• Ensure Your Website Is Accessible to Patients With Low Vision

    By Linda Roach, Contributing Writer
    Interviewing Joseph L. Fontenot, MD, Mary Lou Jackson, MD, Brad B. Martin, Ike Presley, and Kimberly Quintal, MS, OTR/L

    This article is from May 2012 and may contain outdated material.

    When Justin Romack lost 95 percent of his sight in 2008 after a series of retinal detachments and failed corneal transplants, he fell into a profound depression. But then he found other people with low vision on Facebook and Twitter. These online friends lifted his mood and gave him tips for finding tools to live a full life despite his extensive visual loss. However, if he had lost his sight today, Mr. Romack, a marketing consultant in College Station, Texas, would have had much more difficulty finding a lifeline on Facebook. That’s because the site was “upgraded” and now is filled with electronic stumbling blocks that his screen-reading software cannot easily navigate.

    Would he fare any better with your practice website? Read this summary of best practices and common design flaws for tips on making your site more welcoming to low vision patients.

    Design Problems to Avoid

    There are several structural design elements that can make a website unwieldy or outright unusable for low vision patients. Here’s a brief overview of the most common design flaws.

    A lack of customization options. Making a website truly accessible to people who are visually impaired requires much more than a small click-box that increases text size by an inadequate 10 or 20 percent, said Ike Presley, a certified low vision therapist who is manager for professional development at the American Foundation for the Blind (AFB) in Atlanta. His group’s website (www.afb.org) provides an example of the versatility that, with forethought, can be built into a site. Users can completely customize pages to suit their vision. They can change the contrast, font, level of magnification, and colors of both the text and background. They also can move the navigation bar to the bottom of the page so that an automated reader, if they are using one, does not reread the tabs at the top of every column.

    Visual clutter. Joseph L. Fontenot, MD, whose binocular BCVA is 20/250, said he has the most trouble with overstuffed Web pages. “Flashing images are a nightmare for people with low vision. The problem is trying to find the right place to go to on the page,” said Dr. Fontenot, who is a certified low vision therapist and the medical director of Community Services for Vision Rehabilitation in Mobile, Ala.

    Low-contrast color schemes. “You should try to make the page as visually accessible as you can,” said Mr. Presley. “That doesn’t mean you can’t make it attractive. But you can’t have low levels of contrast between colors.”

    Unhelpful tagging of graphics. When graphic elements play an important role on a Web page, it is crucial that they have meaningful “alternative tags.” These tags, commonly referred to as “alt tags,” provide a brief text description of the graphic element. Most Web users only encounter alt tags when a Web browser has problems displaying an image on a Web page, in which case the tag’s text will be displayed instead. However, for Web users who are using text-to-speech software and other assistive technology, these alt tags are critical. Unfortunately, it is common for the tags to be missing from pages or for them to consist of long streams of unhelpful numbers.

    Uninformative links. Users of text-to-speech software often navigate from link to link. If a graphic element acts as a link, then “the alt tag needs to say what the button will do,” said Mr. Presley. Suppose, for instance, that a photo of a doctor acts as a link to his or her biographical Web page; the alt tag should tell you that it is a link to the doctor’s bio, rather than saying “Photo of Dr. X.” Similarly, when text acts as a link, it should not just say, “Click Here” —it should explain what it links to.

    Online forms that time out. “The worst thing is when you try to fill out a form,” said Dr. Fontenot. “Most adults with acquired poor vision are slow with these forms, and it takes us longer to process visual images. Sometimes these forms are timed, so no matter what you do, the form will time out. All your information is lost, and you have to start over again.”

    Barriers to automated reading. Screen readers are software programs that convert text into speech using a speech synthesizer. They are available as add-on programs for computers and mobile devices. Some screen magnification programs also provide synthesized speech. Such software allows the visually impaired to access and surf the Web. Brad B. Martin, who works for HandsOn South Alabama, a community service agency in Mobile, uses a screen-reading program called JAWS. But JAWS cannot read PDF files that have been created as images. The reader also dislikes “flashy” websites like Facebook, which refresh the screen frequently. “The flashier a website is, the harder it is to deal with,” said Mr. Martin. “Every time the page refreshes, my JAWS cursor will lose its place and go back to the top of the page.”

