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Why Do Some People Not Respond to Eye Injections for Macular Degeneration?

British Journal of Ophthalmology logo

Although the advent of anti-VEGF therapy (explained below) has revolutionized the treatment of wet age-related macular degeneration (AMD), there are still a number of persons – although in the minority – who do not respond to treatment. It is these "non-responders" or "reduced responders" who continue to pose significant challenges to clinicians and researchers.

Recently, a team of Japanese researchers attempted to identify a number of factors that could (a) predict non-response to intravitreal [i.e., into the eye] injections of Lucentis for wet AMD and (b) establish criteria for non-responders in order to avoid inefficient treatment.

The study, entitled Predictive factors for non-response to intravitreal [i.e., injection into the eye] ranibizumab [i.e., Lucentis] treatment in age-related macular degeneration, has been published online ahead-of-print in the April 7, 2014 edition of the British Journal of Ophthalmology (BJO).

The authors are Misa Suzuki, Norihiro Nagai, Kanako Izumi-Nagai, Hajime Shinoda, Takashi Koto, Atsuro Uchida, Hiroshi Mochimaru, Kenya Yuki, Mariko Sasaki, Kazuo Tsubota, and Yoko Ozawa from the Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan.

About Wet Age-Related Macular Degeneration (AMD)

In wet, or exudative, macular degeneration (AMD), the choroid (a part of the eye containing blood vessels that nourish the retina) begins to sprout abnormal new blood vessels that develop into a cluster under the macula, called choroidal neovascularization (neo = new; vascular = blood vessels).

The macula is the part of the retina that provides the clearest central vision. Because these new blood vessels are abnormal, they tend to break, bleed, and leak fluid under the macula, causing it to lift up and pull away from its base. This damages the fragile photoreceptor cells, which sense and receive light, resulting in a rapid and severe loss of central vision.

Anti-Angiogenic Drugs and Anti-VEGF Treatments

Angiogenesis is a term used to describe the growth of new blood vessels and plays a crucial role in the normal development of body organs and tissue. Sometimes, however, excessive and abnormal blood vessel development can occur in diseases such as cancer (tumor growth) and AMD (retinal and macular bleeding).

Substances that stop the growth of these excessive blood vessels are called anti-angiogenic (anti=against; angio=vessel; genic=development), and anti-neovascular (anti=against; neo=new; vascular=blood vessels).

The focus of current anti-angiogenic drug treatments for wet AMD is to reduce the level of a particular protein (vascular endothelial growth factor, or VEGF) that stimulates abnormal blood vessel growth in the retina and macula; thus, these drugs are classified as anti-VEGF treatments and are administered by injection directly into the eye after the surface has been numbed.

At present, these anti-VEGF drugs (Lucentis, Avastin, and Eylea) require monthly injections or a pro re nata [meaning "as needed"] (PRN) regimen, with monthly controls and injections for recurrent or persistent macular bleeding.

More about the Study

From Report examines factors for non-response to AMD injections at Insidermedicine:

A new report published in the British Journal of Ophthalmology examines factors that may predict non-response to intravitreal injections for age-related macular degeneration.

Researchers studied 141 AMD patients who had received intravitreal injections with ranibizumab [Lucentis] for three months followed by pro re nata [meaning "as needed"] injections for nine months.

Results showed that initial fibrovascular pigment epithelial detachment and serous pigment epithelial detachment were linked with non-response, as was type 1 choroidal nevascularization as judged by fundus findings.

