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Proceedings of: Workshop on Improving Building Design for Persons with Low Vision

Panel 1: Requirements and Accommodations for Persons with Low Vision (Vijay Gupta, Moderator)

Suleiman Alibhai, O.D., Low Vision Services, PLC.

Introduction

Well, thank you, Vijay. I’m glad we have an opportunity to discuss things, because I think everything I would like to say has been said – thanks a lot, Bob. And apologies to Dr. Brabyn, frankly, because a lot of the slides that I have may also duplicate what you’re going to use.

And I’m going to start with this quote that says, “It’s not the strongest of the species that survives, nor the most intelligent; it is the one most adaptable to change,” and that’s a quote by Charles Darwin (slide 2). I find it fascinating to sit here and participate in this group, because the work that we do as low-vision specialists is not to adapt the environment to the individual; we try to adapt the individual to the environment by providing various tools. So this is a sort of unique opportunity for us to come to you and say, well, look, here are the issues our patients are having. What things can you do to make it easier for them?

And, fortunately, we are the most intelligent of the species on the earth, and therefore we are able to survive because we adapt with tools, and low-vision specialists are the tools of the people that who have low vision. And I think patients always come to me and say, I’ve come to see the toys that you have to help me, because they were expecting some tool, some gadget; hopefully, just a pair of glasses magically is going to fix their vision. Now I think we have a good understanding that we’re talking about people who are beyond basic tools like glasses. 

Role of Low Vision Specialist

The three or four things that we have been emphasizing here are the things I think we have now all really understood: To enable people who are visually impaired to function, we’re talking about modifying light or glare; modifying contrast; as low-vision specialists, we also modify size, or we provide magnification, and we have the tools to do that; or we modify their behavior (slide 3).

As you’ve heard from Dr. Massof’s presentation, for example, we’re talking about, really, older people here having issues with functioning. And they modify their behavior by becoming depressed, by staying indoors, and really becoming restricted in terms of their activities. So how [are] you specialists – how are we going to modify the environment, make it more engaging to them, so they’re not afraid of falling, they’re not afraid of losing their independence, and there are ways to get around? So I think these are the things we’ve all established – the lighting, glare, contrast (slide 4). We haven’t talked much about magnification, but that could certainly be an issue when it comes to signs.

I think it’s important that we realize, like it’s been brought out, that we all have experienced low vision. Initially, I thought about putting up slides of diseases to show you blind spots, and the narrow tunnel view. But you know, it’s really not like that. It’s fine for putting up slides and showing those things, but in the real world, if you want to understand what does the visually impaired person experience, think of things like: the oncoming headlights of a car; the sun low on the horizon, especially for those who drive around the beltway; reading menus in romantic restaurants; finding a seat in a movie theater. I mean, these are things we’ve all experienced. And think of that being as more amplified in people who have low vision.

Contrast, we’ve talked about ad nauseam now, about the edges of steps and curbs; or reading something that hasn’t been printed well; and magnification – going back to that size thing, it’s like the back of a medicine bottle – who is supposed to read those anyway; or the disclaimers on the some of the things that we buy. I think it’s ridiculously small. And like Dr. Massof mentioned, we assume that everyone in the world has next to perfect vision, and if you don’t, try to adapt to it and deal with it. And many of us just kind of fake it. We go, yeah, that’s right. Well, now, how much was it again? They may not really have seen the price, but it’s a way we deal with it.

The other thing we’ve talked about today is: What is low vision? What’s the range of vision? It’s not a number. This is the most frustrating thing I think Dr. Siemsen and I have, is that people come to us and we see them because we are reimbursed to deal with them. Medicare pays me to see these patients. But if their vision is too good, Medicare says, you can’t see this person. We’re not going to pay for it, because this number that we require their vision to be, isn’t satisfied. And so this is frustrating from a practitioner’s standpoint.

There aren’t many low-vision practitioners because of that, because it’s hard for us to make a living when it’s all about reimbursing. We didn’t get into this low-vision field because we were going to make it rich; more because we felt the need – I think, like some here pointed out, that there are people having difficulties functioning. And not just we’re talking about older people, don’t forget, children, and we’ve talked about adaptations in the school system, and playgrounds, and so on and so forth. So it’s hard to give you a definition of low vision in terms of a number, and I would hope that in developing guidelines and in talking about low vision, we don’t use a number to define it. 

Visually Impaired People are not easily Identifiable

And remember, the other thing is that the visually-impaired people are not easily identifiable. This is the difference between somebody you identify as being blind and immediately you can anticipate what the difficulties are, because a visually-impaired person – and we have at least three in this room – are not walking around with a white cane; don’t wear glasses even, except Mr. Gupta perhaps; and don’t look like they’re visually-impaired – they make normal eye contact (slide 5). So how do you know, as you’re dealing with people in the real world, that they’re even visually-impaired, because “they look normal”?

Age and Low Vision

All right, I’m not going to go over these pictures again (slides 6 – 15). Dr. Brabyn is going to discuss these. But the one thing I would bring up here is a study done at Berkeley by a researcher-optometrist-scientist, Dr. Gunilla Haegerstrom-Portnoy, who did a study on 900 people from the ages of 58 to 102 (slide 16). They were normally well-sighted. In other words, their vision was 20/40 or better – what we would consider good vision, not even low vision by any definition. And she measured their vision under various conditions of contrast and glare (slide 17).

And what’s interesting here is what occurs with age. I think we’ve all got this point now that the aging population has low-vision issues, and you’re thinking of the aging population with macular degeneration, glaucoma, cataracts and things like that. This graph is showing you the effect of contrast, glare on an aging population that is well sighted; has had cataract surgery; have been to their ophthalmologist and been told, your vision is good; you’re legal to drive; you’ve been doing well; if you’ve had a problem, we’ve treated it.

