Stuckness and Low Vision
By Gloria A. Reece, Ed.D.
Imagine that the year is 1956 and that you have just given birth to a 3-pound baby girl at a small town hospital in eastern North Carolina about 10 miles away from your home. While in the hospital, you learn that you are not going to be able to take your newborn home immediately because she must remain in an incubator where she can get proper oxygen and nursing care for at least 6 weeks, maybe longer. You follow doctor's advice and agree to leave your infant in the care of the hospital for 6 to 8 weeks. During this time (about four weeks later), you hear television news broadcasts of the dangers of blindness associated with the oxygen and bright blue lights used in hospital incubators-an eye problem described as Retinopathy of Prematurity (ROP) or Retrolental Fibroplasia (www.rnib.org; www.merck.com/pubs/mmanual/section19/chapter260/260l.htm; www.rdcbraille.com/pbpb-par.html; www.rdcbraille.com/pbpb.html; and www.rdcbraille.com/pbpb.html).
After hearing the news announcement, you decide to investigate the incubator care that the hospital is administering for your child more closely. On the day of your unannounced visit to the hospital nursery, you find your child with red, blistered skin-the same danger signs mentioned in the news broadcast. You decide to immediately terminate the incubator care for your child and take her home.
In the months ahead, your child has successful progress checks with the pediatrician and seems to be developing normally. When your child is about 10 to 12 months old, she tries to walk. She takes two steps and falls. You notice that this behavior repeats itself each time she tries to walk. You take the child to your mother's house for a visit. The child tries to walk again with the same result. You are encouraged by your mother to take the child to an ophthalmologist. The examination reveals that the child has Strabismus (commonly referred to as crossed or lazy eye) with amblyopia due to adverse refractive error.
Two months later, the ophthalmologist fits your 14-month-old child with glasses. At this time, your child takes her first steps! By the time your child is 6, the ophthalmologist has not been able to correct the crossing with corrective lenses and patching. Moreover, to prevent a permanently reduced vision outcome or even total blindness by middle-age, the doctor then recommends Strabismus surgery by age 6 (1963).
As time goes by, the progress checks with the ophthalmologist are very good and progressive. But 34 years later (1997), you learn that your daughter is still experiencing vision and motor-related problems (walking and speaking) due to Strabismus and lack of available prescriptions to correct her vision. Through the years, your daughter has used all of the available single-lens prescriptions for stereo vision, and the doctor that performed the Strabismus surgery and monitored her case-a world-renowned ophthalmologist who founded his own hospital in North Carolina-has also retired. Since 1985, your daughter's single-lens prescriptions have not changed. During this time, ophthalmologists have tried a variety of options including bifocals and prism lenses. All of these trials have failed, and doctors have finally told her, "We cannot help you; you'll have to find your own way."
At this point, your daughter conducts research of her own and decides to see a neuro-ophthalmologist who recommends a trial in contact lenses. Your daughter later learns that this strategy is a last attempt to problem-solve her situation. Additionally, the contact lens solution may not work because of the eye muscle problems; irregular astigmatism (relates to the shape of the eye at birth and has resulted in a misshapen cornea on the left eye), dry eye, a retinal scar (possibly a result of premature birth), etc. Other surgeries (e.g., Lasik, additional Strabismus surgeries, astigmatism correction surgeries, etc.) are not recommended. The contact lens manufacturing process is labor-intensive for everyone; some doctors give up because the fittings do not conform to a specific pattern and require too much custom work! Additionally, the contact lens insertion and removal procedure is one that is difficult to accomplish with a strabismic; the eye muscle movements are difficult to control. In your daughter's case, doctors also gave up here too!
Now, let's reflect on the 1960's for a moment. Do you recall the popular 14-inch tall, battery-driven "Chatty Cathy" (walking and talking) doll? Through the years, Chatty Cathy has also undergone changes in her eyes. A similar product, "Dream Baby," is a similar hit among youngsters. This doll also crawls, walks, talks (learns, sings, and plays). Now, hold these thoughts and let's return to the opening scenario.
