Visual Impairment

Visual impairment, also known as vision impairment or vision loss, is a decreased ability to see to a degree that causes problems not fixable by usual means, such as glasses. Some also include those who have a decreased ability to see because they do not have access to glasses or contact lenses. Visual impairment is often defined as a best corrected visual acuity of worse than either 20/40 or 20/60. The term blindness is used for complete or nearly complete vision loss. Visual impairment may cause difficulties with normal daily activities such as reading and walking without adaptive training and equipment.

The most common causes of visual impairment globally are uncorrected refractive errors (43%), cataracts (33%), and glaucoma (2%). Refractive errors include near-sightedness, far-sightedness, presbyopia, and astigmatism. Cataracts are the most common cause of blindness. Other disorders that may cause visual problems include age-related macular degeneration, diabetic retinopathy, corneal clouding, childhood blindness, and a number of infections. Visual impairment can also be caused by problems in the brain due to stroke, premature birth, or trauma among others. These cases are known as cortical visual impairment. Screening for vision problems in children may improve future vision and educational achievement. Screening adults without symptoms is of uncertain benefit. Diagnosis is by an eye exam.

The World Health Organization (WHO) estimates that 80% of visual impairment is either preventable or curable with treatment. This includes cataracts, the infections river blindness and trachoma, glaucoma, diabetic retinopathy, uncorrected refractive errors, and some cases of childhood blindness. Many people with significant visual impairment benefit from vision rehabilitation, changes in their environment, and assistive devices.

As of 2015 there were 940 million people with some degree of vision loss. 246 million had low vision and 39 million were blind. The majority of people with poor vision are in the developing world and are over the age of 50 years. Rates of visual impairment have decreased since the 1990s. Visual impairments have considerable economic costs both directly due to the cost of treatment and indirectly due to decreased ability to work.

Classification

A typical Snellen chart that is frequently used for visual acuity testing.

The definition of visual impairment is reduced vision not corrected by glasses or contact lenses. The World Health Organization uses the following classifications of visual impairment. When the vision in the better eye with best possible glasses correction is:

• 20/30 to 20/60 : is considered mild vision loss, or near-normal vision
• 20/70 to 20/160 : is considered moderate visual impairment, or moderate low vision
• 20/200 to 20/400 : is considered severe visual impairment, or severe low vision
• 20/500 to 20/1,000 : is considered profound visual impairment, or profound low vision
• More than 20/1,000 : is considered near-total visual impairment, or near total blindness
• No light perception (NLP) : is considered total visual impairment, or total blindness

Blindness is defined by the World Health Organization as vision in a person's best eye with best correction of less than 20/500 or a visual field of less than 10 degrees. This definition was set in 1972, and there is ongoing discussion as to whether it should be altered to officially include uncorrected refractive errors.

United Kingdom

Severely sight impaired

• Defined as having central visual acuity of less than 3/60 with normal fields of vision, or gross visual field restriction.
• Unable to see at 3 metres (10 ft) what the normally sighted person sees at 60 metres (200 ft).

Sight impaired

• Able to see at 3 metres (10 ft), but not at 6 metres (20 ft), what the normally sighted person sees at 60 metres (200 ft)
• Less severe visual impairment is not captured by registration data, and its prevalence is difficult to quantify

Low vision

• A visual acuity of less than 6/18 but greater than 3/60.
• Not eligible to drive and may have difficulty recognising faces across a street, watching television, or choosing clean, unstained, co-ordinated clothing.

In the UK, the Certificate of Vision Impairment (CVI) is used to certify patients as severely sight impaired or sight impaired. The accompanying guidance for clinical staff states: "The National Assistance Act 1948 states that a person can be certified as severely sight impaired if they are 'so blind as to be unable to perform any work for which eye sight is essential'". Certification is based on whether a person can do any work for which eyesight is essential, not just one particular job (such as their job before becoming blind).

In practice, the definition depends on individuals' visual acuity and the extent to which their field of vision is restricted. The Department of Health identifies three groups of people who may be classified as severely visually impaired.

