Macular Degeneration and the Skill of Eccentric Viewing
Presented byNancy Parkin-Bashizi
Moderated byDoug Anzlovar
Doug AnzlovarWelcome to Seminars at Hadley. My name is Doug Anzlovar. I’m the Vice President of Education and Training at the Hadley School. Today’s seminar begins a new quarterly series offered to our Low Vision Focus @ Hadley Program. Our topic for today is Macular Degeneration and the Skill of Eccentric Viewing.
Now, let me welcome today’s presenter, Nancy Parkin-Bashizi. Nancy received her Masters’ Degree in Orientation and Mobility and Rehabilitation Teaching for the Blind from the University of Arkansas at Little Rock. She also holds a certificate in The Rehabilitation of Persons Who Are Deaf Blind from Northern Illinois University. Nancy is currently employed at the Vision Rehabilitation Services of
Georgia where she works as an itinerant teacher, providing orientation and mobility training, vision rehabilitation therapy, and access technology training services to clients of all ages to assist them in managing their vision loss and maintaining their independence. I would like to now welcome Nancy.
Nancy Parkin-BashiziI will go ahead and get started by going over the objectives of the webinar. And then we’ll move through the slides in the PowerPoint, and I will pause between each major area and offer the opportunity for questions. So, Doug, if we could go to the objectives slide, which I believe is the first one.
So since I’m not sure exactly who is attending this seminar, I wanted to make sure that I reviewed the basics of macular degeneration, and how that eye disease effects one’s ability to read print. We’ll then next talk a little bit about how eccentric viewing can help people with macular degeneration and other eye diseases improve their ability to read.
Then next, we will actually walk you through each of the steps of learning how to find your sweet reading spot, sometimes referred to as the preferred reading locus by professionals. And then I will work through some different activities that you or your client could
use or family members could use to learn how to practice eccentric viewing so that they may be able to read more effectively even though they have vision lost due to macular degeneration. Finally, we’ll talk a little bit about the resources available to assist you in this process. Next slide please.
So it's really important to understand a little bit about the disease macular degeneration, and how it effects the eye and why eccentric viewing would be necessary to help someone with macular degeneration to read. The macula is your central part of your retina, and it's really responsible for most of the fine details seeing, and pretty much all of the reading that we do. And when someone has macular degeneration, what happens is the macula begins to die and it just doesn't work very well anymore.
Typically the degeneration appears as a blind spot or blind spots in the eye, and these are called scotomas. The progression of macular degeneration could be fast or slow. It can also occur in only one eye, or both eyes simultaneously. What happens in macular degeneration is that as the scotoma forms and as it changes and grows, as the disease progresses, it begins to interfere with your ability to see and read fine print. Next slide please.
For those of you who may not be able to see the screen, I have a small photograph that shows the word box, and there is an oval of light over the word box and it shows a blurry circle that covers most of the word. This blurry circle, for those of us who can see it, represents a scotoma of a pretty large size, and the effects of that scotoma on trying to read. Basically, as the scotoma or blind spots grow, they take up more of the macula, and then it just makes it really hard to see small print. There is a time at which reading with macular degeneration becomes so frustrating and difficult that you may want to consider eccentric viewing. Next slide please.
So, eccentric viewing is really learning how to look around the blind spot so that you can learn to read with the healthy part of your retina. Now for some people, the healthy part of their retina may be another side of the macula, and for others it may be actually a different part of their retina, which is your peripheral vision. And it's really important to note here that for each person with macular degeneration, the way the scotoma grows and where the blind spots are is different. And it's also really important to note that your blind spots may be different in each eye.
So the process of locating your sweet spot and learning how to use it for reading and to see is what
we call eccentric viewing. Now, as a teacher, I find that most people understand the concept of the sweet spot, which is why I use that term. But professionals in the field of low vision call it the preferred reading locus or PRL. So sometimes if you are actually involved with a low vision therapist or an eye doctor, they may talk about your preferred reading locus. But in terms of working with my clients, most of whom are elderly, the sweet spot phrase tends to work a lot better. Next slide please.
