Proceedings of: Workshop on Improving Building Design for Persons with Low Vision

Introduction

Well, I work at world-famous Mayo Clinic up in Minnesota. And, this is the main outpatient building [slide not included]. I work at the building on the right, that’s the Mayo building. And while most people think of Rochester, Minnesota as “the frozen tundra” – and it does look like that sometimes in the middle of winter, right now it looks kind of like this, so, [you may] want to get out of the hustle and bustle of the East Coast here and come out to wide-open Minnesota.

Some of the things that we want to talk about today relate to contrast, plus – (slide 1) and I’m glad you caught the irony of this, because you’ve all probably been in meetings where somebody kind of didn’t get the idea of how colors clash, and what makes it easy to see. You certainly don’t want to put bright red on bright blue. This is a little bit better, but because of this kind of fuzzy background, it’s a little – a little difficult to see (slide 2). And you might also think that, you know, if you want good contrast, you’d want pure black on pure white (slide 3). But even that’s not the easiest thing either because you get all this glare back again. So whenever I do my presentations I like to use something with a darker background, something with a lighter foreground, or with the letters, and so forth, and go from there (slide 4). And I won’t bore you on fonts and things, although that may be a discussion for another day. 

Definitions

Bob already talked about the definitions of low vision (slides 5 and 6), and I understand from Stephanie that you’re all going to get either a CD or an access to a website for all of this stuff. So if you ever want to refer back to this again, you can always look it up again.

Visual Acuity

But the whole point, as Bob mentioned, was: what is visual acuity? It’s really how big a letter you can see at what particular distance (slide 7). And the other thing that you want to remember is that if you come – if you start at one distance, you sit twice as close, it makes it twice as big (slide 8). If you ever – you know, if you wonder why your kids and grandkids sit close to the TV, it’s because if they get twice as close, it makes it twice as big. So that’s really the thing.

The challenge is, of course, you can’t always move closer to this. It’s easy to make things bigger when you – when you either sit closer, walk closer, drive closer, or bring the newspaper closer to you if you’re trying to read. But it becomes more difficult if you’re not able to do that. And part of what we do in low vision is to bring those virtual images closer to our patients. We’ll talk about devices here in a minute. Again, this is just – you know, I wasn’t sure what Bob was going to present, so I threw a slide up here about what visual acuity really means (slide 9). It’s the definition of the resolution of the eye. It really doesn’t tell us anything about how well they function. So let’s go through all of this. 

Visual Field

Now, let’s talk a little bit about visual field. We kind of danced around that a little bit. And, technically, it’s the sensitivity of the vision throughout the field of view; throughout all of this area out here (slide 10). And I think most of you know intuitively that you see very sharply in the center of your vision, but when you get out in the periphery, you don’t see things quite so sharply.

So someone with macular degeneration, where they’ve lost their central vision, well, you know, they can see, they can move around – they actually function very well in mobility situations, but they can’t see the regular-sized print. On the flip side, if you get somebody with retinitis pigmentosa, where they’ve lost all their peripheral vision, they might be able to read – although there are areas that they haven’t been able to [discern] medium or small – but just have them walk across the room, or try and negotiate a room like this, they’d be bumping into things just walking around this room. So you kind of get an idea of what someone with a peripheral vision loss would have. 

So technically, that’s what we’re talking about here. And we measure that by how large and bright the stimulus can be. Now, Fred made a good comment about driving, because when we talk about vision impairment in driving – it’s a little off the subject, but when we talk about vision impairment in driving, when you go to the DMV and have your vision measured, they measure two things: They measure how big a letter you can see at a certain distance – that’s visual acuity; and they measure your peripheral vision, which is visual field.

Neither one of them are good predictors of whether you’re going to have a crash or not; visual acuity, several studies have noted, has no relation to whether you’re going to have a crash or not. So these are just good examples. And if you want to take what we would consider a very visual task, like driving a car, and apply these measures – a visual field, a visual acuity – very poor predictors. So if it’s bad for that, you can imagine that it’s bad for all the other tests that we’re trying to describe.

