March 2013

Low Vision:

A Guide for Educators

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Low Vision:

Developed by:

Julie Garden-Robinson, Ph.D., R.D., L.R.D., Food and Nutrition Specialist

Sherri Stastny, Ph.D., R.D., C.S.S.D., L.R.D., Assistant Professor, Health, Nutrition and Exercise Sciences

Casey Kjera, R.D., Program Assistant (former)

Krystle McNeal, R.D., Program Assistant (former)

Stacy Wang, R.D., L.R.D., Extension Associate

A Guide for Educators

Target Audience

Educators who teach/present to those with low

vision

Activity Time

30 to 45 minutes, depending on activities

Objectives

• Participants will be able to describe

characteristics of low vision.

• Participants will know the main causes of low

vision.

• Participants will learn techniques to adapt

educational presentations and handouts for

low vision audiences.

Preparation and Supplies

• Obtain copies of handouts for each participant

• “How to Teach People With Low

Vision

• Activity suggestion: Peanut butter and water

glass challenge

• Materials:

• Peanut butter

• Sandwich bread

• Plastic knife/spoon (for spreading)

• Plates (paper plates may be most

practical)

Slide 1 – Introduction

Introduce yourself and welcome the

participants. Have the participants introduce

themselves and name a reason for attending.

• Bandana or a semishear material (for

blindfold) that limits sight but does not

eliminate it. You also may use an eye

patch to cover just one eye

• Water and cups

Lesson Plan

Julie Garden-Robinson, Ph.D., R.D., L.R.D., Food and Nutrition Specialist

Sherri Stastny, Ph.D., R.D., C.S.S.D., L.R.D., Assistant Professor, Health Nutrition and Exercise Sciences

Casey Kjera, R.D., Program Assistant (former)

Krystle McNeal, R.D., Program Assistant (former)

Stacy Wang, R.D., L.R.D., Extension Associate

Slide 3 – Overview

Briefly give overview of the presentation.

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What is low vision?

Slide 4 – What is low vision?

Slide 5 – Low Vision

The World Health Organization defines low

vision as 20/70 to 20/400. Remember, perfect

vision is 20/20.

Vision acuity (the clarity or sharpness of vision)

typically is measured using a Snellen Chart (the chart

shown on this slide) and is expressed in a 20/20

format. Normal vision is considered to be 20/20. If a

person has 20/20 vision, he or she can see clearly at

20 feet what normally should be seen at that

distance. On the other hand, if a person has 20/60

vision, this person must be as close as 20 feet to see

what a person with normal vision can see at 60 feet.

Legal blindness is defined as 20/200 vision. The

World Health Organization defines low vision as

20/70 to 20/400.

Sometimes individuals wait too long to get help with

their low vision. Older adults may accept low vision,

thinking “it’s just part of getting older.” It doesn’t have

to be. Those with low vision simply may be in denial,

so they don’t seek help. Vision rehabilitation is more

successful if individuals get help before their vision

worsens. 20/70 is a “red flag” that the individual

requires relearning of everyday tasks. At 20/70, an

individual will have trouble recognizing faces, writing

a check and seeing the television.

Goals of vision rehabilitation include:

• Teaching the individual to use residual vision

(remaining vision), such as use of eccentric (side

vision) viewing

• Helping the individual find optical devices and

nonoptical aids

Only trained professionals can offer vision

rehabilitation. Not all eye doctors are trained in low

vision. For example, contrast sensitivity testing can

reveal more vision difficulty than visual acuity, yet not

all optometrists use contrast testing as part of their

routine exam. Asking patients if they have difficulty

with cooking, shopping, reading and other activities of

daily living probably is needed with older eye exam

patients.

With good assistance, 90 percent of low-vision

problems can be addressed, according to vision

research. Even those with 20/400 vision can be

helped.

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What is having low

vision like?

20/70 20/200 20/400Photo courtesy of the Cao Thang

International Eye Hospital

Slide 6 – What is having low vision like?

The first picture shows 20/20 vision.