1. Those below 3/60 (equivalent to 20/400 in US notation) Snellen (most people below 3/60 are severely sight impaired).
2. Those better than 3/60 but below 6/60 Snellen (people who have a very contracted field of vision only).
3. Those 6/60 Snellen or above (people in this group who have a contracted field of vision especially if the contraction is in the lower part of the field).

The Department of Health also state that a person is more likely to be classified as severely visually impaired if their eyesight has failed recently or if they are an older individual, both groups being perceived as less able to adapt to their vision loss.

United States

In the United States, any person with vision that cannot be corrected to better than 20/200 in the best eye, or who has 20 degrees (diameter) or less of visual field remaining, is considered legally blind or eligible for disability classification and possible inclusion in certain government sponsored programs.

In the United States, the terms partially sighted, low vision, legally blind and totally blind are used by schools, colleges, and other educational institutions to describe students with visual impairments. They are defined as follows:

• Partially sighted indicates some type of visual problem, with a need of person to receive special education in some cases.
• Low vision generally refers to a severe visual impairment, not necessarily limited to distance vision. Low vision applies to all individuals with sight who are unable to read the newspaper at a normal viewing distance, even with the aid of eyeglasses or contact lenses. They use a combination of vision and other senses to learn, although they may require adaptations in lighting or the size of print, and, sometimes, braille.
  • Myopic – unable to see distant objects clearly, commonly called near-sighted or short-sighted.
  • Hyperopic – unable to see close objects clearly, commonly called far-sighted or long-sighted.
• Legally blind indicates that a person has less than 20/200 vision in the better eye after best correction (contact lenses or glasses), or a field of vision of less than 20 degrees in the better eye.
• Totally blind students learn via braille or other non-visual media.

In 1934, the American Medical Association adopted the following definition of blindness:

Central visual acuity of 20/200 or less in the better eye with corrective glasses or central visual acuity of more than 20/200 if there is a visual field defect in which the peripheral field is contracted to such an extent that the widest diameter of the visual field subtends an angular distance no greater than 20 degrees in the better eye.

The United States Congress included this definition as part of the Aid to the Blind program in the Social Security Act passed in 1935. In 1972, the Aid to the Blind program and two others combined under Title XVI of the Social Security Act to form the Supplemental Security Income program which states:

An individual shall be considered to be blind for purposes of this title if he has central visual acuity of 20/200 or less in the better eye with the use of a correcting lens. An eye which is accompanied by a limitation in the fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered for purposes of the first sentence of this subsection as having a central visual acuity of 20/200 or less. An individual shall also be considered to be blind for purposes of this title if he is blind as defined under a State plan approved under title X or XVI as in effect for October 1972 and received aid under such plan (on the basis of blindness) for December 1973, so long as he is continuously blind as so defined.

Health effects

Visual impairments may take many forms and be of varying degrees. Visual acuity alone is not always a good predictor of the degree of problems a person may have. Someone with relatively good acuity (e.g., 20/40) can have difficulty with daily functioning, while someone with worse acuity (e.g., 20/200) may function reasonably well if their visual demands are not great.

The American Medical Association has estimated that the loss of one eye equals 25% impairment of the visual system and 24% impairment of the whole person; total loss of vision in both eyes is considered to be 100% visual impairment and 85% impairment of the whole person.

Some people who fall into this category can use their considerable residual vision – their remaining sight – to complete daily tasks without relying on alternative methods. The role of a low vision specialist (optometrist or ophthalmologist) is to maximize the functional level of a patient's vision by optical or non-optical means. Primarily, this is by use of magnification in the form of telescopic systems for distance vision and optical or electronic magnification for near tasks.

People with significantly reduced acuity may benefit from training conducted by individuals trained in the provision of technical aids. Low vision rehabilitation professionals, some of whom are connected to an agency for the blind, can provide advice on lighting and contrast to maximize remaining vision. These professionals also have access to non-visual aids, and can instruct patients in their uses.

