Visual impairment is included among the top 10 most prevalent causes of disability in the United States.1 Low vision affects more than two million Americans and ranks only behind arthritis and heart disease as the reason for impaired daily functioning in Americans older than 70.1 In addition, blindness ranks third as one of peoples most feared disorders.1
The numbers of low vision patients is expected to increase, according to the National Eye Institute, and the prevalence of low vision is expected to almost triple by the year 2050.2 Practitioners from every state and mode of practice will likely encounter patients who are visually impaired and seeking quality care. This is especially true because the majority of patients with vision impairment have moderate vision loss with median Snellen values ranging from 20/71 to 20/80.3
Most often practitioners will encounter patients who seek care because they are having difficulty with specific tasks, most commonly reading.4 Having difficulty reading is a major consequence of vision loss for Americans with low vision.5 In addition to reading, driving and household chores, self-grooming and meal preparation are common complaints in my practice. The loss of these abilities burdens the patients and their loved ones. Current technological advances in assistive devices and the smartphone allows practitioners to make timely in-office suggestions and implement strategies for immediate use, thereby increasing the quality of life of their clients.
Many practitioners may be tempted to refer these patients immediately to a low vision provider without attempting to make any interventions themselves; however, all optometrists are capable of performing a basic low vision evaluation and providing the patient with vision impairment some initial tools to get started on their journey of improved functioning.
Subsequently, the patient learn as much as they can and then be referred for more extensive low vision exams and training as needed or if vision worsens.
All eye care providers can overcome the challenges of visually impaired patients seeking assistance, through simple low vision intervention techniques and strategies.
Current Advances in Tech
The equipment and technology that is available in low vision rehabilitation is vast and ever-changing, providing optometrists myriad options when providing care to visually impaired patients. The newest technology includes advanced autofocused telescopic devices, portable electronic magnifiers, wearable devices, character readers, apps and built-in smartphones and tablet accessibility options. These options make it easier for eye care providers to assist their patients in living fuller, more productive and more independent lives.
These options range in complexity from low tech to high tech. Telescopic options may be handheld or mounted, monocular or binocular and full diameter or bioptic. A single handheld monocular telescope is oftentimes a good device for distance spotting and enhancing safety during mobility, thus making mobility easier. A focusable monocular telescope in moderate power from 2x to 6x may be used for spotting streets signs and signals and for viewing distance objects or events for short periods of time.
Monocular telescopes are made by a variety of manufacturers and are readily available. They are a cost-effective alternative to more high-tech options in the “tech adverse” subset of patients. When considering prescribing a telescope for patients, practitioners must first determine what magnification a patient will require to perform tasks. Generally, the minimal target acuity is 20/40, for most distance tasks due to this is the minimum distance acuity that is required for unrestricted driving in most states.
A quick way to determine the magnification required is with a simple formula which does not require a calculator: Magnification = Best Corrected Visual Acuity ÷ Target Acuity
For example, if a patient has an entering best-corrected distance acuity of 20/100 and the target acuity is 20/40, the magnification is calculated as follows: 100/40=2.5x. Thus a 2.5x telescope will provide the ability for the patient to see the goal acuity of 20/40 in this example. When choosing a telescope, it is also helpful to understand how telescopes are labeled. Generally, traditional monocular telescopes will have several numbers on them such as 4x12. The first number represents the magnification, in this example 4x. The second number indicates the diameter of the objective lens in this example 12mm. The objective lens is the lens closest to the target which effects the brightness of the image ultimately.
|Binocular telescopic devices can be helpful for sedentary, distance-viewing activities.|
A binocular option for distance viewing that many low vision clinicians recommend is the Eschenbach MaxTV. This is a great binocular telescopic option for multiple reasons. It is practical and easy to maneuver with a minimal learning curve for most patients and patients often get immediate gratification after working with this device. It is made for sedentary, distance viewing tasks such as watching television. Practitioners must warn patients not to walk around in these types of devices due to the risk of falling due to increased magnification. It provides approximately two times magnification and allows each eye to be focused individually, this allows for focus on objects from 10 feet and farther.6 It is good device to consider not only for TV but also for patients who want to watch sporting events, go to movies or who have taken up hobbies such as bird watching.