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Support and review of this project was provided by:

• A Healthy Vision Community Grant from the

National Eye Institute in collaboration with the

North Dakota Optometric Association

• Dr. Michael Ranum,

Low-vision Specialist, Dakota Eye Institute

• Susan Ray-Deggs

NDSU College of Human Development and

Education

Slide 2 – Support and Review

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Symptoms

• Loss of central vision

• Loss of visual field

• Loss of color vision

• Loss of ability to adjust to glare

• Loss of ability to see in dark areas

Slide 7 – Symptoms

Central vision is used when a person is driving,

reading or performing other activities that use

fine, sharp and straight-ahead vision. An

example of central vision is recognizing faces at

the mall.

Visual field is the total area in which you can

see objects using peripheral (side) vision while

looking at a central spot. Driving and finding

one’s way in an unfamiliar area requires good

peripheral vision.

Glare can be a major problem, especially when

doing activities in the kitchen. The issue of

reducing glare will be addressed in greater

detail later in the presentation when cooking is

discussed.

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Causes

Macular degeneration

Cataracts

Glaucoma

Diabetic retinopathy

Slide 8 – Causes

• Macular degeneration affects your sharp,

central vision, so what you see is blurry and

tasks such as reading and driving become

difficult.

• Cataracts are a clouding of the lens in the

eye that affects your vision by creating a

cloudy image.

• Glaucoma is a disease that affects the optic

nerve, leading to low vision and even

blindness.

• Diabetic retinopathy damages the blood

vessels in the retina of the eye, which causes

vision loss and even blindness.

**Damage from cataracts can be corrected with

surgery, but other eye disease damage usually

is irreversible.

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Normal

Vision

Photo courtesy of

the National Eye

Institute

Slide 9 – Normal Vision

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Macular

Degeneration

Photo courtesy of

the National Eye

Institute

Slide 10 – Macular Degeneration

Living with macular degeneration, this is what

the picture might look like.

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Cataracts

Photo courtesy of

the National Eye

Institute

Slide 11 – Cataracts

This is what the same picture looks like for a

person with cataracts.

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Glaucoma

Photo courtesy of

the National Eye

Institute

Slide 12 – Glaucoma

This is what the same picture looks like for a

person with glaucoma.

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Diabetic

Retinopathy

Photo courtesy of

the National Eye

Institute

Slide 13 – Diabetic Retinopathy

When a person has diabetic retinopathy,

oftentimes “spots” block their line of vision,

whether reading, cooking or doing other activities

of daily living. With low vision, a person is not

blind, but vision definitely is impaired.

Transition to next slide:

The word “blind” can be misleading. Often people

have reduced vision that is not correctable (“low

vision”). However, one can take important steps

to live with low vision.

Slide 14 – Risk Factors

The first step is to prevent low vision from the

start.

Diabetes can be kept in check with controlled

blood pressure, blood sugar and blood fats. In

fact, high blood pressure is an independent risk

factor for diabetic retinopathy.

• You can control these through diet, exercise,

medication and regular medical care.

• Poor diets that are low in essential vitamins

and minerals and a lack of physical activity

may cause or contribute to the development of

low vision. Obesity and related diseases such

as sleep apnea cause “neovacularization,” or

the forced growth and rupture of small blood

vessels in the eye.

• Smoking reduces the amount of oxygen to the

eye; our eyes need an oxygen-rich

environment to work properly.

• Poor health habits such as not having

regular eye exams and not getting physical

activity can lead to low vision.

• As our eyes get older, the risk of low vision

also increases. Wear amber-colored

sunglasses and wide-rimmed hats for eye

protection at any age.

Slide 15 – Statistics

Low vision that is not correctable is

increasing, partly due to an aging population;

we are living longer. Eye injuries also

contribute to low vision. A recent study found

that 70 percent of people with low vision who

could be working are not because they do not

know how to adapt. A recent Australian study

found that $1 spent on preventing vision loss

and eye rehabilitation returns $5 to the

community. More veterans are coming home

with eye injuries than lost limbs. Personal

consultation with an occupational therapist,

low-vision specialist or other health

professional trained in low vision is imperative

to help the individual live with low vision. This

program offers tips for the individual with low

vision, plus tips for those serving people who

may have low vision.

