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Planning guide for integrated vision rehabilitation

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Planning guide for integrated vision rehabilitation

Planning guide for integrated vision rehabilitation

Planning guide for integrated vision rehabilitation ISBN 978-92-4-011992-5 (electronic version) ISBN 978-92-4-011993-2 (print version) © World Health Organization 2025 Some rights reserved. This work is available under the Creative Commons AttributionNonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/ licenses/by-nc-sa/3.0/igo).

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Contents

Acknowledgements

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Executive summary

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1

Introduction and key concepts

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1.1

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What is vision rehabilitation

1.2 Global context of vision rehabilitation

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1.3 Purpose and target audience of this guide

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1.4 How to use this guide: three-step process for integration

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2 Three-step process for planning and integrating vision rehabilitation

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2.1 Step 1. Assess the situation

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2.2 Step 2. Identify and implement priority interventions

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2.3 Step 3. Integrate interventions into national plans

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Clinical assessment for vision rehabilitation

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3.1 Preparing the assessment environment

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3.2 Primary care

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3.3 Primary “plus” care

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3.4 Secondary care

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3.5 Optional “secondary plus” care

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3.6 Tertiary care

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Procurement of low vision devices

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4.1 Principles of procurement

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4.2 Selecting a core set of products

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4.3 Quantifying need

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4.4 Sourcing, quality assurance and patient education

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References

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Annexes

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Annex 1. Summary and management of declared interests from external reviewers

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Annex 2. Approach to developing the guide

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Annex 3. Essential diagnostic tests and low vision equipment

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Planning guide for integrated vision rehabilitation

Annex 4. List of low vision assistive devices

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Annex 5. Training programme on vision rehabilitation: curriculum outline

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Annex 6. Essential and optional services

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Annex 7. Vision rehabilitation screening record card

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Annex 8. WHO vision screening chart

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Annex 9. Safe use and maintenance of low vision devices: advice for patients and caregivers

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Acknowledgements

The World Health Organization (WHO) thanks all those whose dedicated efforts and expertise contributed to this resource.

The resource was developed by the WHO Vision and Eye Care Programme team: Pirindhavellie Govender-Poonsamy, Silvio Paolo Mariotti, Andreas Mueller, Mitasha Yu, Vera Carneiro and Stuart Keel; and the WHO Collaborating Centre on Prevention of Blindness and Rehabilitation in Italy: Filippo Amore and Simona Turco. Valuable contributions were made by other WHO staff: Emma Tebbutt (Access To Assistive Technology Programme), Wouter De Groote (Rehabilitation Programme) and Shelly Chadha (Head of the Sensory Functions, Disability and Rehabilitation Unit). The guide was critically reviewed by WHO regional advisers: Joao Marcello Fortes Furtado (Pan American Health Organization), Shirin Kiani (WHO Regional Office for Europe), Batamuliza Kaitesi Mukara (WHO Regional Office for Africa), Tashi Tobgay (WHO Regional Office for South-East Asia) and Jiani Sun (WHO Country Office, China).

The WHO also thanks the following external reviewers: Boshra El Bayoun (Visual Rehabilitation Centre, Egypt), Werner Eisenbarth (Munich Center for Applied Vision Science, Germany), Maria Aparecida Onuki Haddad (University of São Paulo, Brazil), Geoffrey Wabulembo (Light for the World, Uganda) and Sumrana Yasmin (Sightsavers, Pakistan).

The development and publication of this resource was made possible through financial support from The Fred Hollows Foundation.

Assessment and management of conflict of interest from external reviewers All external reviewers completed a declaration of interest form prior to the work, disclosing potential conflicts of interest that may affect, or may reasonably be perceived to affect, their objectivity and independence in relation to the subject matter of this resource. WHO reviewed each of the declarations and concluded that none could give rise to a potential or reasonably perceived conflict of interest related to the subjects covered. A summary of the DOI statements and how conflicts of interest were managed is included in Annex 1. All of the external reviewers acted in their independent and individual capacity.

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Executive summary

The Planning guide for integrated vision rehabilitation provides a structured framework to support World Health Organization (WHO) Member States in developing and integrating vision rehabilitation services into national health and eye care systems. Vision rehabilitation is an essential component of universal eye health and is crucial to enabling individuals with irreversible vision impairment and blindness to maximize their independence, improve their quality of life and fully participate in society.

Purpose and audience This guide is intended to support the development of services for people living with irreversible vision impairment. The guide targets health planners, policymakers, eye care personnel, rehabilitation personnel, nongovernmental organizations and advocacy groups. The objective of the guide is to provide practical steps for planning, implementing and monitoring vision rehabilitation services, aligned with universal health coverage (UHC) and integrated peoplecentred eye care.

Global context An estimated 60 million adults worldwide require vision rehabilitation, with the majority lacking access, particularly in low- and middle-income countries. Barriers to access of vision rehabilitation services include limited trained personnel, weak infrastructure, financial constraints and poor integration into national health care systems. Ensuring equitable access to vision rehabilitation services is both a health priority and a human rights responsibility, aligned with the United Nations Convention on the Rights of Persons with Disabilities and the Sustainable Development Goals (SDGs).

Three-step integration process The guide outlines a three-step process to develop and integrate vision rehabilitation care into national eye health strategies.

1.

Assess the situation. Engage stakeholders, conduct assessments (e.g. using the WHO tool for assessment of rehabilitation services and systems) and identify service gaps.

2.

Identify and implement priority interventions. a. Pathway A. Establish pilot vision rehabilitation services where none exist, focusing on essential equipment and assistive products, workforce training, awareness campaigns and monitoring. b. Pathway B. Strengthen existing services through enhanced training, expanded availability of assistive products, service quality improvement and phased geographic expansion.

3.

Integrate into national plans and monitoring and evaluation frameworks.

Incorporate vision rehabilitation into health policies, clinical guidelines and monitoring systems, ensuring sustainability, funding and accountability through defined key performance indicators.

Executive summary

Service delivery and clinical framework Vision rehabilitation is delivered across primary, secondary and tertiary levels of care, with the complexity of services provided increasing across the levels of care.

– Primary care: screening, functional vision assessment, provision of simple

assistive products, environmental modifications, basic mobility training and referral.

– Secondary care: comprehensive visual assessments, prescription of low vision assistive products, mobility and assistive technology training, psychosocial support and case management.

– Tertiary care: specialized diagnostics, advanced rehabilitation, paediatric

and vocational services, research, training, national advocacy and systemwide data analysis.

Procurement and assistive products A sustainable vision rehabilitation system requires affordable, quality-assured assistive products, including optical and non-optical assistive products and mobility aids. This guide emphasizes needs-based procurement, reliable supply chains, financing mechanisms (for example, subsidies and revolving banks of devices) and patient/caregiver education on assistive product use and maintenance.

Conclusion This guide translates global commitments on disability rights and eye health into practical, country-level action. By embedding vision rehabilitation services in existing health care systems, countries can move toward equitable, sustainable solutions that empower people with vision impairment, reduce inequalities and contribute to achieving UHC and the SDGs.

Silvio Paolo Mariotti Medical Officer, World Health Organisation

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1.

Introduction and key concepts

1.1 What is vision rehabilitation Vision impairment and blindness considerably affect individuals’ quality of life, limiting their ability to perform daily activities, access education and participate in the workforce (1-4).

Vision rehabilitation is an essential component of eye care services that enables people living with irreversible vision impairment to maximize their functional abilities, enhance their quality of life and participate fully in society (5). It encompasses a range of interventions, such as psychological support, optical, electronic and mobility assistive products (assistive products are later referred to as low vision devices), environmental modifications, and vision and mobility skills training (6). These interventions are designed to help people optimize their residual vision and develop adaptive skills for independent living.

It is important to distinguish the scope of vision rehabilitation as addressed in this guide from the broader field of rehabilitation for people who are blind. While both are essential, they address different needs and are often delivered through different systems.

Vision rehabilitation, the focus of this document, relates to interventions for individuals with some degree of functional, residual vision (i.e. low vision). The goal is to optimize the use of this remaining sight through optical devices, environmental modifications and vision skills training, typically integrated within the health system.

Rehabilitation for blindness (often termed habilitation) focuses on developing skills that do not depend on sight, such as Braille literacy, advanced orientation and mobility with a long cane, and the use of non-visual adaptive technology. In many countries, these specialized services are provided by organizations outside the formal health sector, such as those aligned with education and social welfare systems.

This guide concentrates on establishing and strengthening vision rehabilitation services for people with low vision within national health frameworks. However, strong and formal referral pathways between health-based vision rehabilitation services and education and/or social welfare-based services for people with blindness are critical to ensure a comprehensive continuum of care for all individuals with vision impairment.

Vision rehabilitation is a multidisciplinary field that includes ophthalmologists, optometrists, orthoptists, psychologists and psychotherapists, vision rehabilitation technicians, occupational therapists, mobility instructors, special education teachers, physiotherapists, social workers and other physicians (such as geriatricians, paediatricians, diabetologists, geneticists and general practitioners). This comprehensive approach ensures that individuals can achieve autonomy in various aspects of life, including navigation, reading, employment and social participation.

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Planning guide for integrated vision rehabilitation

Despite the availability of effective vision rehabilitation interventions, access remains limited or absent, particularly in low- and middle-income countries (7).

Barriers to access include the limited availability of rehabilitation services outside tertiary centres, financial constraints, lack of integration of these services into national health care policies, inadequately trained personnel, lack of availability of good quality, affordable low vision devices and poor awareness of rehabilitation options among health care providers and patients (8). In contrast, high-income countries often have well established services but face challenges in reaching underserved populations (9).

1.2 Global context of vision rehabilitation Globally, an estimated 60 million adults require vision rehabilitation due to irreversible vision impairment (10). The main causes among adults are glaucoma, macular disease, corneal opacities and diabetic retinopathy, among others.

Congenital and genetic disorders, acquired eye conditions, and cerebral vision impairment contribute to vision loss in children and young adults (10). Addressing this need is not only a health priority but also a human rights imperative, aligned with global commitments such as the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) (11) and WHO Rehabilitation 2030 (12).

Furthermore, providing access to vision rehabilitation is essential for achieving the SDGs, particularly those related to health (SDG 3), education (SDG 4) and reducing inequalities (SDG 10) (13). This guide serves as a practical implementation resource related to the overarching WHO Eye care in health systems: guide for action (14). While the guide on integrated people-centred eye care provides the high-level strategic framework for planning all eye care services, this document offers a detailed, step-by-step pathway to establish and integrate the specific component of vision rehabilitation at the country level.

1.3 Purpose and target audience of this guide This document is a practical planning guide to help WHO Member States integrate vision rehabilitation services into their national health care systems, aligning with the goals of UHC and integrated people-centred eye care (see Annex 2 for the approach used to develop this guide). The guide provides technical guidance to policy-makers, health care personnel and rehabilitation specialists for planning, implementing and monitoring these services.

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Introduction and key concepts

The target audience for this guide includes:

– health planners and administrators managing eye care and/or rehabilitation programmes;

– eye care providers such as ophthalmologists, optometrists, allied

ophthalmic personnel, vision rehabilitation personnel and other health care personnel involved in vision rehabilitation;

– rehabilitation specialists such as low vision specialists, orientation and mobility personnel, physiotherapists and occupational therapists;

– nongovernment organizations, advocacy groups and implementation partners working in the field of vision impairment, disability rights and public health advocacy.

1.4 How to use this guide: three-step process for planning and integration This guide provides a three-step process (Figure 2) for planning and, most importantly, integrating vision rehabilitation interventions (Box 1) into existing national eye care/health plans, rather than creating new, stand-alone strategies.

