society. As society’s access to resources continues to evolve, the landscape will shift, and we anticipate that we will be able to gain more stories of teenagers gaining confidence, offering hope to families and demonstrating that a fulfilling life with visual impairment is possible.
Declaration of competing interests: None declared.