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Font Styles

•Do not use

BroadwayNo

•Do not use Lucida CalligraphyNo

Slide 17 – Font Styles

Avoid decorative script and very condensed

(letters that are very close together) fonts.

Slide 18 – Font: Print

For typed print publications, serif fonts are best.

“Serif” refers to the semistructured detail on the

end of letters, or the “feet.” For example, Arial is a

sans-serif typeface and Times New Roman is a

serif typeface). These little “feet” can help guide

the readers’ eyes and provide a little more space

between letters. Examples of appropriate serif

fonts for print publications include Bookman Old

Style, Times New Roman and Georgia.

Slide 19 – Font: Projecting

For presentations that are projected onto a

screen, such as PowerPoints, sans-serif fonts are

easier to read than serif fonts. Examples of

appropriate sans-serif fonts include Arial, Century

Gothic, Tahoma and Verdana.

Those with low vision can change settings for

email and Web browsers to make them more

readable. Refer to the American Foundation for

the Blind website (www.afb.org/) for specific

details to change computer settings.

* This presentation is done in Arial font and is

bolded.

Slide 20 – Font Size: Print

The best size font for brochures and

handouts for people with low vision is 16 to

18 point. You should not use the standard 12-

or 14-point font because it is too small to

focus on and read.

Tip for those with low vision: Enlarge font size

on the computer before printing or reading

online.

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Presenting to Those with

Low Vision

Slide 16 – Presenting to Those with

Low Vision

Now we will discuss some simple adaptations that

can be made to improve the environment and live

active, healthy lives with low vision. First, we’ll

address how we can better lead presentations

using techniques that can help with learning.

Slide 22 – Font Style

These guidelines apply to projection and print

publications.

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Color: Print

Black letters on a

white background

are ideal for printed

handouts/brochures.

Slide 23 – Color: Print

Black on white is the best option for print

publications because white letters on a black

background use too much ink (plus can give

those handling the publication black fingers).

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Color: Projection

White letters on a

black background

are easiest to read.

Slide 24 – Color: Projection

When presenting a program that will be projected

on a screen (such as a PowerPoint presentation),

a black background with white letters gives the

greatest “brightness” contrast and reduces glare.

White letters on a dark blue background also can

be a very good color combination. Be sure your

screen doesn’t emit glare. Whiteboards used with

dry-erase markers make poor projection screens.

However, remember to ask each person with low

vision what colors are easiest for him or her to

read because some people may see some color

combinations better than others.

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Color

Colored letters on a

colored background

are very hard to

read.

Slide 25 – Color

This is the hardest to read and never should

be used because it creates glare and is very

hard for anyone's eyes to focus and read this

in print publications or projection

presentations. Remember that hand-written

notes also should follow the same rules: Use

black ink on white paper for ease of reading.

Slide 21 – Font Size: Projecting

The best size font for projection presentations

(such as PowerPoints) for people with low vision

is 32+ point font size for content of the slides and

36+ point font size for slide titles.

• The first graphic is 32-point font, which is

appropriate for content, but can be larger.

• The last graphic is an example of 36-point font,

which should be used for slide titles; however,

a larger font usually is the default on

PowerPoints for slide titles. For example, the

title on this slide is 48 point.

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Controlling Glare

Cover windows with blinds or drapes

Use shades on lamps

Slide 27 – Controlling Glare

Even if you make every effort to ensure your

handouts or PowerPoint presentations are

readable, glare in the room may make your

presentation a lost cause. These are general

recommendations for controlling glare in day-to-

day activities as well as during teaching

presentations. Later in this presentation, we will

discuss in further detail how to control glare when

cooking and eating.

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Remember This?

Diabetic

Retinopathy

Slide 29 – Remember This?

Remember this picture? This is what

someone with diabetic retinopathy might see.