This is just a diagram of what we’re talking about. You know, normally sighted individuals can get about 70-to-80 degrees temporally, and about 50-to-60 degrees nasally in each eye (slide 11). When you add the two together, you end up with about 140, 150 degrees all together. And the same thing applies, superior – you know, you get so much superior, so much inferior (slide 12). And why is it more down below? Well, just take a look at your eyes. You’ve got larger brows through that evolutionary process, and you’ve got more space down below. So that’s what visual acuity is. We’ve talked about legal blindness (slide 13).

We’ll touch just a little bit on contrast here too: it is your ability to see, distinguish those shapes and objects from a background (slide 14). I describe this a little bit different. If you have a perfect – 100 percent, 1.0 perfect contrast, the best example of that would be pure black next to pure white; no contrast, the two are exactly the same. It’s all black; it’s white; it’s all gray; it’s all the same, so there’s no difference between the two. And this is just a slide that shows the difference there (slide 15). And you’ve probably been in presentations where the PowerPoint slides look like this too.

Low Vision Rehabilitation

Now, what do we really do at low vision? And it’s so nice when I get together. Now, Suleiman and I probably have met once or twice, but we have the same concept here. What do we really do with low vision (slide 16)? Well, we make it bigger. When somebody comes in and they want to be able to read better, the first thing we do is make things bigger, because it’s easier to see that way. We fiddle around with the illumination and the contrast by adding direct light. I mean, we’ve been talking a lot about overhead lighting, and glare coming at you. but when it’s time to read the newspaper, probably the most important thing that we can do for our patients is to add some direct light right on the newspaper. Most of you probably understand that today newspapers use lots of recycled paper, which isn’t as light, and they use soy-based ink, which isn’t as black. So therefore, the contrast between the background, the newsprint and the print is [not so] hot.

Now, Bob made a comment about what happens when you add that light on there. Well, it’s true that we aren’t actually enhancing the contrast, but the sensitivity of the individual to those contrasting images is improving, because the newsprint is going to reflect more of the light than what the black print is, and therefore it’s going to be a little easier for the individual to see.

So what do we do? We’ve – and I mentioned that, in terms of magnification, twice as close is twice as big. I think most of you in lighting understand the concept of the inverse square law, where if you bring that source places close, it’s going to make it four times square.. So for my patients, I’m going to make sure they’ve got that light nice and close, because it’s going to make t [sic] difference. 

We also train those individuals. I can give them a magnifier; I can give them a device; but if they aren’t trained to use it properly, they’re not going to do very well with it. So what we really engage in is a rehabilitative process. It’s not just, what kind of toys do you have; can I get a magnifier; can I get those glasses stronger? Well, yeah, you can, but we need to make sure that, when you get it home, you’re actually going to be able to use it for the task intended. And because of that, we also add things like using peripheral vision. If the central vision is gone, we need to train the individual to use more peripheral vision, or vice versa.

There was a comment made about increasing depression. We often engage with social and psychological services. I have a social worker who is designated for my service, and I try and get all my new patients, just to have them sit down in a chat with the social worker to find out what life is like, how things are going. I’m not a psychologist, and I rely on other professionals to give me some feedback, because if we don’t deal with some of these social services, psychological issues, nothing I do in the exam room is going to make any difference, because they’re still going to be depressed and they’re not going to want to be rehabilitated.

And finally, we use rehabilitation services. We use teachers of the visually impaired [or] rehab counselors; we use state services for the blind, we use occupational therapy, and a variety of other rehab services, because, really this is a total process, in terms of what we do. I’ll just skip over some of these slides because we’ve covered all of them already (slides 17 – 19).

Low Vision Patient Requests

What does a typical low-vision patient ask for (slide 20)? Number one on the list has got to be reading. I mean, almost everybody, even young, old, you know, the issue is reading, because we have a very visually-oriented society, whether it’s print, computer – computers are becoming more of a problem. Getting a driver’s license – in our society, they need public transportation. It’s better here on the East Coast, but when you get to Minnesota, if you don’t have a driver’s license, you know, you don’t get anywhere. And Rochester, Minnesota is actually, for a town its size – 100,000, has a very good public transportation system, but it gets you downtown; it doesn’t get you to the grocery store. And that doesn’t even talk about, can you see the bus sign; can you see which bus is coming? It helps you get on the right bus, and so forth.