The subjects making the most use of rehabilitation instruments, who lived alone, and preserved their own mobility and occupation were the least depressed, with the lowest risk of suicide and the highest level of social integration.

Those with worsening sight and the prognosis of eventual blindness are at comparatively high risk of suicide and thus may be in need of supportive services. Many studies have demonstrated how rapid acceptance of the serious visual handicap has led to a better, more productive compliance with rehabilitation programs. Moreover, psychological distress has been reported to be at its highest when sight loss is not complete, but the prognosis is unfavorable. Therefore, early intervention is imperative for enabling successful psychological adjustment.

Associated conditions

Blindness can occur in combination with such conditions as intellectual disability, autism spectrum disorders, cerebral palsy, hearing impairments, and epilepsy. Blindness in combination with hearing loss is known as deafblindness.

It has been estimated that over half of completely blind people have non-24-hour sleep–wake disorder, a condition in which a person's circadian rhythm, normally slightly longer than 24 hours, is not entrained (synchronized) to the light–dark cycle.

Cause

The most common causes of visual impairment globally in 2010 were:

1. Refractive error (42%)
2. Cataract (33%)
3. Glaucoma (2%)
4. Age-related macular degeneration (1%)
5. Corneal opacification (1%)
6. Diabetic retinopathy (1%)
7. Childhood blindness
8. Trachoma (1%)
9. Undetermined (18%)

The most common causes of blindness worldwide in 2010 were:

1. Cataracts (51%)
2. Glaucoma (8%)
3. Age-related macular degeneration (5%)
4. Corneal opacification (4%)
5. Childhood blindness (4%)
6. Refractive errors (3%)
7. Trachoma (3%)
8. Diabetic retinopathy (1%)
9. Undetermined (21%)

About 90% of people who are visually impaired live in the developing world. Age-related macular degeneration, glaucoma, and diabetic retinopathy are the leading causes of blindness in the developed world.

Among working-age adults who are newly blind in England and Wales the most common causes in 2010 were:

1. Hereditary retinal disorders (20.2%)
2. Diabetic retinopathy (14.4%)
3. Optic atrophy (14.1%)
4. Glaucoma (5.9%)
5. Congenital abnormalities (5.1%)
6. Disorders of the visual cortex (4.1%)
7. Cerebrovascular disease (3.2%)
8. Degeneration of the macula and posterior pole (3.0%)
9. Myopia (2.8%)
10. Corneal disorders (2.6%)
11. Malignant neoplasms of the brain and nervous system (1.5%)
12. Retinal detachment (1.4%)

Cataracts

Cataracts are the congenital and pediatric pathology that describes the greying or opacity of the crystalline lens, which is most commonly caused by intrauterine infections, metabolic disorders, and genetically transmitted syndromes. Cataracts are the leading cause of child and adult blindness that doubles in prevalence with every ten years after the age of 40. Consequently, today cataracts are more common among adults than in children. That is, people face higher chances of developing cataracts as they age. Nonetheless, cataracts tend to have a greater financial and emotional toll upon children as they must undergo expensive diagnosis, long term rehabilitation, and visual assistance. Also, according to the Saudi Journal for Health Sciences, sometimes patients experience irreversible amblyopia after pediatric cataract surgery because the cataracts prevented the normal maturation of vision prior to operation. Despite the great progress in treatment, cataracts remain a global problem in both economically developed and developing countries. At present, with the variant outcomes as well as the unequal access to cataract surgery, the best way to reduce the risk of developing cataracts is to avoid smoking and extensive exposure to sun light (i.e. UV-B rays).