Imagine trying to perform tasks in the kitchen

when your line of vision looks like this.

Imagine trying to prepare a bowl of cereal and

milk. Imagine trying to grab the bowl, the box

of cereal from the pantry, the milk from the

refrigerator. Would you be able to see well

enough to grab all these things, then open

and pour them into the bowl? Without spilled

milk? How would this effect your ability to eat

the cereal? Would you even try doing

something more complicated, such as

chopping fruit/salad greens or cooking over a

hot stove?

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Things to Note:

The best method is

to ask individuals

what the easiest

way is for them to

learn.

Slide 28 – Things to Note:

Some are visual learners; some learn best by

listening and some by reading. Almost everyone

is distracted by background noise, so be sure to

find a quiet room for presentations, close the

door and remind everyone to turn off his or her

cell phone. Each person may have different

learning style preferences and different

preferences for what color combinations or

adaptive tools work best for him or her while

trying to cope. Next, we will discuss tips for

cooking, eating and grocery shopping with low

vision.

Slide 26 – Document Adaptation

Shiny and glossy paper may create glare, and

turning pages can be difficult if they are too slick.

Using ALL CAPS is difficult to read for those with

low vision and many older adults as well.

Standard format: Use one font style and one color

for any educational material. Combining different

fonts, colors and other elements in any form of

communication can be distracting from the main

message. When writing notes, remember to avoid

nonstandard ink colors, such as pink and green.

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Resourceshttp://aota.org/Consumers/consumers/Adults/LowVision/35190.aspx

http://nei.nih.gov/lowvision

http://ndvisionservices.com

http://ndipat.org

http://lowvisionchef.com

www.shoplowvision.com

http://assistivetech.net

http://ameds.com/daily-living-aids/eating-aids/adaptive-eating-utensils.html

Slide 31 – Resources

The listed websites provide assistive

technology (including the products seen on

the previous slides) that can be purchased to

help with cooking or other daily living

activities. They also contain many resources

and tips for those with low vision and other

common age-related problems.

• Occupational therapists, if trained in low-

vision rehabilitation, can be the expert to

help individuals relearn daily living

activities. A doctor’s referral can help with

insurance coverage.

• The National Eye Institute has a wealth of

materials and tips for people with low

vision.

• North Dakota Vision Services offers

assistance for low vision and blindness.

• IPAT offers “try it first” adaptive equipment

such as magnifiers (participants can take

the equipment home, try it and then decide

whether to buy).

• Vision Chef suggests kitchen gadgets for

help in cooking.

• ShopLowVision has gadgets for cooking

and other daily living activities.

• Assitivetech has gadgets for assistance

with daily living. To find specific assistive

products, use the search bar at the top of

the browser. For example, search “kitchen”

in the “products” part of the site to find

assistive cooking technology.

• Ameds sells items that help with daily

living, including particular service items for

the dining room (such as the plate with no-

slip bottom).

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Peanut Butter

Sandwich and

Glass of Water

Challenge!

Slide 30 – Peanut Butter Sandwich

and Glass of Water Challenge!

Activity Suggestion:

Blindfold Peanut Butter Sandwich Preparation

Materials:

• Peanut butter

• Sandwich bread

• Plastic knife/spoon (for spreading)

• Plates (paper plates may be most practical)

• Bandana or a semishear material (for blindfold)

that limits sight but does not eliminate it. You

also may use an eye patch to cover just one

eye

• Water and cups

Set up materials on a table ahead of time, making

room for “work stations” for as many pairs of

participants as needed.

Have all participants “pair up” and take a minute

so they can introduce themselves to each other.

Have half of the participants position themselves

closer to the materials (if not already) with their

partner nearby to assist if needed. Ask

participants to blindfold themselves and attempt

to gather the materials to make a peanut butter

sandwich, make the sandwich, pour a glass of

water and then eat some of the sandwich. Give

participants several minutes to attempt to make

and eat a few bites of the sandwich. After about

five minutes, ask participants to remove the

blindfold and look at their sandwiches. Ask some

discussion questions after the activity is

completed.

