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Digital reading devices have become increasingly popular among people with low vision. Because displays come in many sizes ranging from smart watches to large desktop computer displays, it is important to have principles to guide people with low vision in selecting suitable displays for reading.The selection of effective digital displays for reading by people with low vision focuses attention on the interacting effects of print size, display size, font, visual acuity, and reading distance. This technical report aims to provide principles for identifying the minimum size of digital displays required for fluent reading by people with low vision.We emphasize two critical factors in selecting an appropriate reading display: angular print size, which should exceed the individual's critical print size, and display size, which should allow at least 13 characters to be presented on each line. Our approach considers a low-vision individual's acuity and preferences for viewing distance and fonts.Through an illustrative example, we demonstrate how our approach can be used to determine display size for a low-vision individual with 20/200 acuity and central field loss who wants to read at 30-cm viewing distance with the Times Roman font. We have developed a web application based on our recommended approach to provide easy access to our algorithm.We provide a procedure to guide the selection of appropriate displays for a wide range of acuities. Our approach can help clinicians in making recommendations for their patients, digital product designers in developing more accessible devices, and low-vision individuals in selecting digital displays for reading.

Purpose To introduce a novel technique of encircling laser prophylaxis (ora secunda cerclage Stickler syndrome, OSC/SS) to prevent rhegmatogenous retinal detachment (RRD) in Stickler syndrome eyes. Patients and Methods After first eye RRD at age 50 and at age 18, respectively, a 53-year-old father and his 22-year-old son with type 2 SS (STL2) gave informed consent and underwent OSC/SS prophylaxis, performed in each fellow eye. A 26-year-old STL2 daughter then suffered first eye retinal detachment and similarly chose fellow eye OSC/SS prophylaxis. A second son, 28 years of age with STL2, chose OSC/SS prophylaxis in both eyes. Results The three OSC/SS treated fellow eyes have gone 12 years, 11 years, and 8 years without RRD. STL1 and less common STL2 eyes are known to have a similar rate of RRD, and 80% of STL1 fellow eyes develop RRD at a median of 4 years in the absence of prophylaxis. Moreover, five of six (83%) known STL2 family members suffered RRD, only the STL2 son with bilateral OSC/SS remaining bilaterally attached. All five OSC/SS treated eyes (average 8.7 years post-prophylaxis) retained preoperative visual acuity of 20/20 to 20/30, with an average, asymptomatic reduction of meridional field in each eye to 50 degrees. In contrast, in the three eyes having suffered RRD prior to presentation, visual acuity ranged from 20/125 to 8/200 and average meridional field was 29 degrees. Conclusion Encircling grid laser (OSC) modified in Stickler eyes to encompass the ora serrata and extend posteriorly to and between the vortex vein ampullae (OSC/SS) is a reasonable RRD prophylaxis option to offer STL1 and STL2 patients as an alternative to no treatment or less effective prophylaxis. Because of rarity and severity, the ultimate proof of safety and efficacy will likely come not from randomized trials, but from a non-randomized, prospective, cohort comparison study of such individual efforts., Video abstract Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/AzHz4xYUV_w

Introduction This study was conducted to evaluate the functional performance of the BrainPort V100 device, an FDA-cleared sensory-substitution system, in persons who are profoundly blind (that is, have some or no light perception). Methods This was a prospective, single-arm, multicenter clinical investigation. Participants received 10 hours of device training and were required to use the device in their everyday environments for 1 year. Functional performance measures of object identification, orientation and mobility (O&M), and word identification were assessed at baseline, in post-device training, and at the 3-, 6-, 9-, and 12-month time points. Results Fifty-seven participants completed the study and used the device for 1 year. No device-related serious adverse events were reported, demonstrating that the risks associated with the BrainPort are minimal. Participants performed object recognition (91.2% success rate) and O&M (57.9% success rate) tasks beyond chance level. Discussion This study demonstrates that the BrainPort can be used safely and independently by persons who are blind. Participants with profound blindness can accomplish a set of tasks more successfully by using the BrainPort than without the device. Following initial training, performance on these tasks was maintained or improved over the course of 1 year. Implications for practitioners The BrainPort is a noninvasive and nonsurgical device that heightens functional independence for persons who are blind. The device presents users with more information about their environment than conventional assistive devices, and can enhance independence in performing activities of daily living.

ObjectiveThis study aimed to determine whether treatment with the 0.2 µg/day fluocinolone acetone implant (FAc; ILUVIEN, Alimera Sciences) and the associated improvements in best-corrected visual acuity (BCVA) and central subfield thickness (CST) demonstrated in the Fluocinolone Acetonide in Diabetic Macular Edema (FAME) study have an impact on the patient’s decision to drive as measured by the National Eye Institute Visual Functioning Questionnaire-25 (NEI-VFQ-25).MethodsThis was a post hoc analysis of up to 3 years of NEI-VFQ-25 data collected during the phase III FAME trial. Patients were divided into four quartiles according to baseline NEI-VFQ-25 driving subscale (DSS) score. Patients who had never driven were excluded. Patients received either the 0.2 µg/day FAc implant or sham (dummy injection). Change in the DSS score of the NEI-VFQ-25 questionnaire over 3 years in FAc-treated versus sham-treated patients was analysed by BCVA, CST and baseline DSS score.ResultsThe proportion of patients achieving BCVA≥20/40 was similar between the FAc and sham groups throughout the study, while improvements in CST were significantly greater in the quartile of FAc-treated patients with the lowest baseline DSS score (quartile 1; p=0.04). Significant improvements in DSS score were also observed in quartile 1 (p=0.024), while numerical—but not significant—improvements in DSS score were observed in the full cohort.ConclusionThis post hoc analysis demonstrates a significant association between clinical outcomes in diabetic macular oedema and improvement in quality of life measures following a single FAc implant.

