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

Open Discussion (Panel 1)

Issue 1: What are the effects of energy-efficient lamps and fixtures on persons with low vision

Comment and Question by [Participant]: The research that you’ve been talking about a little bit as an idea of integrated design, you mentioned LED lighting. I mean, there’s tremendous drive to reduce energy usage in building that impacts lighting because that impacts air conditioning and blah, blah, blah.

And you go to energy conferences, and a lot of times they’ll tell you, we’ve got too much light. You know, some of the buildings are so bright that you don’t need all that. Certainly, that’s probably for normal-vision people, I don’t know. But have any of these studies been trying to integrate LEDs, these T8s, and all that, which are becoming the standard, compact fluorescents, all that are being installed everywhere?

Response by Dave Munson: Those are sciences that evolve so quickly today, that by the time you write a rule for it, it doesn’t exist.

Question by [Participant]: But what impact do they have on low vision and – ?

Response by Dave Munson: Well, there’s no answer but an opposite reaction. We invented all these CFL lamps. I’ll tell you, you want to see a disaster, drop one at the Home Depot on the floor, now you’ve got a hazardous cleanup.

Comment by [Participant]: That’s not going to stop. I mean, the energy is going to be –

Response by Dave Munson: The cost of the energy to light a building, compared to all the costs of all the people in the building is pretty small.

Comment by [Participant]: It impacts air conditioning, too. All I’m saying is, that’s reality.

Comment by Dennis Siemsen: Yeah. I think what Richard’s saying is that we shouldn’t be looking at the individual light sources. We shouldn’t just, you know, worry so much about whether it’s a T8 or a T12 or an LED or a CFL.

What we should be saying is, if, for a given light source and a given surface that will be illuminated, how do the two interact? Because then, you can always work backwards and say, okay, we’ve got a new light technology, whatever the next one is going to be, and it’s a small point source, and it’s got so much spread and gives you so many candelas at this particular point. Once you know that stuff, then whatever new technology comes out you can go through.

What we don’t have, and I think what the DEVA people are trying to do, is, how does that specifically impact the individual, whether they’re normally sighted or not normally sighted? And those are things that we really ought to know. There’s not good research out there.

And [while] we’ve got low-vision researchers on the project, there isn’t a clinician in there. So –

Response by [Participant]: And there’s no electrical lighting person on there that deals with some of these other issues associated with [lighting design].

Comment by Dennis Siemsen: Yeah, so I think what it’s really going to need is a team approach. And hopefully, through the wonder of the Internet and integrated databases, if I were writing a research proposal and I go to NEI – we were talking about this at the break –and I get this right in my search and see who is doing what, who is interested in this – not what’s published because there [are] partners.

But it’s very interesting to go to the NEI or other – and I don’t know what your database is in your area. I would search on NetLine, I might go to the NEI, I might go to NIH. But I’m just stuck. Except that I’ve got a designer [in the] family, I wouldn’t know what database to search to see which one of you is interested in these topics, where I might be able to call you and say, hey, let’s collaborate.

Issue 2: What Approach is needed to develop “Guidelines”?

Comment by Jeanne Halloin: There’s another important issue here, though, and Marsha mentioned how much time that these new regulations or guidelines are put out for us to react to, and a lot of us don’t take the time. Eunice usually prods me to taking the time.

But I mean, we have a period of time that we can get in there and say why something isn’t making sense or why something is making sense. And so we do have a chance to get in and get involved [as] the guidelines become standards. And I think more of us have to take that responsibility.

Question by [Participant]: I guess one question I have, too, is, when a guideline comes out and it would appear to have some connection with vision, do you have a set of consultants that you go to and say, okay, what do you think about this? Maybe FAB is one organization [that] would be someone you would go to. But do you have a set of experts?

And again, you know, if it came to me, I’d say, fine, I’ll do the search, and I’ll do my research, and I’ll come up with this, and I can give you my two cents’ worth. But unless I can come up and cite chapter and verse in the research literature, I’m not sure it’s going to have much impact on the development of your [guideline].