Sample Discussion Questions:

• What was difficult about trying to make this

sandwich when your vision was impaired?

• What was difficult about trying to eat the

sandwich?

• How do you think this would affect your ability

and desire to prepare more complicated

meals?

• What other effects would low vision have on

your food choices? Would you eat different

foods? Eat out more often?

With partner roles reversed, repeat the activity if

time permits.

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Resources

http://Lowvision.org

http://lighthouse.org/navh

www.visionaware.org

www.lowvision.com/tips

www.afb.org/section.aspx?FolderID=2&SectionID=4&DocumentID=1452cclvi.org/large-print-guidelines.html

www.goingblindmovie.com: “Going Blind: Coming Out of the Dark About Vision Loss”

Slide 32 – Resources

These websites contain more general tips but do

not contain products to be purchased as do the

websites on the previous slide.

The first four websites have general tips for

coping with low vision.

The next two are websites specific to adapting

computers or handouts/brochures for people with

low vision:

• American Foundation for the Blind (AFB)

provides tips for adjusting computer settings

for those with low vision

• “Going Blind: Coming Out of the Dark About

Vision Loss” is a film about learning to cope

with vision loss. It is intended to raise

awareness and support for vision loss. More

information can be found at the website

www.goingblindmovie.com. The film is

available for purchase for educational uses. It

also can be streamed online for less cost.

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References• L. Mamer, et al. "Food Experiences And Eating Patterns Of Visually Impaired And Blind

People." Canadian Journal Of Dietetic Practice & Research 70.1 (2009): 13-18. CINAHL

Plus with Full Text. Web. May 31, 2012.

• Massof, Robert. "Low Vision and Blindness: Changing Perspective and Increasing Success."

Braille Monitor. 49.10 (2006): 40-43. Web. June 6, 2012.

https://nfb.org/images/nfb/publications/bm/bm06/bm0610/bm061005.htm.

• Misiano, J. "Low Vision Requires Innovative Prevention And Treatment Strategies." Ocular

Surgery News 26.2 (2008): 41-42. CINAHL Plus with Full Text. Web. May 31, 2012.

• Russell-Minda, E., Jutai, J.W., Strong, G., Campbell, K.A., Gold, D., Pretty, L., Wilmot, L.

The legibility of typefaces for readers with low vision: a research review. Journal of Visual

Impairment and Blindness. 2007; 101:402-415.

• World Blind Union and Cornell University ILR School. “PowerPoint Accessibility.”

http://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?article=1299&context=gladnetcollect

. Publication Date: 2006. Accessed Sept. 10, 2012.

• Holbrook, E.A., Caputo, J.L., Perry, T.L., Fuller, D.K., Morgan, D.W. Physical activity, body

composition, and perceived quality of life of adults with visual impairments. Journal of Visual

Impairment & Blindness. 2009;103:17–29.

• Wilkin, C. University of Florida IFAS Extension. “Designing Educational Programs for Older

Adults.”

Slide 33 – References

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References• www.nei.nih.gov

• www.washington.edu/doit/Faculty/Strategies/Disability/Vision/low_vision_faq.html

• American Academy of Ophthalmology. (2001). There is hope for those with age-related

macular degeneration. Retrieved Nov. 13, 2004, from www.medem.com/medlb

• Pizzimenti, J. Low vision rehabilitation for persons living with retinal disease. Presentation at

the North Dakota Optometric Congress, Bismarck, N.D., September 2012.

• Pizzimenti, J. The eye in obesity. Presentation at the North Dakota Optometric Congress,

Bismarck, N.D., September 2012.

• Peer review lighting and kitchen. Susan Ray Deggs.

• Kammer, R., et al. (2009). Survey of optometric low vision rehabilitation training methods for

the moderately visually impaired. Optometry (80). 185-192.