Age-related maculopathy is the leading cause of vision loss among adults in developed countries, and its prevalence is expected to double over the next decade (Congdon et al., 2004; Friedman et al., 2004). The two forms of age-related maculopathy--exudative and nonexudative--are capable of affecting the macula, with potential symptoms including decreased contrast sensitivity, decreased visual acuity, abnormal adaptation to the dark, and central or pericentral scotomas (Jager, Mieler, & Miller, 2008). When a central scotoma impairs the ability of the fovea to distinguish detail, one or more preferred retinal loci (PRL) (Schuchard & Raasch, 1992; von Noorden & Mackensen, 1962; White & Bedell, 1990), also known as pseudo-foveas (Guez, Le Gargasson, Rigaudiere, & O'Regan, 1993), naturally develop at eccentric retinal locations and become the new points of fixation. The location of the PRL varies from person to person, as does the ability to maintain steady fixation with the PRL and to use it for reading and activities of daily living (Dalgleish & Naylor, 1963; Fletcher, Schuchard, & Watson, 1999; Timberlake et al., 1986; Whittaker, Budd, & Cummings, 1988). Fletcher and Schuchard (1997) reported the results of a study examining patterns of PRL ability and location relative to macular scotomas. They mapped dense scotomas and determined the location of the PRL in 1,339 eyes in 825 persons with a scanning laser ophthalmoscope during a standard low vision rehabilitation evaluation. Fletcher and Schuchard created a scoring system to measure the pursuit ability, fixation stability, and saccadic ability of the PRL. They determined the characteristics of dense scotomas within 2.5 degrees of the PRL or fovea. Of the 1,339 eyes, 84% (1,130) demonstrated an established PRL, ranging in size from 1.0 degrees to 9.0 degrees in diameter, and 82.5% had a central dense scotoma. The PRL had no dense scotomas on any border in 14.8% of the eyes. It had one, two, or three borders with a dense scotoma in 39.7%, 19.0%, and 9.0% of the eyes, respectively. Ring scotomas, bordering the PRL on four borders, were present in 17.4% of the eyes. Of the eyes with one scotomatous border, most had a field defect located either superior (39.0%) or to the right (33.7%). It was less common for the eyes to have field defects to the left or inferior, with 19.9% and 7.5% of the eyes, respectively. This report presents a 10-year comparison of these previous findings. It examines whether the PRL characteristics of persons with low vision remained steady over the ensuing decade. Changes in PRL and visual field characteristics among persons with low vision over time could have implications for the approaches of low vision rehabilitation professionals to training in eccentric viewing and other rehabilitation techniques. METHODS The study used 271 persons who were referred to the Frank Stein and Paul S. May Center for Low Vision Rehabilitation at California Pacific Medical Center (CPMC) in San Francisco between 2005 and 2007. All consecutive patients with low vision were included in the study, regardless of age, gender, race, and other demographic variables. Participants were excluded only if they lacked the cognitive or physical ability to complete a macular perimetry examination, as determined by the clinical impression of the ophthalmologist. Approval from the institutional review board was obtained from CPMC for the retrospective analyses of charts. As part of the standard low vision rehabilitation evaluation, an ophthalmologist measured visual acuity with the Early Treatment of Diabetic Retinopathy System chart (Ferris, Kassoff, Bresnick, & Bailey, 1982). The characteristics of the scotoma and PRL were measured with a Scanning Laser Ophthalmoscope (SLO; SLO-101, Rodenstock, Dusseldorf, Germany). The SLO was outfitted with a "smart microperimetry" (MacKeben & Gofen, 2007) program with a gaze-contingent display that automatically monitors eye movements, blinks, and other factors. …

PURPOSE: To assess whether age-related macular degeneration (AMD) patients are aware of binocular central visual field defects. METHODS: One hundred fifty-three consecutive AMD patients in their initial low-vision rehabilitation evaluation were immediately asked at the beginning of their visit (1) whether they were able to see any blind spots or defects in their field of vision and (2) whether they had any evidence or experiences that led them to believe that they had defects in their field of vision. They then had their vision assessed by binocular central visual field testing using the California Central Visual Field Test, binocular reading performance evaluated using the Smith-Kettlewell Reading Test (SK Read) and MN Read charts, and visual acuity measured using the ETDRS chart at 1 meter. Mean diameters of the scotomas with borders near fixation were noted. RESULTS: Visual acuity median was 20/253 (range 20/40 to hand movements). Binocular scotomas were present in 88% of patients (66% had dense scotoma). Of patients with binocular scotomas, 56% were totally unaware of their presence, even with dense scotomas measuring up to 30° in diameter; 1.5% could fleetingly see a defect in their visual field on waking; and 44% related experiences of things "disappearing" on them. The median and range of scotoma diameters for those unaware vs. those with some awareness of their scotomas were comparable. There was no significant relationship of awareness of the scotoma with age, acuity, scotoma size, density, or duration of onset. Awareness of scotoma was associated with fewer errors on the SK Read (p < 0.01). CONCLUSIONS: Low vision clinicians cannot depend on patients to report the presence of significant scotomas; thus, appropriate testing must be performed. Presence of scotomas decreased reading accuracy, but some awareness of the scotomas had a tendency to improve accuracy. The value of rehabilitation programs aimed at increasing patient awareness of their scotomas may be supported by this evidence.

