A.
Case
Study
Mark is a 29 year old male from Santa Fe,
NM with diabetes who graduated from college with a degree in art
education. He worked for one year as a
substitute teacher and later on was appointed as a middle school art
teacher. During his job, he realized
that his vision has been reduced and soon he was diagnosed with retinopathy, in
particular, nonproliferative, due to his diabetes. His current condition is moderate loss of
vision in both eyes, with his right one slightly worse than the left. As his job is strongly related to visual
skills, Mark is highly concerned and anxious about his future, as he thinks
that if the loss of vision progress it will be impossible to have a similar job
or any job related to his degree (Falvo, 2009).
B.
Diagnosis
Diabetic retinopathy is a condition of the retina, a
layer of the inner structure of the eye, where light is sensed by
photoreceptors, and it is due to diabetes (high blood sugar). Diabetic retinopathy is the most common cause
of blindness (Falvo, 2009). Diabetic
Retinopathy can cause visual loss in three categories: media opacity (cloudy
vision), central field loss and peripheral loss (Khan, 2007). Diabetic Retinopathy is diagnosed by an
ophthalmologist, a physician specialized in eye diseases, by having a retinal examination to check for retina
damage, which requires dilation of the pupil (Falvo, 2009). Another diagnostic
method is fluorescent angiography
helps to detect changes in the blood vessels of the retina. A fluorescein dye is inserted the eye blood
vessels emitting ultraviolet light in order to enable the taking of photographs
of the vessels for later study. If the
retina vessels are swollen or there is a leakage, a bleeding in the retina,
then that will be captured in the photograph (Falvo, 2009).
 |
| fluorescent angiography |
C.
Etiology
The cause of diabetic retinopathy is that
fluctuating blood sugars cause the lens to swell, resulting significant
changes, including refractive error.
This is common in early diagnosis and may result min changes in
eyeglasses prescriptions in days or weeks.
Even with sugars under control, still there may be some fluctuations in
vision (Khan, 2007). There are two types
of diabetic retinopathy based on its etiology (causes): nonproliferative diabetic retinopathy and proliferative diabetic
retinopathy.
Non-proliferative diabetic retinopathy is
caused by changes in the blood vessel walls whose structure has been affected
by sugars. Those changes allow leaks of
fluids into retinal tissue. Small blood
vessels become occluded and circulation is disabled, so that too little oxygen
goes to the tissues (ischemia) and as
a result retinal tissue dies (necrosis)
(Falvo, 2009). 
Poliferative diabetic retinopathy is caused
by the creation of too many small blood vessels, getting overwhelmingly closed
covering extensive areas of the retina.
As a result, ischemia occurs here again, that is too little oxygen going
to the retinal tissue and the body responds with the proliferation of small
blood vessels (neovascularosis), thus
making things worse for the retina (Falvo, 2009). The new blood vessels are abnormally fragile,
as they are too many to take much space, and eventually burst, filling the back
of the eye with blood and vitreous fluid, which is called vitreous hemorrhage (Khan, 2007).
Sometimes, the blood may clear by itself, but if it is too much, then it
covers the back of the eye, thus causing retina damage (Khan, 2007).
D.
Biopsychosocial
Aspects
a)
Biological
Biological aspects of diabetic
retinopathy as a disability are the following symptoms and visual problems that
occur in everyday life and limit the person form various activities: seeing
faces or reading bus numbers or other signs from a distance; reading fine print
(newspaper, letters, bills, etc.), writing in a straight line, reading low
contrast material, increased intolerance to light; inability to move about
alone outdoor after dusk; difficulty locating food in a plate, difficulty
seeing the time on wristwatch; differentiating between coins of similar
dimensions; and seeing in dim illumination (Khan, 2007).
