Our ability to assist our patients with low vision has been significantly enhanced by the increasingly digital nature of our lives.
We are now able to directly improve the visibility and accessibility of daily tasks using the device that is always with them: their cell phone.
This distinguishes us as optometrists who care, is an effective practice- and reputation-builder, and positively influences our patients’ lives.
Overview of low vision
The general optometric practitioner may wonder how this applies to them. However, we regularly see patients with cataracts, glaucoma, macular degeneration, and diabetic retinopathy, which are all leading causes of low vision.1,2
Whether subscribing to a loose definition of low vision as “when a person’s visual demands exceed their visual ability,” or the more formally defined acuity and visual field ranges described by the Centers for Disease Control and Prevention (CDC) or World Health Organization (WHO), it is clear that the need is great.
This presents ample opportunity for us to help as primary care optometrists with the basics while at the same time acting in our patients’ best interests by referring them to colleagues in specialized low vision practice when their requirements are beyond the care that we offer.
Table 1 outlines the classification of visual impairment as referenced by the CDC and WHO. Below, * denotes a WHO definition, ** denotes a CDC definition, and *** denotes both.
| Best Visual Acuity/Visual Field in the Better Eye | Less Than 20/40 | 20/30 to 20/60 | 20/70 to 20/160 | 20/200 or Worse | 20/500 to 20/1000 | 20/1000 or Less | No Light Perception | 20/200 or Less/20° or Less of Visual Field Remaining |
|---|---|---|---|---|---|---|---|---|
| Low Vision** | X | |||||||
| Mild Vision Loss* | X | |||||||
| Moderate Visual Impairment* | X | |||||||
| Severe Visual Impairment* | X | |||||||
| Profound Visual Impairment* | X | |||||||
| Near Total Visual Impairment* | X | |||||||
| Total Blindness* | X | |||||||
| Legal Blindness*** | X |
Table 1: Courtesy of the CDC and WHO.
Fitting low vision assessments into your schedule
You may be asking yourself, “How much chair time will this take, though?” Balancing the needs of our patients with the practical demands of a busy practice is a challenge we all face.
The wins achieved by enhancing the visibility of digital devices are quick and immediately effective. This may take a few minutes to make key basic adjustments to display settings or be a longer training session, with additional training at future appointments.
As a result, the spectacles and low vision aids we have prescribed are that much more effective. Being the eye doctor who helped the grandmother of the family to stay in touch with friends via text despite her low vision is certainly a way to build patient loyalty.
Primary challenges with access to digital devices
Small print, at times low contrast, and cluttered content on a small screen can mean that people can lose access to their cellphones and tablets when their vision changes. However, there are a range of factors affecting how open people may be to digital accessibility adjustments.
Some individuals may feel daunted by technology or resistant to change. Many underestimate their tech-savviness, not realizing how easy the accessibility adjustments are on our devices.
Others may not enjoy having fewer (although larger and clearer) words on the screen at a time. However, the benefit is immediate and definite, and it is a very socially acceptable way of assisting our patients.
Remember, when dealing with someone who is not naturally a “gadget or computer person,” keep the discussion natural and relaxed, easing them into small accessibility adjustments to steadily build their confidence.
Download the patient handout on at-home steps for improving digital accessibility here.
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10 actionable steps for digital accessibility
1. Educate patients and suggest simple environmental changes
The same concepts apply to adjusting digital settings that we use in prescribing low vision aids and recommending environmental changes for those with low vision. Discuss with your patient that “Bigger, brighter, and bolder” is easier to see and will help them understand what to do with their devices.
Suggestions like how to reduce glare, increase contrast, and use the benefits of audio when they need to is a good first step. Please refer to the download available with this article for a useful patient handout introducing these settings for Android and Apple devices as well as Mac and Windows computers.3,4,5,6
2. Adjust contrast and screen brightness
Contrast and lighting are often at the heart of why our patients may battle to see in the real world. Our colleagues with early presbyopia know first-hand how much the brightness and contrast of screens can be used as an aid to clarity on digital devices.
Tip: Consider adjusting all of their settings to the maximum that the individual is comfortable with rather than the minimum that helps. The aim is to make print and images as easily readable and visible as possible. Reducing the transparency of the display is an additional feature worth considering.3,4,5,6
3. Manage glare
The importance of managing glare cannot be overstated. Those with glare sensitivity may lose the benefit of additional task lighting (aimed away from their eyes) for fear of the discomfort associated with their light sensitivity. Similarly, they may lower the brightness of the screen for comfort, not realizing the associated benefit they are losing to their clarity.
In the same way as aiming the light source away from one’s eyes allows us the benefit of brighter task lighting, consider changing to “inverse contrast” (white print on a black background).
This gives the benefits of high brightness and contrast without a bright, white screen background shining back at you. This is also a good way for our cell phone and device batteries to last longer.