So over the years, and I've been teaching clients for about 20 years, as a rehab teacher one of my jobs has been to follow up with clients after their low vision evaluation. I wanted to take a moment just to make sure that I explain that process. For most clients that have macular degeneration, there's a point at which the scotoma gets big enough that they begin to have trouble functioning every day. If they have a proactive eye doctor, a primary health care eye doctor, he will refer them to a local low vision clinic or a vision rehabilitation center.
And a low vision evaluation is usually performed or should be performed by a doctor specializing in low vision or a low vision therapist. And through this process, the individual with macular degeneration or other eye conditions that cause vision loss may be
prescribed magnification and or strong eye glasses to be able to help them see better. And that's because if you have macular degeneration, making things bigger and darker makes it easier to see.
A really simple way for me to describe this would be if you wear glasses and you kind of take a little bit of something dirty like mud or Vaseline, and you kind of rub it on the center of your eyeglass so it kind of simulates a scotoma, and then you put your hand really far away from you, you'll see that most of your hand is missing. But if you bring your hand close and closer and closer to your face, you can see more and more of your hand around that scotoma.
So that's really the principal behind magnification. If you make something big enough, then more of it appears behind the scotoma, and that allows you to read more easily. And magnification works pretty well for most people in the early stages of macular degeneration. Making the print bigger through magnification, writing with dark pens, maybe using large print books, writing things in larger print – all of those things make it easier to see.
What happens, and what I've found is that probably by the time someone comes through our clinic and they're prescribed a 4X magnifier or a 5X magnifier,
that seems to be the point at which the scotoma is really beginning to interfere with their vision and their ability to read small print. And for me over the years, that’s really been my number one indicator that it's time to introduce eccentric viewing. And that's just my own personal observations over doing this job for 20 years.
Typically if someone's got a 3X or a 3 1/2X type magnifier, they can still read using their regular central vision just by making things bigger. But once they get to the 4X or the 5X, that just tells me the scotoma has gotten to a point that it's really in the way, and we may need to start moving the scotoma out of the way and practicing to read from the side.So here are some other clues that I also hear from my clients. I find that they just really stop reading.
They may have used their magnifier for the last couple of years, and then suddenly they just stop and they say that reading is really frustrating and it's hard and it's tiring. They complain that the magnifiers don't help anymore. Sometimes clients will say, "Gosh, I feel like I've really lost a lot of vision. I've had a lot of changes." A lot of clients complain that things seem darker and harder to see. And what that tells me is the scotoma has gotten to a critical point and that it's
really time to start introducing eccentric viewing. Next slide please.
So in terms of learning how to read eccentrically, we have three steps. So the first thing is learning how to find the sweet spot, which we're going to do here in a minute, and then, practicing how to locate it and hold it and use it when you need it. Step two is learning how to identify letters and numbers with the sweet spot. And then step three is really practicing holding your eyes still and moving the paper across that sweet spot to help reading become more efficient. And of course the same thing that you're going to hear me say over and over today is practice, practice, practice. Next slide please.
Okay, so beginning to figure out where the sweet spot is, and this is something that I do with pretty much every single client that I work with who is ready for eccentric viewing. We talk a lot about the ideal reading spot for the client, and this is really important because with macular degeneration, you need to have good light and you need to be comfortable in order to read. So we try to find a desk or a table that has light either from overhead or a small task light that will shine on the paper, or maybe some daylight coming in from behind them. We have our materials, I have training materials – there will be a photograph
here in a minute of what those are. And also Doug let me know that all of the materials that I created and sent to him will be provided to you guys as attachments after the seminar has been completed.
So what you're going to have are some dark pens, either Sharpies or 20/20 pens, several sheets of blank paper, and a clipboard, which is very helpful. So for the first thing, the first exercise, you need to take your dark pen and a blank piece of paper, and you’re going to draw a large circle, which will be a clock face, and you're going to kind of do a little star in the middle. And then you write the numbers 12, 3, 6, and 9 in their correct location around the clock. You want you to write these large enough for the individual to see without magnification. On a second piece of paper, you can go ahead and write two or three block letters in print across the page, maybe three to four lines of these letters. Next slide please.
On this slide, it shows the clipboard with the clock phase, it shows some 20/20 pens and Sharpies, and it's shows examples of big print letter pages that I talked about. Next slide please.