b)
Psychological
People with diabetic retinopathy may not
lose sight overnight or may even not lose it at all, if they finally succeed in
controlling the blood sugar, which, in some cases however, is not easy at all
(Khan, 2007). They may experience rapid
fluctuations in their vision that may make them feel uncomfortable and insecure
with themselves, not sure what to expect to happen next (Falvo, 2009). As diabetes may afflict many different organs
and functions of the body, individual feels very vulnerable and uncertain for
the future (Khan, 2007). Psychological
adjustment to diabetic retinopathy may be hard, as in the beginning, the
individual may not know what category belongs to, as with partial or moderately
low vision that may occur in the early stages, the individual cannot be listed
either in the sighted or the non-sighted people, so that creates an identity
problem. The more visual the interests
and skills before the condition the harder the psychological adjustment of the
person may be to the disability resulting from diabetic retinopathy. When the individual reaches severely low
vision or blindness, as the later commonly happens in the vast majority of
people with diabetic retinopathy, isolation and social withdrawal are very
common along with feelings of helplessness and hopelessness (Falvo, 2009).
c)
Social
1. Interpersonal Relationships
Individuals in the early stages of diabetic
retinopathy with partial or low vision may be often taken as sighted by their
social environment and there may often be misunderstandings (gaps in conversations,
misinterpretation of body language, etc.), as people may expect more from them
and may misinterpret their mistakes that result from their visual problems
(Falvo 2009). As the individual may try
to pass as a fully sighted person in the beginning, misunderstandings become
worse and later on when the condition progresses, they completely give up. Also, when the disease progresses and results
to blindness, people may either show pity, withdraw or be overprotective to the
individual. Thus, the individual may
choose to withdraw and get isolated (Falvo, 2009). Families may react in various ways ranging
from anger to revenge to overprotectiveness, often making the individual
dependent and passive (Falvo, 2009).
Although diabetic retinopathy does not affect sexual functions, facial
and body language recognition may be affected, which may also affect the
quality of a sexual experience. Couple
therapy and counseling could be a way to help in this case (Falvo, 2009).
2. Independent Living
Dependence and quitting may prevent
individual from experience independent living and feel equally normal. Reaching blindness increases dependence and
lack of access to community resources.
Life coaching, training in both independent living (e.g. how to get
dressed, how to get clean/grooming, how to eat, etc.) and assistive technology
(e.g. Braille, cane, etc.) as well as obtaining counseling may help the person
adjust better and prevent dependence, negligence and self-negligence,
isolation, anger, anxiety, depression, learned helplessness or other problems
to take place. However, some people with
diabetes may lose tactile sensation, which makes it hard for them to learn
Braille (Khan, 2007). Having the family
of the individual participating in the training, service coordination/case
management (planning for transportation, financial benefits/assistance, doctor’s
appointments, access to buildings, etc.) and counseling process may enhance communication,
balance, self-resilience, and independent living for the person with the
disability, but also for the entire family to be independent and fully
functioning both as a whole and also as individual members with their own lives
and personalities (Falvo, 2009).
Various state agencies, such as for
instance, the New Mexico State Commission for the Blind have programs for
independent living, where Independent
Living Teachers, as they are called, can do home visits and teach
individuals, such as Mark, how to use a talking computer, calculator, scale,
clock or watch or other devices, so they can become independent and
self-sufficient (NM Commission for the Blind, 2011). Orientation and mobility trainers can also
help a person with visual disabilities navigate independently and safely. Protective shoes, service dogs, and canes can
help them navigate and prevent accidents (Khan, 2007). Also, the NM Commission of the Blind has a
program, Newsline for the Blind,
which provides access to over 30 publications through a touchtone phone. Also,
the Commission sponsors NFB-Newsline,
which provides access to over 200 national newspapers, some of them in Spanish (NM
Commission for the Blind, 2011). Such
programs usually focus on providing services especially to the older consumers
and those with visual problems in both eyes.
However, there are similar services offered for young people with
retinal degenerative disorders, such as diabetic retinopathy and also for those
who have severe visual loss on the one eye, but as they have diabetic
retinopathy or similar progressive disorders, they may be at-risk of complete
blindness in both eyes (NM Commission for the Blind, 2011).