Tip: Consider demonstrating the “smart inverse” on patient’s devices, which shows white print on a black background, while leaving photographs and videos displayed in their original colors.3,4,5,6
4. Magnify images and adjust text size
Magnification is a trusted and effective aid to clarity in low vision practice. This is particularly the case for those with central visual loss, where metamorphopsia and scotomas interfere with print recognition and reading fluency.
Magnification and text size can be set for the device itself, with app-specific adjustments to allow for the most appropriate settings for each person’s specific requirements. Additional larger print options are available in the accessibility settings on the device.3,4,5,6
Screen zoom (either full screen or as a floating magnifier) is also an option. For those with more advanced low vision, consider screen mirroring to a television to view photographs for additional magnification.3,4,5,6
Tip: Set the print to be larger than what the individual needs to allow for longer periods of more fluent reading without tiring their eyes.
5. Enhance color settings
An individual’s ability to distinguish colors may be affected by genetic factors (congenital color vision deficiencies), as well as the effect of the underlying ocular pathology.
Within the accessibility settings of devices, we can now “replace gray” or choose a color display to help those with specific color vision deficiencies, with more easily differentiated color displays on their devices.3,4,5,6
Tip: Be guided by the individual themselves. Also, consider an accessibility shortcut to turn this feature on and off as needed.3,4,5,6
6. Utilize voice input.
In the past, additional software was required at extra expense by those who couldn’t touch-type or see their computer keyboard. We are all aware of “voice note” messaging, but may not realize that both Apple and Android offer “voice typing,” or dictation, as speech-to-text input options on our devices.3,4,5,6
Tip: Our patients may respond with resistance to our recommendations of these adaptations, feeling that their vision isn’t bad enough to warrant these changes. One approach is to normalize their use, speaking of how you use dictation for easy “voice typing” at the end of a long work day.
7. Take advantage of cell phone voice assistants
Familiar and easily accessible digital assistants, including Siri and Google Assistant, can be valuable aids to those with low vision.
Start simply by giving your patient one small task to master at a time. Perhaps try, “Hey Siri, call Kirsten,” so that our patients can work from there in building their skills. Encourage them to experiment.
Tip: Be sure to turn on “spoken responses” as a default rather than simply displaying responses on the screen, which may not be as easily visible (depending on the degree of low vision).
8. Set speech output settings for on-screen reading
While audiobooks are becoming increasingly mainstream, “books on tape” have long been available for those with visual impairment. Many digital low vision aids also include the option of an optical character recognition (OCR) version for text-to-speech output of print.
Spoken content settings on our devices allow for on-demand, simple reading of our messages and our screens, as well as the use of sophisticated screen readers with time-saving screen gestures.3,4,5,6
The first can be demonstrated in a few minutes, while the second, such as Talkback on Android and VoiceOver on Apple, may require significantly more practice to master. However, doing so can be of great benefit.
9. Understand that devices themselves can be low vision aids
We have spoken through accessibility settings for our devices themselves, but our cell phones can also be used as visual aids in the real world. Consider trying the flashlight as a mobility or reading aid and the camera as a magnifying aid.
Built-in magnifier apps also use the camera but include additional zoom and contrast enhancement features. These are of particular benefit for reading small, low-contrast print.3,4,5,6
OCR output can be used by apps to “speak out loud” prices and menus in real-time or for scanned-in documents. Increasingly, devices are including OCR features in their camera and magnifier applications.3,4,5,6
Tip: With so many options, set accessibility shortcuts for devices that your patient is most keen to use so that they can easily turn them on and off.3,4,5,6 For discreet use of voice output in a public setting, the device should ideally be connected to Bluetooth earphones.
10. Don’t forget computers and laptops
Both Windows and Apple software also have vision-enhancing features; however, your patients may not realize that these are at their disposal. Windows Magnifier and screen narration come standard with the latest Windows software.5 High-contrast settings are also available.5
Additional software can be considered for those with more advanced low vision. Mac computers again have screen reading and other accessibility features as standard features.6 Please refer to the download for an introduction to these accessibility settings on Windows and Mac.5,6
Don’t rule out low-tech solutions
Tried-and-tested approaches still have their place in today’s world. The digital adaptations above can also make easier-to-use aids, such as high add readers or a hands-free, two-times-magnification anglepoise magnifier, more effective for the larger, bolder displays we have set up.
Placing high-contrast, large print keyboard stickers on a keyboard with a desk lamp aimed at it, can make these significantly easier to use.
Key takeaways
Using digital accessibility training to point our patients towards these simple digital adaptations around their low vision empowers them to develop these skills incrementally further. Within a few minutes, we can introduce the basic features and encourage them to learn how they can best use these progressively.
Set yourself apart as an eyecare professional who can quickly and effectively make simple and effective life-changing adjustments to a person’s working life and daily life.
We really can make the world easier to see!