An Explanation of Terms

  • Pigment epithelial detachment: A pathological process in which the retinal pigment epithelium separates from the underlying Bruch's membrane
  • Retinal pigment epithelium: A specialized retinal tissue that plays a crucial role in maintaining the equilibrium of all retinal processes. It is the pigmented layer of the retina, containing the deepest cells of the retina.
  • Bruch's membrane: Innermost layer of the choroid, lying beneath the retinal pigment epithelium. The choroid is the part of the eye containing blood vessels that nourish the retina.
  • Fundus: The rear portion of the interior of the eyeball that the doctor sees when looking at the eye through an ophthalmoscope, an illuminated instrument for viewing the interior of the eye.
  • Type 1 choroidal neovascularization: Refers to new blood vessels that grow and multiply underneath the retinal pigment epithelium. Their growth sometimes causes the pigment epithelium to detach.
  • Fibrovascular pigment epithelial detachment: A form of type 1 choroidal neovascularization
  • Serous pigment epithelial detachment: Occurs when the retina detaches from the pigment epithelial layer due to inflammation, injury, or vascular abnormalities. "Serous" refers to fluid that accumulates in the space beneath the retina.

More from the British Journal of Ophthalmology

From the article abstract:

Methods: We reviewed the clinical records of 141 eyes in 141 AMD patients who received monthly [intravitreal Lucentis injections] for three months and thereafter pro re nata [i.e., "as needed"] injections for nine months as the first treatment for AMD.

Patients whose best corrected visual acuity worsened at month 12, and those with increased exudative [i.e., leaking fluid] fundus findings after [intravitreal Lucentis injections] or an increased central retinal thickness of more than 100 micrometers at month 12, were considered to be non-responders as judged by best-corrected visual acuity and fundus findings, respectively.

Results: 14.9% of eyes were non-responders as judged by best-corrected visual acuity, and 17.0% were non-responders as judged by fundus findings.

Initial fibrovascular pigment epithelial detachment and serous pigment epithelial detachment were associated with non-response as judged by best-corrected visual acuity.

Initial fibrovascular pigment epithelial detachment and type 1 choroidal neovascularization were associated with non-response, as judged by fundus findings.

Conclusions: Although most AMD responded to [intravitreal Lucentis injections] non-responders had initial clinical characteristics that might be informative for managing their treatment.

VisionAware will provide updates of this important research as they become available

Low Vision
Medical Updates
Clinical Trials
Macular Degeneration

Meet the Discovery Eye Foundation and the Macular Degeneration Partnership

Discovery Eye Foundation logo

The Discovery Eye Foundation, headquartered in Los Angeles, California, has become an important ally of, especially in the area of patient education for macular degeneration. The primary mission of the Discovery Eye Foundation is twofold:

Recently, the Discovery Eye Foundation launched the Discovery Eye Foundation blog, featuring information on eye disease, eye research, nutrition, low vision resources, technology, and healthy lifestyle choices. Staff writers and guest bloggers include leading ophthalmologists, optometrists, eye researchers, low vision specialists, nutritionists – and even me, who penned a post on a topic near and dear to all vision rehabilitation professionals: Low Vision: What to Do When "There's Nothing More That Can be Done".

Spotlight on Macular Degeneration Partnership at Discovery Eye Foundation

The mission of Macular Degeneration Partnership (MDP) is to employ a multi-faceted approach in both the treatment of the disease and the support of persons with age-related macular degeneration (AMD):

Macular Degeneration Partnership logo

We are dedicated to making sure that you and your family members have the best information available to you and all the tools you need to live well with AMD. We want you to know that there is hope and help.

People who are diagnosed with macular degeneration are often given the impression that they must simply accept vision loss and that there is nothing that can be done. Instead, you can actually do something, even if medicine cannot treat the disease. Our mission is to help you on that journey with information, resources and personal support.

Our mission is to provide comprehensive, easily understood, and up-to-the-minute information about macular degeneration for everyone who needs it.

We support ongoing research in macular degeneration to help find new treatments and a cure for this sight-robbing disease.

Through our efforts, we will continue to coordinate advocacy campaigns throughout the world. We will use all tools available to us - the internet, the telephone, public events, and printed materials.

The MDP website contains a wealth of helpful information, including What is AMD?, Living with AMD, AMD Research, an e-newsletter, an "Ask an Expert" contact form, and a toll-free "warm line" at 888-430-9898.