This group, as you can see, as they get older have increasing difficulty. And this is saying, along the y-axis, times worse than young for those whose vision is 20/ 40 or better, because that’s who we’re comparing this group to. They have more and more difficulty with: high contrast – with low-contrast vision (low contrast vision just means you measure their acuity and the letters are not black on white). Contrast sensitivity in general – how much more black on white they need than the average person. Glare – how much more trouble glare issues are. And, how much more time it takes to recover. So we have to take that into account as well. So if you’re going to build a building with good light, which is great, and then to have to move to another area of the building and it suddenly turns dark, well they have to make a transition. And I think the first speaker [Greg Knoop] brought that out nicely, that we have to find ways of making these transitions from light to dark, or for dark to light.

So the reason I put this graph up really was to say to all of us here that when we think of these issues, all of these things that have been brought up so far, don’t necessarily apply just to the low-vision population. We’re talking about this aging population. And as we know, the group over 65 is the fastest growing segment of our population. So even if we don’t call this “Building Design for People with Low Vision,” I think it’s building design for all of us, assuming we’re all going to get there. But you might say, I’m going to take good care of my eyes and not have a problem with my eyes. I’m going to get my cataracts seen; I’m going to get my glaucoma checked; and I’m never going to get macular degeneration; and I’m going to eat leafy green vegetables every day. You can do everything. You’ll have 20/ 40 vision, but you’ll experience all these difficulties.

So it does behoove us to address these issues and address them in a meaningful way (slide 19). So I’ve skipped all my other slides because I know we’re running out of time, and I think they’ve already been addressed. And I would much prefer now to have a discussion, and questions, and back-and-forth that we can address some of these issues in more practical ways.

Dennis W. Siemsen, O.D., Low Vision Service, Department of Ophthalmology, Mayo Clinic

Introduction

Well, I work at world-famous Mayo Clinic up in Minnesota. And, this is the main outpatient building [slide not included]. I work at the building on the right, that’s the Mayo building. And while most people think of Rochester, Minnesota as “the frozen tundra” – and it does look like that sometimes in the middle of winter, right now it looks kind of like this, so, [you may] want to get out of the hustle and bustle of the East Coast here and come out to wide-open Minnesota.

Some of the things that we want to talk about today relate to contrast, plus – (slide 1) and I’m glad you caught the irony of this, because you’ve all probably been in meetings where somebody kind of didn’t get the idea of how colors clash, and what makes it easy to see. You certainly don’t want to put bright red on bright blue. This is a little bit better, but because of this kind of fuzzy background, it’s a little – a little difficult to see (slide 2). And you might also think that, you know, if you want good contrast, you’d want pure black on pure white (slide 3). But even that’s not the easiest thing either because you get all this glare back again. So whenever I do my presentations I like to use something with a darker background, something with a lighter foreground, or with the letters, and so forth, and go from there (slide 4). And I won’t bore you on fonts and things, although that may be a discussion for another day. 

Definitions

Bob already talked about the definitions of low vision (slides 5 and 6), and I understand from Stephanie that you’re all going to get either a CD or an access to a website for all of this stuff. So if you ever want to refer back to this again, you can always look it up again.

Visual Acuity

But the whole point, as Bob mentioned, was: what is visual acuity? It’s really how big a letter you can see at what particular distance (slide 7). And the other thing that you want to remember is that if you come – if you start at one distance, you sit twice as close, it makes it twice as big (slide 8). If you ever – you know, if you wonder why your kids and grandkids sit close to the TV, it’s because if they get twice as close, it makes it twice as big. So that’s really the thing.

The challenge is, of course, you can’t always move closer to this. It’s easy to make things bigger when you – when you either sit closer, walk closer, drive closer, or bring the newspaper closer to you if you’re trying to read. But it becomes more difficult if you’re not able to do that. And part of what we do in low vision is to bring those virtual images closer to our patients. We’ll talk about devices here in a minute. Again, this is just – you know, I wasn’t sure what Bob was going to present, so I threw a slide up here about what visual acuity really means (slide 9). It’s the definition of the resolution of the eye. It really doesn’t tell us anything about how well they function. So let’s go through all of this. 

Visual Field

Now, let’s talk a little bit about visual field. We kind of danced around that a little bit. And, technically, it’s the sensitivity of the vision throughout the field of view; throughout all of this area out here (slide 10). And I think most of you know intuitively that you see very sharply in the center of your vision, but when you get out in the periphery, you don’t see things quite so sharply.

So someone with macular degeneration, where they’ve lost their central vision, well, you know, they can see, they can move around – they actually function very well in mobility situations, but they can’t see the regular-sized print. On the flip side, if you get somebody with retinitis pigmentosa, where they’ve lost all their peripheral vision, they might be able to read – although there are areas that they haven’t been able to [discern] medium or small – but just have them walk across the room, or try and negotiate a room like this, they’d be bumping into things just walking around this room. So you kind of get an idea of what someone with a peripheral vision loss would have. 

So technically, that’s what we’re talking about here. And we measure that by how large and bright the stimulus can be. Now, Fred made a good comment about driving, because when we talk about vision impairment in driving – it’s a little off the subject, but when we talk about vision impairment in driving, when you go to the DMV and have your vision measured, they measure two things: They measure how big a letter you can see at a certain distance – that’s visual acuity; and they measure your peripheral vision, which is visual field.

Neither one of them are good predictors of whether you’re going to have a crash or not; visual acuity, several studies have noted, has no relation to whether you’re going to have a crash or not. So these are just good examples. And if you want to take what we would consider a very visual task, like driving a car, and apply these measures – a visual field, a visual acuity – very poor predictors. So if it’s bad for that, you can imagine that it’s bad for all the other tests that we’re trying to describe.