Continuing independent living: We heard comments already that it’s certainly a benefit for the patient, as well as society, to keep people in their own homes. I’ve often told my patients, you’re not going to have to leave your home because of your eyes. If you follow our techniques; if you get the devices that you need; if you get the training – not just from us, but from other sources, you’re going to be able to live independently.

Now, you may fall and break your hip, or you may have some other medical issues that will take you out of your home, but you’re not going to have to leave because of your eyes. And that alone just takes a huge weight off their mind. It’s like, oh, really? There is something there? Yes, there is. But bear with me; it’s not – it may not be quite as simple as you might think.

To get and keep a job, we’re going to talk a little bit about environments for a workspace; improve independent mobility – we talked a lot about that so far. My questions of my patients are, what do you want to be able to do that you can’t do because of your eyes? That’s the question you ask. And it’s not just to see better. Okay, fine, sure, I want to see better too. You know, I’d to be able to read without my progressive lenses. But what – and be specific: Is it reading? Is there a specific task? Do you want to play softball again? I mean, what is it that you want to be able to do? You know, just as an example here with reading, newsprint is 1.4 millimeters high on the average – that’s a lower-case “o”. Large print is about twice that high. And as I mentioned before, by bringing it closer makes it bigger (slide 21).

When I consult with the people in employee health at Mayo – we haven’t talked a lot about working situations here (slide 22). We’ve talked about elderly mobility, getting places, but when you talk about what some of the challenges are in the workplace, being able to read the computer screen is top on the list, because we have – we’re entirely electronic at Mayo, even medical records, billing, everything is electronic (slide 23).

I have six programs active on my screen that I use at all times. And, you know when a new program comes out, I’m immediately on the phone with systems and procedures and information technology to get them to fix it, because even I can’t see it. We have 50,000 employees at Mayo Clinic, so even if you get – even if you think of 1 percent have some type of vision challenge, that’s a lot of people who are having trouble seeing the screens. We also have glare issues. I could give you lots of examples of that: reading, and room size and lights; seeing patient’s faces; and all that sort of thing. Well, let me – we’ve talked about walls too. I had one lady who was having trouble with glare, and I said, well, we’ll just move you away from the window. And she said, I worked 15 years to get that place. 

Interaction between clinical practice and research programs

All right, we’re going to go – we’re going to go past these (slides 24 – 26), because you probably know this stuff, and we’ve talked a lot about it already. And there are lots of things that we can do. But what I’d like them to talk about a little bit here is a project that I’m not a signatory to. However, I do work with Dr. Gordon Legge up at the University of Minnesota. He’s got a very active low-vision research lab (slide 27). Gordon’s low-vision research lab is not in the ophthalmology department; it happens to be in the Department of Psychology. And Gordon and his group have provided us with – as Bob has too, I want to give Bob suitable credit here.

I’m a clinician, and for me to do some of this basic research to figure out some of those nuances of why, how vision works the way it does; why do people have challenges; what factors can we modify to make it better, comes from people like Bob and Gordon Legge. And it helps people like me, because where Suleiman and I see a patient in the office, and they have a visual challenge, the basic science researchers are the ones that tell us why, how, and give us some ideas on how we modify it. It also provides us with the ammunition, so that when go to the access board, we can cite chapter and verse, and we’ve got the research to do that. I think part of the reason why low vision hasn’t gotten the attention it deserves, is that we haven’t really done enough of this basic research. So I give – I really give Bob a lot of credit.

This group has done a lot of really cool stuff, and it’s an ongoing process, and it’s difficult to collect this data, partially because we all do things a little differently.