Glaucoma

Glaucoma is a congenital and pediatric eye disease characterized by increased pressure within the eye or intraocular pressure (IOP). Glaucoma causes visual field loss as well as severs the optic nerve. Early diagnosis and treatment of glaucoma in patients is imperative because glaucoma is triggered by non-specific levels of IOP. Also, another challenge in accurately diagnosing glaucoma is that the disease has four causes: 1) inflammatory ocular hypertension syndrome (IOHS); 2) severe uveitic angle closure; 3) corticosteroid-induced; and 4) a heterogonous mechanism associated with structural change and chronic inflammation. In addition, often pediatric glaucoma differs greatly in cause and management from the glaucoma developed by adults. Currently, the best sign of pediatric glaucoma is an IOP of 21 mm Hg or greater present within a child. One of the most common causes of pediatric glaucoma is cataract removal surgery, which leads to an incidence rate of about 12.2% among infants and 58.7% among 10-year-olds.

Infections

The burden of onchocerciasis: children leading blind adults in Africa

Childhood blindness can be caused by conditions related to pregnancy, such as congenital rubella syndrome and retinopathy of prematurity. Leprosy and onchocerciasis each blind approximately 1 million individuals in the developing world.

The number of individuals blind from trachoma has decreased in the past 10 years from 6 million to 1.3 million, putting it in seventh place on the list of causes of blindness worldwide.

Central corneal ulceration is also a significant cause of monocular blindness worldwide, accounting for an estimated 850,000 cases of corneal blindness every year in the Indian subcontinent alone. As a result, corneal scarring from all causes is now the fourth greatest cause of global blindness.

Injuries

Re-educating wounded. Blind French soldiers learning to make baskets, World War I.

Eye injuries, most often occurring in people under 30, are the leading cause of monocular blindness (vision loss in one eye) throughout the United States. Injuries and cataracts affect the eye itself, while abnormalities such as optic nerve hypoplasia affect the nerve bundle that sends signals from the eye to the back of the brain, which can lead to decreased visual acuity.

Cortical blindness results from injuries to the occipital lobe of the brain that prevent the brain from correctly receiving or interpreting signals from the optic nerve. Symptoms of cortical blindness vary greatly across individuals and may be more severe in periods of exhaustion or stress. It is common for people with cortical blindness to have poorer vision later in the day.

Blinding has been used as an act of vengeance and torture in some instances, to deprive a person of a major sense by which they can navigate or interact within the world, act fully independently, and be aware of events surrounding them. An example from the classical realm is Oedipus, who gouges out his own eyes after realizing that he fulfilled the awful prophecy spoken of him. Having crushed the Bulgarians, the Byzantine Emperor Basil II blinded as many as 15,000 prisoners taken in the battle, before releasing them. Contemporary examples include the addition of methods such as acid throwing as a form of disfigurement.

Genetic defects

People with albinism often have vision loss to the extent that many are legally blind, though few of them actually cannot see. Leber congenital amaurosis can cause total blindness or severe sight loss from birth or early childhood.

Recent advances in mapping of the human genome have identified other genetic causes of low vision or blindness. One such example is Bardet–Biedl syndrome.

Poisoning

Rarely, blindness is caused by the intake of certain chemicals. A well-known example is methanol, which is only mildly toxic and minimally intoxicating, and breaks down into the substances formaldehyde and formic acid which in turn can cause blindness, an array of other health complications, and death. When competing with ethanol for metabolism, ethanol is metabolized first, and the onset of toxicity is delayed. Methanol is commonly found in methylated spirits, denatured ethyl alcohol, to avoid paying taxes on selling ethanol intended for human consumption. Methylated spirits are sometimes used by alcoholics as a desperate and cheap substitute for regular ethanol alcoholic beverages.