This is just a diagram of what we’re talking about. You know, normally sighted individuals can get about 70-to-80 degrees temporally, and about 50-to-60 degrees nasally in each eye (slide 11). When you add the two together, you end up with about 140, 150 degrees all together. And the same thing applies, superior – you know, you get so much superior, so much inferior (slide 12). And why is it more down below? Well, just take a look at your eyes. You’ve got larger brows through that evolutionary process, and you’ve got more space down below. So that’s what visual acuity is. We’ve talked about legal blindness (slide 13).

We’ll touch just a little bit on contrast here too: it is your ability to see, distinguish those shapes and objects from a background (slide 14). I describe this a little bit different. If you have a perfect – 100 percent, 1.0 perfect contrast, the best example of that would be pure black next to pure white; no contrast, the two are exactly the same. It’s all black; it’s white; it’s all gray; it’s all the same, so there’s no difference between the two. And this is just a slide that shows the difference there (slide 15). And you’ve probably been in presentations where the PowerPoint slides look like this too.

Low Vision Rehabilitation

Now, what do we really do at low vision? And it’s so nice when I get together. Now, Suleiman and I probably have met once or twice, but we have the same concept here. What do we really do with low vision (slide 16)? Well, we make it bigger. When somebody comes in and they want to be able to read better, the first thing we do is make things bigger, because it’s easier to see that way. We fiddle around with the illumination and the contrast by adding direct light. I mean, we’ve been talking a lot about overhead lighting, and glare coming at you. but when it’s time to read the newspaper, probably the most important thing that we can do for our patients is to add some direct light right on the newspaper. Most of you probably understand that today newspapers use lots of recycled paper, which isn’t as light, and they use soy-based ink, which isn’t as black. So therefore, the contrast between the background, the newsprint and the print is [not so] hot.

Now, Bob made a comment about what happens when you add that light on there. Well, it’s true that we aren’t actually enhancing the contrast, but the sensitivity of the individual to those contrasting images is improving, because the newsprint is going to reflect more of the light than what the black print is, and therefore it’s going to be a little easier for the individual to see.

So what do we do? We’ve – and I mentioned that, in terms of magnification, twice as close is twice as big. I think most of you in lighting understand the concept of the inverse square law, where if you bring that source places close, it’s going to make it four times square.. So for my patients, I’m going to make sure they’ve got that light nice and close, because it’s going to make t [sic] difference. 

We also train those individuals. I can give them a magnifier; I can give them a device; but if they aren’t trained to use it properly, they’re not going to do very well with it. So what we really engage in is a rehabilitative process. It’s not just, what kind of toys do you have; can I get a magnifier; can I get those glasses stronger? Well, yeah, you can, but we need to make sure that, when you get it home, you’re actually going to be able to use it for the task intended. And because of that, we also add things like using peripheral vision. If the central vision is gone, we need to train the individual to use more peripheral vision, or vice versa.

There was a comment made about increasing depression. We often engage with social and psychological services. I have a social worker who is designated for my service, and I try and get all my new patients, just to have them sit down in a chat with the social worker to find out what life is like, how things are going. I’m not a psychologist, and I rely on other professionals to give me some feedback, because if we don’t deal with some of these social services, psychological issues, nothing I do in the exam room is going to make any difference, because they’re still going to be depressed and they’re not going to want to be rehabilitated.

And finally, we use rehabilitation services. We use teachers of the visually impaired [or] rehab counselors; we use state services for the blind, we use occupational therapy, and a variety of other rehab services, because, really this is a total process, in terms of what we do. I’ll just skip over some of these slides because we’ve covered all of them already (slides 17 – 19).

Low Vision Patient Requests

What does a typical low-vision patient ask for (slide 20)? Number one on the list has got to be reading. I mean, almost everybody, even young, old, you know, the issue is reading, because we have a very visually-oriented society, whether it’s print, computer – computers are becoming more of a problem. Getting a driver’s license – in our society, they need public transportation. It’s better here on the East Coast, but when you get to Minnesota, if you don’t have a driver’s license, you know, you don’t get anywhere. And Rochester, Minnesota is actually, for a town its size – 100,000, has a very good public transportation system, but it gets you downtown; it doesn’t get you to the grocery store. And that doesn’t even talk about, can you see the bus sign; can you see which bus is coming? It helps you get on the right bus, and so forth.

Continuing independent living: We heard comments already that it’s certainly a benefit for the patient, as well as society, to keep people in their own homes. I’ve often told my patients, you’re not going to have to leave your home because of your eyes. If you follow our techniques; if you get the devices that you need; if you get the training – not just from us, but from other sources, you’re going to be able to live independently.

Now, you may fall and break your hip, or you may have some other medical issues that will take you out of your home, but you’re not going to have to leave because of your eyes. And that alone just takes a huge weight off their mind. It’s like, oh, really? There is something there? Yes, there is. But bear with me; it’s not – it may not be quite as simple as you might think.

To get and keep a job, we’re going to talk a little bit about environments for a workspace; improve independent mobility – we talked a lot about that so far. My questions of my patients are, what do you want to be able to do that you can’t do because of your eyes? That’s the question you ask. And it’s not just to see better. Okay, fine, sure, I want to see better too. You know, I’d to be able to read without my progressive lenses. But what – and be specific: Is it reading? Is there a specific task? Do you want to play softball again? I mean, what is it that you want to be able to do? You know, just as an example here with reading, newsprint is 1.4 millimeters high on the average – that’s a lower-case “o”. Large print is about twice that high. And as I mentioned before, by bringing it closer makes it bigger (slide 21).

When I consult with the people in employee health at Mayo – we haven’t talked a lot about working situations here (slide 22). We’ve talked about elderly mobility, getting places, but when you talk about what some of the challenges are in the workplace, being able to read the computer screen is top on the list, because we have – we’re entirely electronic at Mayo, even medical records, billing, everything is electronic (slide 23).