    And, as noted above, navigation bars can present problems for screen readers, as can narrowly spaced columns of text. The AFB website provides plenty of space between columns to prevent text-to-speech devices from mistakenly reading across two or three columns as though they were one.

    Design Steps to Take

    If you’re looking to improve your website, here are some steps to take.

    Go for the gold standard. The World Wide Web Consortium, the international coalition that develops open standards for the Internet, has a Web Accessibility Initiative. The group’s recommendations are widely regarded as the gold standard of Web accessibility. Its website (www.w3.org/WAI) contains a wealth of information, from technical guidance for website designers to tips for visually impaired people on making their computer easier to use.

    Analyze your website. There are a wide variety of software tools available that can be used to analyze your practice’s website for its friendliness to the visually impaired user. One that is free online is Wave, which—rather than generating a text report—displays the Web page in question along with icons flagging any problems, such as “missing alt text” (go to wave.webaim.org). The Web Accessibility Initiative also lists several tools.

    Make PDF documents accessible. Adobe Acrobat and Adobe Reader include a number of new features that can make PDF files accessible to the visually impaired. For an overview, see www.aph.org/webfeat/adobe.html.

    Select an easy-to-read font. The bottom line: Steer clear of any and all gimmicks. One font, APHont (pronounced Ay -font), was specifically developed to enhance reading speed, comprehension, and comfort for patients with low vision. As a bonus, it makes reading easier for everyone. The download is free to qualified users (go to www.aph.org/products/aphont.html).

    You may need to start over. If too many problems emerge during your site redesign, you may need to start over. Making a website fully accessible is easier to do from the ground up than via the process of revamping an existing site, the experts acknowledge.

    But before you take this step, make sure that the designer you hire is familiar with the Web Accessibility Initiative’s work. “You want to make sure that the people putting together your website know about the guidelines,” Mr. Presley said. “That would be a realistic requirement” for any Web designer you hire, he said.

    The Power of an Encouraging Word

    With the help of assistive technology, today’s patients with limited or no sight can use the Web to gain information and stay connected to others, said Mary Lou Jackson, MD, chairwoman of the Academy’s Vision Rehabilitation Committee. But these patients need their ophthalmologists to encourage them to find the coping strategies and devices that will enable their continued enjoyment of the Internet, she said.

    This doesn’t mean that you have to become an expert in visual rehabilitation, said Dr. Jackson, director of vision rehabilitation at Massachusetts Eye and Ear Infirmary and assistant professor of ophthalmology at Harvard. “You don’t have to know every assistive device.” Simply realizing that options exist—and then encouraging patients to pursue them—is critical, she said. “That will make a great deal of difference to a patient’s quality of life.”

    SmartSight guidance. Dr. Jackson and her committee are behind the Academy’s SmartSight initiative, which is aimed at encouraging ophthalmologists to help low vision patients make the most of their remaining vision.

    SmartSight urges ophthalmologists to follow the first two Rs of vision rehab: Recognize that reduced vision impacts your patients’ lives and then respond.

    Responding positively can be as simple as downloading a patient information handout from the SmartSight Web page (www.aao.org/smart-sight-low-vision), then giving it to the patient, Dr. Jackson said. The handout includes a link to a website that lists state-by-state contact information for services for the visually impaired.

    Patients should start earlier rather than later. “Sometimes it’s at the very beginning of the visual loss process that they really need to figure out strategies and some direction,” said Dr. Jackson. “Someone who’s 20/50 might be having trouble looking at stock quotes on the Internet or reading bank statements, and they can be helped right now.”

    Kimberly Quintal, MS, OTR/L, a registered occupational therapist who works with Dr. Jackson’s patients, agreed. “It’s always easier for patients when they learn to compensate earlier, so they know what to do if severe vision loss occurs. Sometimes we don’t see these people until it’s much too late. Then it’s just harder to teach them how to cope.”