Alright, so it’s really important when you are working to locate your sweet spot that you start with your good eye. And for most of us who've worked with
individuals with low vision a long time, clients talk a lot about good eyes and bad eyes. So I wanted to take a few minutes to talk a little bit about what that means. Macular degeneration does not usually affect both eyes equally. And what happens over time is the individual will notice that their right eye, for example, is stronger and sees more clearly than their left eye, for example.
So what we want to do when we're working on learning to use the sweet spot is to always start with the good eye because that's the eye that the brain has probably begun paying attention to. When you have macular degeneration or any other eye condition, as the light enters the eye and passes thought to optic nerve to the brain, the brain works really hard to put the two pictures, one from the right eye, one from the left eye, together to create an image. And that's why seeing with low vision can be really difficult, because the image coming in is broken and the brain is having to work really hard to make a picture out of the broken lights.
A lot of times if someone covers their bad eye and allows the light to enter only through the good eye, then the brain will have a lot less trouble putting the images together. And you'll see that when you ask someone to cover their bad eye, they'll actually
appear to see a lot more easily. So covering the bad eye, the individual should have the clipboard in front of them with the clock on the clipboard. And what I have people do is I ask them to look straight ahead at the clock and put their eye so they're looking straight ahead at the star.
Now for classic macular degeneration, the disintegration of the macula is typically in the center of their vision. So when I ask people to look at the star, for most of them a lot of the start is missing. So when they look at it, they really can't see it or they can just see pieces of it, and they'll probably talk about that – “Oh I can't see the star." And what I'm doing from the other side of their body is I'm looking at their eyes to kind of see how their eyes bounce around because you can tell that they're trying to move their eyes around to see where the star is.
So it's really important that you ask them to hold their eye still so that they're looking at the star in the middle. They may say, "Oh if I'm looking at the star, I can see the three or I can see the six." I just let people tell me what they can see because that gives me a clue to where they may have their clearest spot of vision.
So the next step is still holding the clock in front of them, still having their bad eye covered, I ask them to move their eye as if they were trying to look at the 12. So when you shift your eyes ask if you're looking up to the 12, you're really pushing that blind spot or that scotoma up, almost like you're lifting a blind so you can peek out the window. Now for some people when they move their eyes up to the 12, they may see the star, they may not.
The next thing I have them do is returning their eyes to center, I have them then shift their eyes as if they’re looking towards three, which if you want to simulate it, the curtain, it's like pushing the scotoma or the curtain to the right. And if they push the scotoma to the right, again for some of them, the star in the center may come into view. We repeat this exercise going around the clock. We then have them move their eyes down as if they're looking at the six or as if they're pushing the scotoma down to the bottom. And then we try it with the nine.
The idea is at some point in this exercise, the star in the center of the clock will become clear. And for most people, they have one or two areas or directions in which they move their eyes in which the star appears. And so I usually try to have them decide if the star is clearest when you move your eyes to the right
towards 3 o'clock, and the star is clear when you move your eyes down to the six, try moving it to the three and try moving it to the six and see which position is most comfortable for you to hold.
So what you're doing is you're just guiding the person through looking at the clock, pushing their scotoma to one side or up or down, and trying to figure out which position the star in the middle becomes clear. The star in the middle of the clock is going to represent the print that they want to read. Once the person has determined which direction they need to move there scotoma to see the best, we call that your sweet spot.
Okay, you've found your sweet spot. If you move your eyes to 3 o'clock or you move your eyes to 4 o'clock or 5 o'clock and you hold it, that's your sweet spot. I wanted to stop at this point and see if there were any questions about this process because it’s pretty crucial to what we're doing next. Alright, everybody's clear on the process? Then we'll move on to the next slide.
Okay, a few things to pay attention to in this process. You want to hold the paper with the large letters fairly close, and this is really important. Most of us as we age, we move things farther and farther away in order to see them. And a lot of people who are older with
macular degeneration are used to holding things pretty far away in order to see them. And a lot of times, if I just work with them to move the page closer, it’s a very dramatic response. Usually when the page gets to be about 4 to 5 inches or 6 inches away from their nose, they say, "Oh, oh my gosh I can see that."
So what's really happened is that we are re-training these individuals on a new way to read. So it's not just helping them locate the sweet spot, but it's also teaching them that they need to move things closer in order to see them better. And again, moving things closer makes them bigger, and when they're bigger they are easier to see around the blind spot.