I have six programs active on my screen that I use at all times. And, you know when a new program comes out, I’m immediately on the phone with systems and procedures and information technology to get them to fix it, because even I can’t see it. We have 50,000 employees at Mayo Clinic, so even if you get – even if you think of 1 percent have some type of vision challenge, that’s a lot of people who are having trouble seeing the screens. We also have glare issues. I could give you lots of examples of that: reading, and room size and lights; seeing patient’s faces; and all that sort of thing. Well, let me – we’ve talked about walls too. I had one lady who was having trouble with glare, and I said, well, we’ll just move you away from the window. And she said, I worked 15 years to get that place. 

Interaction between clinical practice and research programs

All right, we’re going to go – we’re going to go past these (slides 24 – 26), because you probably know this stuff, and we’ve talked a lot about it already. And there are lots of things that we can do. But what I’d like them to talk about a little bit here is a project that I’m not a signatory to. However, I do work with Dr. Gordon Legge up at the University of Minnesota. He’s got a very active low-vision research lab (slide 27). Gordon’s low-vision research lab is not in the ophthalmology department; it happens to be in the Department of Psychology. And Gordon and his group have provided us with – as Bob has too, I want to give Bob suitable credit here.

I’m a clinician, and for me to do some of this basic research to figure out some of those nuances of why, how vision works the way it does; why do people have challenges; what factors can we modify to make it better, comes from people like Bob and Gordon Legge. And it helps people like me, because where Suleiman and I see a patient in the office, and they have a visual challenge, the basic science researchers are the ones that tell us why, how, and give us some ideas on how we modify it. It also provides us with the ammunition, so that when go to the access board, we can cite chapter and verse, and we’ve got the research to do that. I think part of the reason why low vision hasn’t gotten the attention it deserves, is that we haven’t really done enough of this basic research. So I give – I really give Bob a lot of credit.

This group has done a lot of really cool stuff, and it’s an ongoing process, and it’s difficult to collect this data, partially because we all do things a little differently.

So I wanted to bring this up because, after I got the invite to come to this meeting, Erin and I went up to the University of Minnesota to see what they’re doing. It’s lovingly called the “DEVA project,” Designing Visually Accessible Spaces. And it’s a multi-disciplinary project through the University of Minnesota, the University of Utah and Indiana University. Somewhere along the line you’ll get a handout, or at least access to a webpage that will have the link to the project on [the] bottom of the screen. So some of these slides are right off their stuff, and I give them full credit for it (slide 28).

The goal is to provide an environment so that people can travel safely, perceive the spatial layout and key features in that environment: keep track of where you’re at (slide 29). If you ever hear the term “orientation and mobility,” orientation is where you are at any given time in space, and mobility is, how do I transverse that space without killing myself? So part of what this project is, is: Where are you? How do you get there? How do you move through that space? Ultimately, the aim is to improve accessibility. 

They really want to be able to influence designers. Unfortunately, they don’t have any designers on the team. So they were tickled pink when they heard that I was coming to this meeting. So they would really like you to access their website, and take a look at what they’re doing, and make contact with them and offer suggestions.

I’m going to kind of go through a few things here. One of the things that they’re doing is developing a model, an analytical tool (slide 30). We talk a lot about that. How do you translate what’s going on in the clinic, at a very natural setting, into a research design with backing? And what you have here is – in these two images, on the left side, you have the actual luminance value that they measured in their lab work with different lighting conditions, with luminance values. On the right side is the digital rendering of the simulated lab.

Comment by Erin Schambureck: And the way you can tell that is the door on the right does not exist in the actual room. That’s the only thing that [is different].

So what they’re trying to do is develop this model so that they can change different lighting conditions, and then do some studies with actual subjects; see how well they perform; so that as spaces are designed in the future, you could use a computer model and then work backwards, and know that, that model is [reliable]. Does that make sense? Throw your two cents in here while you’re at it too. She understands this stuff.

This is a digitally rendered model of the lab that we just looked at (slide 31). That platform that was on the right side of the previous slide, basically you’d be standing on top of that. So you’re seeing the rest of the room. And they figured that he’d get within about 5 percent of the measurements in the physical space. So it’s really pretty cool how they do that.

Now, what are they going to do with this? Just as an example, they’re taking a look at how different objects look under different luminance values, different types of illumination – overhead, near the window, by the window, black backgrounds, light backgrounds (slide 32). [They] also have gone beyond this phase, to where they’ve gone to the checkerboard patterns, and lines and stuff to determine what kind of shapes, and what with visual cues an individual can use in order to navigate this better. And, again, that’s the actual set up, and hopefully they’ll be able to put this into that model so that they’ll be able to use it later for your own design purposes (slide 33).

These are just some slides of the main atrium at the Mayo Clinic, the Gonda building [slide not available]. And, you know, this is one of those spaces that’s incredibly difficult to navigate. I don’t like going up and down this thing. It makes me nervous. I can imagine what it’s like to – anyone with a vision impairment, that’s with glare coming in through the atrium. This is where a person who has poor glare recovery would be in a bright situation and then go into a dark undercroft.

But I did want to get to this last – this is the staircase again [slide not available]. And the first one was about 7:00 in the morning. This is about 10:30 in the morning with the light streaming in. It’s great, huh? Now, this is the view right outside my office (slide not available]. The building was built in 1953. For those of you who’ve been around for a while, does that look familiar? Cork floors, which I know are making a comeback. We’re going to be remodeling our floor in the coming year, and were told we’re going to keep the cork. Yet I don’t like the way it looks. However, it’s soft underneath; it’s fairly warm.

And as I look at this from a vision standpoint, because we’ve had these paneled walls to kind of give you this kind of soft, comfortable homey appearance, but this checkerboard pattern on the floor actually helps focus your attention, so you know that’s where the floor is. So you know, there may be some benefit to having designs like this that help channel our focus in the appropriate way. So anyway, that’s– that’s the end.