Those
with some remaining useful vision can use optical devices, such as spectacle
devices (e.g. eyeglasses), stand magnifiers, hand magnifiers, absorptive
lenses, adaptive devices, such as closed circuit television systems (CCTV),
computer software magnification and screen readers and non-optical devices,
such as reading stands, felt-tip pens for dark and thick writing that improves
contrast; letter writers, signature guides, and a notex enable a person to between a currency of various denominations. But still instructional training is needed
for using the above tools (Khan, 2007). Glare control devices can also be used to
prevent distractive scattered light (e.g. sun wear, absotptive filters, tints,
anti-UV, and anti-reflective coatings) (Khan, 2007).
3. Vocational Pursuits
Although diabetic retinopathy is a
progressive and degenerative eye disorder which often leads to complete
blindness in both eyes, it may progress slowly, depending on the person’s
condition, genetic predisposition and the specific diagnosis and type of the
disorder. As a result, a person in the
early stage of visual loss, such as Mark, whose status is moderate and with the
one eye a little bit better than the other, can still work in the same field
and in the same line of work, even at the same work place (e.g. Mark still
working as a teacher at the same school), but taking some measures and some
precautions, as the disorder may exacerbate (Falvo, 2009). Assistive technology, for instance, and
visual aid, such as eye glasses, can be covered by the consumer’s insurance
with no need of accommodation. Later on,
as the disease progresses, reasonable accommodations could be made at the work
place (Falvo, 2009). Most people with
diabetic retinopathy may feel totally insecure of losing their jobs and just
give up or become isolated and depressed quitting their jobs and depending on
disability insurance. Lack of direction
or low expectations from family, friends and the person’s work environment may
be discouraging. Peripheral or central
vision may progressively increase the level of difficulty for doing job tasks
and functions (Falvo, 2009).
In Mark’s case, for instance, an middle
school art teacher, although it may seem to be challenging, as ink, dyes and
other chemicals which may not only risky for accidents, but also may affect
vision, as well as visual skills and increased need to monitor workshop for
effective classroom management, still there are options. For instance, having a teacher aid who has a
break in a period when Mark is in class, placing him in Marks class and working
with him, when needed in a some projects, or placing Mark in art classes with
students of mild disabilities (e.g. physical) where a paraprofessional may be
there helping the students, so there may be no need to have the school spend
extra money for Mark. Also, some
reliable student-helpers carefully selected may help Mark. Art classes that focus on art theory and art
history could be assigned to Mark, if there is such option. Also, Mark could be advised to attend a
School for People with Visual Disabilities, so he can learn Braille and the use
of the white cane. He could also prepare
himself to get a second license, such as special education for people with
visual disabilities, as soon as he could before the disorder progresses.
People like Mark, as there is a high
possibility for not being able to do the job they like, especially if that can
also relate to hobbies and leisure, such as art, can be encouraged to find
alternatives. For instance, Mark could
become a teacher for people with visual problems and give them lessons on how
to do creative arts and crafts using their hands in a safe way, without using
sharp instruments or tools lead and field trips to museums for people with
visual disabilities, where they can touch works of art, in particular inexpensive
replicas of statues, sculpture and buildings, and other crafts. Even when job placement for Mark fails, job
development can be the solution, as a vocational rehabilitation counselor may
work with employers and create a job position that suit the needs and skills of
the person with diabetic retinopathy. In
Mark’s case, a counselor could seek schools that focus on fine arts or special
education school, and such are usually many, which may be interested in having
Mark teaching alternative classes for art appreciation for people with visual
problems, or teach theoretical and historical approaches to the arts. Sponsors could be found in charter schools,
academies, private schools or even public schools with tradition in art
education or special education.
Every state has a state agency, including New Mexico’s Commission for the Blind that
provides vocational rehabilitation to people with visual disabilities. The role of the vocational rehabilitation
services is to provide vocational counseling and assessment and job placement based
on the individual’s strengths, resources, priorities, concerns, abilities,
capabilities, interests, and informed choice.