Says Executive Director Judith Delgado, "What sets us apart is the personal attention and dedication MDP provides. We tailor the information to people's individual needs, whether they are looking for a low vision center, need help understanding their treatment, are worried about a family member, or have questions about their vitamins. While we do not give medical advice, we do provide enough information to help people make their own decisions."

The Macular Degeneration Partnership E-Newsletter

The current MDP e-newsletter contains excellent information on potential resources for financial aid for AMD injections:

The standard treatment for wet macular degeneration involves repeated injections into the eye. These can be very expensive, especially for someone without a secondary insurance. Lucentis and Eylea cost around $2,000 per injection. The financial burden can be overwhelming.

The Patient Access Network (PAN) Foundation is dedicated to providing help and hope to underinsured patients who would otherwise be unable to afford high-cost specialty medications. PAN provides assistance through nearly 60 disease-specific programs designed to help patients being treated for certain cancers, rare diseases and chronic illnesses - such as age-related macular degeneration.

Since 2004, PAN has provided nearly $400 million in financial assistance to more than 200,000 patients. PAN's Age-Related Macular Degeneration Program provides qualifying patients with $4,000 per year to help afford the co-pays and coinsurance associated with their prescribed medications.

To qualify, patients must be insured and their insurance must cover the medication for which the patient seeks assistance, must reside and receive treatment in the United States, and must have a household income at or below 500% of the Federal Poverty Level ($78,650 for a family of two). For more information, visit their website or call 1-866-316-7263.

Both Genentech (Lucentis) and Regeneron (Eylea) also fund patient assistance programs. For Lucentis, it is the Patient Access Program. For Eylea, it is Eylea4U. Your doctor will need to fill out an enrollment form.

Support Groups at Macular Degeneration Partnership

MDP also sponsors monthly peer support groups in the Los Angeles area:

  • Huntington Beach: Second Monday of each month, 12:30-2:00 in the Michael E. Rodgers Seniors Center, 1706 Orange Avenue, Huntington Beach, CA 92648
  • Santa Monica: Second Tuesday of each month, 1:00-2:30 in the Santa Monica YMCA, Santa Monica, CA 90401
  • Beverly Hills: Fourth Wednesday of each month, 1:00-2:30 in the Beverly Hills Library, second floor conference room, 444 N. Rexford Drive, Beverly Hills, CA 90210

Contact Macular Degeneration Partnership

Macular Degeneration Partnership
6222 Wilshire Boulevard, Suite 260
Los Angeles, CA 90048
888-430-9898 (toll free)

Where you can find the Discovery Eye Foundation online:

Where you can find Macular Degeneration Partnership online:

Additional Information about Macular Degeneration

Low Vision
Macular Degeneration

A Potential Intravenous Treatment for Wet Age-Related Macular Degeneration: Interleukin-18

Translational Medicine logo

A research group, composed of members from the Republic of Ireland, the United Kingdom, and the United States, has determined that a protein called interleukin-18 (IL-18), which is a component of the immune system linked to inflammatory disorders, has the ability to suppress production of the harmful bleeding/leaking blood vessels that characterize wet age-related macular degeneration (AMD).

In addition, the researchers have demonstrated that IL-18 can be administered intravenously, which, if proven successful in human clinical trials, could offer advantages over the current treatment model, which requires injection of Lucentis, Avastin, or Eylea directly into the eye.

Please note: This "proof-of-concept" research is in its earliest stages and has been conducted only in pre-clinical settings with laboratory mice. Nevertheless, the concept shows promise for persons with wet AMD.


The research, entitled IL-18 Attenuates [i.e., weakens or reduces] Experimental Choroidal Neovascularization as a Potential Therapy for Wet Age-Related Macular Degeneration (explained below), was published in the April 2, 2014 issue of Science Translational Medicine.

Science Translational Medicine is an interdisciplinary medical journal, established in October 2009 by the American Association for the Advancement of Science, that covers basic, translational, and clinical research on human diseases. Translational research helps to make findings from basic science useful for practical applications that enhance human health and well-being.