I do want to give some credit to my colleagues up in Minnesota low vision lab (slides 33 and 34). Interestingly enough, Rob Shakespeare, with Indiana University, is the kind of the lighting – he’s in the theater department; he’s a professor of theater; and he’s the tech guy from IU.

David L Munson, IALD Aff.

Introduction

I didn’t graduate from medical school but I have learned a couple of lessons. One I’ve learned is that I’m going to get older; I’m going to have vision problems; and somebody is going to make me some more rules. You have an aging orphan. That’s not real popular, because I don’t like rules.

Before I came to HOK, I worked and studied under Jim Knuckles at the Parsons School of Design. And I learned a lot of stories, and I learned a lot of “why.” The neat thing about “why” is that you can make intelligent decisions.

Lighting Design

Current Lighting “Rules” focus on Illuminance Issues; conversely, Lighting Design should focus on Luminance and Contrast Issues

Now people keep talking about lighting rules. Most of the rules – or, most of the things that we’ve caused in lighting aren’t necessarily just a lighting issue, but it’s really a contrast and it’s a luminance issue rather than [an] illuminance issue. You were talking about [lighting], even on the newspaper. I don’t need any on mine.

Comment by [Participant]: There you go.

Response by Dave Munson: It’s illuminance.

I was going to talk about some clients, but you did have an issue this morning, and I don’t think anybody has hit on it yet – lighting in vision can be cured, and be easier with time. When we first did the original lighting studies to determine how much light we needed on objects – that’s why we have 4,000 footcandles inside the body when we’re doing some surgery, and two-tenths of a footcandle when you’re scrubbing the floor in the hallway. More light, height of the iris, greater depth of field.

It all got screwed up with time. Original studies were: let’s raise the illumination models; we’ll do five assimilations per second; and we’ll have a motor action to determine accuracy. The minute we took the motor action out of it, the scores went way up. I mean – we lowered the time, the accuracy went way up. I think we had an – I can’t remember all those numbers, but they – 1973. I forgot, it was 99 – 95 percent accuracy – five assimilations per second. It was crazy. If you take time, it cures it. Just on the highway, I think if everybody drove 35 at night, we wouldn’t have any problems.

Illuminance Requirements can be reduced

Control of Glare (headlight story)

I wrote the “rules” of the new highway [design], and I said, we don’t have a lighting problem here, we have a headlight problem – because now we understand what highways are, if you block the oncoming headlight glare, you don’t need to light the highway because your headlights do it. So I convinced the state of Missouri to put in a 5-foot wall to block all the headlights. I wanted it 8 feet because then we wouldn’t see the short-skirted woman trying to change the spare tire on the other side and control the rubbernecking.

Control of Contrast (colorblind person story)

I’ve been very privileged in my career to deal with a lot of individual problems with lighting. One of my first clients calls up and said he had this beautiful house, and he loved it in the daytime, and he hated it at night, and you’ve got to come over and fix my lighting problem.

Well, we got there, he admitted to me that he was colorblind. And so when I went back to the office, I said, would you send Paula out and photograph the house in low-contrast 5-point film. It got back, I said, it’s really not a lighting problem as much as it is an interior designer problem who put in all beige furniture. [He is] walking over the furniture.

Once I saw the photographs, I said, okay, Sam, let’s add some light. And I also noticed that every time he would go and look at lighting he’d always look at his hands. And I think what he was doing is a contrast between that and this, because I know he can feel light.

So I was known for many years as the guy that saved his house. And then later, I became the guy that fixed his colorblindness. Anybody know Edwin Land? You guys all knew him, okay. Lighting designers don’t know anything about Edwin Land. He had a theory that all color was comprised of black and white and red.

The story that I remember from 1971 is, he took a stereo camera of black and white film, put a primary red subtractive filter over one lens, took a street scene, developed the film with the same primary red subtractive filter over this projecting on the wall, and he had pseudo color enough that you can actually tell what green was.

[At a] cocktail party, I’m talking to this guy who’s an optometrist. He said, is there anything that’s similar between colorblindness and lens theory of color? The guy looked at me, and he was really kind of shaken, and he said, how did you know I was reading that today? He said, I just read a guy named Warner Zentner invented the X-Chrom contact lens, primary red subtractive filter, put it on one eye, and certain people can see color.

Before I came here, I said, you know, I better look on the Internet, make sure I can still justify the story that [occurred] three or four years ago. Now I find out there are people will all kinds of contact lenses that can fix all kinds of things, all color deficiencies.

Now, I have come across a guy with a new vision problem. I’ve never heard of it before; I don’t know if there’s a cure. He’s not colorblind; he’s color dumb. When he was a child, everybody thought he was colorblind, so they never included him in decisions of color or descriptions of color. Nobody taught him that that was red. Now that he’s older, he said, yeah, I can see the difference, and you can sit and explain what colors those are, but in 20 minutes I kind of forget. So it’s early education of color.

Oh, my wife’s grandmother couldn’t play Skipbo which is a card game. And I said, well, let’s just add more light, and it just didn’t help. We fixed it with a set of pinhole glasses, because now the iris is really small. And in fact, I even find that that works for me, too.

Lighting for “Visually Reduced People” is not difficult if a Couple of Rules are followed:

The other thing is, I was – I don’t want to take too much time; I’ve got lots of stories. In doing research, [Missouri] is always a show-me state. So we always try to figure out what people can actually see. Well, I had a welding accident a couple weeks ago and it involved a vision problem in my left eye. We’re not sure whether it’s a welder’s flash or whether it’s an infection or if it’s inflammatory. Think of something; I might have to come see you.

I have developed a pair of glasses that are very similar to what my vision was in this eye a week ago. And here’s the thing. Lighting for visually reduced people is not difficult if you follow a couple of rules. Here’s the first rule. You have to remember that the eye is attracted by the brightest object in a room. It also means the brightest object is also distracted or the eye is distracted by the brightest object in the room.

