• Practice Perfect

    Make Your Office Safer for Patients With Low Vision

    Written By: Sue Mussatt, RN, CLVT

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    When low vision patients visit your office, what sort of experience do they have? As an experiment, put on a pair of trial glasses that blur your vision to 20/200 and imagine that you are visiting your building for the first time. It could be an eye-opener.

    Fortunately, you don’t have to break the budget to make your office easier—and safer—to navigate. You can make a world of difference by paying attention to some of the basics of vision rehabilitation, such as lighting, color, contrast, figure-ground perception, and touch.

    Though different disabilities affect vision in diverse ways, the recommendations below will help most patients who have vision impairment. And while some changes can be made right away, others will need to wait until your next office renovation.

    Doors, Stairs, and Hallways 

    Building’s entrance. Doorways are easier to find when they are offset from the wall, rather than flush with it. If your building wasn’t built that way, you can use color to the same effect. Suppose, for instance, the front of your building is made up of glass panels. An accent trim color around the doorway makes it easier to find the glass panel that is the door. It is also a good idea to put high-contrast printing or graphics on glass doors—particularly sliding doors—so it is easier to tell whether they are open or closed.

    Stairs. Changes in the floor surface are one of the greatest fears of the visually impaired. Stairs should have a handrail, be well illuminated, and have minimal glare. Put a contrasting strip on the leading edge of each step; without that, the stairs can look like a ramp to a person with low vision. If you have concrete steps outside your building, this contrasting strip can simply be painted on. (Those concrete bumpers in the parking lot should also have contrasting strips.)

    Hallways. The next time you recarpet your hallways, put a six-inch-wide, contrasting strip of carpet along the walls. This will highlight where the wall starts. If you break this strip at the doorways, patients can more easily see where the door openings are. Similarly, when you paint the baseboards and door frames, select a color that contrasts with the color of the walls. And when you paint those walls, select a matte finish—gloss and semigloss reflect too much light.

    Signage. When it comes to your Exit and Restroom signs, consider:

    • Lettering. The size of the letters, their thickness and font style, and the space between characters all matter.
    • Color contrast. When selecting colors, you need effective contrast 1) between the letters and the background of the sign and 2) between the background of the sign and the wall or door that the sign is on.
    • Americans With Disabilities Act (ADA). Learn about the ADA requirements (see “Additional Resources”), but keep in mind that you should look beyond the ADA’s minimum requirements in order to create a truly low vision–friendly environment.

    Your Reception Area

    For low vision patients, the challenge of navigating an unfamiliar office can be a source of anxiety. You can eliminate some of that stress if 1) staff members are sensitive to the patients’ visual needs and 2) the design of your office addresses the following issues.

    Color scheme. If a carpet, chair, and wall are all the same tone, patients with blurry vision will be hard-pressed to tell where one stops and the next begins. Choose strong, contrasting colors but avoid distracting patterns such as stripes and checks.

    Furniture. Does your furniture have chrome legs? These are often thin, and they reflect the color of the carpet—and if patients don’t see them, they may catch their canes or walkers on them. Glass-topped tables might also be invisible to your low vision patients. Tabletops and the reception desk’s countertop should have a matte finish, to reduce reflections. When selecting chairs, opt for those with sturdy arms. Patients with poor visual fields often use those arms to orient themselves, so they can rotate into the correct position for sitting down. Also, many elderly patients use the arms of a chair when getting up.

    Lighting. If a patient brings a large-print book to read while she is waiting, will there be enough light for reading? People who are in their 60s may need three to ten times as much illumination as they did when they were 20 years old—so you should make sure that there is good illumination throughout the reception area.

    Your Exam Room

    Anybody who escorts patients from the reception area to your exam room should be trained in the proper technique for guiding the visually impaired (see “Additional Resources”). In conducting the exam, consider the following issues.

    The exam chair. Be specific with your directions. “Have a seat over there” may not be much help to a patient with vision impairment. Instead, say “Have a seat in the exam chair that is three feet directly in front of you.” And watch for clutter—the patient should have a clear path from the door to the exam chair. Put the exam chair in its lowest position, and make sure the footrest is up against the chair. This allows patients to get their feet right against the chair, which gives them more control when they lower themselves into a sitting position.

    Educational materials. Three-dimensional models can help the patient build up a mental image of the eye’s structure. You can, for instance, take the patient’s hand and show them where the lens is in relation to the rest of the eye.

    Count fingers. If your techs use “count fingers” for documenting visual acuity, they should make sure that there is something with a solid, contrasting color (the tech’s shirt), for instance behind the hand. If the fingers are presented out in space with visual clutter in the background, the target is much harder to identify. Of course, a handheld, high-contrast chart that can be presented at any distance is a more accurate method.

    Medications. If patients use more than one type of eye drop, they shouldn’t have to rely on a friend or family member to identify each bottle. Make sure that they have a strategy for telling bottles apart, such as putting a rubber band around one bottle only or, if color perception is adequate, memorizing bottle-top colors. For more ideas, visit your nearest low vision therapist or rehabilitation teacher for the blind.  

    Your Printed Materials

    Although many low vision patients prefer large-print text, some larger organizations have design standards that require a certain-sized font. And some billing houses don’t offer a large-print option for billing statements.

    If you can’t print your materials in large print, how do you meet the needs of your low vision patients? Given such a wide range of visual functioning, no single strategy works for everyone but here are a few suggestions.

    Forms. Offer to read the form to your visually impaired patients; provide a handheld video magnifier for use in the office; use a highlighter or a black marker to indicate where they need to sign; and/or offer them use of a signature guide, which is a plastic square with a rectangular opening where they need to sign.

    Since many patients are becoming more technology savvy, consider loading standard documents onto an iPad (or other tablet), which can then be used to zoom in until the text is large enough for the patient to read.

    Billing statements. Your patients with low vision can have a hard time separating junk mail from important mail, such as billing statements that use standard-sized font. A cover letter in large print can be useful, as can an easily recognizable insignia on your envelopes and at the top of your letters and billing statements. The color and design of the insignia should be distinctive but not complex.

    Business cards. The business cards that I give my low vision patients are “super sized”—3  by 5 inches. But if you don’t want two different sizes of business cards, you can have cards printed on both sides (one side with all your information in standard-sized print; the other with just your name and phone number in large print). 

    ___________________________

    Sue Mussatt, RN, CLVT, is coordinator of low vision services at the University of Missouri at Columbia.

    Additional Resources

    Use SmartSight materials to assist low vision patients. Not all ophthalmologists have the time to manage low vision patients, so the Academy’s SmartSight provides resources for two levels of service. Levels 1 and 2 both involve giving patients a copy of the SmartSight Patient Handout. Level 2 also includes the multidisciplinary vision rehabilitation approach outlined in the Academy’s Vision Rehabilitation Preferred Practice Pattern. Resources include a sample letter to primary care physicians briefly discussing a patient’s vision loss and the potential for Charles Bonnet syndrome.

    Learn the appropriate technique for guiding low vision patients. Contact your state’s commission for the blind, or Rehabilitation Service for the Blind, and you should be able to arrange for training in sighted guide technique. There is typically no fee.

    Help patients find local resources. VisionConnection has partnered with the Academy, Lighthouse International, and the American Optometric Association to provide an online database of resources.

    Know your legal obligations. Download ADA technical assistance manuals at ADA.gov.