The authors are Sarah L. Doyle, Ema Ozaki, Kiva Brennan, Marian M. Humphries, Kelly Mulfaul, James Keaney, Paul F. Kenna, Arvydas Maminishkis, Anna-Sophia Kiang, Sean P. Saunders, Emily Hams, Ed C. Lavelle, Clair Gardiner, Padraic G. Fallon, Peter Adamson, Peter Humphries, and Matthew Campbell, who represent the following institutions: Trinity College Dublin, Ireland; Our Lady's Children's Hospital, Dublin; Royal Victoria Eye and Ear Hospital, Dublin; National Eye Institute, Bethesda, Maryland; and GlaxoSmithKline, UK.

Wet Macular Degeneration

In wet, or exudative, macular degeneration (AMD), the choroid (a part of the eye containing blood vessels that nourish the retina) begins to sprout abnormal blood vessels that develop into a cluster under the macula (called choroidal neovascularization).

The macula is the part of the retina that provides the clearest central vision. Because these new blood vessels are abnormal, they tend to break, bleed, and leak fluid under the macula, causing it to lift up and pull away from its base. This damages the fragile photoreceptor cells, which sense and receive light, resulting in a rapid and severe loss of central vision.

Current Treatments for Wet Macular Degeneration

Angiogenesis is a term used to describe the growth of new blood vessels and plays a crucial role in the normal development of body organs and tissue. Sometimes, however, excessive and abnormal blood vessel development can occur in diseases such as cancer (tumor growth) and AMD (retinal and macular bleeding).

Substances that stop the growth of these excessive blood vessels are called anti-angiogenic (anti=against; angio=vessel; genic=development), and anti-neovascular (anti=against; neo=new; vascular=blood vessels).

The focus of current treatments for wet AMD is to reduce the level of a particular protein (vascular endothelial growth factor, or VEGF) that stimulates abnormal blood vessel growth in the retina and macula; thus, these drugs are classified as anti-VEGF treatments. At present, these drugs (Lucentis, Avastin and Eylea) are administered by injection directly into the eye after the surface has been numbed.

In the case of this particular research, the study team has determined that IL-18 also inhibits VEGF production.

More about the Study

From Scientists make major breakthrough in age-related macular degeneration therapy in Medical Xpress News:

The scientists found that a component of the immune system, IL-18, acts as a guardian of eyesight by suppressing the production of damaging blood vessels behind the retina at the back of the eye. In addition, in pre-clinical models, it was shown that IL-18 can be administered in a non-invasive way, which could represent a major improvement on the current therapeutic options that are open to patients.

"We were initially concerned that IL-18 might cause damage to the sensitive cells of the retina, because it is typically linked to inflammation. But surprisingly we found that low doses had no adverse effects on the retina and yet still suppressed abnormal blood vessel growth," said Assistant Professor in Immunology at Trinity, Sarah Doyle.

Treatment options for wet AMD are currently limited to the end stages of the disease. Regular injections of antibodies must be made directly into the eye to mop up a problematic molecule termed VEGF. However, the Trinity scientists found that IL-18 directly inhibits VEGF production, and that it can work as effectively as the current treatment when administered via a non-invasive intravenous injection in pre-clinical settings.

From Science Translational Medicine

From the article abstract:

Age-related macular degeneration (AMD) is the most common form of central retinal blindness globally. Distinct processes of the innate immune system, specifically activation of the NLRP3 inflammasome, have been shown to play a central role in the development of both “dry” and neovascular ("wet") forms of the disease.

We show that the inflammatory cytokine interleukin-18 (IL-18) can regulate choroidal neovascularization formation in mice. We observed that … administration of … IL-18 has no effect on retinal pigment epithelial (RPE) cell viability, but that overexpression of pro–IL-18 or pro–IL-1ß alone can cause RPE cell swelling and subsequent atrophy, a process that can be inhibited by the promotion of autophagy.

[Editor's note: Autophagy, a basic biological and metabolic process, "self-eats" cellular components that are unnecessary or dysfunctional to the cell, such as those that can cause the degenerative retinal changes that accompany AMD.]

