LOW VISION: What to do when you've been told that there is nothing that can be done.
(presentation 7-13-12 at Noah Conference by Thomas Porter OD)14-20 million Americans have low vision. Age related problems will cause this figure to almost double in the next 30 years.
1.75 to 2.2 million people have some form of albinism and experience low vision. One of the first and most important steps is to get glasses obviously. However, the next step can be harder. It is wise to seek an appointment to a Low Vision Clinic to get direct help for particular problems. These may be more difficult to find, but typically, you can ask an optometrist or ophthalmologist in your area where may be one located. Most university medical centers that have an eye department are required to have a low vision clinic associated with them so contacting the main information number for the medical center may help locate the services. (Be aware that most eye doctors don't have much expertise in low vision at all. It is a very specialized part of vision care. If there is no Low Vision Clinic around, ask about occupational therapy services in your area as some therapists specialize in low vision rehabilitation).
General points made during the presentation:
• Research shows that any vision changes below 20/20 affect the person's safety and independence and their overall functions tend to decline.
• Visual acuity of 20/50(corrected vision) generally is accepted as the level when reading and life management become more difficult.
• Typically, there is a 7 years time lapse between the diagnosis of the visual condition and a referral to a Low Vision Clinic. A lot of life occurs during that time, so the sooner a low vision referral occurs, the sooner management skills can be developed.
• Typically, it is accepted that a person needs to be able to see 7 characters at the same time in order to have a decent reading speed. If the letters need to be enlarged more than that, the reading times will be slow.
• Low vision aids purchased through the internet will vary greatly as to quality.
• If in doubt about things the person is trying to read - always remember:
BIGGER + BLACKER + BOLDER = BETTER
There are 3 things to manipulate to assist vision:
1. Contrast enhancement: contrasting colors such as a beige plate on a brown placement, etc. Driving while looking into bright sunlight is an example of contrast loss. This may manifest itself by the person seeing some things clearly and other items not.
This can be improved by:
• having the proper types of lighting (see below).
• improving the figure ground relationship (dark background with light letters) (avoiding visually busy backgrounds when trying to visualize objects - the clearer the front figure is in comparison to what is behind it helps improve the contrast).
• specially tinted lenses can enhance contrast.
Gray and green glasses lenses decrease glare and enhance comfort but also decrease contrast.
Amber and brown lenses increase contrast but don't decrease glare as well as gray and green so may not feel as comfortable.
(Overall, the presenter stated clearly that amber and brown glasses lenses and contacts are preferable for improving vision.
2. Proper level of magnification. Reading in large print or with a magnifier.
• There are 4 ways to increase magnification:
a. large print
b. change the relative distance (get closer)
c. angular/optical (glasses or magnifier)
d. electronic magnifier.
• Large print may not always be available (restaurant menu's for example) so having a pocket magnifier is a good idea.
• Placing books on a slant board brings them closer to the face.
• Ruby video magnifier is a pocket video magnifier with a folding handle and a stand. Good company/solid reputation.
3. Learning to use remaining vision more effectively. (related to all the above).
Beyond any other factors, the presenter stated that highly motivated individuals tend to do well in their lives. The people who tend to dwell on how bad things are tend to not do as well in life.
Lighting / Bulbs:
Halogen bulbs are generally considered to be the worst for causing glare. CFL and traditional incandescent bulbs cause harsh glare also with a yellowish cast. Typically you need a good balance of brightness and contrast.
Natural daylight bulbs are what are currently recommended as a balance between brightness and glare. Examples of these are Ott Lamps and Daylight Lamps. Similar bulbs are available through traditional lighting sources also.
While not discussed in-depth, mention was made of SynergEyes contacts (hybrid hard and soft lense contacts combined) and a company called Enhanced Vision Systems who has a product called Jordy which is a video magnification systems mounted on glasses.
THE IPAD AND THE K-12 STUDENT
( from the presentation listed above at the NOAH conference 7-14-12 by Joanna Graham)The use of an Ipad in school is very helpful to the student. While the school will likely acknowledge their responsibility to offer large print textbooks to the student, these textbooks are very large and bulky and can be difficult to transport between classes even in a backpack, etc. The chances of injury is higher to a student carrying such a heavy load around. Also, some students have reported difficulty in getting all their texts and belongs in their school lockers.
Most students with visual impairments also use a CCTV unit to magnify and enhance their work. It sits on top of their desk and takes up a lot of room. However, ipad technology makes the use of a CCTV unnecessary as most everything can be done on an ipad that needs to occur in school.
One of the disadvantages of a CCTV is that it is bulky and when the student begins changing classes, it is difficult to change from classroom to classroom as it typically must be transported on a cart. If the child has to do the transporting of the TV, then it prevents them from being able to socialize with the other students at class change times. It also requires several minutes to get set up in the new classroom. So if an ipad can help prevent some of these issues as it is very portable, then the child will benefit. An IPAD is also much cheaper than a CCTV set which costs $2500 to $35OO so many school systems may be willing to purchase an ipad instead for the student to use. If the school purchases the ipad, the student may have to leave it at school at night and through the summers so many families are buying their own ipads so the student has full access to the technology. (It was also noted during the session that many local Lion's clubs may be willing to buy an ipad for a student or may be willing to donate several to the school district for use by persons with visual difficulties).
A protective case is VERY important when giving an ipad to a child to help protect it from being dropped, knocked off the desk, etc. Slant boards are available to purchase to help put the pad at an angle that makes it most readable while avoiding glare from overhead lights. A stylus or a writing glove is available for writing tasks. The stylus is not expensive ($12 or so) and having extras may be a good idea. Wireless keyboards, enlarged keyboards and reverse color keyboard covers (off-white with black text) are available from Apple.
