from top to bottom or haphazardly read single words from the screen. Words are often guessed. Fluent and meaningful reading is no longer possible.

Specialty: However, motivated patients with a strong wish to read may not experience these problems with CCTV-magnifiers. Patients suffering from AMD need high magnification values and a lot of patience, as reading speed is reduced enormously. However, the highly visually impaired patients who are accustomed to reading will eventually regain their reading ability when training over a longer period of time.

20.8Electronic Reading Instruments

If reading ability cannot be achieved with magnifying aids and the patient would very much like to read, a reading system with acoustic output can be tested. Text samples and books are scanned in a relatively short time and converted into synthetic speech of varying quality. Several manufacturers offer easily operated systems for older low vision patients. After some time of getting accustomed to the device, patients also get used to the synthetic maleor female-pitched voices. Nowadays, very natural sounding voices are available. Absence of auditory impairment is mandatory.

Newly available is also a system allowing the download of newspapers and magazines via modem. The patient can choose any article from them to be read to him aloud with the help of a systematic organization of articles and headlines. The number of newspapers - especially local ones - and magazines offering this service is still very small.

The iPad may also be used as an audio reader of a variety of texts, magazines as well as books downloaded from the internet. In the United States numerous newspapers are now offering this service. The current development of an additional camera in connection with a new text recognition software may in the near future present patients with an audio reader suitable to read to them any chosen text.

Advantages: Scanning typed letters, scripts and, most of all, books; this opens the patient a door to recent literature.

Disadvantages: Lines and columns may not be recognized accurately, posing a problem when reading newspapers or bank statements. Newspaper articles have to be scanned according to the sequence of their columns. For bank statements templates are available.

Fig. 20.9 DAISY player

Unfortunately, visually handicapped individuals often depend on help for these tasks.

When using audio libraries the so-called DAISY format is now standard. Here the audio data files are converted to MP3 data files. In this way it is possible to open a single chapter, or a certain page, or to find a particular sentence as well as to jump to a certain part of the text which oneself previously defined. Further, it is possible to be informed about the length time it will take to reach the end of the text (Fig. 20.9).

20.9Additional Aids

•Book holder. Patients with AMD are definitely advised to use a book holder or easel. Book holders may be easily positioned on any table, even if there is little space. Adjustable book rests are practicable as they may be set at different angles, e.g., for reading, writing or doing a crossword puzzle. There is a given distance to the reading material, which the patient easily learns to keep. The angle of the book holder prevents bending towards the text at low reading distances, thus offering a better and more relaxed posture. As an alternative, there are also tables whose height and angle can be freely adjusted for individual positioning.

•Illumination. Elderly low vision patients need a lot of light. If illumination is good it may even be possible to select a lower magnification for reading thereby enlarging the field of view or the section that can be read. Hence, the illumination of a room should be optimized. For manual tasks at low distances or

reading, adequate brightness can only be achieved by direct and bright illumination of the spot in question. Patients should be advised to furnish their home with several of these brightly illuminated areas. Very practicable are adjustable spotlights that can be twisted and turned into almost any position, thereby simplifying the use of low vision aids and book holders. Table lamps are also easily shifted in the required position; alternatively, modern, cost-effective foldable lamps provide good homogenous illumination. White light is usually preferred. Especially cold

light or lamps with reduced heat emission are advisable, as the reflected heat may subjectively impair reading comfort over a longer period of time. We recommend twin intensity desk lights with 50-W halogen low-voltage bulbs with a glass cover in front of it. Small spots with high illumination intensity are not recommended as they may cause blinding reflections.

20.10Noteworthy Details for the Provision of Low Vision Aids

•Reading technique. The ophthalmologist ought to observe the reading technique of visually impaired patients suffering from AMD. They should be asked to practice reading over a period of two weeks, regarding this as their “homework”. For this, the patient chooses an article of interest from the newspaper. Headlines can usually be read because of their large print. For reading the regular font size, a magnifying LVA is lent to the patients.