Response by [Participant]: Well, that’s why some of us [who] worked on [the] documents – there are published documents that were research based – are the ones that should be getting involved in it.

Response by Marsha Mazz: We would not publish a guideline if we didn’t have some research to support that guideline. That’s cart before the horse. We have to have research that will support the claims that the guidelines make. I mean, after all, the whole intent of any of these guidelines is to provide greater accessibility. If it’s not going to achieve the intended goal, then it’s a true waste of money.

Comment by Fred Krimgold: Can I make a point before we take that next question? What worries me is, we’re going to sit here, and let’s say we do come up with some consensus and some guidelines. The other thing to keep in mind is, when you talk about lighting, for example, no two people are the same. We talk about low-vision patients; Dennis will tell you, sometimes that [he] issues a 60-watt incandescent bulb and bring it close. Sometimes it’s a big [magnifying glass] – can you see these new little lights, these LEDs? They’re bright. I take them to the restaurant all the time, they work great for me.

So I think we have to be careful that we’re not going to be able to find a blanket sort of recommendation that’s going to work in every situation, because every individual with low vision is going to be a little bit different.

Question by Marsha Mazz: And I was going to ask you that very question. When I’m asked what can you do for me, I usually say improve the lighting, the illumination, the lumens for everybody, and I’ll benefit. But that’s true for me. I don’t know if there are people who have vision loss whose needs differ greatly from the needs of the population of people who don’t have vision loss.

Response by Dennis Siemsen: They do differ. And I think with the three of you here with low vision, I think each of you would have a unique preference to type of lighting, positioning of lighting and how much glare and things you could tolerate. And I think this is why we do this on an individual basis with each patient and try to adapt the patient to the environment.

Because we’ll say, like, you produce those filters but we would certainly prescribe different types of filters for different situations to try to cope with that kind of situation.

Question by Greg Knoop: How useful is it the term low vision from the perspective of trying to modify the environment, because as you’ve said, there are very different demands. I had a discussion with the ADA people at Washington Metro. And they said, well, what’s good for some is bad for others, so we’re not going to change anything.

Response by [Participant]: That’s Metro’s answer to everything.

That’s right. But how serious is that? Does low vision identify a common set of needs to which we can respond? Or do we need to differentiate that somehow? And how do we balance this individual modification to environmental modification?

Response by Bob Massof: I think it’s very difficult. And I think we can come up with some general rules. You know, we took this inverse-square law, for example, which is a neat law because, like Dennis said, you bring the light source down twice as close; you can get four times as much light.

It may be that we have to think more in terms of, how do we individually be able to shield that light? So just like we’ve sat in this room or I sit in my car now and my wife can have a different air conditioning than I can have, even though we’re sitting in the same car. It may be that each of us sits down in a room like this, and he might say, I want to back-illuminate the system like my iPad to look at the presentation on the screen. Somebody else might say, I want it projected, but not a screen like that, a screen like this.

It may be we have to figure out, is there a way of designing lighting systems, is there a system you implement into a building, which give individuals the ability to adjust lighting, whether we adjust the height of our chair to where we’re sitting, we have to have some type of maybe lamps on the table where it’s a gooseneck and we bring it down and it has a choice of lighting perhaps –

Question by Greg Knoop: Are there useful subdivisions of the concept of low vision that are reasonably similar and consistent?

Response by Dennis Siemsen: Consistent? Boy, I think that’s something that we struggle with a lot, even within our professional organizations. We’re members of the section on low vision in the American Academy of Optometry, okay, so that means something to the doctors that are in the academy. But it doesn’t for other people, low vision could mean anything from, if I take my glasses off, I can’t see the paper, to someone who is totally blind. And we can substitute other terms like vision impairment or [disability] – severe, profound, blah, blah, blah. But again, that doesn’t help the person who only has general knowledge or no knowledge of vision loss.

