Short Days, Long Nights: Low Light and Other Challenges of the Holiday Season
The guest speaker is Stephen Azman, who is Director of Patient Care at Low Vision Specialists of Maryland and Virginia (LVS), a group that specializes in maximizing patient vision and customizing optical systems for adults and geriatric patients suffering from vision loss.
Short Days, Long Nights: Low Light and Other Challenges of the Holiday Season
November 30, 2016
Transcript of Teleconference with Stephen Azman, CPO
1:00–2:00 p.m. EDT
Please note: This Chat was edited for clarity and brevity.
MICHAEL BUCKLEY: Hello, I am Michael Buckley with BrightFocus Foundation. Thank you for joining us for today’s BrightFocus Chat, “Short Days, Long Nights: Low Light and Other Challenges of the Holiday Season.”
If your weather is anything like what we are having in Maryland right now, it is a very timely topic. It is a dark, rainy day here, and we are doing this topic today because around the country the days are getting shorter. That really has a lot of impact on everyone, particularly people who have some vision challenges.
Today we are joined by Stephen Azman, the Director of Patient Care at Low Vision Specialists of Maryland and Virginia. Their practice is a member of the International Academy of Low Vision Specialists. They specialize in maximizing patient vision and customizing optical systems for adults with significant vision loss, including macular degeneration. Their goal is to improve the quality of life in patients whose vision loss makes the activities of daily life more difficult. They have a great rate of success in helping patients improve their vision.
If today is your first time joining us, welcome to the BrightFocus Chat, and thank you. Let me take a moment to tell you a little bit about BrightFocus and what we will do today. BrightFocus Foundation funds some of the top scientists in the world. We support research all around the globe that is trying to find cures for macular degeneration, glaucoma, and Alzheimer’s. We share the latest news from these scientists with families that are impacted by these diseases. We have a number of free publications and plenty of materials on our website, www.BrightFocus.org, that offer tips for living with diseases like macular degeneration. Today’s BrightFocus Chat is another way that we share this information.
Now I would like to turn to Stephen Azman. Stephen, I want to thank you for joining us today. We frequently get questions from people who have some challenges this time of year, since there is less daylight and things get a little trickier driving and around the house. Given that this is occurring for many people, particularly those affected by macular degeneration, we wanted to hear from you. I was wondering if you could tell us a little bit about what you do at your practice.
STEPHEN AZMAN: Sure, absolutely. We have been providing advanced low-vision services for over 40 years now. Dr. Thomas Azman, our lead doctor, has always had a passion for low vision and helping people with macular degeneration and other low-vision conditions, and he helps people—from all across the country, sometimes—by providing them with improved vision. As you mentioned, we will be talking now about improved lighting, especially around this time of year—some of the tips that we can provide to our patients to help them around the house and other common goals.
MICHAEL BUCKLEY: Great! We already have two questions. One is from Helen in New Jersey, the other from Janet in California. Both are asking questions about lighting. This time of year we are awake during dark hours more than other times of the year. Helen and Janet had questions about how to make the most of the lighting in their house. What types of lighting adjustments can you make around the house?
STEPHEN AZMAN: Lighting is a very important concept that unfortunately is sometimes overlooked for people with macular degeneration and other low-vision conditions. Proper lighting is really crucial to maximize the quality of a person’s vision. Now generally speaking, bright light is very important, but sometimes too much light can also be overwhelming for the patient. Sometimes we have to figure out exactly how much light is really going to give us the best quality.
Very often gooseneck lamps are very beneficial to bring the lighting much closer to one who is reading a newspaper or a book, because when you bring the lamp two times closer, that will provide four times the amount of illumination. Having the proper lighting and having it brought close to you will maximize the lighting to provide better vision.
With the gooseneck lamp, there are all kinds of lightbulbs out there and really the best thing is for natural light—using full-spectrum bulbs, which can be incandescent, halogen, and LED—which is the newest technology of lightbulbs that really gives you the brightest and the crispest light. Halogen and incandescent bulbs will obviously work, too. The main conflict to realize is that while we have overhead lighting almost everywhere we go, when bringing that light closer with a device like the gooseneck lamp, that provides four times the amount of illumination when it is brought closer. For reading, that is a very important factor, having that bright light to give you a better quality of vision.