Demographic projections indicate that the population of the Western world is aging, and evidence suggests an increase in the incidence of conditions, such as age-related macular degeneration (AMD), that produce visual impairments and result in low vision (Maberley et al., 2006). It is expected that in the United States and Canada, the annual number of new cases of visual impairment will double that of the current rate by 2025 (Massof, 2002). In light of these expected demographic changes and the expected increase in the demand for services, it is critical to assess low vision rehabilitation outcomes for interventions on various tasks that are commonly performed in activities of daily living. Data in this regard have been incomplete and sketchy. Low vision rehabilitation interventions include prescription and training in the use of low vision devices, such as magnifiers, telescopes, selective transmission lenses, electronic devices, and computers; training in skills, such as reading, writing, driving, orientation and mobility, and other activities of daily living; and counseling and social support (Markowitz, 2006). In addition, one can analyze the impact of low vision rehabilitation interventions on selected tasks that are widely performed by people with low vision. Reading labels on prescription medicine bottles is an everyday task that virtually all persons attempt to perform accurately. There have been no reports in the literature on the impact of low vision rehabilitation interventions on this specific task. Thus, the purpose of this study was to assess the impact of low vision rehabilitation interventions on the ability of individuals with low vision to read standard labels on medication packages. METHODS The study was designed as a prospective nonrandomized interventional case series. Patients were recruited from the clinical offices of some of the authors who provide low vision rehabilitation services. All the patients who were considered for the study received routine complete low vision assessments and were prescribed low vision interventions. Criteria for inclusion in the study were a confirmed diagnosis of low vision that is not amenable to any further medical or surgical treatments and no history of a neurological disease or cognitive impairment. Only patients who were prescribed and received low vision rehabilitation interventions were included in the study. Data were collected on the patients' demographic characteristics, diagnosis of low vision, ocular and medical histories, and details on the low vision rehabilitation interventions that were prescribed and implemented. The study protocol included assessments of the patients' distance best-corrected visual acuities using ETDRS charts (Ferris, Kassoff, Bresnick, & Bailey, 1982). A low vision rehabilitation intervention was counted as such if a device (magnifiers of any kind, reading glasses of any power, and any kind of electronic magnification) was prescribed and was used by the patient for self-help with the study task. Nonvisual techniques for identifying medication were not included in the study. The outcome measure was the ability to read unfamiliar standard labels on prescription medication bottles. Assessments of the use of prescribed medications and of sample medication bottles with standard labels that the patients had not previously used were performed during the initial low vision rehabilitation evaluation and before any devices were prescribed. Sample medication bottles with standard labels were used during testing when the patients' own medication bottles were not available. The patients were asked about the medications they take, the frequency and number of medications that they need to take, and the devices they use to identify the medications, if any. They were allowed to use their own reading devices, if any, for the initial evaluation. Additional sessions before discharge from the study were dedicated to dispensing devices and providing vision rehabilitation training. …

Accumulating evidence indicates that there is considerable variation in the ways persons with visual impairments react and adapt in the wake of vision loss (e.g., Brennan, 2002; Dreer, Elliott, Fletcher, & Swanson, 2005; Schilling & Wahl, 2006; Teitelbaum & Copolillo, 2005). For example, it has been argued that a major loss does not necessarily lead to depression or distress for some (Kleinschmidt, 1999) and yet for others, persistent depression may continue for longer than normally expected (Ciechanowski, Katon, & Russo, 2000). Additional support for the influential role of intrapersonal factors underlying depression associated with vision impairment has also been demonstrated (Tolman, Hill, Kleinschmidt, & Gregg, 2005). In an effort to find explanations for the wide variations in reactions related to adjustment to disability, contemporary models of adjustment and coping have been informative (Dodds, Ferguson, Ng, Flannigan, Hawes, & Yates, 1994; Hayeems, Gellar, Finkelstein, & Faden, 2005). One of the most widely accepted models, the transactional model of stress appraisal and coping, posits that cognitive appraisals of a stressor and coping strategies are important factors that can have an influence on adaptation outcomes (Lazarus & DeLongis, 1983). Individuals presumably appraise a stressful situation for threats to their well-being (primary appraisal) and to assess if their behavior can have an impact on the stressor (secondary appraisal). Thus, the central feature of this model is the subjective, cognitive appraisal of the situation-specific event (rather than an objectively defined stressor, i.e. severity of vision loss) and one’s coping ability; both of which are considered critical to successfully managing a stressful situation (Folkman & Lazarus, 1985; Oliver & Brough, 2002). Thus, from this viewpoint, stress is the culmination of the dynamic interplay between the individual and the environment. Converging evidence indicates that phenomenological appraisals of stress, personal resources, and subjective meaning are predictive of personal adjustment following chronic disease and disability (Elliott & Harkins, 1991; Elliott & Harkins, 1992; Elliott, Kurylo, & Rivera, 2002; Harkins, Elliott, & Wan, 2006). Generally, this work has examined appraisal processes relevant to various health conditions that yield considerable information beyond the concepts of primary and secondary appraisals (Ptacek & Pierce, 2003). Chronic health conditions can disrupt self-regulatory behavior and outcome expectancies, and these disruptions can trigger a variety of affective responses (Orbell, Hagger, Val Brown, & Tidy, 2004; Williamson, 1998). These key findings are consistent with investigations into goal-directed routine behavior that is interrupted or nonrewarded for overlearned responses (Averill, 1982, 1983; Berkowitz, 1989) based on the notion that individuals utilize cognitive schema comprised of expected behaviors, goals, rewards, and reinforcers in ongoing interactions with the environment. Therefore, when events occur that are incongruent with these expectations, a person will automatically appraise the degree to which the event interferes with goal-directed behaviors and previously anticipated outcomes. Individuals appraise the extent to which specific health conditions may interfere with their expected behaviors and goal-directed pursuits. They then appraise the degree to which they may be able to tolerate disruption to expected behaviors and goal-directed pursuits (Elliott & Harkins, 1992; Harkins et al., 2006). Individuals differ, however, in their perceived ability to tolerate disruptions to expected behaviors and goal-directed pursuits imposed by the stress between their personal needs and environmental reinforcers (Dawis & Lofquist, 1984). This may involve efforts to exert control over internal emotional states upon realizing that behavioral control over specific events or symptoms may not be possible (Heckenhausen & Schulz, 1995). Cognitive appraisals have substantial effects on emotional distress associated with a chronic disease, and this association can be stronger than the effects on distress attributable to disease symptom severity (Harkins et al., 2006). However, we do not know the degree to which these cognitive appraisals predict functional disability, as assessed on self-report measures frequently used in clinical research protocols. It is possible that these reports may be directly influenced by the degree to which sight loss interferes with goal-directed pursuits (i.e., interference appraisals), as one’s appraisals may be based in part on the disruptions in daily activities that an individual experiences from the condition. We do not know if the relation of interference to vision related self-reported disability would remain significant once objective-indicators of symptom severity are taken into account. It is also possible that the degree to which an individual can tolerant these disruptions may contribute to the prediction of vision related disability, independent of the variance attributable to perceived interference (e.g., Harkins et al., 2006). The application of these concepts related to the transactional model of adjustment have recently gained increasing attention in the vision literature (Boerner, Reinhardt, & Horowitz, 2000; Jackson & Taylor, 2000; Ringering & Amaral, 2000). However, in comparison to studies examining coping responses (i.e., Boerner, 2004; Brennan, Horowitz, Reinhardt, Cimarolli, Benn, & Leonard, 2001; Ryan, Anas, Beamer, & Bajorek, 2003), only a few empirical investigations of a person’s appraisal of the condition of vision loss or its concomitants have been documented in the vision literature. For instance, Rovner and Casten (2002) found that the relationship between visual acuity and depression is mediated by the loss of valued, discretionary activities. From our perspective, personal reactions are directly determined by the degree to which vision loss interferes with desired pursuits, and with the degree to which an individual can tolerate these disruptions (Harkins et al., 2006). In the current study, we were interested in further examining the relation of appraisal processes and an objective indicator of symptom severity (i.e., visual acuity) to both vision related self-reported disability and emotional distress reported by persons presenting to low vision rehabilitation services. A significant minority of persons with vision loss experience problems with depression and distress (Casten, Rovner, & Edmonds, 2002; Horowitz & Reinhardt, 2000; Scott, Schein, Feuer, Folstein, & Bandeen-Roche, 2001), and distress is associated with impaired activities of daily living (Heyl & Wahl, 2001; Ryan et al., 2003). We argue that emotional distress associated with vision loss is directly influenced by cognitive appraisals of the loss. In contrast to other studies that have relied upon self-reported measures of the stress, we used an objective index to quantify actual dysfunction (e.g., visual acuity). We hypothesized that reports of greater interference from changes in vision on expected behavior would be significantly predictive of greater emotional distress and vision related self-reported disability, above and beyond objective indicators of vision impairment (e.g., visual acuity). We predicted that distress associated with vision loss would be determined more by subjective, cognitive appraisals than by objective visual impairment severity. Based on previous research (Harkins et al., 2006), we expected that greater tolerance would contribute to the prediction of lower distress; however, we were uncertain if tolerance would be associated with self-reported disability.