1.

Step 1. Conduct a situation assessment to understand the existing landscape of vision rehabilitation needs and services and its level of inclusion in any existing eye care or rehabilitation plan.

2.

Step 2. Identify the priority interventions based on context depending on whether vision rehabilitation services need to be established within existing eye-care services or strengthened.

3.

Step 3. Integrate vision rehabilitation interventions into national eye-care plans and monitoring and evaluation frameworks so that vision rehabilitation services are not stand-alone but sustainably integrated.

A central feature of this guide is its focus on two parallel implementation pathways within Step 2, recognizing that Member States have different starting points. Pathway A provides a roadmap for establishing vision rehabilitation services within existing eye-care systems, while pathway B guides the enhancement and expansion of existing vision rehabilitation services within the national eye care system.

Box 1. Adapting the integration process While the guide presents a structured three-step methodology for establishing and expanding vision rehabilitation, the implementation does not have to follow a linear approach. Aligned with the “Analyse–Plan–Do–Review” cycle emphasized in the WHO Eye care in health systems: guide for action, health planners should apply this framework flexibly. Depending on local resources, health system capacity, and ongoing evaluations, these phases can be adapted, reordered, or even carried out at the same time to best meet countryspecific needs.

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2. Three-step process for planning and integrating vision rehabilitation

Figure 2. Three-step process for establishing or enhancing vision rehabilitation services

A three-step process

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Assess the situation – Action 1.1. engage stakeholders.

– Action 1.2. collect data and information via WHO’s Tool for assessment of rehabilitation services and systems.

– Action 1.3. analyse and identify gaps.

2

Identify and implement priority interventions based on context – Execute through tailored pathways as appropriate.

Pathway A. Establish services For countries with no formal vision rehabilitation services but with existing eye care services.

– Action A2.1: establish and equip pilot service.

– Action A2.2: identify and train human resources.

– Action A2.3: launch awareness campaigns.

– Action A2.4: initiate service and monitor.

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Pathway B. Strengthen and expand services For countries with limited vision rehabilitation services.

– Action B2.1: evaluate and enhance service delivery.

– Action B2.2: implement advanced human resources development.

– Action B2.3: expand device availability.

– Action B2.4: plan for phased expansion and monitoring.

Integrate vision rehabilitation interventions into national plans and monitoring and evaluation frameworks – Action 3.1: integrate into national strategic plans.

– Action 3.2: integrate into clinical guidelines.

– Action 3.3: integrate indicators into monitoring and evaluation frameworks.

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Three-step process for planning and integrating vision rehabilitation

2.1 Step 1. Assess the situation A thorough understanding of the status of vision rehabilitation is the foundation for all subsequent planning. This assessment should be conducted at the highlevel policy and systems landscape, and existing service delivery. Also explore whether devices for low vision are included in national essential product lists, and if vision rehabilitation services and relevant products are covered under national health insurance, social welfare schemes or other financing systems.

Action 1.1: engage stakeholders to determine service availability Contact key informants to rapidly determine the existence, nature and scale of any current vision rehabilitation services. Stakeholders should include the health ministry, national or local authorities, professional associations (for example, ophthalmology, optometry and occupational therapy), patient advocacy groups and nongovernment organizations.

Action 1.2: collect data If initial assessment suggests that vision rehabilitation services are absent, fragmented or require strengthening, conduct a formal evaluation. Use a standardized assessment tool specific to vision rehabilitation services such as the WHO Tool for assessment of rehabilitation services and systems (15). This tool is a comprehensive data collection instrument that helps countries systematically assess the current state of their rehabilitation services, including related to leadership, financing, workforce and service delivery. WHO can provide technical support on the implementation and adaptation of the tool to the local context.

Action 1.3: analyse and identify gaps Synthesize the data gathered from stakeholder engagement and the formal assessment into a concise report. This situation analysis should clearly identify the main gaps, challenges and opportunities for developing or strengthening vision rehabilitation services. This report provides the evidence for identifying priority interventions in Step 2.

2.2 Step 2. Identify and implement priority interventions Based on the findings of the situation analysis, the next step is to identify a realistic package of interventions. The approach will differ depending on whether services need to be established or strengthened.

2.2.1 Pathway A. Establishing vision rehabilitation services where none exist This pathway is for countries or regions with no formal vision rehabilitation services. The focus is on creating a foundational, sustainable service model as an integrated component within an existing eye care or health programme that can be scaled up over time.

Action A2.1: establish and equip pilot services Based on the gap analysis confirming the absence of services, the main intervention is to establish a small-scale pilot vision rehabilitation service.

A pilot approach is recommended to:

– demonstrate feasibility and clinical value of vision rehabilitation in the local context;

– raise awareness among policy-makers, health care providers and the public about the benefits of vision rehabilitation;

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Planning guide for integrated vision rehabilitation

– serve as a practical learning ground to identify and navigate potential

cultural, economic, professional and procurement barriers before larger scale implementation;

– generate local data on patient needs and outcomes to support advocacy for sustainable funding for vision rehabilitation and integration into the health system.

The ideal place for piloting rehabilitation services is a densely populated area (for example, a capital or large city) where an eye care facility is available (likely to attract people in need of vision rehabilitation services) and that is run by the government, civil society organization, international nongovernmental organization, or a school for the blind (where people with residual vision might be present) that is willing to develop vision rehabilitation services. The interest in establishing the service should be confirmed with facility management, professional personnel and administrative authorities. As vision rehabilitation services are intended to operate in the long term, full ownership and active participation by all stakeholders are essential to ensure sustainability and success.

It is important to procure essential diagnostic and low vision equipment as outlined in Annex 3. Identify suitable suppliers and procure essential diagnostic tools, alongside an adequate supply of basic low vision assistive products for both patient assessment and rehabilitation (See Box 2). A list of low vision assistive products can be found in Annex 4. The provision of these low vision assistive products is an important component of comprehensive low vision services, because it:

– enables individuals with visual impairment to engage in activities that their condition may otherwise prevent them from doing;

– enhances overall well-being and quality of life; – allows for the collection of user feedback on the efficacy and practical benefits of vision rehabilitation interventions.

Box 2. UNICEF and WHO supply catalogues Procurement of high-quality, appropriate and affordable diagnostic equipment and low vision devices is a challenge for many government and nongovernmental agencies. To address this issue, WHO and UNICEF are working together to make a range of devices available in their supply catalogues. All products in the catalogues have been selected through a robust and transparent procurement process following United Nations procurement guidelines. Product specifications have been verified against the WHO publication Assistive product specifications and how to use them (16) and other international standards. Member States and health planners may contact WHO for ongoing guidance regarding sustainable financing models, physical facility setup, and information on available vision rehabilitation training courses in their respective regions.

Action A2.2: identify and train human resources Identify motivated personnel such as eye care personnel (ophthalmologists, optometrists and orthoptists) or allied ophthalmic personnel (such as ophthalmic nurses, opticians, ophthalmic and optometric assistants, ophthalmic and optometric technicians, vision therapists, and ocularists) who demonstrate interest and willingness to incorporate this additional service into their existing

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Three-step process for planning and integrating vision rehabilitation

working routines. Once identified, implement a two-phase training programme (Figure 3) combining online theoretical learning with hands-on practical skills, based on the core curricula outlined in Annex 5.

Figure 3. Outline of a two-phase training programme on vision rehabilitation for interested personnel

Phase 1: online module

Phase 2: on-site practical

1. Begin by distributing relevant documents and training materials (paper, electronic) on the basics of vision rehabilitation.

2. Organize webinars/distance learning modules, giving enough time (3 to 4 weeks) to go through the material.

3. Organize online question and answer sessions for any clarification.

1. Organize an in-person 2-week practical training on site.

2. Plan a detailed training schedule and request identification of suitable patients.

3. Ensure the provision of essential equipment, where feasible, for donation to the facility.

4. Equipment in an eye care facility can also be used.

Action A2.3: launch awareness campaigns The success of a new pilot service depends on a strategic awareness campaign designed to secure a steady stream of referrals and build community support.

This requires organizing collaborative educational sessions with eye care professional organizations, health care facilities, schools, rehabilitation services and communities. To be effective, these activities must be coordinated with government stakeholders, repeated as necessary and strategically targeted at two key audiences: health workers to establish robust referral pathways; and the community to generate demand for the new service.

Objectives of awareness campaigns: these campaigns should aim to: (i) generate referrals by informing health care personnel about the new service, its benefits and the correct referral pathway; (ii) build patient demand by educating people with vision impairment and their families about the potential of vision rehabilitation to improve quality of life; and (iii) reduce stigma by fostering community understanding and support for people with vision impairment.

Audience-specific messaging: tailor key messages and channels to different audiences, including health personnel, people with low vision and the general public (see Table 1). Messages should also be in accessible formats for people with intellectual disabilities.

Content development: educating patients and the public on vision rehabilitation services and the need for ongoing care is essential. There might be confusion with curative eye-care interventions; therefore, it is important to make clear what vision rehabilitation aims to do and how it helps. Develop specific, standardized manuals to ensure that the right information is provided consistently across services. All educational content must be culturally sensitive and tailored to the local context. Use existing materials from WHO, international professional societies, international nongovernment organizations and societies for the blind,

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but adapt the language, images and case studies to reflect local realities. Ensure materials are available in local languages and accessible formats (for example, large print and audio). Coordination with government stakeholders and local partners is crucial to ensure messages are appropriate and widely disseminated.

Table 1. Examples of tailored messages on vision rehabilitation for different audiences Target audience

Key messages

All health personnel (general practitioners, nurses, other specialists)

– Vision rehabilitation is an – Workshops in hospitals essential part of the care and clinics. continuum.

– Presentations at – Something can be done. professional society meetings.

– Referral criteria and processes are clear and simple.

People with vision impairment and families

General public and community leaders

Channels and activities

– Distribution of referral letters and posters.

– You are not alone.

– Patient testimonials (on radio and in videos).

– Independence and ability to do the things you love – Brochures in accessible can be restored. formats in clinics.

– Services are available and accessible.

– Collaboration with patient support groups and organizations for disabled people.

– Vision rehabilitation empowers community members.

– Local radio programmes and newspaper articles.

– Vision rehabilitation supports inclusion and reduces stigma.

– Engagement with community and religious leaders.

– World Sight Day events.

– Early intervention is key.

Action A2.4: initiate service and monitor Begin providing the planned package of primary-level services as defined by the International Vision Rehabilitation Standards (Box 3), which focuses on basic, accessible rehabilitation interventions that can be delivered by trained nonspecialist personnel (17). If the facility is committed and resources permit, primary “plus” services may be considered. These are additional, optional elements of care for both assessment and rehabilitation. It is important to collect basic monitoring data to demonstrate the feasibility and effect of the newly integrated service from the start of implementation.

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Three-step process for planning and integrating vision rehabilitation

Box 3. International Vision Rehabilitation Standards (17) The International Vision Rehabilitation Standards is a consensus-based framework designed to guide the planning and development of high-quality, equitable vision rehabilitation services worldwide. The standards outline the essential services, required workforce competencies and necessary equipment for each level of the health system. The framework provides a reference for quality and serves as a practical tool for service delivery, identifying training gaps and creating procurement lists.

Establish a monitoring framework: define a core set of key performance indicators to track progress. This framework should cover the following domains: (i) patient outcomes (e.g. improvements in function and well-being); (ii) service efficiency (e.g. wait times, number of people served) – considering informal patient feedback if wanted; (iii) accessibility and equity (e.g. geographic reach and referral sources).