Most of the time if someone has a pair of glasses that helps them to read, we let them do this process with the glasses on. But I would ask that you do not use glasses with bifocals or trifocals because I’ve found over the years that the bifocal and trifocal pieces interfere with trying to find the sweet spot. When you move your eyes down to the 6 o'clock position, it makes it difficult when the bifocal is there.
Once a person has figured out that say their sweet spot is at 3 o'clock, we’ll just use that, I have the client practice resting their eyes and then moving their eyes
to the 3 o'clock position and holding it, and I call that resetting. So this is when you can use the page with large letters that you've written. You can have the person rest their eyes, and then guide them in locating the first letter on the page. You know if it's an N, for example, just say, "Okay, look at the N. The N is missing because you're looking straight at it. Now move your eyes to 3 o'clock and can you see the N?" And I just have them do that going over one of those pages of letters so that they can practice the process of moving their eyes to a certain side and holding it and trying to identify what the letter or the object is.
Sometimes to make it interesting, I might have them practice the technique on a variety of items in front of them. My face – I might say, "Go ahead and try to see the earrings I'm wearing or the necklace I'm wearing. Can you tell me what this card is that I'm holding up in front of you?" So we just bring a lot of different items and have them practice looking at it, they can't see it. They move their eyes to the sweet spot, the item comes into view. Again, reminding them or you guys that thinking of your scotoma as a curtain or a blind that needs to be moved up or moved to the side in order to look through a window is usually an analogy that most people really understand.
Once the individual is comfortable with locating their sweet spot with their good eye, I then introduce the idea of using the same concept to locate the sweet spot in the bad eye. And I wanted to talk a little bit about why that was important. A lot of times with macular degeneration, the disease does not progress the same in both eyes. So in addition to the brain not to getting good information from both eyes, sometimes what happens is the sweet spot of vision is different in both eyes.
So even though they may not be using their bad eye to read, I do like to check to see where the sweet spot is for their bad eye because if the sweet spot is in a very different place for the bad eye, I would recommend patching it. So for example, if we tested the right eye and the sweet spot is at 3 o'clock meaning the person needs to move their eyes to 3 o'clock in order to see the center star more clearly, and then you test the bad eye and you find they need to move their eyes say to nine or 10 o'clock, which is a completely opposite direction, in order to see the sweet spot with the bad eye, that's not something you can do to read. You can't move both eyes in opposite directions.
And since the bad eye isn't going to give a clear picture to the brain, I recommend that patients in that
situation go ahead and patch their bad eye when they're working on eccentric viewing for reading and anytime they're trying to do a reading task because what that does is just cancel out that light and that image to the brain, and the brain doesn't have to struggle to try to really put together two different images to see. And actually, after a couple of lessons and patching the bad eye, the individuals really do talk a lot about being able to see better, not being so tired and frustrated. They just talk about it being a much more positive experience. Next slide please.
Okay, so I do want to talk about some common challenges. Most of the time my clients complain that it's really hard to hold their eye still, and I encourage them to just think about how a person normally reads. Normally, you read by placing your eye at the beginning of the line and moving your eye in a nice, smooth way across the line to read. So your eye is used to moving from side to side when you read. When you learn to read with your sweet spot, it's going to be a very different process because you will no longer be moving your eye to read, you'll be holding it still.
So I really encourage them to do a lot of homework in this area. And when they first get started, I have a number of those pages as letters and some
flashcards and some other things. And I just tell them, for three or four times a day, I want you to take these materials, and for only about five minutes just practice finding your sweet spot with the material and holding it, and holding it for as long as you can. And then once they begin to be able to do that we'll move on to things that are more complicated. But I do encourage them that this is something that is very different to what they're used to doing, and it does require a great deal of practice. I spoke about earlier the sweet spot being different in both eyes so we don't have to talk about that again. May we go to the next slide?
So I just wanted to talk a little bit about the other thing regarding good eyes in bed eyes. With macular degeneration, it’s not completely uncommon that individuals have a rapid change of vision. They may develop wet macular for example in their good eye, and the vision in the eye might decrease really rapidly. And so what happens in that situation is the good eye and the bad eye switch. So my right eye may have been dominant and my better seeing eye, but then I had a vision loss, an additional vision loss in that eye, and now my right eye is my bad eye. And my original bad eye is now my good eye. We call this the switch. When this happens it's really important to understand that your brain will need a lot of time to reprogram itself.