A limiting factor in reading with low vision can be visual acuity that is routinely tested by the MNread test.1 Loss of the central field and interference by a central scotoma can further impair word recognition and localization of the following line. The goal of this work was to evaluate the use of the SKread test in exposing vision problems that may impair reading. The test requires recognition of printed words but does not allow prediction of the next word or letter. The concept is similar to the existing Pepper test2 but in a format designed for straightforward analysis in the clinic, as exemplified by MNread. The resulting SKread test minimizes the influence of linguistics, reading experience, and education level on test outcome. Background Printed words as test material have been common in vision care for at least 150 years because of the importance of reading in cultural and educational contexts.3–6 Two aspects of vision are most frequently tested6: reading acuity and critical print size and reading performance, that is, speed and accuracy The former stresses the point that reading depends on physical dimensions, for example, letter size and contrast.7 In countries with a predominantly English-speaking population, the standard tools are the MNread test charts.1 The latter aspect stresses the fact that reading also depends on cognitive, educational, and linguistic components.2,8 The two most important elements of the linguistics of reading are syntax and semantics.9 Both can transform a random string of words into continuous text, which increases reading speed and fluency by making contextual and lexical inference possible. Thus, they allow associating a probability with each word that determines the likelihood that a certain word may follow.10–13 The ability to use this prediction determines reading speed and is the basis of the difference between fluent and nonfluent reading. Theoretical Considerations If a sequence of words loses the syntactic and semantic coherence, reading becomes more difficult and slows down.14,15 In the simplest case, reading can be performed letter-by-letter, which is very slow because only one letter is recognized at a time. Examples are children who just start to learn how to read or patients with a ring scotoma and a small central seeing island.15,16 Recognizing a group of letters as a word presents an advantage. Consequently, reading word-by-word is faster because it allows a limited degree of prediction of upcoming words. For instance, the ascenders or descenders of letters in an upcoming word can function as guides for rapid recognition of a word shape, as in “reap” vs. “read.” There is evidence that word recognition involves visual cortex that is also sensitive to other shapes as well as colors and faces.17 A further mechanism can contribute to predictions of longer words where recognizing a few letters in the beginning may reduce the range of possibilities to just a few words by lexical inference.10,13,18 The fastest reading speed can be achieved with the highest degree of prediction by using the relationships between words (linguistic inference). This does not even require precise recognition of an upcoming word. Consider the common phrase “for all intents and purposes,” where “purposes” is very predictable once the first three words are recognized. In contrast, the phrase “for all intents and programs” is highly unlikely. Interactions of various linguistic elements are so complex that reading has been used to estimate levels of intelligence.19 There is evidence that prediction of upcoming words during reading is used to determine the landing positions of reading eye movements.20 In real-life horizontal reading, upcoming words are visible as long as a horizontal “perceptual span” of 15 to 20 letters is not obstructed.21–26 The functional importance of this span becomes evident by the poor reading performance of patients with restricted visual fields 27,28 and with central scotomata.29,30 Two established vision tests in the English language focus on the difference between reading with or without linguistic inference. The MNread test uses simple sentences with intact grammar and meaning. Each is composed of 60 letters, including spaces, that are printed on three lines.1 The standardized format allows quick comparisons between reading performance of paragraphs printed in different sizes. It is the preferred instrument to determine reading speed and critical print size and is a well-used clinical tool to evaluate reading performance in low vision.31 Note that the original publication also explored using sequences of unrelated words.1 On the other hand, the Pepper Visual Skills for Reading (VSR) test uses random sequences of words and single letters in a paragraph of 13 lines, which prevents prediction of the next word based on the occurrence of the previous one.2,32 The lines are of different lengths (29 to 45 letters, including spaces). This test allows differentiating nine error types so that accurate scoring requires off-line data analysis from an audio recording. The special feature of this test is that it does not allow prediction based on linguistic inference. Its disadvantage is that the results need to be analyzed and quantified off-line, which is too time-consuming in a clinical setting. To overcome this disadvantage, we applied the proven standardized format of the MNread test to groups of unrelated words and letters, similar to the content of the VSR test to create the SKread test. The gained advantage is that, during the test, the examiner can annotate a score sheet showing the same print material as the test charts without the need for off-line data analysis. For this study, we related data from the de facto standard MNread test to those from the SKread test to investigate the following questions: In what way do the differences in test material influence reading speed and error rate? Does the presence and location of a central scotoma in patients with a maculopathy influence the characteristics of reading errors? A subset of data presented here has been previously published in conference proceedings.33–36