When you do vision studies and we’re doing tests, the task wants to be the brightest object in your field of view. The surface around it should be slightly darker. Putting a white piece of paper on a black blotter is kind of like taking a picture of a white guy against a black wall.

Your candle will overcompensate for one of the fields. The other thing is, the surrounding fields should be slightly darker so you can concentrate on this field.

If you remember those rules, then it gets easier. I think we might have to go back to the future to solve some of these problems. With technology, the light sources have gotten smaller.

[Rule 1: The eye is attracted/distracted by the brightest object in a room

Rule 2: The “task” should be the brightest object in your field of view

Rule 2a: The surface around [the task] should be slightly darker

Rule 2b: The surrounding fields should be slightly darker so you can concentrate on this field] 

Lamps and Fixtures

In the ‘50s, we had something called a comfort lamp. You ever seen one? T16, T20 diameter fluorescent tube, it was nice and big, it wasn’t glary. When we went from T12 lamps – in lighting, everything is measured in one-eighths of an inch – T12 is an inch-and-a-half in diameter. T8 is one inch in diameter. When we went from T12 to T8, lighting got very glary in offices when people would look up [into the] parabolics.

The parabolics in very early lighting were nice and deep, shielded all the lamps. In fact, I remember Jim Knuckles talking about the first time they did recessed down lights in the ceiling, and the lights were made exactly the right color so they were the same color as the ceiling. They had to put table lamps in some of the rooms because it was so disorienting, nobody knew where the light was coming from [important behavioral issue].

MR16s, these little glary things [i.e., halogen light bulbs] here [pointing to the track-lighting in the conference room] made it very difficult to see. And I’m afraid that the newest technology is going to become our worst nightmare, and that’s the LED [light emitting diode bulbs].

Summary

The important thing is that you have to know why things happen. And if you understand why, I mean, I’ve seen so many books that said how to do it. But if you know why, then the how is easy.

Issue 1: What are the effects of energy-efficient lamps and fixtures on persons with low vision

Comment and Question by [Participant]: The research that you’ve been talking about a little bit as an idea of integrated design, you mentioned LED lighting. I mean, there’s tremendous drive to reduce energy usage in building that impacts lighting because that impacts air conditioning and blah, blah, blah.

And you go to energy conferences, and a lot of times they’ll tell you, we’ve got too much light. You know, some of the buildings are so bright that you don’t need all that. Certainly, that’s probably for normal-vision people, I don’t know. But have any of these studies been trying to integrate LEDs, these T8s, and all that, which are becoming the standard, compact fluorescents, all that are being installed everywhere?

Response by Dave Munson: Those are sciences that evolve so quickly today, that by the time you write a rule for it, it doesn’t exist.

Question by [Participant]: But what impact do they have on low vision and – ?

Response by Dave Munson: Well, there’s no answer but an opposite reaction. We invented all these CFL lamps. I’ll tell you, you want to see a disaster, drop one at the Home Depot on the floor, now you’ve got a hazardous cleanup.

Comment by [Participant]: That’s not going to stop. I mean, the energy is going to be –

Response by Dave Munson: The cost of the energy to light a building, compared to all the costs of all the people in the building is pretty small.

Comment by [Participant]: It impacts air conditioning, too. All I’m saying is, that’s reality.

Comment by Dennis Siemsen: Yeah. I think what Richard’s saying is that we shouldn’t be looking at the individual light sources. We shouldn’t just, you know, worry so much about whether it’s a T8 or a T12 or an LED or a CFL.

What we should be saying is, if, for a given light source and a given surface that will be illuminated, how do the two interact? Because then, you can always work backwards and say, okay, we’ve got a new light technology, whatever the next one is going to be, and it’s a small point source, and it’s got so much spread and gives you so many candelas at this particular point. Once you know that stuff, then whatever new technology comes out you can go through.

What we don’t have, and I think what the DEVA people are trying to do, is, how does that specifically impact the individual, whether they’re normally sighted or not normally sighted? And those are things that we really ought to know. There’s not good research out there.

And [while] we’ve got low-vision researchers on the project, there isn’t a clinician in there. So –

Response by [Participant]: And there’s no electrical lighting person on there that deals with some of these other issues associated with [lighting design].

Comment by Dennis Siemsen: Yeah, so I think what it’s really going to need is a team approach. And hopefully, through the wonder of the Internet and integrated databases, if I were writing a research proposal and I go to NEI – we were talking about this at the break –and I get this right in my search and see who is doing what, who is interested in this – not what’s published because there [are] partners.

But it’s very interesting to go to the NEI or other – and I don’t know what your database is in your area. I would search on NetLine, I might go to the NEI, I might go to NIH. But I’m just stuck. Except that I’ve got a designer [in the] family, I wouldn’t know what database to search to see which one of you is interested in these topics, where I might be able to call you and say, hey, let’s collaborate.

Issue 2: What Approach is needed to develop “Guidelines”?

Comment by Jeanne Halloin: There’s another important issue here, though, and Marsha mentioned how much time that these new regulations or guidelines are put out for us to react to, and a lot of us don’t take the time. Eunice usually prods me to taking the time.

But I mean, we have a period of time that we can get in there and say why something isn’t making sense or why something is making sense. And so we do have a chance to get in and get involved [as] the guidelines become standards. And I think more of us have to take that responsibility.

Question by [Participant]: I guess one question I have, too, is, when a guideline comes out and it would appear to have some connection with vision, do you have a set of consultants that you go to and say, okay, what do you think about this? Maybe FAB is one organization [that] would be someone you would go to. But do you have a set of experts?

And again, you know, if it came to me, I’d say, fine, I’ll do the search, and I’ll do my research, and I’ll come up with this, and I can give you my two cents’ worth. But unless I can come up and cite chapter and verse in the research literature, I’m not sure it’s going to have much impact on the development of your [guideline].