Other

• Amblyopia: is a category of vision loss or visual impairment that is caused by factors unrelated to refractive errors or coexisting ocular diseases. Amblyopia is the condition when a child's visual systems fail to mature normally because the child either suffers from a premature birth, measles, congenital rubella syndrome, vitamin A deficiency, or meningitis. If left untreated during childhood, amblyopia is currently incurable in adulthood because surgical treatment effectiveness changes as a child matures. Consequently, amblyopia is the world's leading cause of child monocular vision loss, which is the damage or loss of vision in one eye. In the best case scenario, which is very rare, properly treated amblyopia patients can regain 20/40 acuity.
• Corneal opacification
• Degenerative myopia
• Diabetic retinopathy: is one of the manifestation microvascular complications of diabetes, which is characterized by blindness or reduced acuity. That is, diabetic retinopathy describes the retinal and vitreous hemorrhages or retinal capillary blockage caused by the increase of A1C, which a measurement of blood glucose or sugar level. In fact, as A1C increases, people tend to be at greater risk of developing diabetic retinopathy than developing other microvascular complications associated with diabetes (e.g. chronic hyperglycemia, diabetic neuropathy, and diabetic nephropathy). Despite the fact that only 8% of adults 40 years and older experience vision-threatening diabetic retinopathy (e.g. nonproliferative diabetic retinopathy or NPDR and proliferative diabetic retinopathy or PDR), this eye diseased accounted for 17% of cases of blindness in 2002.
• Retinitis pigmentosa
• Retinopathy of prematurity: The most common cause of blindness in infants worldwide. In its most severe form, ROP causes retinal detachment, with attendant visual loss. Treatment is aimed mainly at prevention, via laser or Avastin therapy.
• Stargardt's disease
• Uveitis: is a group of 30 intraocular inflammatory diseases caused by infections, systemic diseases, organ-specific autoimmune processes, cancer or trauma. That is, uveitis refers to a complex category of ocular diseases that can cause blindness if either left untreated or improperly diagnosed. The current challenge of accurately diagnosing uveitis is that often the cause of a specific ocular inflammation is either unknown or multi-layered. Consequently, about 3–10% uveitis victims in developed countries, and about 25% of victims in the developing countries, become blind from incorrect diagnosis and from ineffectual prescription of drugs, antibiotics or steroids. In addition, uveitis is a diverse category of eye diseases that are subdivided as granulomatous (or tumorous) or non-granulomatous anterior, intermediate, posterior or pan uveitis. In other words, uveitis diseases tend to be classified by their anatomic location in the eye (e.g. uveal tract, retina, or lens), as well as can create complication that can cause cataracts, glaucoma, retinal damage, age-related macular degeneration or diabetic retinopathy.
• Xerophthalmia, often due to vitamin A deficiency, is estimated to affect 5 million children each year; 500,000 develop active corneal involvement, and half of these go blind.

Diagnosis

Play media

Scientists track eye movements in glaucoma patients to check vision impairment while driving

It is important that people be examined by someone specializing in low vision care prior to other rehabilitation training to rule out potential medical or surgical correction for the problem and to establish a careful baseline refraction and prescription of both normal and low vision glasses and optical aids. Only a doctor is qualified to evaluate visual functioning of a compromised visual system effectively. The American Medical Association provides an approach to evaluating visual loss as it affects an individual's ability to perform activities of daily living.

Screening adults who have no symptoms is of uncertain benefit.

Prevention

The World Health Organization estimates that 80% of visual loss is either preventable or curable with treatment. This includes cataracts, onchocerciasis, trachoma, glaucoma, diabetic retinopathy, uncorrected refractive errors, and some cases of childhood blindness. The Center for Disease Control and Prevention estimates that half of blindness in the United States is preventable.

Management

Tommy Edison, a blind film critic, demonstrates for his viewers how a blind person can cook alone.

Mobility

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Folded long cane

A blind man is assisted by a guide dog in Brasília, Brazil

Blind girl feels shape of vehicle near Mana village, Uttarakhand

Visually impaired girl negotiating a rock while rock climbing

Many people with serious visual impairments can travel independently, using a wide range of tools and techniques. Orientation and mobility specialists are professionals who are specifically trained to teach people with visual impairments how to travel safely, confidently, and independently in the home and the community. These professionals can also help blind people to practice travelling on specific routes which they may use often, such as the route from one's house to a convenience store. Becoming familiar with an environment or route can make it much easier for a blind person to navigate successfully.

