**3. Breaking the bad news**

Psychologists agree that the approach by a professional such as an Ophthalmologist in breaking the news of imminent visual impairment or eventual blindness is not unlike that for terminal illness or death; hence the phases of adjustment are similar [4]. The seven phases of adjustment to blindness are: (1) trauma (physical or social), (2) shock and denial, (3) mourning and withdrawal, (4) succumbing and depression, (5) reassessment and reaffirmation, (6) coping and mobilization, and (7) self-acceptance and self-esteem [5]. The duration and outcome of the stages are unpredictable. The social and relational factors discussed in the previous section are among others that will influence the sequence.

synchronization promotion, altered levels of melatonin and serotonin, suppressed corticostriatal glutamatergic neurotransmission, immune response boosting, decreased levels of reac-

Coping with Visual Impairment: Helping our Patients Face the Truth

http://dx.doi.org/10.5772/intechopen.78675

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Invoking healing through prayer has been compared with the placebo effect, influenced by personality, expectancy, optimism, and motivation. Randomized controlled studies, have been inconclusive about the benefits of prayer, though faith has had documented positive impact on outcomes in treatment groups studied. Considerations given to the Hawthorne and Rosenthal effects have been attributed to some of these outcomes [6]. The Hawthorne effect refers to change that occurs as a result of the act of observation or measurement, whereas the Rosenthal effect refers to change resulting from observer or rater expectancy. Study conditions may foster exaggeration of measurement results on the part of the subject, and relaxation of the measurement criteria on the part of the observer respectively. With specific reference to glaucoma, I have found that patients with a positive attitude maintain functional

Andrade and Radhakrishnan [6] examined the correlation of medical and psychosocial benefits to religious affiliations and practices by posing a series of questions (see Appendix 7.1). The results were inconclusive and as such a definite relationship could not be determined. The door to research of this nature remains open, with respect to religious and theological

Optimism in our patients facing blindness has a positive impact on the way they experience environmental stimuli, and how this information is used in coping strategies optimism may contribute to the well-being of persons who have lost their vision both directly and by promoting problem-focused coping and engagement in positive social comparisons [7]. Research has found that non-acceptance of vision loss, using avoidance or ventilation coping, and not facing reality with a positive outlook may lead to negative feelings and low adaptation. Ophthalmologists' attitudes towards the underlying disease, and how they convey hope or despair to patients, can influence psychosocial adaptation in patients. The concept of neuroplasticity and the individualistic nature of healing and repair cannot be minimized. Shifting the focus to realistic goals such as optimal IOP in glaucoma, and discussing breakthroughs in neuro-therapy such as stem cell research will help keep hope alive and foster positive outlook.

Murphy [8] writes of her experience with a poor visual prognosis, where second opinion changed her life in a day, from despair to hope. An ophthalmologist diagnosed her sudden onset of loss of vision as macular hemorrhage of questionable etiology, giving a 2-week period before anticipated total vision loss. Her second opinion from a younger eye surgeon (and has a good prognosis), gave a diagnosis of Central Serous Maculopathy which is self-limiting. Patients are entitled to this review, and doctors should have no insecurities about this, as

tive oxygen species as measured by ultra-weak photon emission and reduced stress.

vision despite advanced disc and Retinal Nerve Fiber Layer (RNFL).

customs and beliefs.

**5. The second opinion**

medical research is very dynamic.

Professionals must stress the positive in all situations, and outline to family members that all aspects of vision must be appreciated and respected. While 20/20 to 20/40 may be the gold standard to function vocationally in everyday life, many will come to appreciate the ability to distinguish light and dark, colors, large gratings and basic physical forms. Conducting acuity tests with the Berkley Rudimentary Vision Charts to establish and define Log Mar vision below the 20/400 line is a good start. At this point, patients with advanced glaucoma, diabetic retinopathy, age related macular degeneration, retinitis pigmentosa, and many others must realize the value of whatever residual vision they have. This will encourage compliance with the control of ocular and systemic diseases leading to blindness.

Patients deal with the sudden traumatic nature of the bad news with denial and disbelief. They view the abyss of isolation and torment socially [5]. Three factors that influence the severity and intensity of shock are: (1) the significance of the loss to the individual, (2) the suddenness or unexpectedness of the event, and (3) the degree of visual loss. Denial often lasts as long as the multiple opinions and therapies continue to change; when the eye care professional admits "we have done all we can do."

Tedrick [4] reports that self-pity is the main characteristic in the mourning and withdrawal phase. In this phase, individuals refrain from activities that they once loved to partake in. Tuttle and Tuttle [5] outlined the "D's" of depression as despair, discouragement, disinterest, distress, despondency and dissentment. The next stage in the adjustment process is reassessment and reaffirmation. In this phase/stage the client self-examines their life and finds meaning (purpose for living).

In the next stage (coping and mobilization), the patient will find information and resource that will support them in the change [4]. This phase has cultural overtones that determine how smoothly, and at what rate it progresses. In Jamaica, the go-to is the Society for the Blind and the philanthropic body that supports rehabilitation is the Lions Clubs spread across the island. As the patient crosses this phase into the final of self-acceptance, he/she gains selfconfidence, and is able to accept the prognosis and move on with life. This may take a long time, and some may never get there.
