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

Introduction

Well, thank you, Vijay. I’m glad we have an opportunity to discuss things, because I think everything I would like to say has been said – thanks a lot, Bob. And apologies to Dr. Brabyn, frankly, because a lot of the slides that I have may also duplicate what you’re going to use.

And I’m going to start with this quote that says, “It’s not the strongest of the species that survives, nor the most intelligent; it is the one most adaptable to change,” and that’s a quote by Charles Darwin (slide 2). I find it fascinating to sit here and participate in this group, because the work that we do as low-vision specialists is not to adapt the environment to the individual; we try to adapt the individual to the environment by providing various tools. So this is a sort of unique opportunity for us to come to you and say, well, look, here are the issues our patients are having. What things can you do to make it easier for them?

And, fortunately, we are the most intelligent of the species on the earth, and therefore we are able to survive because we adapt with tools, and low-vision specialists are the tools of the people that who have low vision. And I think patients always come to me and say, I’ve come to see the toys that you have to help me, because they were expecting some tool, some gadget; hopefully, just a pair of glasses magically is going to fix their vision. Now I think we have a good understanding that we’re talking about people who are beyond basic tools like glasses. 

Role of Low Vision Specialist

The three or four things that we have been emphasizing here are the things I think we have now all really understood: To enable people who are visually impaired to function, we’re talking about modifying light or glare; modifying contrast; as low-vision specialists, we also modify size, or we provide magnification, and we have the tools to do that; or we modify their behavior (slide 3).

As you’ve heard from Dr. Massof’s presentation, for example, we’re talking about, really, older people here having issues with functioning. And they modify their behavior by becoming depressed, by staying indoors, and really becoming restricted in terms of their activities. So how [are] you specialists – how are we going to modify the environment, make it more engaging to them, so they’re not afraid of falling, they’re not afraid of losing their independence, and there are ways to get around? So I think these are the things we’ve all established – the lighting, glare, contrast (slide 4). We haven’t talked much about magnification, but that could certainly be an issue when it comes to signs.

I think it’s important that we realize, like it’s been brought out, that we all have experienced low vision. Initially, I thought about putting up slides of diseases to show you blind spots, and the narrow tunnel view. But you know, it’s really not like that. It’s fine for putting up slides and showing those things, but in the real world, if you want to understand what does the visually impaired person experience, think of things like: the oncoming headlights of a car; the sun low on the horizon, especially for those who drive around the beltway; reading menus in romantic restaurants; finding a seat in a movie theater. I mean, these are things we’ve all experienced. And think of that being as more amplified in people who have low vision.

Contrast, we’ve talked about ad nauseam now, about the edges of steps and curbs; or reading something that hasn’t been printed well; and magnification – going back to that size thing, it’s like the back of a medicine bottle – who is supposed to read those anyway; or the disclaimers on the some of the things that we buy. I think it’s ridiculously small. And like Dr. Massof mentioned, we assume that everyone in the world has next to perfect vision, and if you don’t, try to adapt to it and deal with it. And many of us just kind of fake it. We go, yeah, that’s right. Well, now, how much was it again? They may not really have seen the price, but it’s a way we deal with it.

The other thing we’ve talked about today is: What is low vision? What’s the range of vision? It’s not a number. This is the most frustrating thing I think Dr. Siemsen and I have, is that people come to us and we see them because we are reimbursed to deal with them. Medicare pays me to see these patients. But if their vision is too good, Medicare says, you can’t see this person. We’re not going to pay for it, because this number that we require their vision to be, isn’t satisfied. And so this is frustrating from a practitioner’s standpoint.

There aren’t many low-vision practitioners because of that, because it’s hard for us to make a living when it’s all about reimbursing. We didn’t get into this low-vision field because we were going to make it rich; more because we felt the need – I think, like some here pointed out, that there are people having difficulties functioning. And not just we’re talking about older people, don’t forget, children, and we’ve talked about adaptations in the school system, and playgrounds, and so on and so forth. So it’s hard to give you a definition of low vision in terms of a number, and I would hope that in developing guidelines and in talking about low vision, we don’t use a number to define it. 

Visually Impaired People are not easily Identifiable

And remember, the other thing is that the visually-impaired people are not easily identifiable. This is the difference between somebody you identify as being blind and immediately you can anticipate what the difficulties are, because a visually-impaired person – and we have at least three in this room – are not walking around with a white cane; don’t wear glasses even, except Mr. Gupta perhaps; and don’t look like they’re visually-impaired – they make normal eye contact (slide 5). So how do you know, as you’re dealing with people in the real world, that they’re even visually-impaired, because “they look normal”?

Age and Low Vision

All right, I’m not going to go over these pictures again (slides 6 – 15). Dr. Brabyn is going to discuss these. But the one thing I would bring up here is a study done at Berkeley by a researcher-optometrist-scientist, Dr. Gunilla Haegerstrom-Portnoy, who did a study on 900 people from the ages of 58 to 102 (slide 16). They were normally well-sighted. In other words, their vision was 20/40 or better – what we would consider good vision, not even low vision by any definition. And she measured their vision under various conditions of contrast and glare (slide 17).

And what’s interesting here is what occurs with age. I think we’ve all got this point now that the aging population has low-vision issues, and you’re thinking of the aging population with macular degeneration, glaucoma, cataracts and things like that. This graph is showing you the effect of contrast, glare on an aging population that is well sighted; has had cataract surgery; have been to their ophthalmologist and been told, your vision is good; you’re legal to drive; you’ve been doing well; if you’ve had a problem, we’ve treated it.

This group, as you can see, as they get older have increasing difficulty. And this is saying, along the y-axis, times worse than young for those whose vision is 20/ 40 or better, because that’s who we’re comparing this group to. They have more and more difficulty with: high contrast – with low-contrast vision (low contrast vision just means you measure their acuity and the letters are not black on white). Contrast sensitivity in general – how much more black on white they need than the average person. Glare – how much more trouble glare issues are. And, how much more time it takes to recover. So we have to take that into account as well. So if you’re going to build a building with good light, which is great, and then to have to move to another area of the building and it suddenly turns dark, well they have to make a transition. And I think the first speaker [Greg Knoop] brought that out nicely, that we have to find ways of making these transitions from light to dark, or for dark to light.

So the reason I put this graph up really was to say to all of us here that when we think of these issues, all of these things that have been brought up so far, don’t necessarily apply just to the low-vision population. We’re talking about this aging population. And as we know, the group over 65 is the fastest growing segment of our population. So even if we don’t call this “Building Design for People with Low Vision,” I think it’s building design for all of us, assuming we’re all going to get there. But you might say, I’m going to take good care of my eyes and not have a problem with my eyes. I’m going to get my cataracts seen; I’m going to get my glaucoma checked; and I’m never going to get macular degeneration; and I’m going to eat leafy green vegetables every day. You can do everything. You’ll have 20/ 40 vision, but you’ll experience all these difficulties.

So it does behoove us to address these issues and address them in a meaningful way (slide 19). So I’ve skipped all my other slides because I know we’re running out of time, and I think they’ve already been addressed. And I would much prefer now to have a discussion, and questions, and back-and-forth that we can address some of these issues in more practical ways.