Reading excercises are explained to the patient in

detail and practised. By positioning a small black strip of paper beneath the line that is currently being read, it is possible to prevent losing the line or skipping to the one above or beneath it. Signature aids for blind people may also prove to be helpful. Reading with a finger, a pen (black, if possible) results in eye-hand coordination and a feeling of increasing confidence when reading. Reading with an extended finger is performed by slowly gliding the finger along the line to be read, then returning quickly to its beginning and shifting a black strip of paper beneath the next line. Reading ability can be improved or regained if the described techique is trained three times a day for 10–15 min. If this succeeds, the progress will be easily noticed, provided there is enough motivation for the elderly AMD patient to participate in reading training.

•Provision of low vision aids for AMD-patients as early as possible. Even in patients with slightly

reduced visual acuity in the beginning of AMD, prescription of an adequate low vision aid is needed within a short time [2]. Often an add-on to his glasses - to give better vision in the near range - will be sufficient. Prescribing +4 D or +5 D to the refraction results in increased reading comfort and speed. The major goal is to maintain the reading ability. Once reading ability has been lost for 2 or more years, it is most difficult to regain it. Reading with an LVA requires a great deal of concentration as well as motivation as it can prove to be an enormous effort. The elderly low vision patient should be motivated not to give up. Typically, magnification needs to be higher in the beginning and may be decreased again once the reading ability is restored. Reading does not damage the eyes! This has to be

explained often to elderly visually handicapped patients. They must understand that reading and training to read will result in a better usage of the residual visual function and therefore improvement of reading ability.

The patient needs to be prescribed a LVA as quickly as possible if there is macular pathology including exudates or hemorrhage. In the past a LVA was not prescribed until there was considerable loss of visual acuity. However, experience taught us to provide LVAs or temporary LVAs as soon as possible to support the patient’s reading ability even at the very early stages of disease. Inexpensive LVAs are available, and they maintain reading ability and simplify the prescription of LVAs in the future [2].

Covering the second eye with an opaque spectacles glass is often cosmetically disturbing for the elderly low vision patient. Nevertheless, it is important to occlude this eye, since even a highly reduced visual acuity may cause inconvenient double images.

Magnifier spectacles and spectacle telescopes may only be used when the visually impaired is stationary; he will not be able to walk by using such a device. Low vision aids offer many advantages and restore the elderly low vision patient’s reading ability, however, their disadvantages also have to be accepted. It is advisable for the low vision patient to be accompanied by a member of his family or a friend when being counselled and trained on the use of a LVA.

20.11 Basic Information on Prescription

Low vision aids may only be prescribed following detailed and, especially in elderly low vision patients, repeated testing. It is recommended to lend the chosen

LVA to the patient for a period of 8–14 days accompanied by all the necessary instructions on its use. Specialized low vision advisory centers at the department of ophthalmology of a university, a hospital, specialized ophthalmological surgeries or optometrists will be able to prescibe the correct LVA. Final fitting of the device is usually carried out by an optician.

In Germany, LVAs are usually paid for by the patient’s health insurance. Their regulations state that a LVA is adequate when it enables the patient to read newpaper print. Purchase and usage of the LVA should be as cost effective as possible. In order to obtain a LVA from one’s health insurance, its necessity has to be proven. Thus, in Germany the regulations of a health insurance company will not allow the prescription of a LVA solely used for watching TV.

Summary for the Clinician

›The low vision patient suffering from AMD may regain his ability to read printed media with the help of optical and electronic low vision aids [8, 10, 11]. This increases not only his independence, but will also improve his self-confidence [2]. Not every elderly low vision patient wishes to read or write books. However, there is an enormous variety of low vision aids available, especially for everyday use [8].

›Acceptance of the LVA by the elderly low vision patient is important as well as his acknowledgement of the visual impairment.The desire to read will influence the patient’s motivation. There will be an enormous increase in the number of visually impaired patients because of higher life expectancies. Therefore, more specialized low vision centers are needed at the ophthalmological departments counselling, caring and providing for the visually impaired. Especially when dealing with elderly low vision patients one has to keep in mind that prescribing and fitting visual aids as well as training patients to use them will be a much slower process than for a younger patient. A lot of patience is needed and elderly patients deserve to be treated with respect and kindness.

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