This second case concerns a patient AB who has been diagnosed as having dry age-related macular degeneration (AMD). He was already using simple magnifiers for reading but struggled with his distance vision. He owned an iPad tablet but rarely used this until he was shown how it might help him to see for hobbies and activities.
Clinical details at presentation
Seventy-six-year-old male, AM, was seen in clinic some four weeks after cataract surgery in his second eye. He had an eight-year history of dry AMD which was worse in his left eye than his right. Before his cataract surgery his refraction had found approximately -8.00DS of myopia in each eye. AM had been aware that his recent surgery would not restore his vision to previous levels, but reported positively that his vision was ‘brighter’ since the operation. He was also aware colours appeared to be more vivid.
He owned various illuminated and non-illuminated hand magnifiers, of powers ranging from +4.00DS to +12.00DS, which he had either bought for himself or had been given as presents. He was happy with these for menus and shop prices.
He had well controlled hypertension and mild asthma. He was fit, active, a non-smoker and generally in good health. He wore a hearing aid with which he could hear well. He was not registered as sight impaired or severely sight impaired.
Social details at presentation
A former headteacher, AM described himself as having an ‘active retirement’. He enjoyed art and had travelled widely to visit galleries and museums. He had recently taken the trans-Siberian express to learn more about Mongolia. He participated in various committees and was a trustee for a charity supporting children who have been excluded from school. He had started drawing and painting in his retirement and attended a life drawing class.
He used an Apple computer to deal with correspondence and had set the accessibility options to enlarge the font size. He told me he was a ‘reasonable’ touch-typist but he sometimes lost the mouse cursor. He used a Kindle to read. He had been given an iPad by his daughter, but did not use it much.
He lived with his wife in his own house. He had stopped driving once AMD had been diagnosed in his second affected eye, but his wife had good vision and could drive.
Patient’s stated desired outcome
AM’s particular concern was a lack of detail for distance objects. He could not see platform signs at railway stations and he found art galleries increasingly difficult. He thought his reduced vision was affecting his art: he could not stand back to get an overview of the canvas, and in the life drawing class he could not see the model clearly.
A low vision clinic had previously given him a small 4x monocular hand-held telescope (figure 1), but he found this difficult to align. Also, he refused to use this in his life drawing class: ‘I’d look like a dirty old man, getting a telescope out to ogle the model,’ he pointed out quite reasonably.
Relevant clinical findings
Refraction showed:
- R: +0.50/-1.75 x 95 0.5 logMAR (6/19)
- L: +0.25/-1.50 x 90 0.8 logMAR (6/38)
- VA with both eyes open: 0.48 logMAR (6/19+1)
With a +4.00DS add, he could see N10 slowly at 25cm with both eyes open.
With one of his own magnifiers (a +12.00DS non-illuminated hand magnifier) he could read N5 comfortably.
Slit lamp examination showed white eyes and quiet pseudophakia in both eyes, with no cells, flare or other signs of inflammation. Fundoscopy revealed a large area of geographic atrophy in each eye, with no fluid or haemorrhage. OCT imaging confirmed the absence of wet AMD. There was no distortion on an Amsler grid.
Management
I prescribed new varifocals for AM as his prescription had changed since his cataract surgery. Although he used hand magnifiers for most reading, which have the largest field of view when used with a distance prescription, he found a multifocal correction helpful for eating and for viewing his desktop computer. After demonstrating various reading additions, a +3.25DS add was prescribed.
I suggested using the camera and zoom function on his iPad as a distance magnifier, for galleries and the life drawing class. ‘I can’t believe I’ve never thought of that before,’ he told me.
I demonstrated the SuperVision+ app. This is available as a free app for both Android and iOS and may be used on either a tablet or smartphone. The app uses the inbuilt camera to view an object and offers image stabilisation as well as magnification and contrast reversal (figure 2).1
Figure 2: Use of SuperVision+ on a tablet to view a painting. (Above) The app offers a number of functions including image stabilisation. (Below) Viewing is possible from several metres, as may be required in a public gallery setting
I also showed him the National Rail app, again available on iOS and Android, which offers live platform details without needing to examine the departures board (figure 3).