For the next 4 years, doctors and contact lens designers and manufacturers work to create custom contact lenses for your daughter. With the contact lenses, your daughter can see, walk, and talk! So, the contacts for your daughter are like batteries to a Chatty Cathy doll! Nevertheless, your daughter's motor skill problems resurface as a result of a decline in visual acuity. During the first 2 years she wears contact lenses, daily variances in wearing time continue to create walking and speech difficulties; moreover, acuity readings are not especially improved in either eye. By 1999, your daughter's vision continues to worsen (increased visual field loss), and doctors recommend a best-corrected, monovision solution. The evaluation is ongoing today.
Hi! My name is G-L-O-R-I-A! That's my story! The popular country singer, Reba McIntyre, sums my situation up well in her hit song, "I'm a Survivor!" Now, I will share with you some stories from my own life that may be useful helping web page designers and product developers better understand issues surrounding low vision, hearing loss, and mobility restrictions using my "art of accommodation." In this article, I will discuss my "art of accommodation" as it applies to 6 areas: (1) reading structural cues and wayfinding, (2) multimedia, (3) graphics, (4) text design and visual threshold, (5) contrast, (6) glare and size of electronic displays, and (7) mobility.
"Stuckness" Situation #1: Reading Structural Cues, and Wayfinding
Problem: Reading, Structural Cues, and Wayfinding. As I write this article, I can recall very vividly how I learned to read. In the 1960's, teachers used "reading groups" to assess students' progress in reading. Students in the groups were asked to read from a specified passage without error, using aids to mark their place and sounding out words during reading. The teacher usually began the readings with a student next to her (usually on the right) and went progressively around the group, with each person taking a turn, until the required reading was complete. These reading groups were very problematic for me because I read very slowly and needed to place a pointer on the lines as I read them. Teachers complained to my parents about my reading skills and methods. My parents (also K-12 educators) spent countless hours working these issues with me. These sessions continued through most of the early grades until I learned how to accommodate for reading tasks. One day, during a reading group session, I noticed that teachers most always started with the student on her right first and went progressively around the group until the task was complete. The next day, I decided to change my seating in the group so that I would read last instead of first. When I made this change, I could "hear" the story as others read their assigned lines and point to the lines as they were being read by others. This strategy helped me because I had also learned that I suppressed my right eye during reading tasks, relying on my left eye. Then, when it became my turn to read, I was already familiar with the text and story. (Both of my parents have Strabismus (forms that did not require surgery for the lazy eye condition. My father also suppresses his right eye-consequently, here lies the double-whammy genetic connection for me!)
Some vision problems cause people to lose place when reading from line
to line (Reece, 2002). In my case, it was difficult to see the words on
the page because I always saw my nose first (a result of the eyes crossing)!
Another problem was that I was not allowed to place a pointer at the beginning
of each line (establishes figure-ground) for keeping track of where lines
begin and end. Another problem that contributed to the reading situation
was seeing more than one image of something (e.g., in this case, rows
of text)-a result of the crossed or lazy eye.
I continued using this accommodation strategy until I had a writing class with a new professor (Howard) at Florida Institute of Technology (www.fit.edu). Each term, I usually purchased my books for the upcoming term as soon as they hit the bookstore shelves (not later than the last week of class). In a sophomore-level writing class, this new instructor required us to purchase three books for the class. Two of the texts were on poetry subjects. At this point, I anticipated a problem, yet I didn't know how to fix it. I decided to start with a discussion with the professor about the accuracy of the purchases and if all three books would be read during the course. The answer was "yes" to all of my questions. My next reply was this one, "I read very slowly; I need to start on the readings now so that I'll be prepared!" Before the conversation ended, the instructor talked me into putting the books aside until the start of classes the next term. I trusted his judgment and waited. Until now, I had satisfaction in becoming an educated, non-traditional student. Now, I had some uncertainty about the outcome.