MICHAEL BUCKLEY: It is very interesting that you mentioned how it can be twice as close and actually gives you four times the illumination. I appreciate the point that you make that it isn’t just increasing the overall quantity of lights, there are factors such as the type of lightbulbs and types of lamps, and I think that is really interesting. I am glad you mentioned reading. That is something that is very popular among people, particularly in the winter months. What about for people who do their reading on an iPad, a Kindle, a tablet, a device like that? What can they do to help them read the best and minimize discomfort or eye strain?
STEPHEN AZMAN: Now that we are in the 21st century, we have people of all ages using iPads, iPhones, Kindles, and all kinds of wonderful new tablets and devices. Thankfully, most of these devices already come incorporated to help patients with low vision. They have the option to maximize the fonts, and some of them have the ability to zoom already built into the operating systems of these devices—increasing the contrast, the brightness. With these options, it really can help a person out when they are using these devices.
In our practice, we very frequently have patients who are working these tablets very successfully by using the settings that are already built in. Additionally, there are many applications out there that you can download that give you more advanced function—zooming in, some of them can do OCR, which is optical character recognition. Functions can include content on your device to being read to you, instead of you actually having to read it. Content will be read out loud to you.
One of the products that we recommend often is called ZoomText, and that is by Ai Squared. They have multiple versions of applications that work on tablets, iPhones, Android devices, desktop computers, and laptops, which can really increase the quality when reading on these devices.
Additionally, for the old-fashioned people like myself who prefer to read from a book or newspaper, you have a lot of common things and generic devices like handheld magnifiers, desktop magnifiers, magnifiers with lights built in. As we just discussed a few moments ago, having proper lighting is beneficial. If you have a magnifier with a light built into it, that is putting that light source right on top of the paper or book that you are reading, therefore providing much more illumination.
There are things that many people are familiar with, like the PCTV readers. For people who want the best possible vision, there are custom bioptic microscope glasses that can be designed specifically with one’s prescription, providing the magnification with the prescription to ultimately give them the best vision possible. There are many options that one can use. Sometimes you can incorporate using all of these options. So there are many wonderful options there to help people be able to get back to reading a book, a magazine, or just using their tablet or laptop or desktop computer.
MICHAEL BUCKLEY: That is fantastic. I know that reading is such a key part of quality of life and people continue to keep their brain fresh and challenged. So, Stephen, related to your good suggestions about using a Kindle, a tablet, a device like that, what about watching TV? Are there any particular tips in terms of the type of lighting in the room or the proximity of you to the TV? Anything related to that, which might help particularly when it is dark outside?
STEPHEN AZMAN: Obviously every person is different. You could have multiple people with macular degeneration or another low vision condition, but it can affect them all in different ways. Generally speaking, if someone is having trouble with their distance vision, the larger the TV screen the better. The closer they sit, generally the better. The lighting option, sometimes you have to play around with that to figure out what is going to be best for that individual person when watching TV. When reading books you want to have the best illumination, but when watching TV it is really a different function because it has its own colors and lights, and sometimes maybe a darker room could be better. It is really a matter of figuring that out.
Additionally, as I mentioned earlier, bioptics—microscope glasses can be designed for reading—the inverse is true for distance for TV as well. So you have bioptic telescope glasses that can be made with one prescription with their magnification that can allow a person to watch TV from the couch at a normal distance.
Again, every person is different, so for one person they might be able to sit back and watch from 20 feet away, or someone might need to sit much closer. In our practice this is a common theme that, unfortunately, some people out there forget—that we are all individuals and, we all can have the same medical condition but it affects our lives in different ways, and we all have different goals as to what we want to accomplish. Sometimes the generic things—while they are a good first line of defense—aren’t always the best thing for the individual.
MICHAEL BUCKLEY: That is a great point. Related to the goals that you mentioned, one of the things we hear a lot at BrightFocus is that people want to remain in their homes as long as they can. They enjoy being in familiar homes and neighborhoods, and they want to stay there as long as they can, but one of the challenges is falls. A lot of times falling is a major reason why people can’t live in their home anymore. I was wondering if you have ideas, particularly as the lighting changes. Are there tips about safety around the house? Specifically as it relates to falling?
STEPHEN AZMAN: This actually relates back to the lighting again. In this sense, we aren’t talking about lighting, close-up, right in front of your book. We are talking about overhead lighting. Obviously, the brighter the overhead lighting, the more one will be able to see around their house.