• Marinoff, R. (2012). Referral patterns in low vision: a survey of mid-south tri-state eye care

providers. J of Behav Optometry (23) 9-15

• Adam, R., and Pickering, D. (2007). Where are all the clients? Barriers to referral for low

vision rehabilitation. Visual impairment research (9) 45-50

• Lamoureux, E., et al. (2007). The effectiveness of low-vision rehabilitation on participation in

daily living and quality of life. Investigative Ophthalmology and Visual Science (48). 1476-

1482.

Slide 34 – References

County commissions, North Dakota State University and U.S. Department of Agriculture cooperating. North Dakota State University does not discriminate on the basis of age, color, disability, gender expression/identity, genetic information, marital status, national origin, public assistance status, race, religion, sex, sexual orientation, or status as a U.S. veteran. Direct inquiries to the Vice President for Equity, Diversity and Global Outreach, 205 Old Main, (701)231-7708. This publication will be made available in alternative formats for people with disabilities upon request, (701) 231-7187.

For more information on this and other topics, see www.ag.ndsu.edu

NDSU does not endorse commercial products or companies even though reference may be made to tradenames, trademarks or service names.

Resources: • http://aota.org/Consumers/consumers/Adults/LowVision/35190.aspx • http://nei.nih.gov/lowvision • http://ndvisionservices.com • http://ndipat.org • http://lowvisionchef.com • www.shoplowvision.com • http://assistivetech.net • http://ameds.com/daily-living-aids/eating-aids/adaptive-eating-utensils.html • http://Lowvision.org • http://lighthouse.org/navh • www.visionaware.org • www.lowvision.com/tips • www.afb.org • www.goingblindmovie.com: “Going Blind: Coming Out of the Dark About Vision Loss”

References: • L. Mamer, et al. "Food Experiences And Eating Patterns Of Visually Impaired And Blind People." Canadian Journal Of

Dietetic Practice & Research 70.1 (2009): 13-18. CINAHL Plus with Full Text. Web. May 31, 2012. • Massof, Robert. "Low Vision and Blindness: Changing Perspective and Increasing Success." Braille Monitor. 49.10 (2006):

40-43. Web. June 6, 2012. https://nfb.org/images/nfb/publications/bm/bm06/bm0610/bm061005.htm. • Misiano, J. "Low Vision Requires Innovative Prevention And Treatment Strategies." Ocular Surgery News 26.2 (2008): 41-

42. CINAHL Plus with Full Text. Web. May 31, 2012. • Russell-Minda, E., Jutai, J.W., Strong, G., Campbell, K.A., Gold, D., Pretty, L., Wilmot, L. The legibility of typefaces for

readers with low vision: a research review. Journal of Visual Impairment and Blindness. 2007; 101:402-415. • World Blind Union and Cornell University ILR School. “PowerPoint Accessibility.”

http://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?article=1299&context=gladnetcollect. Publication Date: 2006. Accessed Sept. 10, 2012.

• Holbrook, E.A., Caputo, J.L., Perry, T.L., Fuller, D.K., Morgan, D.W. Physical activity, body composition, and perceived quality of life of adults with visual impairments. Journal of Visual Impairment & Blindness. 2009;103:17–29.

• Wilkin, C. University of Florida IFAS Extension. “Designing Educational Programs for Older Adults.” • www.nei.nih.gov • www.washington.edu/doit/Faculty/Strategies/Disability/Vision/low_vision_faq.html • American Academy of Ophthalmology. (2001). There is hope for those with age-related macular degeneration. Retrieved

Nov. 13, 2004, from www.medem.com/medlb • Pizzimenti, J. Low vision rehabilitation for persons living with retinal disease. Presentation at the North Dakota Optometric

Congress, Bismarck, N.D., September 2012. • Pizzimenti, J. The eye in obesity. Presentation at the North Dakota Optometric Congress, Bismarck, N.D., September 2012. • Peer review lighting and kitchen. Susan Ray Deggs. • Kammer, R., et al. (2009). Survey of optometric low vision rehabilitation training methods for the moderately visually

impaired. Optometry (80). 185-192. • Marinoff, R. (2012). Referral patterns in low vision: a survey of mid-south tri-state eye care providers. J of Behav

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