A Brief Overview

Historically the cornerstone of optical low vision prescriptions, any lens type or power that can be found in other devices, can be mounted in an eyeglass frame, though you might not like the resultant compromises in ergonomics. These glasses range from slightly stronger than usual reading glasses and bifocals (for patients with relatively good vision), to extremely strong lenses or lens systems that require extremely close working distances.

The principle patient objection to strong prescriptions is the close working distance is required. This is often more of a psychological barrier than a physical one, although there is some initial arm discomfort when working at distances closer than about four inches.

Research has shown that a well adapted patient will read faster with spectacles than with any other optical magnification device. In fact, the only devices that can yield faster reading speeds are video and computer based devices costing at least ten to twenty times as much. As glasses.

Hand Magnifiers

Hand magnifiers are the most familiar of Low Vision Optical devices. They are available in powers ranging from 1X to 20X. These are NOT the lenses you will find in your local hobby shop or dime store. The stronger powers should be made in aspheric curves or even doublets to reduce distortion. The biggest patient complaint about hand magnifiers is that they become smaller as they become stronger. a limitation based upon optics.

Limitations of Magnifiers:

I wish I had a dollar for every time someone said that the 5X magnifier I just prescribed would be perfect if only it covered the area of an entire page! It cannot be done with Optics!

I almost daily find myself explaining to patients why a particular magnifier costs $50 to $300 dollars when the ones their cousin purchased in a store was only $4.00!

Quality optics are expensive. The higher cost magnifiers we prescribe are made up of computer designed ASPHERIC curves to minimize distortion. That said, there are a couple of levels of quality that we offer our patients. The truth is that some patients cannot see the quality differences, and therefore should not pay for the highest quality magnifiers.

Stand Magnifiers

Stand magnifiers are the easiest to use Optical devices. You do not have to focus them as they sit ON the page. They are available with and without built-in LED illumination systems.

While these devices are often the easiest to use, they are also optically complicated to prescribe. Because the height the lens is mounted varies widely, relative to the lens’ focal length, some of these may produce unclear images when used with distance or reading prescriptions that do not match the design of the lens. Proper prescribing or Stand magnifiers requires not only knowledge of each particular lens’s idiosyncrasies, but a thorough knowledge of the patients prescription glasses as well.

Just as with Hand Magnifiers, the most common patient disappointment is when the size of the higher powered magnifiers shrinks.

Why not buy a magnifier from a store?

Several reasons:
1) Most stores that carry magnifiers have a small selection of hobby magnifiers in low powers. These are not suitable for most low vision patients.
2) Magnifiers are frequently mislabeled in their power –

3) Patients have unrealistic expectations of how a magnifier should work and often choose a “large” magnifier that covers more area, only to find it doesn’t magnify enough for their eyes.
4) Conversely, some patients become “magnification junkies” selecting a lens that gives a high amount of magnification, but has a smaller field of view than lens of appropriate for their eyes.

The proper lens power will allow for faster, longer, and more comfortable reading.

Whether a patient realizes it or not, a Low Vision Doctor is constantly evaluating all of these factors and how they ultimately affect reading fluency and comprehension.

Electronic Magnification

PORTABLE ELECTRONIC MAGNIFIERS

The latest and most progressive solutions in electronic magnification are seen in these devices.
They are offered in truly portable models with 3.5 to 5 inch screens and go up to “luggable” models with 7 to 13 inch screens. Cost varies with screen size, features , and quality from around $70 to $2500 dollars.

These devicees however are fast becoming the sweet spot of Low Vision.

Prices of quality optical magnifiers keep rising while technology advances have so far held the line on prices of electronics.

In addition, optical magnifiers , have one FIXED Magnification, while electronic magnifiers offer Variable magnification along with contrast enhancement, and often provide image quality that is noticeably better than the source material.

For patients that can afford these, they are now frequently the best option available.

The ability to increase magnification as one’s vision changes, may actually make these less expensive in the long run than changing optical magnifiers as the vision changes

CCTV’s

CCTV’s are LARGE Desktop Flat screen monitors coupled with a camera and special circuitry to produce real time magnification of printed materials.

Unlike a system you could create yourself with a camcorder, the circuitry helps assure higher contrast and reversed contrast of printed material.

A critical and often overlooked component of these systems is an x-y table. X-Y Tables allow for smooth movement of the pages or books under the CCTV’s Camera.

The smooth scrolling of printed material plays an important part in how many patients deal with their scotomas (blind spots) that are a result of their condition.

iPhones and iPads (and other tablets and phones)

The Apple products get top billing here because Apple has taken steps to make their products more accessible. Print on iPhones and particularly on iPads can be significantly enlarged, and contrast-enhanced.

In addition, APPS are available that convert printed materials into speech FOR FREE!

The problem is that your children, grandchildren, and friends, even if they are users of this wonderful technology, generally do not have the slightest idea of how to make the accessibility work.

A low vision provider can determine if this technology may help you, and give you information about using the accessibility functions and APPs, but ultimately you may need training of about 6 hours to learn to use these devices efficiently. A Low Vision specialist will generally know where you can get this training in your area.

Print to Speech Options:

For those patients who cannot read VISUALLY even with CCTV magnifications and letter sizes over 3 inches high, or who find reading too frustrating and slow, many options are now available that can read printed material to you.

If you fall into this category, Dr. O’Connell will discuss these options, which range from FREE (if you have a Smart Phone or Tablet – particularly one from APPLE) to around $2000.

HEAD MOUNTED VIDEO MAGNIFIERS – “Video Telescopes”

The Low Vision field has advanced markedly in the last six years. Lately, the big press has been given to HEAD Mounted systems that either Magnify or Convert text to speech like the Orcam.