Patients often complain of their inability to enjoy outings with family to sporting events or being able to watch their grandchildren in extracurricular activities. They appreciate this device because it allows them to return to enjoying these activities.
Another telescopic device that practitioners will find helpful and easy to incorporate into practice is the VES-Falcon Autofocus Bioptic Telescope. The VES-Falcon is available in several power options and covers a wide range of prescriptions.5 It provides the user with hands-free, immediate clear vision at almost any distance and covers refractive error ranging from +8.00D to -8.00D.5 This wide array will encompass most patients who present for a low vision exam making this an easy to fit and train device for most eye care practitioners. It is lightweight and comes with a rechargeable battery that lasts up to eight hours on a single charge, providing patients who use it to drive with the peace of mind that it will be ready to use, especially at the end of a work day. This is an option for patients a who have difficulty manipulating dials and buttons due to arthritis or neuropathy.
|Electronic magnifiers such as these allow the visually impaired to have a portable, customizable device to assist in their visual tasks.|
Portable Electronic Magnifiers
When convenience and portability are a priority, a tablet or an electronic video magnifier is a good place to start. Small portable electronic magnifiers are a great way for technologically savvy, visually impaired users to have portability and variable magnification in one piece of equipment. These devices are ideal for patients who require more assistance than optical aids such as high-powered reading glasses can provide, but do not necessarily need or want a large stationary closed circuit television (CCTV).
This category of devices can be moderately priced and can be used in a variety of settings. Furthermore, electronic video magnifiers as a whole provide a wide range of magnification, contrast and enhancement modes allowing for customization by the user.
With all the devices that are available currently, it can be a daunting task to help patients decide which may be the best device for their needs. Practitioners must take into consideration the patient goals, best-corrected visual acuity, size of magnification and portability including size and battery life.
With these considerations, there are some options such as the Explore 5 (New England Low Vision and Blindness), the Ruby XL HD (Freedom Scientific) and the Pebble HD (Enhanced Vision). The Explore 5 may be used simply handheld like a cellular phone, with the attached folding handle or on a tabletop.7 It offers magnification extending from 2x to 22x on a five-inch screen.7 It can store images for viewing at the user’s convenience and also be connected to a television to display both pictures and text. The Ruby XL HD offers a built-in reading line to help users keep their place on a page while reading, which is a common complaint amongst people with visual impairment in my experience. Its large color-coded buttons with easy to decipher markings make it simple for patients to adjust the level of magnification.8
The Ruby XL is useful to a broad spectrum of users, including those with central vision loss and monocular patients, due to its ability to enlarge objects of interest two to 14 times the original size, decreasing strain and fatigue many patients with low vision experience. Moreover, it is compatible with computers.
Lastly, the Pebble HD has a real-time clock and calendar and provides audible feedback.9 These features can help users keep track of appointments, scheduling and time management. This device allows practitioners an option for those requiring either a little or a lot of help with visual tasks as well as those needing a convenient portable option.
Hotline for Low Vision Consumers
Patients suffering from vision loss need all the allies they can get. Now there’s a phone number they can call to seek help in finding products that can make their lives a bit easier. The Accessible Products Hotline (316-252-2500) connects low vision patients with professional advice about purchasing and operating products especially suited for their unique accessibility needs. Items highlighted by the hotline, such as memo recorders, microwave ovens and headsets, were selected for their strong accessibility features and were recommended by other users who are blind or have low vision. The hotline was recently launched by Envision, an advocacy group for the visually impaired, based in Wichita, KS.
These assistive technologies are among the newest options available to eye care practitioners and patients. This branch of technologically advanced options is growing rapidly and extending the list of choices to consider when implementing a low vision device as part of a treatment plan.
As a group they offer extensive magnification ranges and great portability. They are also becoming less bulky and more aesthetically pleasing to potential users. Eye care professionals may want to consider wearable devices in patients with tremors, paralysis or muscle weakness and for long-term tasks.