For a long time your brain has been paying attention to mostly the information coming from your good eye. And when your good eye suddenly doesn't work, the brain has to switch and begin paying attention to the new good eye which was your bad eye. This process does not happen quickly and does not happen without a lot of time and patience. Again, patching the bad eye, in this case the new bad eye, can really help the individual’s brain to adjust more quickly. I also encourage them to really practice reading every day with the new good eye so that they can exercise it and exercise the brain to help them learn how to read with that new good eye.
It's really important, patients and clients need a lot of encouragement and they need a lot of support during this process. So before we go on, I just wanted to see if there were any questions at this time regarding how to locate the sweet spot and how to practice using it. Okay, I must be doing a good job then. Next slide please.
Okay, techniques for identifying letters and numbers. Again, this is a reiteration to what I just said. The individuals will need to practice a lot, so I try to provide to them a lot of information and materials for which they can do that. And I encourage them to
practice every day and that this process may take up to three months to get good at. To learn to read with macular degeneration and eccentric viewing, the full way may take as long as a year. So it's not something that's going to happen quickly.
So here is a list of items that they may want to read. I usually start with large print letters and numbers on the page. Sometimes I might write out a list of phone numbers so they can get used to reading the phone numbers, shopping lists, which are kind of one word, shopping lists, and attached in the documents I also have lists of words, animals, plants, cars, fruit, flowers. I try to make lists of words that are common, easy to identify, and interesting for the person to read.
A really funny story is I usually was working with the women so I had a lot of shopping lists and flowers. And then I realized that when I was working with men, I might have more success if I had lists of things like tools and cars. And so it was really funny that when I started losing a list of cars and tools that the ability of the men to read improved quite dramatically. So that's just a kind of funny side note there. Next slide please.
This is blank and I don't know why. I guess, Doug, our picture didn't load up. But it was a picture that I had
included that had just pictures of things that the individual could read. Next slide please.
So the third step in learning to read with low vision or with eccentric viewing is what I call hold your eyes still and move the paper. And remember, I'm just going to refer her back to the conversation I had. We all learned to read by moving our eyes across the paper, and we use that technique our whole lives. But what happens when you have macular degeneration and you try to read like that is that your blind spot sort of jumps around the page and it covers everything, and you just really can't make heads or tails of what you're reading.
So the next step is once you've learned to hold your sweet spot still, and once you've mastered reading numbers and letters and maybe some short words, we're now going to practice holding the spot still and sliding the paper across the spot and begin to read longer words. Again this process is going to take a lot of time and a lot of practice. Next slide please.
So for practice materials, you'll want to have several types of reading material in large print. Again, I start with short words or phrases, things like blue moon or green sum, something that people are really used to reading, and then I work my way up to maybe bible
verses or nursery rhymes. I have lots of material that I've found that helps people feel better, it's sort of like phrases and short things that are kind of common sense sayings that make people feel good. And so I basically blow those up in really large print, and those are the materials I give individuals for practicing this next phase. Next slide please.
So what you're going to do is you're going to have the individual put the piece of paper with large print on the clipboard, and I find it’s easier if they put their elbows on the table. And they hold their eyes still on the first letter or first word, and they should be able to read that now that they've learned that skill. And then holding their eyes still, they're going to slide the paper across the sweet spot. And what that does is that moves the words across the spot of viewing, and they read each word or each letter as it comes across their clear spot or their window.
I always liken this for some of my clients to looking through a microscope like you did when you were in school, and sliding the slide under the microscope. So you’re looking through a small hole and you're sliding the thing you want to see across that hole. Again, this is something that they're going to need to practice a lot, and so I try to make it really fun. And basically it's not any more complicated than that. They just hold
the paper in front of them, they find the first letter, and they slide the paper across. Then once you get to the end, you slide the paper back, move it up a line and move their eye down a little bit, and slide the paper back across.
Now when an individual begins to feel more confident with this process, this is when I might introduce magnification. So up until this point, we've only been using large prints. And what I do is I try to incorporate things they need to read in their daily life, and I make it in large print so that they can practice their eccentric viewing as they go about their daily life. So for example, I might have their medications labeled in large prints with a 3 x 5 card so then when we practice reading, they pick up medication, they hold the card, and they practice using the technique that I taught them to read the card.