Data collection: implement simple and practical data collection mechanisms that do not overburden staff. For a detailed list of the specific data variables to be collected at the primary level, refer to Section 3.2.6 of this guide.

2.2.2 Pathway B. Strengthening and expanding existing services For countries with limited services, the focus is on improving quality, expanding reach and ensuring integration.

Action B2.1: evaluate and enhance service delivery Some vision rehabilitation services may already exist in government settings or private facilities. It is important to visit these facilities, meet with service providers and understand how their services align with international recommendations, such as the International Vision Rehabilitation Standards (17). The WHO Tool for assessment of rehabilitation services and systems (15) can be used to assess coverage of vision rehabilitation services, or simpler facility-level surveys can identify patient needs and barriers. It is also important to consider how new services might affect existing ones. The goal is to collaborate with and enhance existing services through shared resources and training, not to disrupt them, while expanding access to underserved populations. Existing services may also help identifying ideal settings for the new services and the required level of services.

Action B2.2: implement advanced human resources development Training institutions should be encouraged to incorporate international resources – such as the advanced curriculum of the International Vision Rehabilitation Standards (17) – to review, strengthen and update their curricula and training materials. Vision rehabilitation requires a multidisciplinary workforce and offers opportunities to engage personnel from all levels of the health system.

While specialized training is essential for those directly providing vision rehabilitation services, it is equally important that all health personnel possess a basic understanding of vision rehabilitation. This includes awareness of the purpose and benefits of vision rehabilitation, the target population and appropriate referral pathways for individuals who may benefit from such services. For formal vision rehabilitation training, a final assessment to evaluate both theoretical knowledge and practical competencies is recommended.

Successful candidates should receive an accredited diploma or certificate, which not only certifies their qualifications and readiness to deliver vision rehabilitation

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Planning guide for integrated vision rehabilitation

services, but also provides a clear career pathway. This certification is important to differentiate formally trained personnel from self-taught individuals and foster trust among health-facility managers.

Action B2.3: expand device availability A core component of strengthening vision rehabilitation is ensuring a consistent and affordable supply of assistive devices. Since vision rehabilitation interventions require specific tools to translate theory into practice, establishing access to low vision devices is an essential step that must precede the expansion of other services.

Establish quality-managed supply chains: the first priority is to secure reliable supply chains for a wide range of low vision assistive products. This may involve identifying and vetting existing in-country providers or establishing relationships with international suppliers to procure an initial stock of essential devices.

Establish financing and distribution models: to ensure affordability and equity, service managers must implement clear strategies for device distribution, especially where they are not provided free of charge. To ensure access, establish alternative financing mechanisms, such as subsidy schemes, in collaboration with charitable organizations or local companies. For higher-cost devices, a structured loan system can be effective, requiring a partial payment from the patient and a standardized loan agreement that outlines responsibilities for repair or replacement.

Implement comprehensive service delivery: the provision of an assistive product is part of a broader cycle of care. Planners must ensure that services are structured to include four key steps.

– Assessment and prescription: a thorough assessment of the individual’s

needs and environment should be done by a trained professional to ensure the correct device is prescribed.

– Fitting and customization: proper fitting of the product must be done to match the user’s specific requirements.

– User training: comprehensive instruction should be given to the user and

their family or caregivers on how to use, maintain and care for the device.

– Follow-up and maintenance: a system for follow-up, including maintenance, repairs and reassessment, is required as a person’s needs may change over time. Establishing services for repair and refurbishment is a sustainable practice that extends device life and value.

Ensure sustainability through a loan system for low vision devices: to enhance affordability and reduce waste, establish a loan system for low vision devices.

This system allows patients to trade in a device that is no longer useful against the cost of a new one. These device banks can be staffed with technicians who repair and refurbish returned devices, extending their life and value. Any devices that cannot be repaired should be disposed of using an environmentally conscious method.

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Three-step process for planning and integrating vision rehabilitation

Action B2.4: plan for phased expansion and monitoring Based on the assessment of existing services or the success of a pilot scheme, plan a systematic expansion of the services. Based on the prevalence of low vision, it is recommended to:

– plan expansion in the most densely populated areas/cities/regions; – plan expansion in connection with eye care services (expected to be the main source for referrals);

– identify suitable civil society organizations in the target area to conduct

advocacy and education activities for the personnel and the population;

– identify existing services (schools for the blind which could share service spaces, personnel (orientation and mobility, psychological and home adaptation) and equipment for vision rehabilitation.

While the above are general rules, opportunities may arise for establishing/ expanding services in defined areas. Such opportunities should be studied carefully, bearing in mind the longer-term sustainability of these services. As always, ownership by and participation of the local government, facility managers, professional teams and civil society may be key to success. In every new area where services are considered, the same implementation model used for pilot services (train personnel, equip the facility and raise awareness) can be followed.

Establishing functional links between vision rehabilitation centres is also important to build a support network. These connections facilitate continuing education, reduce professional isolation and provide opportunities for peer consultation. Furthermore, they allow for the sharing of specialized competencies, thus helping to fill expertise gaps that may exist in the early stages of developing a service in a new area.

2.3 Step 3. Integrate interventions into national plans The final step ensures the long-term sustainability of vision rehabilitation by integrating its components into the existing national health system. The goal is not to create a new, standalone vision rehabilitation plan, but to make vision rehabilitation an integral part of routine health care policy, clinical practice and monitoring.

Action 3.1: amend national strategic plans and priority assistive product lists to include vision rehabilitation This requires modifying key national policy documents to ensure vision rehabilitation is recognized, budgeted for and implemented as part of the broader health strategy.

Identify integration points in existing plans and product lists: convene a stakeholder working group to review the current national health plan, national eye health strategy, national rehabilitation strategy and disability inclusion policies, and priority assistive product lists. Instead of creating a new section for vision rehabilitation, identify existing strategic objectives where vision rehabilitation is a logical component. For example, an objective on strengthening primary care can be amended to include the integration of basic vision rehabilitation screening and referral. Similarly, an objective on improving quality of life for people with chronic conditions is a key integration point for rehabilitation. A target can be added to ensure access to rehabilitation, including vision rehabilitation for

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Planning guide for integrated vision rehabilitation

conditions such as diabetic retinopathy. Ensure priority low vision devices are included within national assistive product lists, and related product specifications are developed and used to ensure procurement of good quality, appropriate low vision devices.

Draft specific amendments and targets: develop the exact text for the proposed amendments. For instance, add a key activity under an existing disability objective, for example, “Procure and distribute essential low vision devices for all levels of care as per the national list” (see Annex 6). Propose specific targets such as, “By 2030, 75% of all diabetic clinics will have a functional referral pathway to vision rehabilitation services.”

Advocate for and submit amendments: formally submit the drafted amendments – not as a new plan, but as proposed improvements to the existing plan – to the national health planning committee for inclusion in the next official revision.

Action 3.2: amend clinical guidelines and protocols to standardize vision rehabilitation referrals This amendment ensures that identifying and referring people for vision rehabilitation becomes a standard part of routine clinical practice for a wide range of health personnel.

Map referral pathways within existing workflows: create a clear flowchart that visually maps how a person can be referred to vision rehabilitation services from different, existing entry points in the health system (for example, from a diabetic clinic, primary care post or school screening programme).

Draft amendments for existing clinical guidelines: write the exact text to be inserted into current standard treatment guidelines. For example, in the primary care guideline, amend the section on geriatric assessment to include the instruction, “during any consultation with a person older than 50 years, ask about difficulties with daily tasks due to vision. If challenges are reported, conduct a basic functional vision assessment and refer to the nearest vision rehabilitation service using the standardized referral form.” In the Diabetes management guideline, amend the annual patient review protocol to state, “in addition to screening for retinopathy, all patients must be asked about their functional vision. Any patient reporting difficulty with reading, mobility or self-care due to vision must be referred for a vision rehabilitation assessment.”

Obtain endorsement and disseminate: submit the drafted amendments to national clinical review committees for formal endorsement. Once approved, ensure the updated guidelines are distributed and integrated into both pre-service and in-service training for health care workers.

Action 3.3: integrate vision rehabilitation indicators into the national monitoring and evaluation framework This step makes the tracking of vision rehabilitation services a routine part of the existing national health information system, ensuring accountability and datadriven decision-making.

Finalize key performance indicators: formally adopt the list of indicators from this guide (for example, number of people receiving vision rehabilitation services, referral sources and improvements in functional ability, found in section 3.2.6) as the national indicators for vision rehabilitation.

Coordinate with the national health information management unit: work directly with the team that manages the national health database to integrate the new vision rehabilitation indicators into the existing system.

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Three-step process for planning and integrating vision rehabilitation

Add vision rehabilitation data elements to existing data collection forms: for each key performance indicator, provide a precise definition, metadata and data source (for example, the primary-level record card in Annex 7). Work with the health information management unit to add these new data elements to the official data collection forms already in use.

Update existing reporting tools: ensure that the vision rehabilitation data are included in current national health dashboards to allow easy tracking by managers and policy-makers.

Train staff on updated reporting: develop simple job aids for facility-level staff and data clerks on how to correctly collect and report vision rehabilitation data using the updated versions of the usual forms and systems.

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3.

Clinical assessment for vision rehabilitation

Effective vision rehabilitation is delivered across a continuum of care, from primary to secondary and tertiary levels. Having planned the vision rehabilitation service model in step 2, this section provides a detailed, practical guide to clinical service delivery. A systematic, step-by-step summary is given of clinical care for health workers to provide at each level of the health system, from initial patient contact through to rehabilitation and referral (Figure 4). The required workforce competencies, aligned with the WHO Eye care competency framework, are also provided at each level of care (18). For a complete and detailed list of essential and optional services at each level of care, please refer to Annex 6.

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Clinical assessment for vision rehabilitation

Figure 4. Summary of clinical assessment at various levels of care Clinical assessment at the three levels of care Primary care

Secondary care

Awareness and identification – Conduct community outreach and awareness campaigns.

– Undertake routine vision screening (of adults and children) by trained eye care personnel.

Tertiary care

– Use simplified visual acuity charts and pen torch.

– Observe behaviour and movement patterns.

History-taking – Gather demographic and medical data.

– Explore presenting complaints (e.g. distance/near vision, glare, loss of fields.

– Identify other disabilities such as motor impairment and hearing loss.

– Assess functional vision challenges in daily life.

– Consider psychosocial context (occupation, education, support system).

Vision assessment – Measure presenting visual acuity (distance and near).

– Check confrontation visual fields.

– Conduct basic functional vision assessment (daily task simulation).

Comprehensive assessment – Collect full history: goals, comorbidities, psychosocial background.

– Conduct visual function testing: – visual acuity, – contrast sensitivity, – depth perception, – colour vision, – visual fields, – light/dark adaptation.

– Refraction and functional vision evaluation.

Advanced assessment – Conduct full ophthalmic exam: cause of vision loss and comorbidities.

– Conduct advanced visual function testing: – electrophysiology, – retinal sensitivity, – fixation stability.

– Conduct comprehensive functional vision assessment (education, mobility, work tasks)

Rehabilitation – Provide non-optical devices (e.g. bold pens, high-contrast tools, lamps).

– Train in basic activities of daily living and mobility (sighted guide techniques, environmental modifications).

– Offer information and refer for: – eye care, – general health care, – social and educational services.

– Conduct follow-up as needed.

Rehabilitation – Trial and prescribe low vision aids.

– Provide training in: – activities of daily living and mobility – orientation and mobility with cane or guide, – assistive technology: screen readers, mobile accessibility, – Braille (optional).