Also, things like home automation—motion sensors for outside the house, and sometimes for inside your house. So, when it gets dark the lights are automatically going on by the time it gets dark outside. For the outdoor lighting motion, sensors are very useful. As soon as you walk up the light goes on. Having proper lighting is really a common theme for many tasks among people with low vision.
Inside the house, lighting is very important. Most of us are familiar with the settings in our home. It is important to identify potential risk factors around the house. Is there a step down? Is there a step up? Tripping hazards like carpets, rugs, wires? Uneven surfaces? Slippery surfaces? When you’re going from one room to the next, well, one room might be a carpeted den while the next room might be a marble or wood floor, which can be slippery sometimes. It is important to be aware of your surroundings.
Obviously, most of us know our house inside and out, but it is still something to think about—what are the potential risk factors in my home and environment? What rooms can I prevent myself from falling in? Being aware of your surroundings. A common area is the bathroom—bathtubs, showers can obviously be very slippery—even for people without macular degeneration. Things like bathmats are very important. Additionally, some people have low-vision glasses that can help them get around. Wearing their glasses will obviously help them to know their environment better and see it better. It will really help prevent people from falling.
MICHAEL BUCKLEY: Sure. I would like to continue on the falling in a moment. Because you mentioned the glasses, we’ve gotten two questions, one from Thelma in New Jersey and one from Annette in Colorado. They are really interested in the glasses that you mentioned a few minutes ago. What type of vision practice would you get with some of those glasses that you mentioned?
STEPHEN AZMAN: Very good question. There are many low-vision practices around the country. Many of them will provide low-vision devices like handheld magnifiers, stand magnifiers, the TV readers, and a lot of other wonderful devices. In our practice, we consider these a first line of defense, but with our doctors’ 40 years of experience, we have noticed that while these work in the beginning, they are not long lasting. They really can’t provide the best vision for our patients. Essentially, in really simple words, these are special glasses that utilize telescope and microscope lenses to provide the best vision possible. They are generally designed at the proper magnification and the precise prescription, not only for each individual but for their individual tasks—whether it be reading, watching TV, driving, or seeing family members’ faces. Obviously, as I mentioned before, everybody had their own goals and agenda. As you mentioned in the beginning, we are part of an association called the International Academy of Low Vision Specialists—that is IALVS.com—that can be found online. There are about 50 or 60 doctors who specialize in advanced low vision, designing these special glasses, and they have trained doctors throughout the country. The best resource to learn more about these glasses is going to IALVS.com and reaching out to a doctor who is closest to you. Those doctors can provide more details for the specific person.
MICHAEL BUCKLEY: Great. One quick thing related to that. As a general rule, does insurance cover some of this?
STEPHEN AZMAN: That is a very good and important question. Generally speaking, it does not cover it because Medicare and most providers follow the Medicare rules that because this is not “treating” a medical condition, it is generally not covered by Medicare and generally not covered by other insurance providers.
MICHAEL BUCKLEY: Well, that’s good to know. I want to get back to the good points you were making about safety around the house. One of the big areas we hear about is stairs. Do you have any suggestions for this very high-risk part of peoples’ homes?
STEPHEN AZMAN: Sure. It is funny, repeating it again, but lighting is very important. You want to be aware of where the steps are in your home. So lighting is a common theme across the board for patients with macular degeneration.
Some of the obvious basics are having the proper grab bars and handrails and making sure they are properly secured and mounted, however the environment is. Of course, using this handrail is a great idea. You can go one hand at a time, taking your time going up or down the steps, one-by-one, looking at the heights. Again, being aware of your surroundings makes things much easier: When you know the steps are there, use the guardrails, and don’t try to overdo it by carrying objects when walking down or up the steps.
A very common concept is a chairlift. Some people, even though they might not have problems walking, they are concerned about going up and down the steps. A very common thing is to have a chairlift installed in one’s home to take the person up and down the staircase. Some more basic tools are: don’t be ashamed to use a cane or some kind of walking assistance that will make you feel more comfortable.
MICHAEL BUCKLEY: I appreciate that, and following up on it, I’ve heard of people who might create a color contrast at the end of the stairs. Would you be able to tell us a little bit about how to do that or what that is?