I might write their names and phone numbers of the people they like to call in large print, and again that's something else they can practice reading. Calendars, putting events on calendars, making labels for food items or cleaning products, anything that you can put into large print to encourage the individual to read using this technique will help them to learn it faster.
Now what I’ve found when the person is ready to incorporate magnification is we have a conversation about starting with a lower power magnification like a 3X or a 4X, and combining the magnification with large print, but not as large of print as they have been reading. So the ultimate goal for individuals is to get them to be able to read the smallest print that they need to read in their lives. Now for some of them that's the mail, for some of them it might be food labels, for other people it might be the newspaper. All of these items are pretty small print. And so the ultimate goal will be using a combination of eccentric viewing and strong magnification to read that small print.
But what I like to say is you can't go out and start driving an 18-wheeler, you kind of really have to learn how to drive in a small car first. So really this is a step-by-step process. You learn the eccentric viewing techniques using large print and no magnification. Once you're comfortable with the technique, then you add smaller print with a low-power magnifier. In my agency, if I find individuals are needing to do this, we'll recommend a lower power magnification for starting. And then as they get better, we might switch it out for something stronger. So a low-power magnifier has a bigger viewing area and it just helps make the individual more successful. So what they're
going to do is they'll hold their print or have their print on a clipboard with one hand, they'll hold the magnifier with the other hand, and keeping the magnifier and their eye still, they'll move the clipboard across the space.
So just like the microscope analogy, you're now holding your sweet spot still, holding the magnifier still, and sliding the paper. It's really helpful if the individual reads sitting down at a table so that their elbows are nice and sturdy. This is also the point at which I would introduce reading with a video magnifier or a closed circuit television because these machines are designed to help individuals read by moving the paper. If you have a CCTV that you could work with that has a tray, the tray moves the paper for you from side to side, or you put your hands on the tray and move the paper. So the individual can practice looking and holding their sweet spot still on the screen and sliding the paper across. As the words move across the screen, they're able to see it.
Again, I always start with very easy short material. And as the individual gets better and more efficient, we move into longer and longer passages. Again, this process takes a lot of time and a lot of practice. Alright, so this is really the summary if you want to go to the next slide.
Learning to read with eccentric viewing is a very complex process that requires a lot of time, patience and practice. I wanted to say that the majority of individuals that we work with will practice this technique with their vision rehabilitation therapist which is a teacher that has gone to school to learn how to teach people who are visually impaired. Other practices may have someone called a low vision therapist that would also be able to teach these skills.
Through this seminar, I think most individuals could get really good basic understanding of how macular degeneration affects the macula, understanding the concepts of locating a sweet spot, discussing things like why one eye might see differently than the other eye, and I tried to include a lot of materials to give you ideas for practice. But if you're trying to do this by yourself and you're really having a lot of trouble, I would recommend contacting a local agency that works with people who have vision loss, and having a teacher come out to your home or meet with you at the center to really work with you on learning the techniques more efficiently.
Reading with advanced macular degeneration is possible, and it can allow you to maintain a good quality of life and most importantly your
independence. This technique was developed through lots and lots of research, I believe primarily through the Veterans Administration. There are manuals and there are lots of papers and research indicating that the technique does work and that an individual who practices and takes the time to learn the steps can actually learn to read again even though their vision loss is pretty significant.
Again, it's really important to ask the clients to have patience with themselves. Taking the time to explain to them that a lot of what's going on is the brain, and the brain needing to adapt. So it's okay to go slow and take their time. And most importantly, it's really important to try to make reading fun just like we do with our kids. Try to help them by reading things that are important to them and that are fun to read, and that makes the whole process go a lot more smoothly.
At the next slide, there are some resources. The best way to find a low vision therapist or a vision rehab therapist in your area would be to go to the American Foundation for the Blind's Directory of Services, and I've included the website link there. You just need to type in your state and your city, and it should bring up some services located near you. If you have any difficulties, you can contact me at any time and my number and information is there.
So I see that there is a question that has come up. I'm not sure if I'm seeing the entire question. Is there any difference for someone who had [Inaudible 00:44:16] for macular dystrophy, I’m probably not saying that right? Is this method to use this sweet spot the same? My good eye has amblyopia. Is there anything specific that could help me improve reading ability using my lazy eye?