– Provide psychosocial support: counselling, support groups – Manage case and refer to tertiary services if required

Specialized rehabilitation – Provide advanced low vision devices and assistive technology (e.g. GPS, CCTV).

– Provide training in visual skills (e.g. scanning, eccentric viewing).

– Provide psychological services and family counselling.

– Provide vocational assessment and retraining.

– Provide paediatric rehabilitation: learning media assessment, cognitive development, school integration.

Data collection – Track individuals served, services provided.

– Collect basic demographic and service use data.

Data collection – Collect data on service use.

– Use of questionnaires and interviews to assess quality of life.

Data collection and research – Analyse national datasets at all levels.

– Conduct clinical and health-systems research.

– Use findings to shape policy and monitor service quality.

Optional

Optional

Training and education – Train professionals at all levels (curricula, fellowships, mentorship).

– Provide expert consultation to lower-level centres via telemedicine.

Primary plus services – Simple refraction and reading assessment.

– Basic low vision device trials and training.

– Peer support and family counselling.

– Remote consultation via telephone or internet.

Secondary plus services – Neurovisual rehabilitation (biofeedback, fixation training).

– Vocational counselling.

– Leisure and community participation programmes.

– Home and environment adaptations.

Awareness and advocacy – Design and disseminate national campaign materials.

– Build stakeholder networks (government, civil society, health).

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Planning guide for integrated vision rehabilitation

3.1 Preparing the assessment environment A well-prepared clinical environment is a prerequisite for a high-quality, personcentred assessment. The space should be designed to be comfortable, safe and functional for individuals with vision impairment.

– Space and privacy: a dedicated room is ideal because vision rehabilitation

consultations are longer and more complex than routine vision tests. Thus, a dedicated room ensures both patient privacy and sufficient time. The room should be spacious enough to allow for basic mobility assessment and free of clutter or obstacles to prevent trips and falls.

– Lighting: the room should have adjustable lighting to simulate different

conditions (for example, bright daylight and dim indoor light). Additional directable lighting is essential for near-vision tasks. Glare should be minimized by using blinds on windows and avoiding reflective surfaces.

– Contrast: use high-contrast features where possible (for example, a dark

chair against a light-coloured wall, and light-coloured equipment on a dark tabletop). This helps individuals with low vision navigate the space more easily.

3.2 Primary care Primary care is the first point of contact with the health system. Typically, this could be a general/family doctor or staffed by a nurse or physician assistant.

Staff at this level play an important role in identifying individuals who need vision rehabilitation, providing basic interventions and making appropriate referrals.

Care is usually given in community and other settings that provide services such as primary care centres, kindergarten, community-based rehabilitation centres, maternal and child centres, eye care centres and health care centres, schools and community centres. The district hospital serves as the referral site for patients from these facilities. The facilities may require telemedicine capability to receive consultation and training support from secondary care experts.

3.2.1 Initial patient engagement and observation The assessment begins the moment the individual enters the facility. Observing their movements and interactions as they wait and navigate the facility provides important information about their functional abilities.

With paediatric patients,1 while in the waiting room, the following should be noted.

– Does the child have isolated visual impairment alone or other disabilities (such as hearing or motor disability)?

– Does the child navigate confidently or by using his/her hands for touch (suggesting a sensory shift)?

– Does the child have nystagmus, a squint or abnormal head posture?

With adult patients, in the waiting room, the following should be noted.

– Does the person navigate the space confidently or with hesitation?

– Do they have a companion, and what is the nature of their interaction?

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Note the age of the child: neonate, toddler or preschool age or school age.

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Clinical assessment for vision rehabilitation

– Do they exhibit an abnormal head posture? (e.g. a chin-up or head-turn),

which may indicate an attempt to use a preferred part of their visual field?

– Do they seem defiant or hopeful?

– Are they wearing dark lenses?

– Does the patient have visual impairment only or dual sensory issues (such as

wearing a hearing aid) or motor disability (such as Parkinsonism observed in seniors)?

As a patient moves into the assessment space, following should be noted.

– Does the person stumble or bump into furniture/obstacles?

– Do they orient themselves quickly?

– Can they locate the chair they are directed to with ease?

3.2.2 History taking A thorough empathetic history is the most important part of the assessment. It enables an understanding of the impact of the vision impairment and allows any potential obstacles to vision rehabilitation to be identified.

With paediatric patients, in the consultation, ask the parents if their baby/child:

– can make steady eye contact; – has strabismus (misaligned eyes) or nystagmus (unsteady fixation); – has had onset of visual problems at the school; – has any disabilities other than those related to sight.

Additionally, ask the parents about the following:

– pregnancy complications or birth trauma (incubation); – history of genetic or hereditary disease in the family; – associated disabilities, history of early intervention.

With adult patients, ask the patient for the following personal and demographic data:

– name and contact details (address and phone number); – age and sex; – educational attainment (grade level achieved); – primary language; – any disabilities other than those related to sight; – occupation, main daily tasks and hobbies.

Also ask the patient about the reason(s) for visit and history of complaint, including:

– specific difficulties such as blurred vision at distance or near, double vision, glare, difficulty seeing in low light, or sections of vision that appear to be missing;

– history of each presenting complaint in detail, including onset (gradual/

sudden), duration, course (how it has progressed) and eye or eyes affected.

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Planning guide for integrated vision rehabilitation

Additionally, document the patient’s general medical history (for example, diabetes), medications and family history of eye disease, and explore the patient’s social context, including their living situation, family support, occupation and hobbies, as these factors are key to successful rehabilitation.

3.2.3 Clinical assessment Examination at the primary level uses simple, effective tools to assess visual function.

Essential equipment This includes simplified visual acuity charts (distance and near, for adults and children, culturally and ability appropriate) and a pen torch. A vision screening chart can be found in Annex 8.

Visual acuity Measure and record distance visual acuity for each eye separately and then together, with and without the patient’s current spectacles (if any).

Measure and record near visual acuity for each eye separately and then together, with and without the patient’s current spectacles (if any).

Confrontation visual field screening Perform a confrontation visual field test to screen for peripheral vision loss. This type of screening will identify large defects that can severely impact mobility.

Functional vision assessment This crucial step links clinical findings to the person’s real-world function. The goal is to understand how they use their vision in daily life.

– With paediatric patients, evaluate the developmental milestones of the child according to age:

– Birth to four months: follows light and objects, exhibits eye–hand coordination, focuses their eyes on the face of a parent.

– Five to eight months: recognizes familiar faces, visually explores a new environment, grasps objects.

– Nine to twelve months: voluntary control of eye movements, focuses and fixes on objects of interest.

– One to two years: interested in exploring their environment, recognizes familiar objects and pictures in books.

– Two to three years: matches identical objects, seeks missing objects or persons visually.

– Three to five years: has developed pre-reading and pre-writing skills,

matches simple forms, does a simple board or puzzle, can accurately discriminate sizes and lengths regardless of orientation.

With adult patients, assess functional vision through a structured discussion focused on the following three areas.

– Individual goals and needs: ask the person to identify their most important

goals. What specific near, intermediate and distant tasks do they want to be able to do?

– Current functional ability: enquire about their current ability to complete essential activities of daily living that require vision. Examples include reading medication labels, preparing food safely, managing finances,

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Clinical assessment for vision rehabilitation

recognizing faces, navigating familiar places, seeing in a classroom and playing games on a playground.

– Personal risks: discuss any personal risks the individual faces because of

their vision impairment, such as a fear of falling, difficulty with personal safety or using a stove safely, or challenges managing health conditions like diabetes.

3.2.4 Basic vision rehabilitation interventions Based on the assessment, primary care workers can provide a range of simple, non-optical devices and basic training.

Non-optical devices Provide and demonstrate the use of simple, non-optical devices that can immediately improve daily functioning. These include tools such as bold pens, reading stands, lamps, high contrast items, filters, devices to listen to audio books, talking watches or toys that offer increased contrast.

Environmental modifications Advise the person and their family on simple changes to make the home safer and easier to navigate. These include strategies to improve lighting, increase contrast between objects and their background (for example, a dark mat on a light floor) and reduce glare from windows and reflective surfaces. The role of family members extends beyond simply receiving advice; they are active partners in care. They can help implement and sustain the recommended environmental modifications and reinforce new skills by assisting the practice techniques, such as the sighted guide method. Furthermore, they can provide emotional and psychological support as the individual adjusts to vision impairment and assist with communication and advocacy, ensuring that the person’s needs are understood and met during follow-up appointments and interactions with other services. Children in school should be allowed to sit in the centre front row so they can see the board.

Training in basic mobility Teach essential and safe mobility techniques for navigating familiar spaces.

This includes the sighted guide technique, where a person with vision impairment holds the arm of a guide, and basic protective techniques for independent movement (for example, holding an arm out in front of the body).

Information and referral A central function of primary care is to act as a gateway to further services.

Provide clear information and referrals for all individuals who could benefit from more comprehensive eye examination or other levels of rehabilitation. Use a standardized referral form to refer the person for a comprehensive eye examination (to confirm diagnosis and rule out treatable conditions) and to a secondary level vision rehabilitation service if available. Referrals may also be needed for other services, including general health care, aged care, early childhood services, and social and education services.

Where possible, follow up with the person to confirm they attended their referral appointment and to assess the outcomes of the services they received.

Paediatric patients Primary level intervention programmes for children focus on enhancing visual skills through varied activities, such as encouraging visual fixation and following with colourful toys. Early intervention services require a team approach, with the family as an important member of the team.

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Planning guide for integrated vision rehabilitation

3.2.5 Awareness Information on the benefit of vision rehabilitation should be provided for all people with low vision or blindness, and for the wider community, to raise awareness about vision loss and the benefits of early intervention. This awareness-raising should be achieved using promotional campaigns or routine communication that draw attention to vision rehabilitation and methods for referral to services. All individuals working in community-based rehabilitation can contribute to these efforts to raise awareness of the vision rehabilitation process.

3.2.6 Data collection Data collection at the primary level should be simple and practical, focusing on useful information that demonstrates impact without overburdening staff.

Mechanisms for data collection The pre-defined key performance indicators can be collected through a variety of mechanisms, ranging from simple paper-based forms to integrated electronic systems. The choice of mechanism will depend on the resources and infrastructure available at the primary level. The following are some key mechanisms for data collection.

– Electronic health records: where possible, use standardized templates within electronic health records for recording patient rehabilitation progress and outcomes, integrated with broader health databases.

– Patient registries: establish simple national or regional registries to track long-term patient progress and service utilization.

– Service utilization reports: use facility-based data to report on the volume of services provided, patient demographics and referral pathways.

– Patient feedback and satisfaction surveys: implement structured, simple

feedback mechanisms to assess patient experiences and identify areas for improvement.

– Digital and remote monitoring tools: in settings where feasible, use

telerehabilitation platforms and mobile applications to track patient progress and engagement.

Performance indicators Key performance indicators help monitor the output and reach of the vision rehabilitation service.

Service efficiency indicators include the following measures:

– Total number of individuals served. This is a basic count of who is accessing the service.

– Demographic characteristics of individuals served. This includes basic details such as age and gender.

– Number of follow-up visits. This tracks continued engagement with the service.

– Patient retention rates. This measures how many individuals complete the recommended rehabilitation plan.

– Average wait times. This measures accessibility and efficiency.

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Clinical assessment for vision rehabilitation

Accessibility and equity indicators include the following measures:

– Number of people referred to the service. This tracks the demand and awareness among other health workers.

– Source of referrals. This identifies which facilities, community workers or programmes are successfully identifying and referring people.

