Findings from a recent cross-sectional study published in JAMA Ophthalmology suggest that self-reported hearing impairment is independently associated with reduced functional gains from low vision rehabilitation.
The association held after adjusting for age, sex, visual ability, cognitive status, and physical health, and it persisted regardless of whether patients used hearing aids.
Give me some background first.
Some context: Low vision, defined as vision loss that can’t be corrected by medical, surgical, or refractive means, affects individuals across all ages but is most common after age 50.
In fact, an estimated 2.2 billion people globally have vision impairment or blindness, with 20% of individuals in the US older than 85 having irreversible vision impairment.
Go on …
Vision rehabilitation targets functional independence: activities of daily living like bathing and eating, plus instrumental tasks like meal preparation and transportation.
And visual acuity alone is a poor predictor of rehabilitation outcomes.
Case in point: Psychosocial factors matter too, as baseline depression has been associated with better rehabilitation outcomes, while poor adherence to occupational therapy has been linked to reduced improvement in vision-related quality of life.
So what’s the issue?
Dual sensory impairment—a combination of vision and hearing loss—is common in aging populations.
- The global prevalence is estimated at 5.5% and is projected to reach 27.2% by 2050.
Unlike people with a single sensory loss who can lean on their remaining senses, those with both impairments lose that compensatory ability
This can lead to greater cognitive load and increased social isolation, compounded by higher rates of cognitive impairment exceeding the risk associated with single sensory loss alone.
And to manage this?
Rehabilitation for low vision often relies on verbal communication with clinicians, and treatment options involve auditory cues and feedback.
- But for patients who can’t hear well, those approaches may fall short.
As such: Until now, limited research had directly examined whether hearing impairment affects vision rehabilitation outcomes.
Noted. Now, talk about the study.
Investigators at the Wilmer Eye Institute, Johns Hopkins University, conducted a cross-sectional analysis using data from the Low Vision Rehabilitation Outcomes Study (LVROS), a prospective cohort study on clinical outcomes of vision rehabilitation.
The question: Is hearing impairment associated with a lower likelihood of achieving clinically meaningful functional improvement after outpatient low vision rehabilitation?
- Data was collected at 28 clinical centers across the U.S. between April 2008 and May 2011.
- Rehabilitation services varied by site and provider, with no single uniform protocol.
- Follow-up assessments were conducted via telephone interviews 6 to 9 months after the initial evaluation.
Who was included in the study?
The baseline analysis included 611 adults with vision impairment and available self-reported hearing status. Of those, 358 had normal hearing and 253 reported hearing impairment.
Demographics: Mean age was 73 years (SD 15.3; range 19 to 101). The cohort was 66% female, with participants presenting with a broad range of ocular diagnoses.
- Baseline visual acuity was comparable between groups.
And of these, how many patients were included in the final analysis?
For the post-rehabilitation analysis: 407 participants completed follow-up.
Retention rates were similar:
- 66.4% for the normal hearing group
- 66.7% for the hearing impairment group
Findings?
The primary outcome was whether participants achieved a minimum clinically important difference (MCID) in ability on the Activity Inventory, a validated visual function questionnaire covering everyday tasks like reading, mobility, and meal preparation, administered before and after rehabilitation.
The gap: Among those with normal hearing, 74 of 238 (31%) achieved MCID. Among those with hearing impairment, only 39 of 169 (23%) did.
- That translated to an odds ratio of 0.58 (95% CI, 0.34 to 0.95; P = .03) on multivariable logistic regression.
Baseline Activity Inventory ability did not differ by hearing status (β = −0.08; 95% CI, −0.56 to 0.41; P = .75), so the hearing impairment group started from a similar functional baseline.
- However, they did not improve as much.
Tell me more.
Hearing aids didn’t help: Among participants with hearing impairment, 74 (44%) reported using hearing aids. The proportion achieving MCID was 17 of 74 (23%) among hearing aid users vs 21 of 95 (22%) among those without.
Vision severity mattered: Self-reported severe vision impairment was associated with higher odds of achieving MCID (OR, 3.32; 95% CI, 1.20 to 11.90; P = .04). When the investigators combined ratings 0, 1, and 2 as mild vision impairment, MCID was achieved in 13% of mild cases, 24% of moderate cases, and 32% of severe cases. The authors noted that patients with more severe baseline impairments may have greater room for measurable improvement and may be more motivated to engage.
Depression played a role too: Higher scores on the Geriatric Depression Scale (GDS), indicating greater depressive symptom burden, were associated with increased odds of improvement (OR, 1.38 per logit increase in GDS score; 95% CI, 1.17 to 1.63; P < .001).
- There was no interaction between hearing status and GDS score (χ² = 0.21; P = .65).
And was this consistent across vision levels?
At every level of self-reported vision status, participants with hearing impairment showed lower rates of achieving MCID.
The researchers also tested whether the hearing-loss penalty varied by vision severity. It didn't (P = .64), meaning hearing loss limits improvement regardless of how severe the patient's baseline visual function is.
Limitations?
- Hearing impairment was self-reported, not measured by audiometric testing, which opens the door to misclassification of hearing loss severity.
- The LVROS dataset was collected more than a decade ago, and vision rehabilitation practices have likely changed since then.
- Follow-up data wasn’t available for all participants (introducing the potential for bias)
- Sample size also limited the ability to run detailed subgroup analyses by ethnicity, educational level, or other participant characteristics
- Rehabilitation varied by site and provider with no standardized protocol, making it harder to isolate which aspects of rehab were most affected by hearing status.
Expert opinion?
That said: The authors argued that it may be necessary to modify existing vision rehabilitation strategies to provide hearing enhancement devices and incorporate more visual supports—along with written materials and multimodal instruction—for patients with dual sensory impairment.
They also flagged that clinicians should set realistic expectations for vision rehabilitation outcomes when working with this population, particularly when patients select goals that are likely influenced by auditory limitations.
Anything else?
The goal-oriented nature of vision rehabilitation complicates things for patients with hearing impairments.
The authors suggested future research could investigate which specific goals in the Activity Inventory are hearing-relevant, allowing clinicians to stratify outcomes based on auditory dependence and better identify where hearing-impaired patients are most disadvantaged.
Take home.
For clinicians managing low vision patients: ask about hearing status and factor it into the rehabilitation plan.
Interdisciplinary approaches that address both sensory impairments together may be the clearest path to better outcomes for this population.