Response by [Participant]: Well, that’s why some of us [who] worked on [the] documents – there are published documents that were research based – are the ones that should be getting involved in it.

Response by Marsha Mazz: We would not publish a guideline if we didn’t have some research to support that guideline. That’s cart before the horse. We have to have research that will support the claims that the guidelines make. I mean, after all, the whole intent of any of these guidelines is to provide greater accessibility. If it’s not going to achieve the intended goal, then it’s a true waste of money.

Comment by Fred Krimgold: Can I make a point before we take that next question? What worries me is, we’re going to sit here, and let’s say we do come up with some consensus and some guidelines. The other thing to keep in mind is, when you talk about lighting, for example, no two people are the same. We talk about low-vision patients; Dennis will tell you, sometimes that [he] issues a 60-watt incandescent bulb and bring it close. Sometimes it’s a big [magnifying glass] – can you see these new little lights, these LEDs? They’re bright. I take them to the restaurant all the time, they work great for me.

So I think we have to be careful that we’re not going to be able to find a blanket sort of recommendation that’s going to work in every situation, because every individual with low vision is going to be a little bit different.

Question by Marsha Mazz: And I was going to ask you that very question. When I’m asked what can you do for me, I usually say improve the lighting, the illumination, the lumens for everybody, and I’ll benefit. But that’s true for me. I don’t know if there are people who have vision loss whose needs differ greatly from the needs of the population of people who don’t have vision loss.

Response by Dennis Siemsen: They do differ. And I think with the three of you here with low vision, I think each of you would have a unique preference to type of lighting, positioning of lighting and how much glare and things you could tolerate. And I think this is why we do this on an individual basis with each patient and try to adapt the patient to the environment.

Because we’ll say, like, you produce those filters but we would certainly prescribe different types of filters for different situations to try to cope with that kind of situation.

Question by Greg Knoop: How useful is it the term low vision from the perspective of trying to modify the environment, because as you’ve said, there are very different demands. I had a discussion with the ADA people at Washington Metro. And they said, well, what’s good for some is bad for others, so we’re not going to change anything.

Response by [Participant]: That’s Metro’s answer to everything.

That’s right. But how serious is that? Does low vision identify a common set of needs to which we can respond? Or do we need to differentiate that somehow? And how do we balance this individual modification to environmental modification?

Response by Bob Massof: I think it’s very difficult. And I think we can come up with some general rules. You know, we took this inverse-square law, for example, which is a neat law because, like Dennis said, you bring the light source down twice as close; you can get four times as much light.

It may be that we have to think more in terms of, how do we individually be able to shield that light? So just like we’ve sat in this room or I sit in my car now and my wife can have a different air conditioning than I can have, even though we’re sitting in the same car. It may be that each of us sits down in a room like this, and he might say, I want to back-illuminate the system like my iPad to look at the presentation on the screen. Somebody else might say, I want it projected, but not a screen like that, a screen like this.

It may be we have to figure out, is there a way of designing lighting systems, is there a system you implement into a building, which give individuals the ability to adjust lighting, whether we adjust the height of our chair to where we’re sitting, we have to have some type of maybe lamps on the table where it’s a gooseneck and we bring it down and it has a choice of lighting perhaps –

Question by Greg Knoop: Are there useful subdivisions of the concept of low vision that are reasonably similar and consistent?

Response by Dennis Siemsen: Consistent? Boy, I think that’s something that we struggle with a lot, even within our professional organizations. We’re members of the section on low vision in the American Academy of Optometry, okay, so that means something to the doctors that are in the academy. But it doesn’t for other people, low vision could mean anything from, if I take my glasses off, I can’t see the paper, to someone who is totally blind. And we can substitute other terms like vision impairment or [disability] – severe, profound, blah, blah, blah. But again, that doesn’t help the person who only has general knowledge or no knowledge of vision loss.

Comment by Vijay Gupta: I think there are two separate issues. One is the workstation and one is the public space. I think [the] work place is very clear, all these [workstation] or other issues. Then there are the public space types of issues. I mean, we can at least modify a workstation to suit an individual, right? Whereas in a public space, we’re at the mercy of –

Comment by Dave Munson: [For a] GSA project several years ago, they put out the requirements of footcandles and ESI and VCP and all these technical terms. And then after the job was completed, they wrote a paper called “Lessons Learned.” The problem was, in order to meet the guidelines, the lights were spread so far that by the time you put the workstation in, there was no light in the workstations. So everybody added all workstation lighting. Guess what? Twice as much energy being consumed by the lighting. But if it was an overhead system, it was lighting each individual space.

Question by Jim Woods: I want to pick a little bit up on what Fred was saying and maybe twist it just a bit. Since we’ve got practitioners at the table, what would you like to see from the design profession that is going to help you the most?

Response by Dennis Siemens: I think consistency would be one thing. Because what we are faced with is, we have no clue when a patient comes and says to us, I’m having a problem getting to work because of lighting. I don’t know really what the lighting in the building is. I don’t do site visits, so I don’t know what’s sort of the minimum standard with which they’re working. I can relate to the Metro, because I take the Metro, so I definitely know what the issue is in the Metro station.

But because there is no consistency, I guess, you know, I didn’t know I’d walk into this room and there would be lights like this. How do we as practitioners – that’s why I went back to that original thing, that all we’re able to do is to try to adapt the individual to the situation. In other words, you throw the situation at us, and we’ll go, okay, yeah, what do you think?

And it’s trial and error. I wish I could say it was more scientific, but it’s not.

Question by Jim Woods: So is that what you need, then, is a scientific base from the environmental standpoint to help you make decisions?

Response by Dennis Siemsen: Some consistency. I think if we knew that all hallways have this amount of luminance and this amount of glare and this is what it would be like, then I think it’s certainly easier to work with.