STEPHEN AZMAN: Something that makes an obvious difference on the flooring—whether it be different lighting again, some kind of bright tape on the floor, or even on the wall— some kind of signal that you can actually see and know that they are going from one area to the next, where the carpet might be changing or there is a step. It’s precautionary and proactive instead of reactive, which is always beneficial.
MICHAEL BUCKLEY: Fantastic. So, Stephen, I would like to take you and our listeners from inside the house to outside. As we mentioned earlier, BrightFocus funds research on Alzheimer’s and macular degeneration and glaucoma. A recurring theme in age-related diseases is the importance of maintaining an active and healthy social life and being as challenged as possible. I know it gets harder this time of year, when it is darker earlier. People want to keep doing their activities, their social clubs, their faith-based communities, or holiday gatherings, and now it is dark at dinner time in most parts of the country. Could you tell us a little bit about driving and the importance of being safe, but also the importance of maintaining a pleasant life outside of the home?
STEPHEN AZMAN: Unfortunately, with macular degeneration, sometimes people are stuck in their homes because driving is a bit scary. The first thing, and most important thing, is making sure that if you are still driving that you are driving safely and, of course, legally.
Let’s just talk a little bit about some of the concepts around this. The first thing is to make sure of is, are you driving legally? Unfortunately, we see many patients who drive to our office and they are legally blind. They do not meet the requirement of the state to legally drive. Now, they feel comfortable that they are driving safely, but the reality is that they are not meeting the state’s requirements. So, knowing your state requirements for vision is very important. On our website, which is LowVisionMD.org, at the bottom of our homepage we actually have a link for all of the state laws and requirements regarding vision. It is important to make sure first that people are driving safely and legally.
MICHAEL BUCKLEY: Sure. One of the phrases you hear a lot is “visual acuity,” and I think it is a term that people use but don’t know. Would you be able to tell us what visual acuity is? When you look at some of these state websites you mentioned, that is a phrase that you see. So, what is visual acuity?
STEPHEN AZMAN: Visual acuity is the amount of vision that is measured when you go to the eye doctor, like 20/20, 20/100, 20/200, whatever it is for the person. On average, visual acuity for a driver’s license is usually around 20/40 or 20/60, depending on the actual state. Somebody who has 20/20, that is considered normal vision, which means at 20 feet they can read a sign properly. For somebody who is at 20/100, that means that they are seeing the same thing the person would see from 100 feet away. It is important to understand basic vision and what it really means. Again, the general rules for driving are based on visual acuity. It also is sometimes based on peripheral vision, which isn’t usually a concern for macular degeneration, but other low vision conditions.
MICHAEL BUCKLEY: We are going to continue to discuss driving for another moment or two Now, Stephen, one of the questions that we hear a lot with driving is that people say, “I can drive places where I have been before—places where I know how to go.” My question for you is, does that make sense? Or are these people negotiating with themselves or trying to rationalize their choices? What do you think?
STEPHEN AZMAN: In my opinion, of course every person is different, many people with low vision and macular degeneration—if they are meeting the legal requirements but they don’t feel safe driving—then it is probably best that they don’t drive. Everyone has to be at their own comfort level, but it is very common that we will hear from our patients that they don’t drive at night anymore or they only drive locally in their neighborhood where they know the streets. Honestly, I get a little concerned when I hear that or when I see patients drive to our office and I know that they are legally blind or that they meet the legal requirements officially, but they maybe still shouldn’t drive. There are things that can be done for that.
MICHAEL BUCKLEY: I know this is a terribly sensitive topic in a lot of families. Do you have any suggestions on how families should talk to someone about this, or the services that you and others provide? Do you offer tips for how to make something less awkward?
STEPHEN AZMAN: Well, obviously having one-on-one conversations with the parent, grandparent, or spouse is very important. It is a delicate situation. Nobody wants to lose their independence, especially if they have been driving for 30, 40, or 50 years. Sometimes we just have to come to the reality that, if you can’t drive safely and legally, if you can’t see the traffic lights, other people on the road, street signs, obviously that is very concerning, and it is highly recommended at that time to discuss with the family either having a spouse or another family member drive and to give up your license.
Now, for those who want to potentially still drive, and there are many of those people out there, there are options of these bioptics—those glasses I mentioned earlier—where in many cases, not every case of course, it is possible to provide that legal and safe vision by using these glasses, these bioptic telescope glasses.