So I wanted to bring this up because, after I got the invite to come to this meeting, Erin and I went up to the University of Minnesota to see what they’re doing. It’s lovingly called the “DEVA project,” Designing Visually Accessible Spaces. And it’s a multi-disciplinary project through the University of Minnesota, the University of Utah and Indiana University. Somewhere along the line you’ll get a handout, or at least access to a webpage that will have the link to the project on [the] bottom of the screen. So some of these slides are right off their stuff, and I give them full credit for it (slide 28).

The goal is to provide an environment so that people can travel safely, perceive the spatial layout and key features in that environment: keep track of where you’re at (slide 29). If you ever hear the term “orientation and mobility,” orientation is where you are at any given time in space, and mobility is, how do I transverse that space without killing myself? So part of what this project is, is: Where are you? How do you get there? How do you move through that space? Ultimately, the aim is to improve accessibility. 

They really want to be able to influence designers. Unfortunately, they don’t have any designers on the team. So they were tickled pink when they heard that I was coming to this meeting. So they would really like you to access their website, and take a look at what they’re doing, and make contact with them and offer suggestions.

I’m going to kind of go through a few things here. One of the things that they’re doing is developing a model, an analytical tool (slide 30). We talk a lot about that. How do you translate what’s going on in the clinic, at a very natural setting, into a research design with backing? And what you have here is – in these two images, on the left side, you have the actual luminance value that they measured in their lab work with different lighting conditions, with luminance values. On the right side is the digital rendering of the simulated lab.

Comment by Erin Schambureck: And the way you can tell that is the door on the right does not exist in the actual room. That’s the only thing that [is different].

So what they’re trying to do is develop this model so that they can change different lighting conditions, and then do some studies with actual subjects; see how well they perform; so that as spaces are designed in the future, you could use a computer model and then work backwards, and know that, that model is [reliable]. Does that make sense? Throw your two cents in here while you’re at it too. She understands this stuff.

This is a digitally rendered model of the lab that we just looked at (slide 31). That platform that was on the right side of the previous slide, basically you’d be standing on top of that. So you’re seeing the rest of the room. And they figured that he’d get within about 5 percent of the measurements in the physical space. So it’s really pretty cool how they do that.

Now, what are they going to do with this? Just as an example, they’re taking a look at how different objects look under different luminance values, different types of illumination – overhead, near the window, by the window, black backgrounds, light backgrounds (slide 32). [They] also have gone beyond this phase, to where they’ve gone to the checkerboard patterns, and lines and stuff to determine what kind of shapes, and what with visual cues an individual can use in order to navigate this better. And, again, that’s the actual set up, and hopefully they’ll be able to put this into that model so that they’ll be able to use it later for your own design purposes (slide 33).

These are just some slides of the main atrium at the Mayo Clinic, the Gonda building [slide not available]. And, you know, this is one of those spaces that’s incredibly difficult to navigate. I don’t like going up and down this thing. It makes me nervous. I can imagine what it’s like to – anyone with a vision impairment, that’s with glare coming in through the atrium. This is where a person who has poor glare recovery would be in a bright situation and then go into a dark undercroft.

But I did want to get to this last – this is the staircase again [slide not available]. And the first one was about 7:00 in the morning. This is about 10:30 in the morning with the light streaming in. It’s great, huh? Now, this is the view right outside my office (slide not available]. The building was built in 1953. For those of you who’ve been around for a while, does that look familiar? Cork floors, which I know are making a comeback. We’re going to be remodeling our floor in the coming year, and were told we’re going to keep the cork. Yet I don’t like the way it looks. However, it’s soft underneath; it’s fairly warm.

And as I look at this from a vision standpoint, because we’ve had these paneled walls to kind of give you this kind of soft, comfortable homey appearance, but this checkerboard pattern on the floor actually helps focus your attention, so you know that’s where the floor is. So you know, there may be some benefit to having designs like this that help channel our focus in the appropriate way. So anyway, that’s– that’s the end.

I do want to give some credit to my colleagues up in Minnesota low vision lab (slides 33 and 34). Interestingly enough, Rob Shakespeare, with Indiana University, is the kind of the lighting – he’s in the theater department; he’s a professor of theater; and he’s the tech guy from IU.