Comment by Vijay Gupta: I think there are two separate issues. One is the workstation and one is the public space. I think [the] work place is very clear, all these [workstation] or other issues. Then there are the public space types of issues. I mean, we can at least modify a workstation to suit an individual, right? Whereas in a public space, we’re at the mercy of –

Comment by Dave Munson: [For a] GSA project several years ago, they put out the requirements of footcandles and ESI and VCP and all these technical terms. And then after the job was completed, they wrote a paper called “Lessons Learned.” The problem was, in order to meet the guidelines, the lights were spread so far that by the time you put the workstation in, there was no light in the workstations. So everybody added all workstation lighting. Guess what? Twice as much energy being consumed by the lighting. But if it was an overhead system, it was lighting each individual space.

Question by Jim Woods: I want to pick a little bit up on what Fred was saying and maybe twist it just a bit. Since we’ve got practitioners at the table, what would you like to see from the design profession that is going to help you the most?

Response by Dennis Siemens: I think consistency would be one thing. Because what we are faced with is, we have no clue when a patient comes and says to us, I’m having a problem getting to work because of lighting. I don’t know really what the lighting in the building is. I don’t do site visits, so I don’t know what’s sort of the minimum standard with which they’re working. I can relate to the Metro, because I take the Metro, so I definitely know what the issue is in the Metro station.

But because there is no consistency, I guess, you know, I didn’t know I’d walk into this room and there would be lights like this. How do we as practitioners – that’s why I went back to that original thing, that all we’re able to do is to try to adapt the individual to the situation. In other words, you throw the situation at us, and we’ll go, okay, yeah, what do you think?

And it’s trial and error. I wish I could say it was more scientific, but it’s not.

Question by Jim Woods: So is that what you need, then, is a scientific base from the environmental standpoint to help you make decisions?

Response by Dennis Siemsen: Some consistency. I think if we knew that all hallways have this amount of luminance and this amount of glare and this is what it would be like, then I think it’s certainly easier to work with.

Question by [Participant]: What color?

Response by [Participant]: In the Labor Department, we got sued many times, not because we didn’t have enough illumination, it’s because we didn’t have enough luminance.

That’s where [there were] dark, dark, dark, dark, dark green walls. Some of the light, we couldn’t get quite 50 footcandles in the toilet and the cost for not having open enough [lighting], because you couldn’t get an occupancy permit, gets really expensive. So it’s a total environmental issue. It’s not just lighting, it’s not just interior design, it’s a coordination of all of this. And the architects with the clear glass and the, you know – it’s a very complicated problem. There’s not just one solution.

Issue 3: Is there a need for a different kind of Practice?

Question by [Participant]: Does this suggest possibly the evolution of different kind of practice? That is, you know, I watch “House,” and invariably, he sends out his team to check the place where people have come from to see what the chemicals in their environment are. Should there not be a counterpart of that to what you do, that there would be a component of your low-vision practice, which actually looks at the environments that the patient deals with?

Response by Dennis Siemens: I think what Suleiman and I do is, we take the existing environment, whatever that is, because we have little or no control over what happens, even at Mayo Clinic. I yell and scream at them, and they smile and nod. But I have the luxury of being able to go out and do site visits within my institution. So if I have an employee that has a challenge, I go out and say, okay, where you at, get there early so I can go in before I see patients, or go over at lunch, and I’ll take a look and we’ll see what it looks like.

And you know, sometimes I have to look for the supervisor, and they said, well, we just remodeled this whole thing. You’re going to have to do it over because you’ve got one in particular lady [who] was doing appointments, so they wanted her at patient height, you know, eye level. So she was sitting on a tall stool. They had spotlights coming on her and the screen. You know what I showed you on here with the red and the blue? That’s what her screen looked like because that’s what the computer program was. I said, you’ve got to change this, this, this and this, you know? Well, we can’t. Well, you have to, because you’re making this not accessible for this patient. So they hated me but I have the liberty of doing that.