Protection from theft at school may be an issue also. Free etching is available from Apple to help identify the pads owner. There are also apps such as Find My Phone or Find My Ipad that helps pinpoint the ipads location if it has been lost or stolen. Classrooms are typically left unlocked when the students leave their rooms for library or recess, so the Ipad should be locked up somewhere. Small safes are available for around $25 from Wal-Mart that can be left at the teacher's desk or in a closet so the student can lock it up when they leave the room.
If the parent is the one with the Itunes account, then any apps purchased for the Ipad can be shared on devices associated with the account.
Ask the school for any wireless internet information. If there is a group activity to look up information/research on a computer, then sometimes the teacher is happy to have another device to be used for research projects. The student's group can share on the ipad rather than waiting for a computer. You may have to make the point to the school that if the other kids are looking up items on the internet for their class, then the visually impaired student has the right to be able to do so also so the wireless info will be necessary. Ipads can use wireless or 3G/4G but the wireless option is typically best for school.
The news and current events features are helpful for school reports, etc. If the teacher has regular magazines that will be used for research, these can be downloaded onto the Newstand feature for the student's use. If the school has a subscription to the print version, they may have access to a downloadable one also that can be used free or the school may need to opt to pay for this for the ipad.
(The policy on playing games, etc. at school should be verified to avoid any misunderstanding between the student and teacher.)
ZOOM is probably the most useful function that an ipad has for someone who is visually impaired. Any text can be zoomed (magnified) up to whatever size is needed. There are several ways to use the zoom although many just use the pinch feature like an iphone works. ($19.99 for this App)
In the Settings: General: Accessibility features, the font size can be set to a permanently enlarged size. The background color can also be changed to a black background.
There is also a Voice Over feature in the accessibility settings. However, currently Zoom and Voice Over can't be used together although this is supposed to change in the near future.
Speak Selection is a feature that lets you highlight text and then the device will read the highlighted area to you.
Ipad 3's have a mic and can take some verbal commands, much like an Iphone Siri function.
The Ipad has a place for headphones for listing to music, podcasts, videos, etc.
Calendars, Reminders, Notes features can be used for the student to record classroom assignments.
Any internet features that are needed regularly can be added to the homepage of the device by going to internet options and doing Add to home screen and it will appear as an app.
Printing from an Ipad is difficult unless you have a MAC printer. However, there are some apps in development to help with this (one is listed below). For now, it usually is easiest to email the document to someone who can then print it off.
With all of the above noted, it may be necessary for the student to have a laptop available to them. The Ipad doesn't read all textbooks well and some people find that a small laptop at school may still be necessary depending on the textbooks being utilized. If the school has purchased textbooks for the normally sighted kids, the school should approach the textbook company representative and request an electronic large print version of the textbook also. Not all but some companies give these free to the school as a service after they have purchased a certain number of hardcopy textbooks. The school may be able to push the representative some to get free large print/electronic versions in order to be able to keep the school's business.
Several people indicated that the battery will hold up for a school day without problem.
• Join Me allows the ipad to show presentations/etc from the teachers computer. Not interactive = just reads what is showing on the screen. Both need to have downloaded the app.
• Splash Top performs the same as Join Me but allows for interaction between the 2 devices.
• Notability allows writing with a finger or stylus to take notes.
• Noteshelf allows taking notes on a page that looks like a notebook.
• Italk allows recording the teacher's lecture and play back at a later time.
• Imovie lets the student make videos for projects.
• Pages functions like Microsoft word for documents.
• Keynote functions like a PowerPoint presentation function.
• ECAMM Printopia makes any printer believe it's a MAC printer. (still has some bugs apparently at this point).
• Dropbox is an app that lets the teacher share their documents/videos/photos easily with the student.
• Coursesmart is a reader that allows rental of textbooks with large print and can be used for quite a few textbooks.
• Pearson Success Net is a web based textbook service that can be very useful but doesn't always work well (textbook formatting doesn't always hold up the way it should).
• Kindle is free and is great for novel reading. The font can be made larger easily and it was indicated that the background color can be changed also.
• Nook and Nook Kids apps work much the same way as Kindle.
• Glio, E pub, Goggle books are all other book readers. (Most book readers will only show text - not illustrations. For small children - having a hardback book to look at the illustrations simultaneously may be a good idea).
• Bookshare.org is an accessible online library for people who are print disabled. Gives you access to thousands of books and textbooks. If an MD will provide a letter indicating the person is "print disabled" then this service is free.
• Storia/Sholastic are books that many schools utilized - the company will provide E versions of their books if the school requests them.
• Public Library - many libraries have apps available for free lending.
• Dictionary app - several types exist at differing levels of cost. An app that will verbally read the word is a good idea.
• Alphabet apps will be good for younger students who are learning to read. One that will verbally say the alphabet and words are important.
• 1000 sight words is also a good idea for younger kids.
• Telling Time or Interactive Telling Time is helpful when learning this skill.
• US Map is a good app for learning geography and state capitols.
• Periodic Table will help older students in chemistry.
• Math Practice apps may assist with math learning.
• Handbooks for group activities such as Boy Scouts and Girl Scouts are available for downloading onto an ipad.
• Instructions for many toys/puzzles/games (Lego's for example) are available for download to an ipad.
• Music Zoom - this is an app that is not out yet but is under development. Someone that attended this session announced that he is developing this app for learning to play musical instruments with a visual impairment.