Purpose Examination information gained from a simple tactile analogue scale technique (10 cc syringe) of measuring psychological aspects of coping in a low vision patient population. Methods In routine low vision rehabilitation evaluations, patients were asked to estimate the impact of their vision loss on emotional factors. A 10 cc syringe was used by the patient with closed (0 cc level) indicating no problem and totally open (10 cc level) indicating greatest difficulty. Results The sample included 25 male and 29 female low vision patients. Mean scores ( x / 10) for emotional distress variables were frustration 7.4, anxiety 5.5, depression 4.8, fear 4.1, and anger 4.1. Mean scores ( x / 10) for cognitive appraisal variables were: interference 7.8 and intolerance 4.4. Younger age was associated with greater anger ( r = − 0.45, p Discussion This technique demonstrated patients to have a noteworthy amount of distress which is important clinical information in low vision rehabilitation programs. Visual acuity and demographic factors did not predict the distress. This 10 cc syringe technique is inexpensive and easy to administer. It opens a helpful dialogue that may not occur otherwise. Support Helen Keller Foundation for Research and Education

Contrast sensitivity is widely regarded as an important visual parameter. Yet, it is rarely measured in routine eye examinations, since busy practitioners do not take time for an extra test. A new test has been produced that reduces the time requirement to a minimum. An existing reading test with logarithmic progression and standardized sentence length was modified by alternating high-contrast (HC) sentences with low-contrast (LC, 10%) ones of the same size. Thus, the routine test “What is the smallest (black) line you can read?” is simply extended with the question “What is the smallest gray line you can read?” The difference (HC − LC) is immediately obvious and can be expressed as a number of lines. We found this number to be independent of visual acuity. A 2- or 3-line difference is normal (even in patients with reduced acuity); in some patients, we have observed differences up to 9 or 10 lines. The card is also a good demonstration and education tool to demonstrate the importance of contrast and the beneficial effect of illumination to patients and to family members. The cards are available in several languages.

Objective: Tested the relations of social problem-solving abilities to distress, depression, and well-being and impairment reported by persons participating in a low vision rehabilitation program. Study Design: Correlational and multiple regression analyses. Setting: Outpatient low vision rehabilitation clinic. Participants: 25 men (M 73.88 years old, SD 11.94 years) and 29 women (M 68.79 years old, SD 17.25 years) participating in a comprehensive admitting examination. Main Outcome Measures: Emotional distress specific to the condition, depressive behavior, satisfaction with life, and functional ability. Results: A negative problem orientation significantly predicted depression and emotional distress; rational problem-solving skills predicted life satisfaction. Conclusions: A negative problem orientation toward problem solving predicts poor emotional adjustment reported by persons with low vision, and proactive problem-solving skills appear to promote optimal adjustment.

OBJECTIVE: The purpose of this study was to determine if combining visual acuity (VA) and visual field (VF) measures in the manner proposed in the 1999 Guide for the Evaluation of Visual Impairment1and incorporated into the 5thEdition of AMA Guides for the Evaluation of Permanent Impairment2(Guide) would be more predictive of self-reported vision-targeted quality of life than standard vision measures of VA or VF alone. DESIGN: Visual function and quality of life (QOL) were assessed in 200 visually impaired individuals. Tests included visual acuities, visual fields, and vision specific QOL using the National Eye Institute Visual Function Questionnaire (NEI VFQ). Visual acuities and visual fields were scored in the usual manner and then rescored using methodology proposed in the Guide to derive measures of functional vision. Relationships among the visual function, functional vision and QOL outcomes variables were determined using correlation and stepwise regression analyses RESULTS: High correlations were ...

The National Eye Institute developed a visual functioning questionnaire (NEI-VFQ) designed to assess health-related quality of life of patients with visual impairments. The developers of the NEI-VFQ distributed the original 52 items into 13 different domains. The recommended method for scoring the NEI-VFQ is to linearly transform the sum of the ordinal ratings to each item within each domain to produce 13 scores. The major shortcoming of this scoring method is that sums of ordinal numbers do not necessarily generate valid measurement scales. However, Rasch models can be used to estimate interval measurement scales from ordinal responses to items. We administered 27 items from the 52-item NEI-VFQ to 341 patients with low vision. Rasch analysis was used to estimate the ‘visual ability’ required by each item for a particular response (item measures) and to estimate the ‘visual ability’ of each patient (person measures). The validity of the model was evaluated by examining the distributions of residuals for item and person measures. We observed that the 17 items we tested from the NEI-VFQ that require difficulty ratings produce a valid interval scale for low-vision patients. The estimated person measures of visual ability are linear with log MAR acuity. The ten items that require frequency or level of agreement ratings do not work together to produce a valid interval scale. Rather, these items appear to be confounded by other variables distributed in the patient sample (e.g. psychological state). The visual ability scale estimated from the 17 NEI-VFQ items is proportional to the visual ability scales estimated from two earlier studies that also elicited difficulty ratings from low-vision patients.