So those are both good questions, I actually have found that this technique does work with a lot of different eye conditions. I think anytime you have an eye condition that affects the macula and makes reading difficult with the central vision, you can try this technique and see if you get can indeed locate a sweet spot or a clearer spot somewhere on your retina and learn to use that to read. So the best advice I would have in that for you would be to actually just go ahead and try the techniques and see if you can find a sweet spot to use.
I'm not sure about amblyopia, but I think again if you want to cover your good eye – let’s see, your good eye has amblyopia – again, if you wanted to try to patch the eye you're not using, anytime you do that and you practice reading with your lazy eye as you
call it, it could help to make it a little bit easier. I'm not sure. I haven't tried that with a client.
The next question is how long do you keep the bad eye patched? What I tell my clients is to only patch the bad eye when they're trying to read because a lot of times they need the information from their bad eye if they're doing some other tasks or they're moving around. We practice patching the eye mostly for the reading exercises. If they find it's helpful for doing other tasks, then we'll patch it as well.
For things like cooking, sometimes we’ve found clients that are trying to use knives or trying things like pouring. When they've got both eyes open, their brain is really having trouble with the depth perception. So we may have them patch the bed eye to just allow the brain to focus on the good eye for things like using knives and pouring. But at the same time, as a vision rehab therapist, we'll also teach non-visual ways of doing those things as well. If the better eye is not your dominant eye, the best way to correct that is to cover the dominant eye. And that sounds like a classic case of good eye, bad eye switch to me.
A video magnifier is another word for CCTV. CCTV stands for closed-circuit television. And just a quick description of these machines, basically it's a camera
that can be connected to a computer screen or a television screen or sometimes the camera and the screen are one unit. And the camera takes the picture or shows the image live, and it gets projected onto the computer screen or the TV screen. And the video magnifier is designed to allow you to turn a button or a dial and increase the magnification of the image.
And the more fancy CCTVs or video magnifiers allow you to do other things like change the color. You can change the print so it's white on black, for example, or it allows you to increase or decrease the brightness of the image. So CCTV's are devices that are sometimes recommend to clients to help them to see. The hand held magnifiers and the stand magnifiers are a typical thing that we would recommend to clients for using magnification because they're less expensive. But for some of our clients, a CCTV, which can range in the price range from $1,500 to $3,000, for some clients that's the tool of their choice. So we try to make sure that we give clients all options, and we teach them using all the tools that are available to them. And then they decide which one they want to use.
Okay, so the next question asked me to repeat my comment about the non-dominant eye. Yes, that was a question that came through. Someone was asking if
their good eye is not dominant, how to fix that or how would that work. That's pretty much the same thing I explained earlier which is the good eye, bad eye switch. At some point, the brain learns to pay attention to one eye for whatever reason. And that eye is called your dominant eye. For most people, I just call it the good eye. It's the eye that works the best. But for the brain, the brain has one eye or a dominant eye that it pays attention to. If your dominant eye’s vision is not good, the question was how do you teach the brain to pay attention to the non-dominant eye. And the best way to do that is to patch the dominant eye.
The next question is do you find that after sufficient practice, individual is able to read with magnification, there are limits on the length of the time the technique can be used before needing to rest the eye, or can training allow eventually for the use of the skill for significant lengths of time, for example an hour or more? That's a really great question, and what I like to tell clients is that everybody's different. I have some clients usually who are younger and who's eye condition hasn’t deteriorated too badly yet that they’re actually able to read for long periods of time, taking a rest maybe every 10 or 15 minutes to look away from the screen and do something else.
But for the majority of my clients that we are working with who have macular degeneration, they are over the age of 75 or 80. A lot of my clients are in the range of 85 to 95, so these individuals are not going to be reading for hours at a time. We are really just trying to get them to be able to read for independent living and mail and the really critical things. And, yes, if they have a lot of practice and they have the right tools, they may be able to read some short newspaper articles or magazine articles or maybe some books, but only a little bit at a time.