There are many of these on the market and all have advantages and disadvantages. All are expensive as well. We will not get into specifics here as there are too many options and they keep changing.

Patients must first decide if they NEED their system to be head-mounted and if they can afford the head-mounted options.

For some patients an OPTICAL Telescopic system has better image quality, do not forget these.

Then WE advise that patients try out at least 3 of the available options before deciding.

The PROBLEM is that the people selling these systems frequently do NOT want you trying the competition’s device, so if you want head borne options, talk to us about how to go about testing devices, what to look for, and the advantages and disadvantages of the models you might see.

Computers

If you use a computer, ask the doctor about computer adaptations and modifications, and other state-of-the-art high-tech devices such as computer screen enlargement software, and print-to-speech software.

Computers can enable visually impaired and blind individuals to work as efficiently as fully sighted workers. Many screen adaptation systems exist that allow the screen to either be enlarged for a low vision patient or to have the contents of the screen reader in a computer-synthesized voice. Some systems combine both technologies to further enhance performance.

There are so many choices, that it can be confusing. Vendors for these systems will tout their own systems, and in fact, most are pretty good. Your Low Vision specialist can give you some unbiased guidance in this area, and then you should follow up by trying several systems from several vendors to see which fits best for you.

The Key is to KNOW YOUR NEEDS!

Employment or business needs require a computer.
Recreational Desires and personal needs may be met with a Table or Phone.
Minimal needs, particularly when you have little background computing experience, may best be service with one of the new speech only devices such as the Amazon Echo or Google Home.

Other considerations:

Other measures available include sunwear evaluations, lighting and environmental design consultations to maximize function in the patient’s real world setting, and visual therapy to enhance performance.

Lighting

Proper lighting is often crucial to optimize visual performance in patients with low vision. Most of the time, at the end of the low vision exam, we will recommend task lighting to enhance a patients ability to read printed materials. This is particularly important when the materials in question are of poor contrast, such as newsprint. We evaluate the amount of light that works best for each patient as the exam proceeds, and may further recommend a particular type of lamp. Mostly, we recommend LED reflector lamps, which concentrate the light onto the patient’s work area.

Most of the patients we see have more than one problem. For example, many of the patients with Age Related Macular Degeneration also have cataracts of varying degree. A strong level of illumination is usually required for the retinal problem, but the cataract causes glare from this higher illumination. The doctor must then consider further adaptations to allow for maximum illumination on the task while minimizing glare.

Absorptive Lenses

Many Low vision patients also suffer from glare outdoors in the sun. In severe cases, even indoor lighting may prove a problem for some patients. During the low vision exam, these problems are explored both by patient history and by observations and testing. When necessary, a trial of different absorptive lenses is done to find the best lens to reduce glare without compromising vision. While this is to some extent a trial and error process, the expertise of the doctor and his staff will assist the patient in making the correct choices. Unlike the selection of sunwear in a drugstore or optical store, our offices have not only many more colors of absorptive lenses, but we carry each of these colors in several densities as well. This is because the need for a glare protective lens of certain darkness will vary with lighting conditions.

Visual Training

Many of our patients require not only adaptive devices for their vision loss, but training in how to better use their remaining vision. The complicated term for this is Neuro-muscular re-education.

It consists of eccentric viewing training for patients with central scotomas (blind spots), scanning and localization training for patients with peripheral vision loss, eye hand coordination training for patients whose vision loss has effected this area, and often, after stroke or head trauma, specialized training for conditions known as neglect and postural or gait difficulties. All low vision evaluations look for any of these problems that often accompany vision loss, and training is provided as needed.

Other Services you might consider:

Social Services and referrals for Orientation and Mobility Training and Activities of Daily Living Programs are provided as indicated after your low vision examination.

Social Services can assist with both psychological adaptation to your vision loss, and with finding assistance for related difficulties you may be having. For example, if a patient is having housing problems, problems managing their home, problems with an employer, or problems with disability coverage, a social worker can help you navigate the bureaucratic paperwork jungle. In addition, more than a third of patients who lose vision become depressed from the loss. It is a normal reaction, but one that you can be helped to deal with. It isn’t necessary to suffer alone.

Rehabilitation Teachers

Rehabilitation Teachers help patients to adapt to difficulties in their work or daily living activities through the use of training and adaptive devices, many if not most patients with low vision can continue on their jobs, and continue to manage a home and remain independent.

Orientation and Mobility

Orientation and Mobility teachers more specifically work with any travel difficulties a low vision patient may experience. They can help if you have trouble seeing curbs or steps while walking, trouble crossing streets and seeing cars or traffic signals, or trouble finding your way around unfamiliar areas.

Often, an O&M teacher will work with a low vision patient who has had a telescope prescribed, to make sure they can use it safely and efficiently in the street environment.

Non Optical Aspects of Low Vision Care:

Other measures available include sunwear evaluations, lighting and environmental design consultations to maximize function in the patient’s real world setting, and visual therapy to enhance performance.

Who do you turn to when you have Low Vision?

The answer to this question may vary with the severity of your vision loss, and the part of the country you live in.

For those patients with Minimal vision loss, say 20/100 vision or better, you may find all the help you need with a local Optometrist who “dabbles” in Low Vision and has had minimal training in the techniques and devices available.

For patients suffering from moderate vision loss, you would be better served by a doctor who “specializes” in Low Vision. These doctors will have a wider range of optical and non optical devices to assist you, and typically see at least three low vision patients weekly. They should also have at least one CCTV in their office to demonstrate this technology.

For patients with severe vision loss, generally 20/200 or worse, or those having unusual types of vision loss such as field defects from R.P., Stroke, or glaucoma, you would be best served by someone who practices Low Vision Care on a full time, or nearly full time basis. These individuals generally have a much higher level of expertise, and a greater variety of assistive devices to help patients with very poor vision.