It is generally appreciated that patients with macular disease frequently experience reduced visual acuity. It is not as widely appreciated that they often have significant central visual field disruption, which, by itself, can cause significant problems with activities of daily living, such as reading and driving, even when they maintain good visual acuity. Few patients who are referred for low vision rehabilitation are free of scotomas in their macular area. A scanning laser ophthalmoscope (SLO) macular perimetry study involving 1,339 eyes of 825 patients with low vision showed that 90.9% of the eyes had a dense scotoma somewhere within the area of the central 20 degrees (Fletcher & Schuchard, 1997). With SLO, perimetry is performed with direct observation of stimuli falling on the retina; the central visual field can be mapped onto an image of the macula. In testing for dense scotomas, a bright stimulus is flashed onto a macular location, and the patient indicates whether he or she is able to see it. This method of testing provides a more accurate map than do other techniques. In the large population of patients with low vision in the study conducted by two of the authors of this report (Fletcher & Schuchard, 1997), the method showed considerably complex scotoma patterns. Whereas some scotomas were round and centered on the fovea, many were not. Some patients maintained fixation at the fovea but had nearby scotomas on all four sides of fixation (right, left, superior, and inferior). When all four borders of fixation were scotomatous, we classified the pattern as a ring scotoma (like looking at the world through a doughnut hole). These patients could fixate in a small central island of vision and could see in their peripheral fields but had an area of scotoma in all directions immediately around the fixation. This ring scotoma pattern occurred in 17.4% of the patients (73.5% of the patients had some other type of scotoma pattern in their central field, and 9.1% did not have any scotomas). Patients with ring scotomas often maintain relatively good visual acuity but have significant functional problems on the basis of the disruption in their central field. In this report, we describe the case of a patient with macular disease whose relatively good visual acuity was maintained but whose fixation was surrounded by a ring scotoma. The patient experienced considerable difficulty maintaining an independent lifestyle, and many of the subject's activities of daily living were disrupted. REPORT OF THE CASE A 79-year-old retired physician with age-related macular degeneration had been told that he also had cataracts. At the evaluation, he wondered if his increasing visual difficulties were related to the cataracts. He was found to have cataracts in both eyes, which were mild and not thought to be a significant contributor to his complaints. There was severe macular degeneration in the right eye with a disciform scar and overlying hemorrhage. The macular degeneration in the left eye appeared to be atrophic, with a central island of intact macular area. This patient also complained of difficulty with several activities of daily living and was appropriately referred for low vision rehabilitation in spite of his relatively good visual acuity. He had stopped driving five years earlier even though he maintained sufficiently good visual acuity and peripheral fields to pass the vision testing at the department of motor vehicles. He did not feel confident driving and was happy to let his wife do all the driving for them. He reported difficulty with reading both small and large print and in writing. He was also a golfer, and his primary difficulty with the sport was in following the ball after a tee shot. He had reported these difficulties to his ophthalmologists in the state of his summer residence and was told on several occasions that his vision tested fine and that he should not be having any problems. …

* BACKGROUND AND OBJECTIVE: Diabetic patients undergoing cataract surgery have been demonstrated to have a guarded prognosis. Small incision cataract surgery has been postulated to cause fewer complications than other techniques of cataract extraction. We looked at small incision cataract surgery to see how diabetics fared. * PATIENTS AND METHODS: One hundred fifty-four eyes of diabetic patients were evaluated preoperatively through dilated fundus examination and Snellen visual acuity. The eyes then underwent small incision cataract surgery and were followed, undergoing periodic ophthalmoscopy, Snellen visual acuity measurement and additional postoperative therapeutic and surgical intervention. * RESULTS: Final visual acuity improved by two Snellen lines or more in 61 out of 154 (40%) eyes. Final visual acuity worsened in 38 out of 154 (25%) eyes. * CONCLUSIONS: Our results are similar to those reported for extracapsular surgery and phacoemulsification, suggesting that the prognosis is guarded for diabetics, even when undergoing small incision cataract surgery. [Ophthalmic Surg Lasers 1999;30: 6-11.]

Objective To assess whether performance on the Smith–Kettlewell Reading (SKread) test is a reliable predictor of handwriting performance in patients with low vision. Design Cross-sectional study. Participants Sixty-six patients at their initial low-vision rehabilitation evaluation. Methods The patients completed all components of a routine low-vision appointment including logMAR acuity, performed the SKread test, and performed a handwriting task. Patients were timed while performing each task and their accuracy was recorded. The handwriting task was performed by having patients write 5 5-letter words into sets of boxes where each letter is separated by a box. The boxes were 15 × 15 mm, and accuracy was scored with 50 points possible from 25 letters: 1 point for each letter within the confines of a box and 1 point if the letter was legible. Correlation analysis was then performed. Results Median age of participants was 84 (range 54–97) years. Fifty-seven patients (86%) had age-related macular degeneration or some other maculopathy, whereas 9 patients (14%) had visual impairment from media opacity or neurologic impairment. Median Early Treatment Diabetic Retinopathy Study acuity was 20/133 (range 20/22 to 20/1000), and median logMAR acuity was 0.82 (range 0.04–1.70). SKread errors per block correlated with logMAR acuity ( r = 0.6), and SKread time per block correlated with logMAR acuity ( r = 0.51). SKread errors per block correlated with handwriting task time/accuracy ratio ( r = 0.61). SKread time per block correlated with handwriting task time/accuracy ratio ( r = 0.7). LogMAR acuity score correlated with handwriting task time/accuracy ratio ( r = 0.42). All p values were Conclusions SKread scores predict handwriting performance in patients with low vision better than logMAR acuity.

Purpose: The authors identified patterns in preferred retinal locus (PRL) ability and location relative to macular scotomas in a low-vision patient population. Methods: Scanning laser ophthalmoscope macular perimetry and PRL testing were performed on 825 patients with low vision. The PRL location was determined, and a PRL scoring system was devised and used to measure the pursuit ability, fixation stability, and saccadic ability of the PRL. The characteristics of dense scotomas within 2.5 degrees of the PRL were noted. Results: Eighty-four percent (1130 of 1339 eyes) of the eyes had an established PRL. Preferred retinal loci varied across the full range of ability scores and varied in size for fixation stability from 1.0° to 9.0° in diameter. There was a central dense scotoma in 82.5% of the eyes, whereas 8.4% had a paracentral dense scotoma. In 14.8% of the eyes, the PRL had no dense scotomas on any of its borders; one, two, three, or four (a ring) borders had a dense scotoma in 39.7%,19.0%, 9.0%, and 17.4% of eyes, respectively. When the PRL had only one scotomatous border, the resulting field defect was located superior in 39.0%, right in 33.7%, left in 19.9%, and inferior in 7.5% of eyes. Conclusions: The majority of patients with low vision, as many as four of five patients, have dense scotomas encumbering the PRL for visual tasks. Approximately one of six patients with low vision have the PRL completely surrounded by dense scotomas. The visual system shows a strong tendency not to place a PRL anatomically above a scotoma (field defect below fixation) and a weaker tendency not to place the PRL anatomically to the right of a scotoma (field defect to the left of fixation). Macular perimetry and PRL evaluations can provide considerable information on the functional status of the macula, which may be useful to rehabilitation professionals.