Question by [Participant]: What color?

Response by [Participant]: In the Labor Department, we got sued many times, not because we didn’t have enough illumination, it’s because we didn’t have enough luminance.

That’s where [there were] dark, dark, dark, dark, dark green walls. Some of the light, we couldn’t get quite 50 footcandles in the toilet and the cost for not having open enough [lighting], because you couldn’t get an occupancy permit, gets really expensive. So it’s a total environmental issue. It’s not just lighting, it’s not just interior design, it’s a coordination of all of this. And the architects with the clear glass and the, you know – it’s a very complicated problem. There’s not just one solution.

Issue 3: Is there a need for a different kind of Practice?

Question by [Participant]: Does this suggest possibly the evolution of different kind of practice? That is, you know, I watch “House,” and invariably, he sends out his team to check the place where people have come from to see what the chemicals in their environment are. Should there not be a counterpart of that to what you do, that there would be a component of your low-vision practice, which actually looks at the environments that the patient deals with?

Response by Dennis Siemens: I think what Suleiman and I do is, we take the existing environment, whatever that is, because we have little or no control over what happens, even at Mayo Clinic. I yell and scream at them, and they smile and nod. But I have the luxury of being able to go out and do site visits within my institution. So if I have an employee that has a challenge, I go out and say, okay, where you at, get there early so I can go in before I see patients, or go over at lunch, and I’ll take a look and we’ll see what it looks like.

And you know, sometimes I have to look for the supervisor, and they said, well, we just remodeled this whole thing. You’re going to have to do it over because you’ve got one in particular lady [who] was doing appointments, so they wanted her at patient height, you know, eye level. So she was sitting on a tall stool. They had spotlights coming on her and the screen. You know what I showed you on here with the red and the blue? That’s what her screen looked like because that’s what the computer program was. I said, you’ve got to change this, this, this and this, you know? Well, we can’t. Well, you have to, because you’re making this not accessible for this patient. So they hated me but I have the liberty of doing that.

But I think you’re absolutely right. And even a group like occupational therapy, who some therapists are very well-versed in this, reminds me that might be a way. But again, they’ve got to be able to bill for it too or they can’t do it either. So it’s tough to do that stuff.

Sometimes we do those with simulations in our office with a workstation so that we can kind of demonstrate what’s going on and simulate things, but that’s not [practical].

Comment by Eunice Noell-Waggoner: I wanted to say that what you had suggested, I actually participated in. I was invited to Los Angeles from a low-vision specialist, David Slay, who works for the V.A. And with the returning veterans that have a lot of head, brain trauma, although this person could see, the glare was really horrific for him.

Since I worked for a nonprofit, I said, well, I’ll come down, and I’ll see if I can help analyze the situation. It was in the veteran’s home. And the wife had heard, well, you know, he has problems with vision, and you need a lot of light. Well, so she had gone to a big-box store and bought these really glary light fixtures. And I’m thinking, oh, no.

I was traveling from Portland, so I had a suitcase of stuff, but [it was] kind of hard to get through security with that. But I happened to have some light bulbs that had a silver bottom on the bowl. And I just screwed that light bulb in, and it shot the light to the ceiling, removed the bright glare, and it was kind of like he said, oh, this is great. And when you talk about quality of life, the glare was so bad that his wife would have to prepare dinner at 3:30 in the afternoon when there was enough light in the kitchen from natural light sources without turning on these lights so that they could have dinner.

Well, I mean, it’s like their whole life was turned upside-down because of, you know, inadequate and not understanding the problem. And so I think, you know, it really goes to a lot of different issues.

Comment by Bob Massof: Let me add one more note on that same idea here. When you describe a head trauma situation, for example, and I think the data coming out of the V.A. with our returning veterans who have had significant head trauma. I’ve talked to some of the people who do research in this area. These guys are coming back. It’s not something that’s easily measurable, the visual acuity, the peripheral vision, but it’s their visual perception that is screwed up.

This is a good example that we don’t see with our eyes, we see with our brains. Remember, a lot of you are old enough now, when you were a kid that in science class they look like the eye was like a camera with film? It doesn’t work that way at all. The light comes into the eye, hits the retina. The signal then goes from the retina back to the brain, and the brain translates it into what we know as vision.

And part of what we’re describing here is that we’re all different, and our visual perception is different for different circumstances. And so that’s why, you know, one size doesn’t fit all. And it’s helpful for us if we can quantify, you know, what your vision problem is and yours. But even at that, I can take all my patients with glaucoma or macular degeneration, but they’re still different.

Comment by Marsha Mazz: I wanted to follow up on something that Vijay said, because I see the conversation may be going in certain directions. If we’re looking to write guidelines or standards under the Americans With Disabilities Act, for example, bear in mind that the Americans With Disabilities Act does not establish guidelines or standards for home environments or for work environments. So we don’t regulate under the ADA an employee work area, because the ADA under Title I entitles, gives a civil right to each employee with a disability to advocate for their modifications that he or she needs. And the employer must provide them unless there is a substantial undue burden.

So as we begin to think about writing guidelines or standards or using existing, which would be my first choice, using existing standards that are out there or reviewing those existing standards, we probably should be thinking about public environments, you know, public-use spaces, such as National Airport, the Metro station, corridors within an office building, which we do regulate, and on another track be dealing with environments that people can adjust to suit their own needs, such as their homes and their work environments.

I’m not saying don’t work on both, but I’m saying realize that there is sort of a natural division here.

Question by [Participant]: Are you saying that the worker has no rights under ADA for the employer to modify the workspace?

Response by Marsha Mazz: Exactly the opposite. The ADA standards for design and construction do not regulate the workspace because Title I of the ADA extends the right to a reasonable accommodation to the employee so that the reasonable accommodation actually meets the unique individual needs of that person.

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