In the wee hours of a morning in May 2015, a bull weighing some 2,500 pounds wandered onto I-25 south of Pueblo, Colorado. The errant animal paused, blocking the right lane of the highway, just beyond a small rise in the road.
Unaware of the danger that lay ahead, a young man driving north crested the rise and smashed into the bull at full speed. It flew onto the car and killed the young driver, then landed legs up in the right lane.
South of the spot, Keith Cunningham, a truck driver from Divide, Colorado, was bringing his rig back from Texas. Unaware of the wreck ahead, Cunningham reached the same rise and he too plowed into the bull before he could touch his brakes. He lost his steering, his truck flipped, and he found himself hanging upside down in his cab, suspended by his seatbelt.
That wasn’t the worst of it. As Cunningham tells it, he could have escaped with three broken ribs and a dislocated shoulder – fortunate, considering a full-speed encounter with “2,500 pounds of bull” – but for one crucial failure. His airbag didn’t deploy.
That failure cost Cunningham dearly. His face smashed into the steering wheel, causing massive facial fractures, shattering his eye sockets, rupturing both eye globes, and tearing his retinas. All in a matter of moments.
“You don’t have time to think about it, and your life is changed forever,” Cunningham says, five years after the disaster.
Rays of light
The accident began a medical odyssey to save his eyes – more on that later. Today, Cunningham dwells in a twilight world: a series of surgeries over three years to reattach his retinas left him with very little vision in his right eye and greatly diminished vision in the left. He has, though, steadily learned to adapt to the challenges with the help of the Low Vision Rehabilitation Service at the UCHealth Sue Anschutz-Rodgers Eye Center on the Anschutz Medical Campus.
The National Eye Institute defines low vision as a vision problem that cannot be fixed with glasses, contact lenses, medication or surgery. The result: difficulty doing everyday activities. Low vision rehabilitation addresses these functional problems. Common conditions that are seen in the clinic include macular degeneration, glaucoma, neurological problems, like stroke or optic neuropathy, inherited eye diseases, vision loss in one eye, trauma, and more, said Dr. Kara Hanson, director of the Low Vision Rehabilitation Service.
“We concentrate on what vision the person still has rather than what they’ve lost and help them to use it as effectively as possible,” said Hanson, who is an optometrist specializing in helping patients adapt to low-vision issues. (For a description of the differences between her field and those of ophthalmologists and opticians, click here.
Hanson and her optometry colleague Dr. David Lewerenz also collaborate with occupational therapists (OTs) Leah Muntges and Amy Dobbs. Together they help patients find practical solutions to challenges caused by their diminished vision. These include difficulties with central vision (seeing small details and facial features); peripheral vision (seeing steps or curbs, objects and people around them); contrast sensitivity (difficulty seeing faded print, unmarked curbs, facial features); light sensitivity; eye alignment issues, and more.
The help begins in two exam rooms in the Eye Center. Hanson takes a detailed case history, asking patients to describe their vision, such as whether it is blurry or washed out, and works with the patient to help them identify their specific goals. Do they want to be able to read for extended periods? Cook? Work at a computer? Walk short distances? Return to work? The goals are as varied as people’s lives, but it’s important to identify them so that Hanson and her colleagues can devise strategies to meet them.
Hanson also identifies physical impairments that could be impediments to improvements. A person with a tremor, for example, may not benefit from a hand-held magnifying glass. Other details include assessing a person’s daily activities and hobbies, support they have at home, and identifying low-vision devices they are already using.
The session then moves to gathering information about the patient’s visual acuity; peripheral vision; need for enhanced contrast; sensitivity to light, and other factors that affect the ability to function. Dr. Hanson evaluates how the patient uses their vision and helps guide them in how to use it more efficiently. For example, people with central vision loss can no longer see detail when they look straight at it. Based on performance during testing, she helps the patient find the proper eye position to see detail better (slightly up, down, left, right or a combination thereof). This skill is known as “eccentric viewing” (EV). Hanson uses a retinoscope to measure problems like near-sightedness, far-sightedness and astigmatism. She also tests whether conventional glasses could improve clarity.
Tools of the trade
Of course, Hanson’s patients typically require more than a simple updating of their eyeglass prescription. She wheels out a multi-drawer “tool chest” with dozens of lenses and devices designed to address the patient’s specific goals. Colored filters enhance contrast. Tiny telescopes mounted on spectacle frames assist with distance vision. High-powered glasses called microscopes allow patients to read for relatively long periods. These glasses may also have LED lighting built into the frame to add illumination for the reader. Illuminated hand-held and stand magnifiers help with short- and long-term reading, respectively.
In another room, electronic magnifiers enlarge characters and enhance contrast for reading, writing and other daily tasks. Some of these tools can convert type to speech.