I attended Howard's classes that next term, and excelled at many reading tasks! Howard's use of Socratic dialogue in class discussions taught me more about critical thinking and how to solve real-life problems than any class I had ever taken. Additionally, his encouragement for us to infuse technology into our writing process was also helpful. For the first time in my life, I could "see" and "hear" the words on the page and write (and revise) responses to my readings. He gave structural pointers (chunking, queuing, filtering, mixed mode (lists, tables, figures), abstracting (layout)) to information in the text that allowed me to develop better wayfinding strategies for locating information in dense text. His dialogue with students was exceptional; it helped me keep pace when eyestrain hit. And, he frequently said to me, "It's okay to mark up your book. Make it your own!" By the end of this class, I was taking my first two baby steps again-learning how to read and write!
Today, I continue to use the strategies that I learned in Howard's class.
As I write this article, I have successfully graduated from my doctoral
program in Instruction Curriculum Leadership with a concentration in Instructional
Design and Technology at The University of Memphis (www.memphis.edu),
and have completed an empirical, clinical study entitled, "Text Legibility
for Web documents and Low Vision" (available in Dissertation Abstracts)
"Stuckness" Situation #2: Multimedia
In general, computer-driven multimedia is difficult for me due to use of animation and clarity. For example, videos need to be very clear in both sound and image before they are useful. Since I rely on lip reading to understand conversation, a lack of clarity in image can impede communication. For example, if I am looking at a video of someone giving a presentation, the image and actions in the clip must be extremely clear. If the person reads or looks away from the audience (me), then there is too much opportunity for confusion about the communication. Lack of sound clarity can also be problematic, as my ability to hear clearly fluctuates with my mode of visual accommodation. (As I change reading aids, I note differences in my ability to hear clearly.) Conversely, music played loudly on the computer via CD is the most relaxing method that I can use to relieve pain from visual and mobility stress.
"Stuckness" Situation #3: Graphics
Problem: Multidimensional Images. While in Florida (mid 1980's to 1994), I had an opportunity to design a logo for a small business owner. The owner wanted a simple logo to match the name of business, "Fulcrum Associates." The first graphic that came to my mind was a fulcrum. All of the textbook examples seemed to be renderings of objects-circles, lines, and triangles. With textbook in hand and an object-oriented drawing tool launched on the computer, I created my own version of a fulcrum for the logo in three variations. I asked for a preliminary opinion on the designs from one of my professors (Carol). After reviewing the materials, she asked, "Gloria, why don't you try a 2- or 3-dimensional image?" That conversation left me a bit puzzled. On the way to the computer lab, I kept asking, "What is 2D or 3D?" I decided to have a conversation with my husband John, an electrical engineer on a subject that I called, "Drawing for Dummies." I showed him my logo examples, and asked him to explain the concept of 2D and 3D images. For the first time in our married life (now nearly 23 years), he realized that I could not perceive depth. Strabismus has an impact on one's ability to see depth. With his help and an electronic drawing tool, I was able to successfully create a logo for the client.
Current Strategy. Today, there is a lot of hoopla about creating multidimensional images for web pages. In cases like mine, fancy graphics may not matter. Rather, alternative text descriptions ("Alt" text) are more helpful for graphics. Breaking news reveals that blind engineering students at the University of California at Berkley are developing a computerized drawing program that allows people with vision problems to create and "see" graphics on-screen.
Problem: Text on Curves. Web pages and some applications that contain circular objects using reverse print on small circles containing color (like M&M candies) for key navigational elements (e.g., menu names) are also difficult to read.
Current Strategy. People with vision problems may perform such tasks very slowly because they may first need to train their eyes to follow the circumference of the circle in order to "visualize" the background object and then extract its meaningful content-the text message (e.g., "File Menu").
Problem: Text that Blinks and Moves. Web pages that contain moving and blinking text leave me bewildered and asking this question: "Can people read those moving and blinking objects that fast?" Since I read with one eye, moving objects and blinking text are very difficult to process because they change before they can be seen!