Tools such as the white cane with a red tip – the international symbol of blindness – may also be used to improve mobility. A long cane is used to extend the user's range of touch sensation. It is usually swung in a low sweeping motion, across the intended path of travel, to detect obstacles. However, techniques for cane travel can vary depending on the user and/or the situation. Some visually impaired persons do not carry these kinds of canes, opting instead for the shorter, lighter identification (ID) cane. Still others require a support cane. The choice depends on the individual's vision, motivation, and other factors.

A small number of people employ guide dogs to assist in mobility. These dogs are trained to navigate around various obstacles, and to indicate when it becomes necessary to go up or down a step. However, the helpfulness of guide dogs is limited by the inability of dogs to understand complex directions. The human half of the guide dog team does the directing, based upon skills acquired through previous mobility training. In this sense, the handler might be likened to an aircraft's navigator, who must know how to get from one place to another, and the dog to the pilot, who gets them there safely.

GPS devices can also be used as a mobility aid. Such software can assist blind people with orientation and navigation, but it is not a replacement for traditional mobility tools such as white canes and guide dogs.

Some blind people are skilled at echolocating silent objects simply by producing mouth clicks and listening to the returning echoes. It has been shown that blind echolocation experts use what is normally the "visual" part of their brain to process the echoes.

Government actions are sometimes taken to make public places more accessible to blind people. Public transportation is freely available to the blind in many cities. Tactile paving and audible traffic signals can make it easier and safer for visually impaired pedestrians to cross streets. In addition to making rules about who can and cannot use a cane, some governments mandate the right-of-way be given to users of white canes or guide dogs.

Reading and magnification

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Braille watch

Most visually impaired people who are not totally blind read print, either of a regular size or enlarged by magnification devices. Many also read large-print, which is easier for them to read without such devices. A variety of magnifying glasses, some handheld, and some on desktops, can make reading easier for them.

Others read braille (or the infrequently used Moon type), or rely on talking books and readers or reading machines, which convert printed text to speech or braille. They use computers with special hardware such as scanners and refreshable braille displays as well as software written specifically for the blind, such as optical character recognition applications and screen readers.

Some people access these materials through agencies for the blind, such as the National Library Service for the Blind and Physically Handicapped in the United States, the National Library for the Blind or the RNIB in the United Kingdom.

Closed-circuit televisions, equipment that enlarges and contrasts textual items, are a more high-tech alternative to traditional magnification devices.

There are also over 100 radio reading services throughout the world that provide people with vision impairments with readings from periodicals over the radio. The International Association of Audio Information Services provides links to all of these organizations.

Computers and mobile technology

Access technology such as screen readers, screen magnifiers and refreshable braille displays enable the blind to use mainstream computer applications and mobile phones. The availability of assistive technology is increasing, accompanied by concerted efforts to ensure the accessibility of information technology to all potential users, including the blind. Later versions of Microsoft Windows include an Accessibility Wizard & Magnifier for those with partial vision, and Microsoft Narrator, a simple screen reader. Linux distributions (as live CDs) for the blind include Vinux and Adriane Knoppix, the latter developed in part by Adriane Knopper who has a visual impairment. macOS and iOS also come with a built-in screen reader called VoiceOver, while Google TalkBack is built in to most Android devices.

The movement towards greater web accessibility is opening a far wider number of websites to adaptive technology, making the web a more inviting place for visually impaired surfers.

Experimental approaches in sensory substitution are beginning to provide access to arbitrary live views from a camera.

Modified visual output that includes large print and/or clear simple graphics can be of benefit to users with some residual vision.