It is important to check with your local state vision requirements, because while they are accepted in most states, there may be one or two states where they are not acceptable. It is important, again, to go back to the state laws and to know, even though I meet the visual requirements, are these glasses allowed to be used? Again, in most states they are allowed, the bioptics are approved for driving when meeting the vision requirements.
Additionally, there is some other technology called E-Scoops, which are specially developed lenses that sometimes have a special tinted yellow or orange lens, which helps with the contrast. It can be very beneficial for nighttime driving, as well as daylight. E-Scoops are specially developed lenses designed in Denmark for people with macular degeneration. Many people find them very beneficial.
MICHAEL BUCKLEY: That is good to know. Increasingly, people have a GPS or some sort of navigation system in their car. I have heard mixed opinions about this for folks with vision challenges. You hear people say that it is very helpful to have the audio function, but some people say it is distracting. What do you think about GPSs for people with low vision?
STEPHEN AZMAN: I think, like any tool, when it is used properly it can be very beneficial. But sometimes, if we just listen to the GPS—you will hear stories where someone actually drove into a lake or into a forest because they weren’t really paying attention. So while it can be very beneficial, it is always, from a safety perspective, good to pre-program your routes beforehand and before you even get into the car or drive away. This way you have your route already planned. With many GPS devices, you can see the route ahead of time and make sure it makes sense. I think it is a wonderful tool that could be used, especially with the audio. Sometimes they can be combined into a tablet, or an iPhone, or another device, and you can use that in conjunction with the low vision settings to zoom in and really get a better understanding. It’s a wonderful device, and even for people without macular degeneration, they are very beneficial.
MICHAEL BUCKLEY: That’s great. I would like to continue our travel theme for a moment. This time of year, the holidays, more people go to airports and train stations. That can be a little overwhelming for all of us. There are a lot of signs you have to read or other things. Do you have any tips for navigating a train station, bus station, or an airport?
STEPHEN AZMAN: Absolutely. The most common thing is that if you are traveling with someone or find a traveling partner—that can be very beneficial. This way you know the person isn’t out there on their own and is out there with someone who may have better vision than the person traveling. Obviously, a travel partner can be very beneficial.
We discussed using a cane or a walker—don’t be shy. We have to recognize that, unfortunately, there are some things that we can’t do on our own and we need to be smart and take advantage of technologies and other devices, even simple devices like a walker or a walking cane, to really help us out.
Again, regular glasses or bioptics that can be used while walking to help read signs in a train station or an airport could be very beneficial. Smartphones and tablets, again, for checking on the travel schedules—using that ZoomText and other technologies--this can also be beneficial. Work with the train station, bus station, or airport transportation center or reservation center saying, “I do need some additional assistance.” This could be a wheelchair or someone to walk you to your seat. It is important to take advantage of these options that are provided everywhere for people with any type of disability, including a vision disability.
MICHAEL BUCKLEY: Those are some great points. How would you respond to someone who, in their gut, knows they need that type of assistance but is also concerned about not wanting to look vulnerable? There are, unfortunately, people in those public transportation settings at the holiday time that do prey on folks. How do you suggest that somebody reconcile that in their mind?
STEPHEN AZMAN: As I mentioned before, a travel partner is always a good idea. Two heads are always better than one! That confidence and not struggling through the airport or train station or whatever it is, or doing the best they can, and again, being aware of surroundings. That is true for everyone these days with society and the world that we live in.
MICHAEL BUCKLEY: Yeah, I think you are right. We have an interesting question, switching gears back to some of the devices around the house. Ron from Maryland is wondering about websites that often have a lot of different colors and backgrounds, and shading. At BrightFocus, we launched our new website about a year and a half ago—again, this is something we were very cognizant of. Do you have any suggestions for if someone finds a website that is literally hard on the eyes? Hard to navigate?
STEPHEN AZMAN: Depending on what aspect we are talking about, if it is a brightness issue—it’s too bright or too much color—most monitors or tablets, devices, most of these devices do have some kind of setting where you can adjust the brightness and tone it down a little bit or change the contrast. Most devices give you the option to adjust the color and the brightness level. Another option is using some of these built in functions of a computer or device, like the zoom feature, to maybe zoom into one section at a time. This way it isn’t too overwhelming, and you can just go one section at a time to really understand what is going on and not be distracted by all of the other things on the page.