Figure 3: National Rail app showing platforms for departures
Next, I told him about the option built-in to Mac computers to find his mouse pointer: shaking the mouse quickly left and right (or doing the same on a trackpad) enlarges the cursor size.
Finally, I directed him to the www.applevis.com website, which has up-to-date information on accessibility options for Apple users.
Follow-up
At his next appointment, AM told me he was using his iPad every day and had considered using it for drawing as well. He was using the camera and zoom function rather than SuperVision+, and was comfortable using it in his life drawing class. He told me about David Hockney’s new artwork, made on an iPad, and said he was considering drawing on his iPad as well. He had not used the National Rail app yet. He was happy with his spectacles.
After reading the applevis.com website, he had bought a smart speaker and was using it to listen to music in his study. ‘The funny thing is, I don’t see myself as a big technology user,’ he told me. ‘It just seems to make everything so much easier.’
Discussion
Tablets, such as the iPad, are widely used by people with low vision.2 In their simplest form, the camera and zoom function can be used in the same way as a portable video magnifier. For spot reading tasks, such as reading a bill or identifying medication, an iPad is just as effective as a handheld electronic magnifier.3 When combined with a stand, they can be used as a rudimentary desktop video magnifier, although the tablet computer will have fewer options for displaying text, such as showing print against different colour backgrounds unless dedicated apps are also used.
As well as being quite intuitive for older adults to use, tablet computers are widely used in educational settings4 and by younger adults with low vision. In a 2014 survey of people with visual impairment, older people were more likely to use a tablet computer than a smartphone, while those under 65 were more likely to use a phone.2
There are dozens of apps designed for people with visual impairment (see page 24). As well as magnifiers, there are text-to-speech programmes which use the camera to read text aloud (such as Seeing AI, Speak! and Supersense); navigation apps (such as Soundscape, Blindsquare and Lazarillo) and product identification (Digit-eyes, Seeing AI).
Of course, people with visual impairment primarily use the same apps as everyone else, perhaps with larger print or a screen reader such as VoiceOver (Apple devices) or TalkBack (Android).
AM is wealthy and uses Apple devices. Accessibility options are also available on other operating systems such as Windows (available through Start > Settings > Ease of Access), Ubuntu (System Settings > Universal Access) and Chrome (Settings > Advanced > Accessibility > Manage Accessibility Features).
The applevis website is comprehensive but only applies to Apple products: alternative sources of information for other operating systems include Sight Advice FAQ (sightadvicefaq.org.uk) and AbilityNet (abilitynet.org.uk).
The shortcut for maximising the visibility of the pointer on an Apple computer is available to all users, without needing to be set up. This is an example of ‘universal design,’ where systems are developed for all users by default. The same could be said of smart speakers such as Amazon’s Alexa, which have no screen interface.
A surprisingly large number of artists had some visual impairment, including Monet, Degas, Cézanne, Pisarro and Munch.5 By using an iPad, AM could appreciate art when visiting galleries, and was also able to improve his own drawing skills without feeling uncomfortable.
Dr Michael Crossland is Senior Optometrist, Moorfields Eye Hospital NHS Foundation Trust & Honorary Senior Research Associate, UCL specialising in low vision.
References
- Luo G. How 16,000 people used a smartphone magnifier app in their daily lives. Clinical & Experimental Optometry, 2020;103(6):847–52.
- Crossland MD, Silva RS, Macedo AF. Smartphone, tablet computer and e-reader use by people with vision impairment. Ophthalmic and Physiological Optics, 2014;34(5):552–7.
- Wittich W, Jarry J, Morrice E, Johnson A. Effectiveness of the Apple iPad as a spot-reading magnifier. Optometry and Vision Science, 2018;95(9):704–10.
- Gothwal VK, Thomas R, Crossland M, Bharani S, Sharma S, Unwin H, et al. Randomized trial of tablet computers for education and learning in children and young people with low vision. Optometry and Vision Science. 2018; 95(9):873–82.
- Trevor-Roper P. The world through blunted sight. Third Edition. London: Souvenir Press Ltd; 1997.