Other aids and techniques

A tactile feature on a Canadian banknote

Blind people may use talking equipment such as thermometers, watches, clocks, scales, calculators, and compasses. They may also enlarge or mark dials on devices such as ovens and thermostats to make them usable. Other techniques used by blind people to assist them in daily activities include:

• Adaptations of coins and banknotes so that the value can be determined by touch. For example:
  • In some currencies, such as the euro, the pound sterling and the Indian rupee, the size of a note increases with its value.
  • On US coins, pennies and dimes, and nickels and quarters are similar in size. The larger denominations (dimes and quarters) have ridges along the sides (historically used to prevent the "shaving" of precious metals from the coins), which can now be used for identification.
  • Some currencies' banknotes have a tactile feature to indicate denomination. For example, the Canadian currency tactile feature is a system of raised dots in one corner, based on braille cells but not standard braille.
  • It is also possible to fold notes in different ways to assist recognition.
• Labeling and tagging clothing and other personal items
• Placing different types of food at different positions on a dinner plate
• Marking controls of household appliances

Most people, once they have been visually impaired for long enough, devise their own adaptive strategies in all areas of personal and professional management.

For the blind, there are books in braille, audio-books, and text-to-speech computer programs, machines and e-book readers. Low vision people can make use of these tools as well as large-print reading materials and e-book readers that provide large font sizes.

Computers are important tools of integration for the visually impaired person. They allow, using standard or specific programs, screen magnification and conversion of text into sound or touch (braille line), and are useful for all levels of visual handicap. OCR scanners can, in conjunction with text-to-speech software, read the contents of books and documents aloud via computer. Vendors also build closed-circuit televisions that electronically magnify paper, and even change its contrast and color, for visually impaired users. For more information, consult Assistive technology.

In adults with low vision there is no conclusive evidence supporting one form of reading aid over another. In several studies stand-mounted devices allowed faster reading than hand-held or portable optical aids. While electronic aids may allow faster reading for individuals with low vision, portability, ease of use, and affordability must be considered for people.

Children with low vision sometimes have reading delays, but do benefit from phonics-based beginning reading instruction methods. Engaging phonics instruction is multisensory, highly motivating, and hands-on. Typically students are first taught the most frequent sounds of the alphabet letters, especially the so-called short vowel sounds, then taught to blend sounds together with three-letter consonant-vowel-consonant words such as cat, red, sit, hot, sun. Hands-on (or kinesthetically appealing) VERY enlarged print materials such as those found in "The Big Collection of Phonics Flipbooks" by Lynn Gordon (Scholastic, 2010) are helpful for teaching word families and blending skills to beginning readers with low vision. Beginning reading instructional materials should focus primarily on the lower-case letters, not the capital letters (even though they are larger) because reading text requires familiarity (mostly) with lower-case letters. Phonics-based beginning reading should also be supplemented with phonemic awareness lessons, writing opportunities, and many read-alouds (literature read to children daily) to stimulate motivation, vocabulary development, concept development, and comprehension skill development. Many children with low vision can be successfully included in regular education environments. Parents may need to be vigilant to ensure that the school provides the teacher and students with appropriate low vision resources, for example technology in the classroom, classroom aide time, modified educational materials, and consultation assistance with low vision experts.

Communication

Communication with the visually impaired can be more difficult than communicating with someone who doesn't have vision loss. However, many people are uncomfortable with communicating with the blind, and this can cause communication barriers. One of the biggest obstacles in communicating with visually impaired individuals comes from face-to-face interactions. There are many factors that can cause the sighted to become uncomfortable while communicating face to face. There are many non-verbal factors that hinder communication between the visually impaired and the sighted, more often than verbal factors do. These factors, which Rivka Bialistock mentions in her article, include:

• Lack of facial expressions, mimics, or body gestures/responses
• Non-verbal gestures that could imply the visually impaired individual not appearing interested
• Speaking when not anticipated or not speaking when anticipated
• Fear of offending the visually impaired
• Standing too close and invading the personal comfort level
• Having to exercise or ignore feelings of pity
• Being uncomfortable with touching objects or people
• A look of detachment or disengagement
• Dependency
• Being reminded of the fear of becoming blind

The blind person sends these signals or types of non-verbal communication without being aware that they are doing so. These factors can all affect the way an individual would feel about communicating with the visually impaired. This leaves the visually impaired feeling