– Geographic distribution of individuals. This tracks the localities where

people accessing the service come from, which helps in assessing equity and reach.

Patient outcomes indicators are the most critical category for demonstrating the value and impact of the rehabilitation services:

– Changes in visual function. This identifies basic pre- and post-rehabilitation levels of vision.

– Changes in ability to perform daily life skills. This assesses improvements in activities of daily living after rehabilitation.

– Improvements in mobility and independence. This measures the effect of the interventions provided on the functional ability of patients.

– Quality-of-life measures. Where feasible, simple, structured surveys can be used to assess the impact on overall well-being after rehabilitation.

Workforce and training indicators include the following measures:

– Ratio of trained vision rehabilitation workers per population is a direct

indication of workforce availability, allowing planners to identify workforce shortages in specific regions and to advocate for and plan new training programmes.

– Participation in continuing education monitors the commitment of the

workforce to ongoing professional development and quality assurance. This is critical for keeping personnel’ skills updated to address expertise gaps and reducing professional isolation, especially in new or remote services.

Low vision devices indicators include the following measures:

– Percentage of patients receiving prescribed low vision aids. Since providing

assistive products are a critical component of vision rehabilitation, this indicator helps determine if the procurement and supply chain systems are successfully delivering the necessary tools to the people who need them.

– Adherence rates measures whether a patient continues to use the device after it has been prescribed. It is a key proxy for the effectiveness of the rehabilitation process.

– Device functionality tracking measures the quality and durability of the assistive products being supplied.

A sample vision rehabilitation record card that can be used at the primary level of care is provided in Annex 7.

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Planning guide for integrated vision rehabilitation

3.3 Primary “plus” care Additional, optional elements of care under both assessment and rehabilitation are recommended to enhance service provision at the primary level. Primary “plus” services are not included in the basic package because they cannot be universally implemented in all primary level settings. They should be integrated only in those facilities that have, or can be equipped with, the necessary trained personnel and diagnostic/rehabilitation tools.

3.3.1 Assessment With paediatric patients, screen for ocular abnormalities (such as congenital disorders of the eye), visual acuity and contrast sensitivity assessment using special charts for children.

With adult patients, evaluate refraction and reading. A formal refraction assessment can be done by trained personnel (such as optometrists, vision technicians or ophthalmologists) to prescribe corrective spectacles. This is followed by a detailed evaluation of reading ability using standardized tests.

3.3.2 Rehabilitation With paediatric patients, rehabilitation involves early intervention rehabilitation programmes in neonates, toddlers and preschool children who are visually impaired to enhance neuroplasticity.

With adult patients, rehabilitation involves the following interventions:

– Support services: Offer comprehensive support for individuals and their families, including information about available community services, counselling on adjusting to vision loss and connections to peer support groups.

– Prescription of low vision devices: Prescribe, provide and train individuals in

the use of low-power low vision assistive products. This can include distance and near devices, therapeutic filters and other adaptive tools for activities of daily living. Training resources to assist with prescribing assistive products are available within WHO platforms (19).

– Advanced skills training: Provide specific recommendations on how to

manage daily activities and how to modify one’s environment at home, school or work. This also includes reinforcement of techniques such as the sighted guide.

3.4 Secondary care Secondary level services are typically based at more sophisticated facilities such as district or regional hospitals. They are staffed by medical specialists, eye care workers and other health personnel who provide multi-specialist care and should be equipped with technology for teleconsultation with tertiary care experts.

Beyond direct clinical care, secondary level services play a role in supporting individuals to navigate legal, educational and social systems. A key function is providing legal and administrative documentation. In some countries, specialists at this level are responsible for providing the detailed medical reports and functional assessments required by law for individuals to access social security benefits, disability pensions or other entitlements. Staff must be familiar with the relevant national legislation to provide this essential documentation.

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Clinical assessment for vision rehabilitation

Another key function is advocating for educational adaptations. For children with low vision, the secondary care team should act as a key advocate. This includes providing formal recommendations and liaising with educational institutions to demand and guide the implementation of necessary adaptations, such as preferential seating, large-print materials or access to assistive technology in the classroom.

3.4.1 Comprehensive assessment History and goal setting This assessment includes a detailed review of the individual’s history, personal goals, co-morbidities, specific needs and living situation. Discussion and education with the person and their family are particularly important at this level and it should be repeated as necessary.

Visual function testing A comprehensive assessment of visual functions is performed using vision assessment and ophthalmic equipment. This includes testing visual acuity, contrast sensitivity, depth perception, colour vision, light and dark adaptation, and visual fields (peripheral and central) as indicated. A detailed refraction is also performed.

Functional vision evaluation An assessment is made of how the individual uses their residual vision to perform tasks (functional vision). This includes evaluating their ability to carry out activities of daily living that require vision, such as reading, writing, using a computer or mobility. A full visual function assessment is done, including contrast sensitivity, colour vision and detailed visual field testing, as well as a cycloplegic refraction.

3.4.2 Rehabilitation interventions Prescription and training with low vision aids Low vision aids are demonstrated using trial devices. Following initial training, devices are prescribed and provided to the individual. This includes training on how to use the specific devices for distance and near vision; conducting activities of daily living; and the use of alternate strategies and senses, and modifications to the environment. Training must also be given on proper care and maintenance of low vision assistive products (Annex 9).

Orientation and mobility training Formal orientation and mobility training is provided as required to ensure the person can navigate their environment safely and independently. Training should be done using distance and near vision devices, activities of daily living and mobility devices, filters, and sighted guide techniques.

Assistive technology integration Training is provided in the use of assistive technologies matched to the user’s goals. This can include computer and cell phone accessibility features, text-tospeech software and global positioning system (GPS) technologies. Braille instruction may also be offered at this level.

Psychosocial support Counselling and peer support groups are provided for persons with vision impairment and their families to address the emotional and social impact of vision loss.

Case management Ongoing care is managed by rehabilitation staff who monitor the rehabilitation process, clinical status and progress toward goals.

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Planning guide for integrated vision rehabilitation

Remote consultation Telephone and internet communication may be used to provide early intervention, education and rehabilitation advice to individuals in remote areas.

Referrals Where necessary, formal referrals are made to other levels of vision rehabilitation or other health, social and education services as needed.

3.4.3 Awareness Information about vision loss and the benefits of rehabilitation are provided to individuals, families and the wider community through various communication methods and promotional campaigns.

3.4.4 Data collection Data are collected using validated tools such as quality-of-life questionnaires and structured interviews to measure the impact of the interventions.

3.5 Optional “secondary plus” care The following services are additional, non-essential services that can be offered at secondary care centres with specialized personnel and resources to build on the essential services.

3.5.1 Assessment Specialized, age-appropriate visual function assessments are conducted for young children to identify the need for early childhood intervention services.

3.5.2 Rehabilitation Interventions Advanced psychological support: formal psychological support, such as counselling for complex needs, is conducted by psychologists or other trained personnel.

–

– Vocational counselling: vocational counsellors provide advice and

information about employment and vocational retraining opportunities.

– Neurovisual rehabilitation: this includes interventions that use biofeedback or other techniques to enhance residual visual functions, such as fixation stability or retinal sensitivity.

– Home and environment evaluation: specialists may conduct on-site evaluations of the home and work environment to provide tailored recommendations for adaptations.

– Leisure and recreation programmes: recreational programmes, such as

sports camps or community activities, can be organized to promote social inclusion and well-being.

3.5.3 Data collection Data collected at this level may be formally analysed and reported by statisticians or researchers using comprehensive checklists and assessment tools.

3.6 Tertiary care The tertiary level delivers specialized consultative health care, usually based at a national level and provided in hospital settings, typically a university teaching hospital. In addition to direct clinical services, this level of care is the highest in the country or region, and includes research, programme development, staff training,

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Clinical assessment for vision rehabilitation

professional development, advocacy, data collection and analysis. Specialists in attendance typically monitor and communicate with lower-level centres by telecommunication.

3.6.1 Assessment Etiological diagnosis A complete ophthalmic assessment is conducted to determine the precise cause of vision loss.

Detailed history and goal setting A comprehensive history is taken to understand the individual’s goals, comorbidities and specific living situation.

Advanced visual function testing In-depth assessment of all visual functions is performed for both children and adults using a full range of diagnostic equipment. Evaluations include visual acuity (distance and near), contrast sensitivity, fixation stability, retinal sensitivity, light and dark adaptation, depth perception, colour vision, central and peripheral visual fields, refraction, and neurosensory evaluation (including electrophysiological instruments).

Specialized functional vision assessment The individual’s ability to complete basic to complex tasks is assessed, including the ability to carry out activities of daily living, such as reading, writing, driving, using a computer and mobility/navigation.

3.6.2 Rehabilitation Advanced low vision devices and assistive technology A wide range of simple and advanced low vision devices are demonstrated, trialled and prescribed, along with training in advanced visual skills and assistive technologies such as text to speech, activities of daily living, orientation and mobility, GPS, sighted guide technique, Braille training and methods to modify the environment.

Specialized paediatric services Comprehensive assessment and rehabilitation services are provided for children with low vision, including visual processing evaluation, learning media assessment (to decide which sensory channel (or combination of channels) the child should use for literacy), literacy instruction, assessment of neurodevelopment (cognitive, visual and spatial perception), social relations (with family and peers), scholastic progress and handling of concurrent disabilities.

Vocational rehabilitation In-depth vocational counselling and retraining services are provided to support individuals in seeking or retaining employment.

Psychosocial support Counselling, self-help groups and peer support are provided for adults, children and families facing complex challenges related to vision loss.

Case management and ongoing care Tertiary care staff supervise the rehabilitation process for complex cases and ensure effective communication and referral pathways exist between all levels of care.

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Planning guide for integrated vision rehabilitation

3.6.3 Training Tertiary centres are responsible for developing curricula and providing training, including courses and fellowships, and mentorship programmes for all members of the vision rehabilitation workforce. Training should be conducted by educators and trainers experienced in low vision, blindness and vision rehabilitation.

3.6.4 Awareness and advocacy Networking and collaboration Establish and maintain strategic networks with other eye care subspecialties, health care sectors, and regional, national and international stakeholders. These collaborative platforms should be driven by national eye care committees and vision rehabilitation practitioners, with the active involvement of researchers, administrators and, crucially, people with low vision and their families.

Public awareness and information dissemination Lead the development and dissemination of national awareness campaigns for both the wider community and individuals with low vision or blindness. This involves producing evidence-based educational materials at the national centre and distributing them through media, promotional campaigns and outreach events to inform people about vision loss and the benefits of rehabilitation.

Policy advocacy Coordinate advocacy efforts to address the needs of individuals with irreversible vision loss. This involves initiating collaboration with all stakeholders – including provincial and national governments, national eye care leaders and community groups – to develop and implement policies that ensure the long-term development and sustainability of vision rehabilitation services nationwide.

Data collection and research Tertiary centres serve as the central hub for system-wide data analysis and for driving the national research agenda in vision rehabilitation. This dual role includes two key functions:

– First, in coordination with national health information system, the tertiary

level contributes advanced analytical expertise to interpret data collected from all levels of care (primary, secondary and tertiary). This includes information from quality-of-life questionnaires, clinical tools and structured interviews to evaluate system performance and patient outcomes. This specialised analysis should be conducted by experts such as epidemiologists and data scientists.

– Second, tertiary facilities should lead and coordinate investigations into key

areas such as the impact of vision loss, the effectiveness of new technologies and treatments, service delivery outcomes, and the principles of universal design (which refers to the design of materials, environments, products, and communications that will be accessible and usable by all people). This research is achieved by establishing multidisciplinary collaborative networks that bring together researchers, clinicians, engineers, epidemiologists and health services researchers.