One such device is the OrCam MyEye 2.0. The OrCam is a wearable pair of glasses with an accompanying camera. It is easy to use and responds to simple hand gestures.10 It is capable of reading printed text as well as text displayed on electronic screens such as computers, tablets or phones. It affords the user the ability to recognize faces and audibly announces the person in real-time.10 OrCam does not need an Internet connection and can be controlled with more than 20 voice commands.10
IrisVision is one of the newest wearables among low vision devices. It may be used in patients with a variety of ocular diseases including age-related macular degeneration and retinitis pigmentosa, which cause central vision loss and peripheral vision loss respectively. This device is able to give patients an individualized experience with the unit. The IrisVision allows the operator to enjoy hobbies, read and recognize faces with a 70-degree field of view. 11 It uses the power of a headset along with a smartphone camera to capture the scene.
The Jordy (Enhanced Vision) holds a battery life of eight hours and an autofocus camera that works at distance, intermediate and near.12 It gives the user clear vision through a wide range of tasks and can be worn like glasses.12 The Jordy also has CCTV with docking station available for users who may be interested in a stationary desktop device in the home, giving two-in-one convenience.
Devices in this category are exceptional options for practitioners looking for portable, versatile and hands-free suggestions for patients with vision loss. This area is rapidly growing and is becoming a mainstay of low vision intervention. These devices allow users to regain and maintain an active lifestyle and independence.
Becoming familiar with devices for low vision patients, such as a monocular telescope (left) or a stationary CCTV (right), can help your practice assist in a wide range of their visual needs.
Apps and Accessibility
Regardless of age, many patients that optometrists encounter have some working knowledge of smartphones and tablets and often use these devices daily for work, entertainment or school. These common devices are obvious choices for practitioners to recommend as part of their low vision treatment plan. Two paramount reasons for this are that most patients already possess the hardware with some built-in accessibility options and that many very useful, applications (apps) are free and accessible within minutes. Whether the patient is an Apple user or an Android devotee, both operating systems have an “accessibility” menu of settings where these built-in features can be enabled and adjusted to the user’s preference.13
These built-in accessibility features are often intuitive and simple to use, making them a good first-line rehabilitation tool for patients. Optometrists can easily do this training as part of a basic low vision exam. Often, this is one of the first things I go over with patients when inquiring about their previous use of low vision devices. If a patient is unaware of the built-in features, I do some training during their first visit with the phone they already own.
Some of the most useful built-in features include voice-command, enlarged text, VoiceOver and a built-in zoom capability. Voice-command assistants are available on multiple platforms, most popularly Siri for iPhone. This feature allows users to vocally request for multiple tasks such as making phone calls, reading/sending text messages or making list and reminders. This common feature is invaluable to users for navigating their commonly used devices. Teaching visually impaired patients how to use this feature effectively allows for more independence and control while using technology.
Many of the devices in this genre include the ability to enlarge text, photos and images displayed on the screen through finger gestures, eliminating the need for additional devices or magnifiers for visual tasks. The VoiceOver option allows the device to verbally speak word, numbers, or icons displayed on the screen.13 Navigating the plethora of options available can be tricky and many owners of smartphones and tablets do not realize that they are available and can instantly make many daily activities easier to manage.
Along with included features, apps are another area of growth in the assistive technology space. Apps allow for personalization of a user’s smartphone or tablet to assist with daily tasks such as splitting a check at a restaurant or managing bank accounts. A currently promising and useful app is Seeing AI by Microsoft. It helps describe environments and people in the space around the user, including both indoor and outdoor spaces. Furthermore, the app reads aloud text, reads documents and handwriting, recognizes currency, recognizes people and reads barcodes for product recognition.14 This one app encompasses multifunctionality, offering the operator the capacity to move seamlessly and comfortably through environments where multiple types of visual tasking is required.