Purpose We set out to determine whether individuals with central field loss benefit from using two eyes to perform a grasping task. Specifically, we tested the hypothesis that this advantage is correlated with coarse stereopsis, in addition to binocular summation indices of visual acuity, contrast sensitivity, and binocular visual field. Methods Sixteen participants with macular degeneration and nine age-matched controls placed pegs on a pegboard, while their eye and hand movements were recorded. Importantly, the pegboard was placed near eye height, to minimize the contribution of monocular cues to peg position. All participants performed this task binocularly and monocularly. Before the experiment, we performed microperimetry to determine the profile of field loss in each eye and the locations of eccentric fixation (if applicable). In addition, we measured both acuity and contrast sensitivity monocularly and binocularly, and stereopsis by using both a RanDot test and a custom stereo test. Results Peg-placement time was significantly shorter and participants made significantly fewer errors with binocular than with monocular viewing in both the patient and control groups. Among participants with measurable stereopsis, binocular advantage in peg-placement time was significantly correlated with stereoacuity (ρ = -0.78; P = 0.003). In patients without measurable stereopsis, the binocular advantage was related significantly to the overlap in the scotoma between the two eyes (ρ = -0.81; P = 0.032). Conclusions The high correlation between grasp performance and stereoacuity indicates that coarse stereopsis may benefit tasks of daily living for individuals with central field loss.

A detailed understanding of overall quality of vision may help primary care physicians, optometrists, and general ophthalmologists to improve the care of patients with choroidal neovascularization (CNV) resulting from age-related macular degeneration (AMD).Published literature was reviewed using Medline searches and the authors' knowledge of the field.Both visual acuity and contrast sensitivity are strongly associated with the ability to perform vision-related activities of daily living. CNV resulting from AMD often leads to scotoma, which is also strongly associated with the ability to perform everyday activities such as reading and driving. Contrast sensitivity and visual field extent may be better predictors of many abilities than visual acuity. Laser photocoagulation, verteporfin therapy, and pegaptanib sodium have been proven to reduce the risk of visual acuity loss in patients with CNV resulting from AMD. Laser photocoagulation frequently causes scotoma, but data on its effects on other aspects of overall quality of vision are scarce. Verteporfin therapy has been shown to also reduce the risk of contrast sensitivity loss and has been associated with stabilization or reduction of scotoma size. Treatment effects beyond visual acuity have not been investigated for pegaptanib. Detailed assessment of overall quality of vision also aids the design of vision rehabilitation programs tailored to the needs of individual patients.Understanding the impact of vision loss on patients with CNV resulting from AMD and assessing treatment benefits requires assessment of overall quality of vision. Primary care physicians and optometrists have an important role in ensuring that patients receive the best possible care, which can be aided by prompt referral to an ophthalmologist or retina specialist and collaboration with low-vision specialists and optometrists who together can make detailed assessments of overall quality of vision, implement appropriate treatment, and design effective rehabilitation strategies.

The goals of counseling are to comfort the patient and family, and to provide them with the information necessary to achieve informed consent and to optimally participate in treatment. Effective counseling requires accurate and compassionate communication, continuing at least until the conclusion of treatment. Comforting the patient Because the first contact occurs in the emergency setting, the physician–patient relationship does not enjoy the usual benefits of an orderly, planned encounter. The patient may be anxious, frightened, confused, and in pain. Due to the stress associated with an unexpected injury, it is especially important for the ophthalmologist to communicate calmness and seriousness of purpose. Careless words or gestures may quickly handicap this delicate and beginning relationship. Since suffering patients are difficult to counsel, the pain of the injured eye should be alleviated immediately, if possible. The patient will then be more able to participate in critical decision-making.

IMPORTANCE: Most patients with low vision are elderly and have functional limitations from other health problems that could add to the functional limitations caused by their visual impairments. OBJECTIVE: To identify factors that contribute to visual ability measures in patients who present for outpatient low vision rehabilitation (LVR) services. DESIGN, SETTING, AND PARTICIPANTS: As part of a prospective, observational study of new patients seeking outpatient LVR, 779 patients from 28 clinical centers in the United States were enrolled in the Low Vision Rehabilitation Outcomes Study (LVROS) from April 25, 2008, through May 2, 2011. The Activity Inventory (AI), an adaptive visual function questionnaire, was administered to measure overall visual ability and visual ability in 4 functional domains (reading, mobility, visual motor function, and visual information processing) at baseline before LVR. The Geriatric Depression Scale, Telephone Interview for Cognitive Status, and Medical Outcomes Study 36-Item Short-Form Health Survey physical functioning questionnaires were also administered to measure patients’ psychological, cognitive, and physical health states, respectively. MAIN OUTCOMES AND MEASURES: Predictors of visual ability and functional domains as measured by the AI. RESULTS: Among the 779 patients in the LVROS sample, the mean age was 76.4 years, 33% were male, and the median logMAR visual acuity score was 0.60 (0.40–0.90 interquartile range). Correlations were observed between logMAR visual acuity and baseline visual ability overall (r = −0.42) and for all functional domains. Visual acuity was the strongest predictor of visual ability (P < .001) and reading ability (P < .001) and had a significant independent effect on the other functional domains. Physical ability was independently associated with (P < .001) overall visual ability as well as mobility and visual motor function. Depression had a consistent independent effect (P < .001) on overall visual ability and on all functional domains, whereas cognition had an effect on only reading and mobility (P < .001). CONCLUSIONS AND RELEVANCE: Visual ability is a multidimensional construct, with visual acuity, depression, physical ability, and cognition explaining more than one-third of the variance in visual ability as measured by the AI. The significant contributions of the nonvisual factors to visual ability measures and the rehabilitation potential (ie, ceiling) effects they may impose on LVR are important considerations when measuring baseline visual ability and ultimately LVR outcomes in ongoing clinical research.

Over the past two decades, more than a dozen visual function questionnaires have been offered as instruments to measure the impact of visual impairment on a person’s ability to perform common daily activities.

Reading performance is becoming a de facto standard for assessment of functional vision especially with respect to low vision function. This emphasis on reading performance has encouraged the development of new tests of reading vision such as the MNREAD Acuity Chart, Pepper Test, and Morgan Test. MNREAD Acuity Charts were designed so they can be used to quantify reading speed across a range of sentence character sizes in patients with normal and low vision. Previous studies have found that MNREAD measures of reading acuity, critical print size, and maximum reading speed are very useful indices for characterizing reading abilities in patients with low vision (Bane, Fish et al. 1996; Mansfield, Legge et al. 1996). However, the results of the MNREAD Acuity Chart can give the complete functional relationship between reading speed and character sizes. Clinically we have found that there is considerable differences in the rise (or slope) of the function from no reading ability to maximum reading ability. In addition, the length of the maximum reading speed plateau and whether the reading speed decreases at larger character sizes also has considerable variability. The significance of these characteristics of the reading speed curve to reading training has not been thoroughly investigated, but intuitively these characteristics would have significance in reading training. For example, the amount of magnification that is prescribed for reading would be more or less critical depending on the slope of the reading speed curve and the length of the maximum reading speed plateau. Also, if visual factors influence the reading speed curve than it might be possible to design rehabilitation training protocols to improve reading performance. The relationship between the reading speed across character sizes curve and visual function were examined to establish which visual factors influence the characteristics of the reading speed curve.