Current Strategy. Be proactive about the situation and ask for help.
Problem: Menus. Lengthy pull-down and right-extending types of menus are problematic for me due to the fine motor skills that are required to use them. Oftentimes, it requires multiple attempts to complete a single task.
Current Strategy. Explore keyboard shortcuts or link alternatives. When all else fails, ask for help.
"Stuckness" Situation #4: Text Design and Visual Threshold
In writing programs, I adjust font size through the "View" menu expressed in percent. When type is outside of my visual threshold, I rely on print materials and accommodation through various reading aids (e.g., contact lenses and/or eyeglasses designed for specific purposes, hand-held magnifiers, enlarged print, custom room lighting, etc.). These strategies are very apparent to my students during class; some of them ask, "Dr. Reece, how many pairs of glasses do you have?" Other instances where font size could be improved are in documents associated with shopping (e.g., charge card and cash receipts, tags for clothing size, and bank teller receipts, etc.).
Problem: Text Size. Text size is something that I frequently customize when I am writing a document. Programs like Zoom Text are not especially helpful for me because they create too much distortion; I see better at near distances than far. Keypads that contain small letters and numbers are also difficult. For example, I have an older model cell phone that contains a small, difficult-to-read display and keypad. Each month, when the phone bill arrives, my husband asks, "Honey, who do you know at ?" I reply, "Well, what's the date of the call? Oh, that must have been the call I made with a dialing error." Adding information to a stored phone book does not help me because the display is incompatible with my visual threshold. Additionally, dimly lit environments and those with glare add further complications. (See also, "Glare and Size of Electronic Displays.")
Current Strategy. When viewing an on-line document, I usually change text size through the percentage view. As for the small keypad on the cell phone, I memorize the sequence of the buttons. And, sometimes I still get stuck!
Problem: Fonts. Fonts that have insufficient contrast between foreground and background are difficult to read, encouraging premature reading fatigue.
Current Strategy. Terry Clark, a country music singer, best sums up my approach about using fonts with her hit song, " Easy on the Eyes!" In general, I prefer familiar, easy-to-read typefaces. For dense text, I prefer a serif face and print on a high-contrast (black or white) background. (See also, "Contrast.")
Problem: Proportional and Monospaced Print and Dense Text. Since I rely on one eye for both reading and distance activities, electronic documents (e.g., web pages) that require reading of dense, proportionally-spaced text on screen is difficult and causes reading fatigue.
Current Strategy. Whenever a web page requires me to read dense
text, I generally print the material out so that I can accommodate using
a variety of reading and printing aids. I can also use self-generated
Socratic questioning strategies to make content my own.
Problem: Headings and Structural Cues. When headings lack a clear structure and are inconsistent in style and placement, it creates confusion about the document's structure and impedes wayfinding.
Current Strategy. I prefer left-aligned headings and structural cues. Since I read with my left eye, this alignment makes the task much easier.
"Stuckness" Situation #5: Contrast
Contrast between foreground and background is essential for good web page design and navigation in real-life settings.
Problem: Lack of Depth Perception. Strabismus is responsible for my lack of depth perception. This inability to perceive depth causes "stuckness" of various forms. In order to see, I rapidly parse a visual scene into discrete parts and then use figure-ground strategies to help me navigate. Some examples of where these strategies occur are writing (with or without a computer), drawing (with or without a computer), filling a coffee pot with water, driving a car, and moving objects from one place to another.
Current Strategy. For example, when using Microsoft Word, I use the "Normal" view with paragraph symbols turned on. The dots between words and the paragraph symbols help me keep my place. The paragraph symbols are helpful cues for visualizing and processing "chunks" of information.
Problem: Technology for Changing Contrast. I have also explored accessibility accessories for modifying contrast in on-line documents. For example, when using Microsoft Word, I have used the "Accessibility Wizard" for changing the background color of a document; however, the accessory that came with my PC is difficult to maintain as a "standard" setting between boot and shutdown processes in spite of specifying appropriate setup information. Additionally, the wizard does not seem to translate to all of the applications that I use and poses usage limitations.