The Visor-Magnifier app essentially turns the user’s current device, (iPhone or iPad) into a portable electronic magnifier. This app in conjunction with any built-in accessibility features provides a robust experience for the visually impaired user without the cost of purchasing a new piece of equipment.15
Aira is an innovative app and service that can either be used with an existing smartphone or with Aira smart glasses. The app along with a smartphone camera allows live video stream to be sent to a real person, who can be immersed into the user’s environment in real-time to provide assistance. The service’s agents have access to maps, search engines and ride share services to facilitate the users experience.16 The app is free and many of the features may be used for free in certain locations such as drug stores, airports and federal buildings. The service is available anytime 24 hours a day/seven days a week. This service, via its app provides the ultimate in independence, safety and freedom for visually impaired individuals.
All eye care providers can overcome the challenges of visually impaired patients seeking assistance, through simple low vision intervention techniques. With the help of these quick tips and resources, most practitioners will successfully be able to implement basic, cost-effective and timely low vision strategies. With these strategies, practitioners may return functioning and hope to those experiencing vision loss.
Consider simple telescopic devices, portable electronic devices, wearables and apps as viable options for low vision patients when implementing a low vision plan of care. In addition, embrace an interdisciplinary approach—including occupational therapists, low vision therapists, orientation and mobility specialists and mental health professionals will aid in the care of the “whole” patient, which is the future of healthcare at its best. Using these tools and technologies will broaden your patient base and enhance the quality of care provided to your patients and their families.
Dr. Wright is an assistant professor at Midwestern University-Chicago College of Optometry in Downers Grove, IL, and completed her residency training in low vision rehabilitation and geriatric optometry at the VA Medical Center in Birmingham, AL. She is a fellow of the American Academy of Optometry.
1. Glaucoma Research Foundation. Glaucoma facts and stats. www.glaucoma.org/glaucoma/glaucoma-facts-and-stats.php. May 5, 2015. Accessed August 9, 2019.
2. National Eye Institute. Projections for Low Vision (2010-2030-2050). nei.nih.gov/eyedata/lowvision/tables. Accessed August 9, 2019.
3. Goldstein JE, Chun MW, Fletcher DC, et al. Visual ability of patients seeking outpatient low vision services in the United States. JAMA Ophthalmol. 2014;1232(10):1169-77.
4. Brown, J.C, et al. Characterizing functional complaints in patients seeking outpatient low-vision services in the United States. Ophthalmology. 2014;121(8):1655-62.
5. Ocutech. VES-Falcon autofocus bioptic. ocutech.com/all-products/ves-falcon-autofocusbioptic/. Accessed August 9, 2019.
6. Eschenbach. MaxTV (for distance). www.eschenbach.com/products/telescopes-galilean-maxtv.asp. Accessed August 9, 2019.
7. New England Low Vision and Blindness. Explore 5 portable electronic video magnifier. nelowvision.com/product/explore-5-handheld-electronic-magnifier/. Accessed August 9, 2019.
8. Freedom Scientific. Ruby XL HD. www.freedomscientific.com/Products/LowVision/RubyXLHD/. Accessed August 9, 2019.
9. Enhanced Vision. Pebble HD 4.3 inch. www.enhancedvision.com/low-vision-product-line/pebble-hd-hand-held-portable-electronic-magnifier.html. Accessed August 9, 2019.
10. OrCam. Life-changing device for people who are visually impaired. explore.orcam.com/en/for-people-who-are-blind-or-partially-sighted-ca/. Accessed August 9, 2019.
11. IrisVision. IrisVision product information. irisvision.com/product/. Accessed August 9, 2019.
12. Enhanced Vision. Jordy. www.enhancedvision.com/low-vision-product-line/jordy.html. Accessed August 9, 2019.
13. Irvine D, Zemke A, Pusateri G et al. Tablet and smartphone accessibility features in the low vision rehabilitation. Neuroophthalmology. 2014;38(2):53-9.
14. Microsoft. Seeing AI. www.microsoft.com/en-us/ai/seeing-ai. Accessed August 9, 2019.
15. VIsor. Magnifier app for iPhone & Android smartphones. www.visorapp.net/. Accessed
16. Aira. Using free Aira access. aira.io/free-access. Accessed August 9, 2019.