PURPOSE Submacular surgery for choroidal neovascularization (CNV) is under investigation in the treatment of age-related macular degeneration (AMD) and the presumed ocular histoplasmosis syndrome. Four case studies are presented to demonstrate scanning laser ophthalmoscope (SLO) testing in the pre- and postsurgical evaluation of visual function in patients with subfoveal CNV secondary to AMD, presumed ocular histoplasmosis syndrome, and submacular hemorrhage secondary to AMD. METHODS Patients underwent a visual assessment pre- and 6 months postoperatively, consisting of low vision visual acuity measurement, SLO macular perimetry of dense and relative scotomas, and analysis of the preferred retinal locus for fixation (PRL) location and ability. RESULTS Visual acuity, dense and relative scotoma size and location, and PRL location were compared; and relationships between anatomic and functional changes were observed. Decreases in scotoma size and improvement in PRL location and ability usually corresponded with improved visual acuity. Preoperative scotoma and PRL location guided retinotomy site selection. CONCLUSION Scanning laser ophthalmoscope macular perimetry and PRL testing may be useful adjuncts in the visual assessment of submacular surgery and may advance under-standing of the effects of submacular surgery on visual function. In addition, this testing may be used to plan location of surgical interventions for macular diseases.

As the involvement of occupational therapists in the rehabilitation of people with visual impairments increases, it is important for all professionals involved to communicate clearly by using the most accurate terminology. This article suggests the most appropriate use of terms and concepts. It recommends that the distinctions between the various aspects of vision loss be recognized and that the old dichotomy of legally blind versus legally sighted be replaced by the more detailed classification of the International Classification of Diseases, 9th version, Clinical Modification (ICD-9-CM), Which recognizes multiple levels of visual performance.

PURPOSE. To introduce a novel approach to topographic function assessment in visual impairment that requires neither fixation nor reading. METHODS. One hundred thirty-five consecutive low vision patients with varying diagnoses and 30 control subjects of comparable median age participated. Performance was measured in a search task that required finding and identifying visual targets which appeared consecutively on a monitor in 32 locations of the central field of gaze. The task specifically discourages steady fixation and the subjects could make eye movements as needed to locate targets. Target size was always double the size threshold, and no manual action was required. The best attainable reading speed at any size was routinely measured (MNread). Main outcome measure was response latency necessary to solve the task. Data were median latencies and sums of all latencies. RESULTS. Measurements yielded a wide variety of performance levels, with a factor of 14 to 16 between best and worst performers. The highest correlation existed between median response latency in the search task and best attainable reading speed. Only a weak correlation was found between performance and visual acuity. No statistically significant correlations were found with age or diagnosis. CONCLUSIONS. The “search-and-identify” paradigm and continuous text reading share an important mechanism that determines performance in both tasks. The authors hypothesize that the factor enabling patients to perform well in both paradigms is oculomotor skill and/or eye movement strategy. Results show that the search test is a useful tool for the easy assessment of impaired vision independent of language, level of literacy, and reading habits. (Invest Ophthalmol Vis Sci. 2011; 52:7603‐7609) DOI:10.1167/iovs.10-6728

A novel technique, Multiply Scattered Light Tomography (MSLT), and confocal Infrared Imaging are used to provide diagnostic information using a comfortable, rapid, and noninvasive method. We investigated these techniques in detecting neovascularization in age-related macular degeneration. The MSLT used a Vertical Cavity Surface Emitting Laser (VCSEL) at 850 nm, while the confocal imaging technique used either the VCSEL or a 790 nm laser diode. Both were implemented into the topographical scanning system (TopSS, Laser Diagnostic Technologies, Inc.) Confocal imaging with both lasers provided different information about neovascularization as a function of focal plane, and different also from MSLT.

Retinal imaging may seem a simple endeavor, given that the eye is far more transparent and accessible than internal organs such as the heart. Optical imaging techniques allow high resolution, with measurements of living tissues reported in microns, in comparison to magnetic resonance imaging. Most retinal imaging techniques are less invasive than endoscopy. There is a long-standing acceptance of retinal imaging as an important set of techniques in research and medicine.(c) 2000 Optical Society of America.

As The Aging Eye and Low Vision points out, any physician caring for the geriatric population will encounter patients with reduced vision. The growing senior population with permanent visual impairment faces many lifestyle disruptions that can successfully be addressed by rehabilitation efforts; all physicians need to be aware of this rehabilitation potential. This book is appropriately titled "A Study Guide for Physicians," which includes ophthalmologists as well as primary care physicians, internists, physiatrists, psychiatrists, and others. It is neither too complex for the non—eye care physician nor too basic for ophthalmologists. This short, 64-page book is filled with pearls of valuable information on the implications of vision loss and appropriate adaptations. The complex interaction of eye function with hearing, neurological capacity, emotional status, physical impairments, and activities of daily living is highlighted and the need for all caregivers with various expertise to work together as a rehabilitation team is emphasized.

Coping With Low Vision is one of a series of books addressing health-related challenges that aging individuals face. Other books in the series consider hearing loss; depression; sexual dysfunction; immobility; intellectual, language, speech, and swallowing impairments; and death and dying. Visual impairment is an appropriate topic for this series as it is one of the most frequent problems that disrupts daily living activities in the aging population. This book is primarily for those who are attempting to deal with the lifestyle changes caused by a permanent reduction in vision. Its message is that adaptations and training can reduce the impact of the impairment, and it attempts to tell readers how to be advocates for their own rehabilitation. The rehabilitation services the authors recommend are outside the health care system—no mention is made of rehabilitation services available within medicine. In addition, there is no discussion of the interaction between vision loss