Current Strategy: Continue to accommodate.
Problem: Lack of Color Application at the "File" Level for Outlining Tasks. I use color as a wayfinding strategy. Few word-processing or publishing programs have the capability to change the color designation of sections in the document from the "file" level.
Current Strategy. For example, I use Inspiration software for outlining when I write. I use red headings for first-level items and then change colors for headings at lower levels. This strategy helps me locate information faster.
"Stuckness" Situation #6: Glare and Size of Electronic Displays
For computer work, I use three types of displays: (a) active (commonly found on most PC monitors), (b) reflective (commonly found on most LCD monitors such as laptops), and (c) backlit (commonly found on most Portable Desk Accessories (PDAs) and cell phones).
Problem: Glare. Glare is a problem for me in many settings. And, electronic displays in general cause me difficulty. For example, recently, my 1990 Toyota Camry started having trouble with the air conditioning-lack of cooling on days when temperatures in Georgia were in the 100-degree range! After taking the car to the mechanic for a check-up, the mechanic replied, "Your car passed all of my tests-I don't see a mechanical problem!" A couple of days later, the air conditioning quit working again on a long distance trip to Memphis, TN. Apparently, something tripped the control and caused the air conditioner to stop producing cool air. The indicator light on the air conditioner display panel was a problem. From my perspective, it was difficult to tell if the "green" light was on or off. Cell phone conversations with my husband then became interesting. He kept asking, "Is the light on the air conditioner control panel on or off?" I kept responding, "Honey, it's black-either way the air conditioner button is pressed on or off-it's black; I don't think that I see the same things you see!" There were two problems here: First, the air conditioner control panel was in the area of my reduced visual field and was not clearly discernable. Second, illumination and glare (bright sunlight) was a also a factor.
Current Strategy. When doing computer work, I prefer laptops to
regular computer monitors because they reduce problems with on-screen
glare. For example, when I work at a regular monitor using Microsoft Word,
I usually accommodate and change the background color to something other
than white or bold blue (see (Tools Menu, Options+General Tab)). In doing
so, I can achieve better contrast and less glare. I do not use the bold
blue settings that Microsoft provides because that color causes severe
headaches. (I have trouble with using bold blue in large, backlit areas.
This sensitivity may be due to a retinal problem.)
Stuckness Situation #7: Mobility
As vision problems develop, mobility issues may also become apparent. For example, in the introduction to this article, I was not able to walk until the doctors fitted me with eyeglasses, which also corrected my spatial world. As a result, mobility issues have also been part of my accommodation strategies through the years.
Problem: Navigation in Unfamiliar Settings. Navigating in unfamiliar environments is also problematic for me due to lack of depth perception due to Strabismus and amblyopia due to adverse refractive error.
Current Strategy. Boarding airplanes pose mobility stress because they have poor ventilation and small signage (seat assignments). As I board, I usually ask for assistance with a question such as this one: "Where can I find this seat number?" In general, when I am in unfamiliar settings, I generally rely on asking others for help and use questions in this form:
My husband is very skilled at giving me advanced cues for walking and locating signage. My lack of depth perception causes mistakes in walking into or out in front of things; therefore, I cannot let my guard up. For example, one of the easiest intersections for me to cross is one that has a "whistle" that indicates when it is appropriate to cross the street.
Last year, I went to a shopping mall in Boston, MA. One of the doors to the breezeway was clear glass. I never mastered detecting my distance from the door because it was always in motion-someone coming or going.
A pastime that I enjoy is shopping for jewelry; however, I usually give it up after a few bumps on the forehead from my inability to detect my distance from the glass wall that often surrounds entrances to such stores. There's nothing like smashing yourself in the head in front of other window-shoppers! So, my husband saves a lot on jewelry purchases; sometimes the embarrassment overcomes me, and I never make it into the store!