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4.

Procurement of low vision devices

Ensuring a sustainable supply of affordable, quality-assured low vision devices is a critical component of a functional vision rehabilitation service.

4.1 Principles of procurement

– Needs-based selection: the selection of products should be based on a local situation analysis, the level of care being provided and the skills of the available workforce.

– Quality assurance: clear criteria should be established to ensure that all procured products meet minimum quality and durability standards.

– Affordability and sustainability: develop a comprehensive financing model to ensure products are affordable for the end-user. This should consider mechanisms such as subsidies run in collaboration with local partners, formal loan systems for higher-cost items and advocacy for inclusion in national health insurance schemes. For long-term sustainability, establishment of a device revolving bank, where patients can trade in old devices for new ones, is an effective model.

4.2 Selecting a core set of products It is recommended to start with a limited, essential list of products that can cover most needs at the primary and secondary levels. A sample list of assistive devices and technologies is provided in Annex 4. The list typically includes:

– Optical devices, such as a range of handheld and spectacle magnifiers, and simple telescopes;

– Non-optical devices, including reading stands, lamps, bold pens and highcontrast materials; and

– Mobility devices, such as a selection of appropriate white canes.

4.3 Quantifying need Use data from the situation analysis and any pilot services to forecast demand for devices. Consider factors such as the prevalence of vision impairment in the area, the number of service delivery points and estimated patient uptake rates to avoid over-stocking or stock-outs.

4.4 Sourcing, quality assurance and patient education Identify reliable local, regional or international suppliers. Reliable international suppliers, such as the Vision 2020 Low Vision Resource Center (20), offer affordable devices and have established experience in international shipping, making them a viable procurement option. When possible, procure samples to test for quality before making large orders and engage with national standards bureaus to align with any existing regulations for medical devices.

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Planning guide for integrated vision rehabilitation

Successful procurement must be paired with education. Service managers should refer to Annex 9 on education for patients and caregivers on device use and maintenance to ensure that individuals are trained on how to properly use and care for their devices and hence maximize the benefit and longevity of the products.

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References2

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Nuzzi A, Becco A, Boschiroli A, Coletto A, Nuzzi R. Blindness and visual impairment: quality of life and accessibility in the city of Turin. Front Med. 2024;11:1–10 (https://doi.org/10.3389/fmed.2024.1361631).

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McLinden M, Douglas G, Hewett R, Lynch P, Thistlethwaite J. Teaching learners with vision impairment: an analysis of evidence-based practice. Oxford: Oxford University Press; 2020.

3.

Mojon-Azzi SM, Sousa-Poza A, Mojon DS. Impact of low vision on employment. Int J Ophthalmologica. 2010;224(6):381–8 (https://doi. org/10.1159/000316688).

4.

Management of low vision in children: report of a WHO consultation, Bangkok, 23–24 July 1992. Geneva: World Health Organization; 1993 (https:// iris.who.int/handle/10665/61105).

5.

World report on vision. Geneva: World Health Organization; 2019 (https://iris. who.int/handle/10665/328717).

6.

Ryan B. Models of low vision care: past, present and future. Clin Exp Optom.

2014;97(3):209–1 (https://doi.org/10.1111/cxo.12157).

7.

Burton MJ, Ramke J, Marques AP, Bourne RRA, Congdon N, Jones I et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020.

Lancet Glob Health. 2021;9(4):e489–551 (https://doi.org/10.1016/S2214109X(20)30488-5).

8.

Cyuzuzo C, Dukuzimana MJ, Muhire C, Sheldon Ames M, Ngwakongnwi E. Challenges to rehabilitation services in sub-Saharan Africa from a user, health system, and service provider perspective: scoping review. JMIR Hum Factors. 2025;12:e58841 (https://doi.org/10.2196/58841).

9.

World report on disability. Geneva: World Health Organization; 2011 (https:// iris.who.int/handle/10665/44575).

10. Steinmetz J, Bourne R, Briant P, Flaxman S, Taylor H, Jonas J et al. Causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to VISION 2020: the Right to Sight: an analysis for the Global Burden of Disease Study. Lancet Glob Health. 2021;9(2):e144–60 (https://doi.org/10.1016/S2214-109X(20)30489-7).

11.

United Nations General Assembly. Convention on the Rights of Persons with Disabilities. 13 December 2006. A/RES/61/106. (https://www.un.org/en/ development/desa/population/migration/generalassembly/docs/ globalcompact/A_RES_61_106.pdf).

12.

World Health Organization. (n.d.). Rehabilitation 2030 initiative. 2025. (https://www.who.int/initiatives/rehabilitation-2030).

13.

The UN Sustainable Development Goals [website]. United Nations; 2015 (https://www.un.org/sustainabledevelopment/development-agenda/).

2

All references were accessed on 19 October 2025.

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Planning guide for integrated vision rehabilitation

14. Eye care in health systems: guide for action. Geneva: World Health Organization; 2022 (https://iris.who.int/handle/10665/354382).

15. Tool for assessment of rehabilitation services and systems. Geneva: World Health Organization; 2015 (https://www.who.int/publications/m/item/tool-forassessment-of-rehabilitation-services-and-systems).

16. Assistive product specifications and how to use them. Geneva: World Health Organization; 2021 (https://iris.who.int/handle/10665/339851).

17.

International Vision Rehabilitation Standards. Rome: Polo Nazionale di Servizi e Ricerca per la Prevenzione della Cecità e la Riabilitazione Visiva; 2022 (https://polonazionaleipovisione.it/wp-content/uploads/2022/07/ International-Vision-Rehabilitation-Standards.pdf).

18. Eye care competency framework. Geneva: World Health Organization; 2022 (https://iris.who.int/handle/10665/354241).

19. Learning on tap. Eye and vision care [internet]. Geneva: World Health Organization 2025 (https://www.gate-tap.org/course-list/eye-and-visioncare/)..

20. Vision 2020 Low Vision Resource Center (operated by Barrier Free Access (HK) Limited) [website]. Hong Kong Society for the Blind; 2016 (https://www.hksb. org.hk/en/product/61518/Vision2020LowVisionResourceCentre/).

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Annexes

Annex 1. Summary and management of declared interests from external reviewers All external reviewers completed a declaration of interest form prior to the work, disclosing potential conflicts of interest that may affect, or may reasonably be perceived to affect, their objectivity and independence in relation to the subject matter of this resource. WHO reviewed each of the declarations and concluded that none could give rise to a potential or reasonably perceived conflict of interest related to the subjects covered. All of the external reviewers acted in their independent and individual capacity.

Name

Expertise contributed to the recommendation’s development

Declared interest

Management of declared interest

Boshra El Bayoun

Low vision, Vision rehabilitation, Clinical Ophthalmologist, Services planner and manager

None declared

Not applicable

Werner Eisenbarth

Vision sciences, Low vision, Vision rehabilitation

Global medical director – low vision rehabilitation in patients with retinal implants – at Science Corporation

This declared conflict of interest was not considered significant enough to pose any risk to the resource development process or to reduce its credibility.

Peer review group

Manager of humanitarian low vision project in Ghana – from Else-Kröner-Fresenius Foundation, Germany Maria Aparecida Onuki Haddad

Low vision, Vision rehabilitation, Clinical Ophthalmologist, Services planner and manager

None declared

Not applicable

Geoffrey Wabulembo

International development; None declared public health; eye care programme development, management and implementation in lowresource settings; content expert.

Not applicable

Sumrana Yasmin

Optometry; public health; programme development, management and implementation in lowresource settings; capacity building; content expert and end-user.

Not applicable

None declared

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Planning guide for integrated vision rehabilitation

Annex 2. Approach to developing the guide The development of the Planning guide for integrated vision rehabilitation draws on two key foundational documents such as the WHO Package of eye care interventions, 2022 (1) and the International Vision Rehabilitation Standards (2), established following an international expert consultation in Rome in 2015. The preparation of the document followed a systematic and consultative process led by the WHO Vision and Eye Care Programme in collaboration with the WHO Collaborating Centre for Rehabilitation of the Visually Impaired in Italy and WHO regional and country advisers. The resulting draft then underwent a formal peer-review process to ensure its quality and accuracy. The guide also aligns with high-level global commitments such as the UNCRPD and the SDGs.

References 1.

Package of eye care interventions. Geneva: World Health Organization; 2022 (https://iris.who.int/handle/10665/354256).

2.

International Vision Rehabilitation Standards. Rome: Polo Nazionale di Servizi e Ricerca per la Prevenzione della Cecità e la Riabilitazione Visiva; 2022 (https://polonazionaleipovisione.it/wp-content/uploads/2022/07/ International-Vision-Rehabilitation-Standards.pdf).

Annexes

Annex 3. Essential diagnostic tests and low vision equipment Diagnostic tests and equipment for low vision testing Distance visual acuity — ETDRS illuminator cabinet — ETDRS charts (Sloan letter series) for adults — ETDRS charts (tumbling E; Lea symbols) for children or illiterate people Near visual acuity — LEAT reading chart (BAL chart) — Desk lamp — Reading stands Contrast sensitivity — Pelli–Robson charts for adults — Hiding Heidi low contrast face test for children or illiterate people Stereopsis — Lang stereo test II ETDRS: Early Treatment of Diabetic Retinopathy Study

33

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Planning guide for integrated vision rehabilitation

Annex 4. List of low vision assistive devices Non-optical devices (from primary to tertiary levels of care) High contrast and large print products; for example, keyboards, highcontrast toys, typoscopes and bold pens.

–

– Daily living equipment, for example, soap dispensers, vegetable peelers,

kitchen timers, liquid level indicators, measuring spoons, talking food scales, tactile clothing symbols, washing machine labels, talking product labels, high contrast pill boxes and needle threader.

– Lamps and torches.

– Watches, talking and touching.

Devices for orientation and mobility activity (from primary to tertiary levels of care) White canes, folding and non-folding.

–

Optical low vision devices (from primary plus to tertiary levels of care) Spectacles, near vision; for example, ready-made reading glasses.

– – Prescription spectacles, distance vision; for example, custom-made glasses for refractive errors.

– Magnifiers, optical; for example, dome, stand, illuminated, hand-held

magnifiers (4X (12D), 5X (16D), 6X (20D), 8X (28D)), and spectacle magnifiers.

– Binocular magnifying prism glasses; for example, +4 dioptres and +8 dioptres.

– Telescopes; for example. monocular Keplerian telescope (4X).

– Filters, for example, lens filters to absorb all light up to 450 nm (colour:

lemon), up to 511 nm (colour: orange) and up to 527 nm (colour: dark orange); low vision polarized lens filter 400 nm polarized 65% (colour: light grey), 450 nm polarized 65% (colour: light green) and 511 nm polarized 65% (colour: light brown).

Electronic low vision devices (from primary to tertiary levels of care) Magnifiers, digital; for example, portable digital video magnifiers (5-inch liquid crystal display [LCD] display).

–

– Stand video magnifiers, for example closed circuit television (CCTV) a.

– Applications on for example, mobile telephones, tablets and laptops a.

– Accessible audio players, for example, devices with recording functions for

audiobooks and notes used with internet-enabled portable devices (mobile telephones, tablets and laptops)a.

a

These devices would be desirable, depending on the local economy and environment conditions.

Annexes

Annex 5. Training programme on vision rehabilitation: curriculum outline Phase 1. Online module (8-hour webinars covering the following topics) 1. Introduction to low vision:

– Definition and causes of low vision.