MICHAEL BUCKLEY: Yes, that is great advice. Martha from Virginia is asking about the glasses you mentioned before, the bioptics. Do those require training? Would someone work with a specialist like you, or are they more straightforward to get adjusted to?
STEPHEN AZMAN: They are pretty straightforward. Generally, training is not required. For some people to get back to driving, people who haven’t driven in a while, sometimes a low-vision occupational therapist is required. It really depends on the individual. For the most part, at least an hour of practice once the glasses are designed or fabricated. The doctor dispenses the glasses and goes over how to use them, and that could be a 45-minute process. There is some adjustment period to get used to the glasses, but generally an occupational therapist is not required. However, it sometimes is required for driving. Again, every person is different. Some people can pick it up right away and get used to it, others take a bit more time.
MICHAEL BUCKLEY: I certainly appreciate the distinctions there. As we reach the end of our conversation today, I was wondering, as you have been in this line of work for a number of years, is there a recurring misperception or myth that people bring to these issues? Is there a big picture philosophy or message you would like to give people with low vision?
STEPHEN AZMAN: Yes, unfortunately there is. Most of our patients and most people out there with macular degeneration, they are being told that nothing more can be done for them. I want to really clarify what that means when your doctor says that to you. Of course your doctor is wonderful, and these retina specialists and other doctors they are saving the vision in people from going completely blind. When people are told nothing more can be done for them, they are talking about at a medical level. Unfortunately, today, we do not have a cure for macular degeneration. Hopefully one day very soon we will, and there is lots of research, as we all know, being done every single day. BrightFocus is involved in that.
At the end of the day, there is something that can be done—whether it is bioptics, generic devices, magnifiers, PCTV readers, whatever it is—there are many options out there, and people should not give up hope. There is something that can be done, and the goal is to provide functional vision for a better quality of life. People should not get distraught when they hear that nothing more can be done, because there are options out there. Sometimes it might take a little work to find out about them, but they are there.
Again, you can go to our website, which is LowVisionMD.org, or a nationwide site, IALVS.com; both sites have a wealth of information of resources and low vision specialists throughout the country. We are in the 21st century, and we have Mr. Google that we can always go to and ask questions. Simply Googling low vision specialists and other information like that, there are lots of resources out there.
MICHAEL BUCKLEY: Thanks. I appreciate that, Stephen. I think that is really good advice for people in a lot of situations: that hope and persistence are important. I would like to tell our listeners about several resources that BrightFocus offers for free. BrightFocus has a publication called Safety and the Older Driver, and it contains some of the good tips that Stephen mentioned today and it also offers some alternatives to driving. You can reach us toll-free at (800) 437-2423, for the free BrightFocus publication.
With that, Stephen, I want to thank you so much for your time. You were very, very helpful and gave people a lot of good advice and were very positive about how to make the most of this time of year when the weather gets tougher and the days get shorter. We really appreciate that.
Again, we offer publications such as Safety and the Older Driver, another one called Macular Degeneration: Essential Facts. All of these resources are available free to you and your family.
Stephen, again I just want to thank you very much for your generosity. I think you gave a lot of great advice to people.
STEPHEN AZMAN: Thank you very much for having me.
MICHAEL BUCKLEY: This concludes today’s BrightFocus Chat. I want to say thank you to everyone. Bye.
BrightFocus Foundation: 1-800-437-2423 or visit us at www.BrightFocus.org. Available resources include:
- Information on research funded by BrightFocus
- Amsler grid
- Macular Degeneration: Essential Facts
- Safety and the Older Driver
- The Top Five Questions to Ask Your Eye Doctor
- Clinical Trials: Your Questions Answered
Other resources related to this call:
- Low Vision Specialists of Maryland and Virginia
- International Academy of Low Vision Specialists
- E-Scoop glasses
- bioptic microscope glasses
- PCTV readers
- E-readers and tablets
The information provided in this transcription is a public service of BrightFocus Foundation and is not intended to constitute medical advice. Please consult your physician for personalized medical, dietary, and/or exercise advice. Any medications or supplements should be taken only under medical supervision. BrightFocus Foundation does not endorse any medical products or therapies.