Patients get additional help with “non-optical” strategies from OTs Muntges and Dobbs, Hanson noted. For example, patients with central vision or peripheral vision get help with EV and scanning skills training. The OTs also ensure patients are properly trained to use any low-vision devices that the doctors prescribe and review the importance of task lighting, contrast, decluttering and organization, based on the patient’s goals and challenges.
Struggle after surgeries
Keith Cunningham has benefited from the resources at the Low Vision Rehabilitation Service, but it took some time. Long before he saw Hanson, Cunningham needed a herculean effort to save even a fraction of his vision. Air rescue flew him to a Denver hospital after his disastrous encounter with the bull. Surgeons there saved what they could of his ruined retinas.
He was blind for two weeks. A series of eight surgeries – four in each eye – to reattach his retinas over the next three years produced mixed results. He’s essentially blind in the right eye. The vision in his left eye, which Hanson puts at 20/120, is “the thread I’m hanging by,” Cunningham said.
He speaks without rancor about his experience, emphasizing what he still has: his wife and son, his animals, their house in the hills around Divide. But Cunningham is also open about what he’s lost. He had no plans to retire from truck-driving, but after 15 years, at age 60, that’s finished, along with driving of any kind. A native of Hawaii, he knows that with his washed-out vision, he’ll never again see the islands he remembers. The joys of packing in for solo climbs of 14ers, which he did avidly before the accident, are over.
“I haven’t come to peace with all of that,” he said candidly. His frustration is even more understandable given that he assiduously avoided accidents of any kind, let alone a run-in with a bull. He was a million-mile safe driver, “the first guy to shut it down” when the weather turned and the roads got bad.
He struggled to adjust in the early years after the accident. His workers’ compensation carrier helped him financially, but through no fault of their own, he said, “they had no real idea of the kinds of things I might be needing” to function. He recalled visiting a store with equipment for the visually impaired, but leaving with no clear idea of how to make things like a video magnifier for the computer work in his everyday life.
“I got things to help but they didn’t improve my functionality,” Cunningham said. “Once you got them, you had to figure out for yourself how to make them work in your own life.”
Making the most of low vision that is left
That changed when his retina specialist, Dr. John Zilis, referred him to Hanson. She improved the vision in his left eye with new glasses, and Muntges helped him learn to use his peripheral vision to compensate for his impaired central vision. Those changes helped him to reclaim, at least to a limited extent, one of his pre-accident joys: reading.
Donning special reading glasses, which help to magnify characters and align his vision, Cunningham settles into an easy chair with a book. A strong light shines over his shoulder to give him further help with making out the print. Holding the page close to his eyes, he can get in 15 to 20 minutes of reading.
“It’s one of my rewards for making it through the day,” Cunningham said. “It’s a link to what I was able to do before the accident.”
The injuries made him very sensitive to light, so much so that regular sunglasses don’t provide enough protection. Hanson provided three filters of various strengths to address that problem. Cunningham also struggles with distinguishing contrast. Muntges suggested using brightly colored stickers and tapes to help him delineate objects and borders. He used that strategy to help him change the oil in his cars: he wrapped bright tape around the opening for the dipstick so he can easily put it back into place after checking the levels.
Hanson also referred Cunningham to a certified orientation and mobility specialist for more training in moving safely about his home and in public. He completed 10 sessions with the specialist and received a long cane, which he uses to help climb steps and to move safely about city streets, open spaces and other unfamiliar environments.
During his yearly visits with Hanson, Cunningham also gets to try new equipment that might help. On a past visit, he tested bioptic telescope glasses for distance viewing. He decided against them, but knows they are a possible future option. “The big thing is I get to try them,” Cunningham said
He has found more promising aids. During a visit with Hanson in early August, Cunningham tried a device called IrisVision: a headset equipped with a smartphone that provides a wide field of vision, strong magnification, improved lighting and the ability to watch movies, take photos and more. After the visit, he said he’s leaning toward trying the device. If he does, he’ll return to the Eye Center for training in using it.
Ultimately, he’s grateful for the help from Hanson and her team. “The things I’ve gotten are not a permanent fix, but they have made things better than before. The ophthalmologists take care of my eye health, but Dr. Hanson improves my functionality.”
For her part, Hanson said Cunningham has handled adjusting to his situation well, especially considering the sudden setback caused by the wandering bull.
“When you lose vision, it’s like losing a loved one,” she said. “You go through the same grief process. It can be very devastating for people, but my patients have taught me that humor and a positive attitude go really far. If people are willing to adapt and are motivated to use their vision in different ways than they are used to, then we have an excellent chance to be successful.”
For more information about the Low Vision Rehabilitation Service, contact Dr. Kara Hanson at firstname.lastname@example.org or 720-848-5005