– Global prevalence of low vision.

– Impact of vision loss on daily life.

2.

Understanding vision impairment:

– Types of vision impairment (central vision loss versus peripheral vision loss).

– Contrast sensitivity and glare sensitivity.

3.

Assessment and diagnosis of low vision:

– Techniques for assessing low vision.

4.

Low vision devices and rehabilitation techniques:

– Essential low vision devices.

– Step-by-step guides and demonstrations through video content.

Phase 2. In-person module (2-week practical training on site) 1. Creating activities that simulate different levels and patterns of vision impairment.

2.

Demonstration of visual tests and how they guide assistance.

3.

How to use assistive devices effectively.

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Planning guide for integrated vision rehabilitation

Annex 6. Essential and optional services This annex summarizes the essential and optional services at primary, secondary and tertiary levels of care. It is taken from the International Standards for Vision Rehabilitation report (1).

Essential services at primary level What (services)

How (equipment)

Who (workforce)

Where (places where services are provided)

Assessment Vision screening for adults Simplified visual acuity and children including charts (distance and near, distance and near visual adult and paediatric), pen acuity and confrontation torch. The WHO Low Vision visual field assuring that eye Kit can be used care is available.

Assessment of individual needs of adults’ and children’s goals and personal risks. Assessment of functional vision (how the individual uses their vision)

Primary eye and health care Community and other workers, community settings that provide workers, teachers, or others services such as primary trained to measure visual health centres, communityacuity and confrontation based rehabilitation visual field centres, maternal and child centres, eye and health centres, schools and community centres

Functional vision assessment Primary eye and health care Community and other such as doing daily tasks workers, community settings that provide that are important to the workers, teachers, or others services such as primary individual or using WHO trained to assess personal health centres, CBR centres, Low Vision Kit needs and environment maternal and child centres, eye and health centres, schools and community centres

Rehabilitation Provision of non-optical devices, training in activities of daily living, basic mobility and modifications of the environment

Non-optical devices such as writing instruments, bold pens, activities of daily living equipment, reading stands, lamps, high contrast items, filters, increased contrast toys.

Instruction such as sighted guide technique or basic protection technique

Primary eye and health care workers, community workers, teachers, or others with the capacity to provide basic rehabilitation methods for adults and children with visual impairment

Community and other settings that provide services such as primary health centres, CBR centres, maternal and child centres, eye and health centres, schools and community centres

Information and referrals for adults and children such as referrals for comprehensive eye examination, other levels of rehabilitation, general health care, aged care, early childhood services, social and education services

Specific referral contacts

Primary eye and health care Community and other workers, community settings that provide workers, teachers, or others services such as primary with an understanding of health centres, CBR centres, needs for referral to vision maternal and child centres, rehabilitation, eye care, eye and health centres, general health care, aged schools and community care, early childhood centres services, social and education services

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Annexes

What (services)

How (equipment)

Who (workforce)

Where (places where services are provided)

Follow up to use of rehabilitation services as needed

Evaluation/contact as required

Primary eye and health care Community and other workers, community settings that provide workers, teachers, or others services such as primary with knowledge of vision health centres, CBR centres, rehabilitation, eye care, maternal and child centres, health care, aged care, eye and health centres, early childhood services, schools and community social and education centres services

Awareness Information for adults and children with low vision or blindness and the wider community to raise awareness of vision loss and the benefit or rehabilitation and early intervention

Through effective CBR, volunteers, primary communication instruments health care workers and and promotional vision technicians or others campaign. With awareness with knowledge of eye and access to education/ disease, knowledge of the information material vision rehabilitation process and visual milestones

Community and other settings that provide services such as primary health centres, CBR centres, maternal and child centres, eye and health centres, schools and community centres

Data collection Data collection

Indicators such as numbers Primary eye and health care Settings that provide and details regarding workers, community services such as primary individuals served workers, teachers or others health centres, CBR centres, with a knowledge of data maternal and child centres, collection eye and health centres, schools and community centres

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Planning guide for integrated vision rehabilitation

Primary “plus” services What (services)

How (equipment)

Who (workforce)

Where (places where services are provided)

Refraction equipment, reading tests

Ophthalmologists, optometrists, orthoptists, vision technicians, ophthalmic technologists or other personnel trained in refraction

Community and other settings that provide services such as primary health centres, CBR centres, maternal and child centres, eye and health centres, schools and community centres

Support for persons with visual impairment and families such as information, counselling and peer support groups

Access to information and services such as self-help organizations

Primary eye and health care Community and other workers, community settings that provide workers, teachers, or others services such as primary with knowledge of health centres, CBR centres, information and services maternal and child centres, eye and health centres, schools and community centres

Prescription, provision and training with low vision devices for adults and children

Distance and near devices, adaptive devices, filters, accessible cell phones, audio book players, ADL devices (Annex 4)

Eye care practitioners such Eye care and rehabilitation as orthoptists, optometrists, centres and schools ophthalmologists, vision technicians (refractionists), rehabilitation workers, itinerant or school-based teachers, CBR workers, social welfare staff

Basic rehabilitation for adults and children including training in the use of optical low vision devices

Devices identified as most useful to satisfy the personal needs, recommendations on how to best manage daily activities and recommendations on how to best modify their environment (domestic, school and work) and conduct sighted guide

Primary eye and health care Community and other workers, community settings aiming that provide workers, teachers services such as primary health centres, CBR locations, maternal and child centres, eye and health centres, schools and community centres

Telephone/internet communication for consultations with adults and children in remote areas or with distant consultant

Early intervention, education and rehabilitation advice

Any individual involved in vision rehabilitation

Assessment Refraction, reading evaluation

Rehabilitation

Primary, secondary or tertiary services

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Annexes

Essential services at secondary level What (services)

How (equipment)

Who (workforce)

Where (places where services are provided)

Record individual history, Interview goals, comorbidities, needs, living situation, etc.

Eye and health care workers, ophthalmic nurses, teachers, social workers, rehabilitation staff or others with knowledge of causes of vision loss and vision rehabilitation process

Settings such as schools, community settings, secondary eye and health centres, district hospitals and rehabilitation centres

Assessment of residual visual functions (visual acuity, contrast sensitivity, depth perception, colour vision, light and dark adaptation, central/ peripheral visual field as indicated) and refraction.

Discussion and education with patient and family.

Repeated as necessary at follow up visits

List of vision assessment equipment, ophthalmic equipment

Eye care providers such as ophthalmologists, optometrists, ophthalmic clinical officers, ophthalmic technicians or orthoptists

Health settings providing a low vision rehabilitation service, schools, optometry clinics, orthoptic clinics, eye care or refraction centres, homes, ophthalmology clinics, homes

Assessment of functional vision and ability to carry out activities of daily living requiring vision (such as reading, writing or using a computer), assessment of vision for mobility

Assess use of vision by adults and children to complete a range of tasks such as reading, using a computer, ambulating, etc.

Eye health personnel, allied health personnel, rehabilitation specialists, orientation and mobility specialists, education specialists

Settings such as schools, community settings, secondary eye and health centres, district hospitals, homes and rehabilitation centres

Prescription and provision of low vision aids

Trial devices for demonstration and prescription for use by people with low vision or blindness (Annex 4)

Eye care providers such as orthoptists, optometrists, ophthalmic clinical officers, ophthalmologists

Health settings providing a low vision rehabilitation service, schools, optometry clinics, orthoptic clinics, eye care or refraction centres, homes, ophthalmology clinics

Rehabilitation including training in the use of vision with and without low vision devices, activities of daily living, orientation and mobility, visual and alternative strategies and senses, Braille and modifications to the environment

Distance and near devices, activities of daily living and mobility devices, filters, resources regarding sighted guide techniques

Eye health personnel, allied health personnel, rehabilitation specialists, orientation and mobility instructors, education specialists

Settings such as secondary eye and health centres, district hospitals and rehabilitation centres, schools and community or home settings

Assessment

Rehabilitation

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Planning guide for integrated vision rehabilitation

What (services)

How (equipment)

Who (workforce)

Where (places where services are provided)

Training with assistive Appropriate technologies Rehabilitation specialists, technologies, audio, Braille, for patients goals e.g. cell orientation and mobility GPS, etc. phones, tablets, computers specialists, educational specialists

Settings such as secondary eye and health centres, district hospitals, rehabilitation centres, schools, homes and community settings

Psychosocial support such Individual and group as counselling and peer interaction support groups for persons with visual impairment and their families

Psychologists, counsellors, self-help organizations, social workers, teachers, rehabilitation staff

Settings such as schools, community, secondary eye and health centres, district hospitals and rehabilitation centres

Case management and ongoing care

Rehabilitation staff

Settings such as secondary eye and health centres, district hospitals, rehabilitation centres, schools, community centres and homes

Telephone/internet Early intervention, communication with adults education and and children in remote rehabilitation advice areas or with distant consultants

Any individual involved in vision rehabilitation

Educational and rehabilitation resource centres

Referral to other levels of vision rehabilitation, eye care, health care, aged care, paediatric and education services

Eye health personnel, allied health personnel, rehabilitation specialists, orientation and mobility instructors, education specialists

Settings such as secondary eye and health centres, district hospitals, rehabilitation centres, schools, homes and community settings

Awareness of information Through effective Eye and health care for adults and children with communication instruments workers, ophthalmic nurses, low vision or blindness and and promotional teachers, social workers, the wider community to campaigns with awareness rehabilitation staff or others raise awareness of vision and access to education/ with knowledge of causes loss, benefit of rehabilitation information material of vision loss, vision and early intervention rehabilitation process and visual milestones

Wide range of communities and settings aiming to provide broad coverage and accessibility in settings such as schools, community, secondary eye and health care centres, district hospitals and rehabilitation centres

Supervision of vision rehabilitation process, monitoring clinical status

Specific referral letter

Awareness

Data collection Data collection

Questionnaires QoL, structured interviews for specific purposes

Eye care and rehabilitation staff

Eye care, low vision clinics and rehabilitation centres

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Annexes

Secondary “plus” services What (services)

How (equipment)

Who (workforce)

Where (places where services are provided)

Ophthalmologists, optometrists, orthoptists, paediatric neurologists

Paediatric hospitals, schools, settings such as secondary eye and health centres, district hospitals, habilitation/rehabilitation centres and homes

Psychologists or trained personnel

Settings such as secondary eye and health care centres, district hospitals, rehabilitation centres, schools, homes and community settings

Assessment Assessment of young Age appropriate visual children for early childhood function assessment intervention

Rehabilitation Psychological supports such as counselling

Clinical interviews, QoL questionnaires

Vocational counselling

Interviews, advice and Vocational counsellor information about retraining and employment

Leisure programs for adults Sports, summer camps, and children such as community programs recreational camps and sport

Rehabilitation staff, technical experts, occupational therapists

Settings such as secondary eye and health care centres, district hospitals, rehabilitation centres, schools, homes, work and community settings Communities, schools

Rehabilitation through neurovisual interventions

Instruments for biofeedback Rehabilitation personnel, stimulations, instruments health care personnel, aimed at enhancing teachers residual visual functions such as fixation stability, retinal sensitivity, saccadic movements, etc.