But I think you’re absolutely right. And even a group like occupational therapy, who some therapists are very well-versed in this, reminds me that might be a way. But again, they’ve got to be able to bill for it too or they can’t do it either. So it’s tough to do that stuff.

Sometimes we do those with simulations in our office with a workstation so that we can kind of demonstrate what’s going on and simulate things, but that’s not [practical].

Comment by Eunice Noell-Waggoner: I wanted to say that what you had suggested, I actually participated in. I was invited to Los Angeles from a low-vision specialist, David Slay, who works for the V.A. And with the returning veterans that have a lot of head, brain trauma, although this person could see, the glare was really horrific for him.

Since I worked for a nonprofit, I said, well, I’ll come down, and I’ll see if I can help analyze the situation. It was in the veteran’s home. And the wife had heard, well, you know, he has problems with vision, and you need a lot of light. Well, so she had gone to a big-box store and bought these really glary light fixtures. And I’m thinking, oh, no.

I was traveling from Portland, so I had a suitcase of stuff, but [it was] kind of hard to get through security with that. But I happened to have some light bulbs that had a silver bottom on the bowl. And I just screwed that light bulb in, and it shot the light to the ceiling, removed the bright glare, and it was kind of like he said, oh, this is great. And when you talk about quality of life, the glare was so bad that his wife would have to prepare dinner at 3:30 in the afternoon when there was enough light in the kitchen from natural light sources without turning on these lights so that they could have dinner.

Well, I mean, it’s like their whole life was turned upside-down because of, you know, inadequate and not understanding the problem. And so I think, you know, it really goes to a lot of different issues.

Comment by Bob Massof: Let me add one more note on that same idea here. When you describe a head trauma situation, for example, and I think the data coming out of the V.A. with our returning veterans who have had significant head trauma. I’ve talked to some of the people who do research in this area. These guys are coming back. It’s not something that’s easily measurable, the visual acuity, the peripheral vision, but it’s their visual perception that is screwed up.

This is a good example that we don’t see with our eyes, we see with our brains. Remember, a lot of you are old enough now, when you were a kid that in science class they look like the eye was like a camera with film? It doesn’t work that way at all. The light comes into the eye, hits the retina. The signal then goes from the retina back to the brain, and the brain translates it into what we know as vision.

And part of what we’re describing here is that we’re all different, and our visual perception is different for different circumstances. And so that’s why, you know, one size doesn’t fit all. And it’s helpful for us if we can quantify, you know, what your vision problem is and yours. But even at that, I can take all my patients with glaucoma or macular degeneration, but they’re still different.

Comment by Marsha Mazz: I wanted to follow up on something that Vijay said, because I see the conversation may be going in certain directions. If we’re looking to write guidelines or standards under the Americans With Disabilities Act, for example, bear in mind that the Americans With Disabilities Act does not establish guidelines or standards for home environments or for work environments. So we don’t regulate under the ADA an employee work area, because the ADA under Title I entitles, gives a civil right to each employee with a disability to advocate for their modifications that he or she needs. And the employer must provide them unless there is a substantial undue burden.

So as we begin to think about writing guidelines or standards or using existing, which would be my first choice, using existing standards that are out there or reviewing those existing standards, we probably should be thinking about public environments, you know, public-use spaces, such as National Airport, the Metro station, corridors within an office building, which we do regulate, and on another track be dealing with environments that people can adjust to suit their own needs, such as their homes and their work environments.

I’m not saying don’t work on both, but I’m saying realize that there is sort of a natural division here.

Question by [Participant]: Are you saying that the worker has no rights under ADA for the employer to modify the workspace?

Response by Marsha Mazz: Exactly the opposite. The ADA standards for design and construction do not regulate the workspace because Title I of the ADA extends the right to a reasonable accommodation to the employee so that the reasonable accommodation actually meets the unique individual needs of that person.