The next question is, is there a standard of large print – 12 or 16 point block letters, for example? I think if you order items in large print, for an example Reader's Digest or some of the other materials that can be commercially available, the standard size is usually 14 to 18 point, which is not very large. The majority of the materials that I have attached for your clients to practice reading on are going to range from 72 point down to probably 24 point, bold. So again, when I'm training individuals in this technique, I want the print to be pretty big so that they're not struggling to see. That makes it very success oriented. But the goal is over time to get them to be able to read the smallest print that they need using a combination of eccentric viewing and magnification.
For the majority of these patients or these clients, they are not going to be able to read small print without significant magnification. The reason we call it eccentric viewing or eccentric reading as you called it is because you are no longer reading the traditional way. Eccentric viewing basically means you're looking through another part of the eye in order to see. So a normally sighted person whose eyes are working perfectly well can look through their straight part of their central vision and see clearly. For folks with macular degeneration, they have to push that blind spot out of the way and look around the blind spot using a different part of their eye, a different part of their retina. And that sometimes makes them look like they're looking out the side of their eyes, and that is why it's called eccentric viewing.
These are great questions, by the way. And again, my contact information is on the PowerPoint, and so if you had additional questions after reviewing the material, you can email or call me at the office at your convenience and I'd be happy to answer any additional questions.
There's a question that was posted that is referencing my comment regarding handouts. I think Doug will address that again at the end of the session, but yes, I have created a number of practice reading materials
that will be attached to the seminar once it is uploaded onto the Hadley website which is my understanding. Doug, did you want to comment at this point?
Doug AnzlovarYes, thank you Nancy. We're coming to the end of our seminar, but I want to thank Nancy for her comments and her presentation. And a lot of you have been entering questions into the text chat, but I wanted to give just a couple of minutes’ opportunity for anyone who may not be typing or want to type into the text chat who wants to ask a live question through the microphone. So I'm going to release to mic here and open it up to participants, and if anyone has a voice question, please feel free to chime in at this point.
Okay, with hearing no questions, I'm going to go ahead and bring today's seminar to a close. Just a couple of reminders here, this seminar recording, the PowerPoint that was shown today, as well as additional handouts, I believe there are going to be six or seven handouts, resources are going to be archived with this audio recording both on the Low Vision Focus website which is www.lowvisionfocus.org, as well as the Hadley School website, www.hadley.edu. The recording on either website and resource documents are available 24/7.
Each of our popular Seminars@Hadley is also now available as a podcast, which you can download and listen to at your computer or on your mobile device. And we've recently added a Twitter hashtag, so for those of you that are on Twitter, Hadley’s Twitter hashtag is hashtag or pound sign SeminarsAtHadley, it’s a capital S in the word Seminars, capital A in the word at, capital H in the word Hadley, no space. So pound sign or hashtag, SeminarsAtHadley.
Thank you for participating today. We value your feedback. Please let us know what you thought of the seminar, and if you have any suggestions for future seminar topics by sending an email to [email protected], and also by completing the short survey that I'll launch in just a moment.
I'm going to go ahead and hand the microphone back to Nancy so she can give her final comments and her farewell. So Nancy, take it away.
Nancy Parkin-BashiziThank you very much, Doug, for allowing me the opportunity to participate in my very first webinar. It was very interesting and very, very fun. And I also wanted to thank the group of you who took the time to join us today. Your questions are really good, and I'm
actually going to ask my doctor the question that came through earlier about the other eye disease. I look forward to hearing from any of you who may have additional questions, and I hope you all have a great rest of the week. Thank you
Doug AnzlovarAnd thanks again, Nancy. Some additional comments here – for those of you who wish to earn continuing education hours or credits for today's seminar, today's quiz will be open for approximately 15 minutes after the seminar is aired. You are allowed two tries per registration to achieve a passing grade of 70% or more. If failed twice, you would need to re-register and pay the registration fee again. And you will have up to seven days from the first failed attempt to try again. Once passed, the certificate will be issued electronically only, and it will be in a PDF format right after they short survey and evaluation. The system will provide access to you within seven days of successful completion to view, save, or to print the certificate.
Lastly, if you are having any technical difficulties please feel free to contact our helpdesk at [email protected]. For general inquiries, you're certainly welcome to contact our student services
So thank you for your participation today, and again please offer any suggestions for future seminar topics either in the area of low vision or other areas that you are interested in. Thanks, and have a great day.