The NM Commission for the Blind does not offer transportation services,
but there are other agencies that do so and a vocational rehabilitation or a
case manager could take care of this and have it in the rehabilitation plan (NM
Commission for the Blind, 2011).
4. Recreation/Leisure
 |
| Museum for the blind |
Leisure and recreation are very important
parts of one’s life and people with visual or any disabilities should not be
deprived from them, but have equal opportunities, instead. People with visual disabilities and
especially severe and progressive conditions such as diabetic retinopathy may
be really challenged in this domain as outdoor activities and even simply
getting outside the home may be quite difficult and unsafe (Falvo, 2009). Transportation to places of recreation or
entertainment could be a part of the rehabilitation plan and such resources
should be allocated and their access ensured by the counselor or case
manager. A service dog could be a great
help as well as the use of a cane. There
are several sport organizations and social clubs that serve people with visual
disabilities that may provide recreation for this particular population, such
as the American Blind Bowlers Association, Beep Ball teams and the United
States Blind Golfers Association, and many more (Falvo, 2009). Recreation for Mark may be very important as
he is a young person whose hobbies in studio were strong enough to make them
his job, as he is an art teacher. As a
person for whom vision is extremely important and a vital part of his
lifestyle, a good idea would be being able to get close to landscapes, nature,
outdoors, and places he could try to visualize and imagine how they really look
like. Also, another good idea would be finding
new hobbies and getting into sports or music.
All that requires the help of a team, such as counselors, case managers,
social workers, transportation specialists and, of course,
rehabilitation/independent living teachers and orientation and mobility
trainers as well as assistive technology professionals.
E.
Treatment/Intervention/
Suggestions
 |
| Vitrectomy |
Diabetic Retinopathy can be treated with
refractive correction (e.g. eyeglasses and magnifiers for those who still have
some vision left) and surgery (for more severe cases and for prevention of
blindness). Vitrectomy is a surgery performed to remove hemorrhage and laser
surgery can be applied to stop bleeding, namely, laser photocoagulation, where laser passes through the lens of the
eye and the vitreous fluid and burns with precision the broken vessels’ wound
and stops bleeding without damaging surrounding structures and tissues (Falvo,
2009). Although laser photocoagulation
can reduce the risk of visual loss, it cannot stop the progression of the
disorder. Such interventions can often
take place at an outpatient center (Falvo, 2009). Refractive correction may include low vision
devices that can be prescribed to individuals with nonproliferative diabetic
retinopathy who may have some remaining useful vision. But for people with proliferative diabetic
retinopathy and a history of recurrent hemorrhages, low vision devices are not
prescribed (Khan, 2007).
 |
| Laser Photocoagulation |
 |
| Talking Glucose Meter |
Diabetes management is very crucial for
people with diabetic retinopathy as diabetes is the cause of the disorder. Keeping blood sugar low and under control
should follow a carefully designed plan by a team of ophthalmologists, diabetologists/endocrinologists,
primary care physicians/internists, independent living/rehabilitation teachers,
counselors, and clinical nutritionists/dieticians. Numerous insulin-loading devices are
available as well as “talking” blood glucose monitors and most don’t require color
matching (Khan, 2007). Consumers should
also be trained to read insulin syringe and medicine labels. Regular follow-up with medical doctors and
frequent comprehensive low vision evaluation in order to identify goals and
visual needs are very important and crucial for a successful individualized
rehabilitation, diabetes control and prevention of further visual loss and
blindness (Khan, 2007).
References
Falvo. D.R. (2009). Medical and Psychosocial Aspects of Chronic
Illness and Disability. Sudbury, NJ: Jones and Barlett Publishers.
Khan, S. (2007). Low Vision
Rehabilitation and Diabetic Retinopathy. Saudi
Journal of Ophthalmology,21(3), 161-165.
Retrieved from: http://www.csid-bd.org/VI/VI-02.pdf
State of New Mexico Commission
for the Blind (2011).