Conclusions and Recommendations
In conclusion, blends of technology and Socratic dialogue have been the
keys to my professional success. ROP does affect premature infants. In
my case, the earliest sign of Strabismus was an inward turning of the
right (amblyopic) eye, also a late sign of ROP damage. Oftentimes, this
problem is difficult to detect. Parents of preemies write:
Additionally, the Texas School for the Blind and Visually Impaired now reports that there are late complications from ROP that include Strabismus (crossed eyes), amblyopia (lazy eye), myopia (near-sightedness), and glaucoma and that regular follow-up is needed to monitor and treat these conditions.
Currently, there does not appear to be a solution for my vision situation. Current work in the field indicates that implantable contact lenses and a non-laser radio frequency procedure are two relatively new procedures for correcting farsighted vision problems. My own self-evaluation of these two procedures indicates that I am not a good candidate for either implantable contact lenses (see Table 1) or the radio frequency procedure (see Table 2) because I have already had one surgical procedure (Strabismus surgery) and have too much astigmatism.
Table 1. Profile for Implantable Contact Lenses for Gloria Reece
Table 2. Profile for Radio Frequency Procedure for Gloria Reece
On behalf of all people with Strabismus due to adverse refractive error (and that's less than 2% of the nation's population (see www.lighthouse.org), I wish for you success in accommodating for your vision loss. It is a lot of work for me to keep my guard up; sometimes when "stuckness" happens, it can be a serious wakeup call. And, my husband John often comments, "Life with Gloria is interesting!" If you are interested in knowing about more resources for Strabismus, please contact me.
My area of professional expertise is design of web pages for low vision; nonetheless, I am hopeful that this case study material is useful to web page developers and others interested in signage and accessible environments. In closing, here are a few "Questions to Ask" when designing accessible, usable web pages:
Additional principles for usable, accessible design are given in Reece (2001, 2002), Reece and Bine (2003), and Reece, Vinegar, and Gillen (2003). These materials are located at (www.stc.org).
Reece, G. A. (May 2001). Year II and growing: A report from the STC Special Needs Committee: Usable, accessible web pages for low vision: Criteria for designers. In Proceedings of the 48th Annual Conference of the Society for Technical Communication (STC): Vol. 1. Arlington, VA: STC.
Reece, G. A. (2002). Text legibility for web documents and low vision. Unpublished doctoral dissertation, The University of Memphis, Memphis, TN, USA.
Reece, G. A. (May, 2002). Accessibility meets usability: A plea for a paramount and concurrent user-centered design approach to electronic information technology accessibility for all. In Proceedings of the 49th Annual Conference of the Society for Technical Communication (STC): Vol. 1, Arlington, VA: STC.
Reece, G. A. (May, 2002). Usability testing techniques for accessible web pages. In Proceedings of the 49th Annual Conference of the Society for Technical Communication (STC): Vol. 1. Arlington, VA: STC.
Reece, G. A. (May, 2002). Let's take the "dis" out of disabilities: A progression on how to harness technology to meet special needs in technical communication and to ensure user accessibility in communication products: Working to 508: Web page assessment for compliance with the American with Disabilities Act. In Proceedings of the 49th Annual Conference of the Society for Technical Communication (STC): Vol. 1. Arlington, VA: STC.
Reece, G. A. & Bine, K. (2003). From disabled to enabled: A goal we can achieve! Leveraging technology and philosophy to meet special needs and ensure user accessibility to communication products: Traveling 'Route 508:' A One-way street to universal accessibility." In Proceedings of the 50th Annual Conference of the Society for Technical Communication (STC): Vol. 1. Arlington, VA: STC.
Reece, G. A., Vinegar, J., & Gillen, L. (2003). Working to 508: Seeing,
hearing, and understanding accessible web pages. In Proceedings of the
50th Annual Conference of the Society for Technical Communication (STC):
Vol. 1. Arlington, VA: STC.
Wasowicz, L. (2002). Program let's blind 'see' and draw. [www.upi.com/view.cfm?StoryID=29062002-013151-6549r],