Health settings providing low vision rehabilitation services such as optometry clinics, orthoptic clinics, eye care or refraction centres, ophthalmology clinics

Home and work environment evaluation

Home and work environment assessment and adaptation

Multi-disciplinary team including specialist teachers, eye and health care personnel

Home and work environment

Assessment tools and checklists

Statisticians, researchers, epidemiologists

Settings such as secondary eye health centres, district hospitals, rehabilitation centres, schools, university and research centres

Data collection Data collection, analysis and reporting

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Planning guide for integrated vision rehabilitation

Tertiary level services What (services)

How (equipment)

Who (workforce)

Where (places where services are provided)

Complete ophthalmic assessment instruments

Ophthalmologists and optometrists

Clinical and hospital settings, low vision centres

Record individual history, Interviews, QoL goals, comorbidities, needs, questionnaires for specific living situation, etc. purposes

Eye and health care workers, ophthalmic nurses, teachers, social workers, rehabilitation staff or others with knowledge of causes of vision loss and vision rehabilitation process

Settings such as tertiary and secondary eye and health centres, district hospitals, rehabilitation settings, schools and community settings

Assessment of visual function in children and adults (visual acuity, contrast sensitivity, fixation stability, retinal sensitivity, light and dark adaptation, depth perception, colour vision, central/peripheral visual field, refraction, and neurosensory evaluation)

Distance and near visual acuity charts (for adults and children), contrast sensitivity tests, tests for light and dark adaptation, depth perception, colour vision, visual field assessment equipment, refraction equipment, electrophysiological instruments and ophthalmic diagnostic equipment

Eye care personnel, Eye care settings providing ophthalmic nurses or others a low vision rehabilitation with ability to perform service through a multiophthalmic examination disciplinary team, school or and neurosensory community assessment

Assessment of functional vision and ability to carry out activities of daily living requiring vision (such as reading, writing, driving, using a computer) and assessment of mobility

Assess use of vision by adults and children to complete a range of tasks such as reading, using a computer, ambulating, etc.

Eye and health care personnel, allied health personnel, rehabilitation specialists, orientation and mobility specialists, educational specialists

Eye care settings providing a low vision rehabilitation service through a multidisciplinary team, school or community

Prescription and provision of low vision devices

Trial devices for demonstration; devices for prescription and use by people with low vision or blind (list of devices for tertiary centres)

Eye care providers such as orthoptists, optometrists, ophthalmic clinical officers, ophthalmologists

Eye care settings providing a low vision rehabilitation service through a multidisciplinary team, school or community

Rehabilitation including training in visual skills, the use of simple and advanced low vision devices, activities of daily living, orientation and mobility, and modifying the environment

Distance and near devices, activities of daily living and mobility devices, filters, resources for mobility and use of sighted guide technique

Eye health personnel, allied health personnel, rehabilitation specialists, orientation and mobility instructors, education specialists

Eye care settings providing a low vision rehabilitation service through a multidisciplinary team, school or community

Assessment Assessment of cause of vision loss/eye examination

Rehabilitation

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Annexes

What (services)

How (equipment)

Who (workforce)

Where (places where services are provided)

Training with assistive Appropriate technologies Rehabilitation specialists, technologies, audio, Braille, for patients goals e.g. cell orientation and mobility GPS, etc. phones, tablets, computers specialists, educational specialists

Settings such as tertiary and secondary eye and health centres, district hospitals, rehabilitation centres, schools, homes and community settings

Psychological support such Counselling, self-help as counselling and peer groups, clinical interviews, support for adults, children QoL questionnaires and families

Eye care settings providing a low vision rehabilitation service through a multidisciplinary team, school or community

Psychologists or trained personnel

Vocational counselling

Interviews, advice and Vocational counsellor information about retraining and employment

Settings such as tertiary eye and health centres, district hospitals, rehabilitation centres, schools, work settings, homes and community settings

Childhood specific assessment and services

Visual processing evaluation, learning media assessment, literacy instruction, assessment of neurodevelopment area (cognitive, visual and spatial perception), social relations (with family and peers), scholastic programs

Paediatric ophthalmologists, teachers, orthoptists, rehabilitation personnel, orientation and mobility specialists

Settings such as tertiary eye and health centres, district hospitals, rehabilitation centres, schools, home and community settings

Case management/ Ongoing care

Supervision of vision rehabilitation process, monitoring clinical status

Rehabilitation staff

National tertiary centre

Communication with and referral to other levels of vision rehabilitation, eye care, health care, aged care, early childhood services, social and education services

Specific referral contacts and information

All eye care, rehabilitation and education staff

Eye care, primary, secondary or tertiary rehabilitation centres or schools

Training in rehabilitation for Curriculum, courses, all cadres of rehabilitation fellowships, mentorships teams

Educators/trainers experienced in low vision, blindness and vision rehabilitation

National tertiary centre

Training

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Planning guide for integrated vision rehabilitation

What (services)

How (equipment)

Who (workforce)

Where (places where services are provided)

Networking with national, international and regional stakeholders and subspecialty health care

Establish linkages and contacts

Vision 2020 committees, National tertiary centre practitioners in low vision centres and trained national focal person.

Stakeholders, researchers, administrators, people with low vision and families

Awareness and information for adults and children with low vision or blindness and the wider community

Through effective communication materials, promotional campaigns, media, outreach and education/information material, design and production of materials in national centres

Eye and health care Rehabilitation, academic or workers, ophthalmic nurses, health care settings teachers, social workers, rehabilitation staff or others with knowledge of causes of vision loss, vision rehabilitation process and visual milestones

Advocacy on needs of people with irreversible vision loss, policies on development and sustainability of services

Multimedia, collaboration with stakeholders and National Eye Care Committee

Allied eye health and civil society groups

National tertiary centre

Epidemiologists, data scientists

Primary, secondary and tertiary centres

Awareness and advocacy

Data collection and research Data collection, analysis and reporting

Questionnaires, QoL tools, structured interviews for specific purposes

Research (new Establishing collaborative technologies, novel networks, investigation, treatments, outcome and analysis of data collected impact of services), from service delivery levels universal design of materials and environments

Researchers, clinicians, National tertiary centre engineers, epidemiologists, health services researchers

References 1. International Standards for Vision Rehabilitation. Rome: Polo Nazionale di Servizi e Ricerca per la Prevenzione della Cecità e la Riabilitazione Visiva; 2022 (https://polonazionaleipovisione.it/wp-content/uploads/2022/07/ International-Vision-Rehabilitation-Standards.pdf).

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Annexes

Annex 7. Vision rehabilitation screening record card Sample screening record card that can be used in primary care which records all the necessary history, examination and intervention details of the patient.

Record form

Date:

Person’s details Family name: Date of birth:

Given names: Gender:

Male

Female

Other

Address: Occupation:

History and goals Presenting complaint(s) (Tick all that apply): Difficulty with distance vision

Glare or light sensitivity

Difficulty with near vision

Difficulty seeing in low light

Missing or blurry parts of vision

Other: History of main complaint Onset

Duration

Progression

Gradual

Stable

Sudden

Getting worse Improving

Other: Patient’s goals (What are the most important things you want to be able to do?)

Functional difficulties (Tick all that apply): R eading (books, telephone, labels)

Navigating indoors/outdoors

Recognizing faces

Writing

Cooking/preparing food

Managing money or medications

Reading the chalk/white boards

Personal grooming

Using a mobile telephone

Other: Relevant medical and ocular history: Known eye conditions: General health conditions (e.g. diabetes, hypertension):

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Planning guide for integrated vision rehabilitation

Current medications: Family history of eye disease:

Clinical examination Key observations Head posture Normal Abnormal (Specify):

Mobility

Other: (e.g. signs of photophobia, nystagmus)

Navigates confidently Hesitant/stumbles

Vision screening details Distance visual acuity (Record best-corrected vision if possible):

Distance visual acuity chart: Vision screening distance: Vision tested: Distance vision test results:

Tumbling E

LogMAR

Other

3 metres

6 metres

Without spectacles

With spectacles

Right eye: <6/12

Other

Left eye: <6/12

Other

Notes: Near visual acuity (Record best-corrected vision if possible): Near visual acuity chart used: Vision screening distance: Vision tested: Near vision test results:

Reading card

LogMAR

Other

Normal reading distance

Other

Without spectacles

With spectacles

Right eye:

Left eye:

Constricted (right eye) Specify area:

Constricted (left eye) Specify area:

Confrontation visual field test: Full in both eyes

Notes on practical functional tasks: (e.g. describe attempt to read telephone screen or identify an object):

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Annexes

Plan and interventions Interventions provided today (Tick all that apply): Information on vision rehabilitation services provided

Sighted guide technique taught

dvised on environmental modifications A (e.g. lighting, contrast)

Basic protective techniques taught

Provided non-optical device(s) (tick all that apply) Bold pens Filters

Lamps

Other (specify):

Activities of daily living equipment (specify):

Increased contrast Notes: Referral (Tick all that apply): R eferred for comprehensive eye exam (ophthalmologist or optometrist)

Follow-up plan: Date for next appointment: Notes:

R eferred to other service (e.g. social services, community-based rehabilitation programme)

R eferred to secondary level vision rehabilitation service

o referral needed N at this time

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Planning guide for integrated vision rehabilitation

Annex 8. WHO vision screening chart This chart should be used for distance and near vision assessment.

Printing instructions:

– Print on white A4 card. Choose card that is as strong and durable as possible.

– Print full size. Do not shrink the document to fit the paper.

– Print so that the Es are a dark, rich black.

– Do not use if the print is grey, distorted or blurry.

– To ensure you have printed the chart the correct size, measure the 10cm ruler on the page to verify its accuracy.

Annexes

Annex 9. Safe use and maintenance of low vision devices: advice for patients and caregivers Safe use and care of low vision devices to keep them working well and lasting longer 1.

Care of optical assistive devices

– Cleaning. Always clean lenses and surfaces using a soft, lint-free, slightly damp cloth. Avoid using paper towels, tissues, or dry cloths, as these may scratch the lenses.

– Handling. Handle devices with care, especially when adjusting or transporting them.

– Storage: ° Store the device in a designated location to prevent misplacing them. devices away from edges or high surfaces to reduce the risk of ° Keep falls, particularly as individuals with vision impairment may not easily see where devices are placed. the storage area is free from dust, moisture and direct sunlight, ° Ensure which can degrade components over time.

2. Care of electronic low vision devices

– Battery maintenance. Remove batteries if the device will not be used for an extended period to prevent leakage and corrosion.

– Storage conditions: in a dry environment to prevent moisture build-up, which can lead ° Store to the growth of bacteria and potential damage to internal circuits. exposure to extreme temperatures, which can affect electronic ° Avoid performance.

– Usage caution: not attempt to disassemble the device unless instructed by a ° Do professional. devices are turned off when not in use to conserve power and ° Ensure reduce wear.

49

WHO NEAR VISION SCREENING CHART (40 CENTIMETRE TEST DISTANCE)



WHO DISTANCE VISION SCREENING CHART (3 METRE TEST DISTANCE)

N6

6 12

6 60

50 Planning guide for integrated vision rehabilitation

50

Annexes

3. Repairs and maintenance services

– Repairs. Return devices to a designated service point if repairs are needed.

– Common repairs: optical devices: lens replacement, case repairs and re-alignment of ° For optical components following drops or impact. electronic devices: repair or replacement of battery compartments, ° For switches, or internal circuit components.

– Procurement. Procure devices from reliable suppliers to ensure

availability of spare parts for future maintenance and to facilitate service support.

4. General recommendations

– Maintain regular checks on device condition and performance.

– Inform care providers or rehabilitation personnel of any changes in device functionality.

– Take time to learn proper handling, especially if vision loss is recent.

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Chapter

Planning guide for integrated vision rehabilitation

World Health Organization Department of Noncommunicable Diseases 20 Avenue Appia 1211 Geneva 27 Switzerland https://www.who.int/health-topics/blindness-and-vision-loss