A direct comparison of local and systemic administration of … IL-18 with current anti-VEGF (vascular endothelial growth factor)–based therapeutic strategies shows that IL-18 treatment works effectively alone and more effectively in combination with anti-VEGF therapy and represents a novel therapeutic strategy for the treatment of wet AMD.

VisionAware will provide updates of this research as it moves from the laboratory into human subject testing.

Additional Information

Low Vision
Medical Updates
Macular Degeneration

Our Readers Want To Know: Can I Continue Gardening with Vision Loss?

Editor's note: One of the many benefits associated with an online information center and website, such as VisionAware, is the ability to survey our readers in order to keep VisionAware relevant, timely, and useful.

Most recently, our reader survey responses also included several inquiries about hobbies or recreational activities for adults and older adults with vision loss:

  • I would like to help a social director in an independent living facility find activities that are appropriate for people with vision loss/macular degeneration. Can you help?
  • Can you suggest activities or hobbies that would be fun for older adults with very limited – or no – vision?

What about Gardening?

With Earth Day approaching on April 22, it's appropriate (and timely) to enjoy the sensory and physical joys of gardening, along with helpful adaptations for gardeners with vision loss.

Use Colorful and Tactile Borders

rose garden and fence
  • Use commercial edging products, such as crushed stone, bricks, pavers, pieces of lumber, or fencing to mark where one area ends and another begins.
  • Use planking, long boards, rocks, or bricks to mark off the outer edges of your garden for easier location and separation from lawn or play areas.
  • Paint your fencing or stones in contrasting colors, such as white or yellow, that will contrast with the green grass.
  • Use textured and/or colorful materials, such as crushed white marble chips, natural wood chips, or crushed seashells.
  • Consider using natural or organic fertilizers and pest control treatments, especially if you use your uncovered hands to feel your plants or tend your garden.

Create Your Own Plant and Row Markers

  • If you have low vision, create large print labels with index cards and a wide-tip black marker. Laminate the cards or seal them in plastic sandwich bags. Attach each card to a small craft stick.
  • See Labeling and Marking for hints on making large print and other types of labels for your plants.
  • Use brightly painted stones in different colors to indicate the type of flower or plant. For example, white stone=daisies, red stone=tulips or tomatoes.
  • Yogurt cups with the bottoms removed can protect young plants. Sink the cup halfway into the soil and plant inside it. The cup will outline the area in which your seedlings are growing and can also help with weed control.
  • Use an egg carton as a planting spacer. Poke a one-inch hole in the bottom of each egg portion and position the egg carton/spacer on the soil. Place one seed into each hole and cover with soil. Gently remove the spacer and continue planting.
  • Lay down a fishing line or a cane and use it as a guide for planting straight rows.
  • If you form rows by running strings between stakes, you can secure old tennis balls or another type of tactile reminder on the top of each stake for identification purposes.
  • A long-handled garden tool can also become a measuring stick by placing contrasting tape along the handle every six inches, or whatever distance you need to measure.

Try Container Gardening

a container garden

Container gardening is easy and enjoyable. Flowers, herbs, and many vegetables grow well in containers – and even shallow six-inch-deep pots full of basil, parsley, or chives can sit on a porch rail. Container plants have several advantages, including:

  • They make it easier to identify plants and seed locations.
  • They let you garden anywhere without digging garden beds.
  • They allow you to have the best soil, moisture, and growing conditions for a particular plant.
  • They make changing a plant's location much easier.

Preparing Containers

Good soil is the foundation of a garden and allows plants to thrive. Try using topsoil or potting soil from a garden center to fill containers. The quality will be good and it will be free of weeds and weed seeds. Also, you'll have to do less weeding later in the season.

  • Use containers with good drainage holes in the bottoms. The holes must be small enough so that soil stays in the pot, but large enough to let excess water drain out. If water collects and pools in the bottom of a container, it will damage plant roots. Place a layer of small pebbles or wood chips in the bottom of the container, about half an inch deep, to absorb water and help with drainage.
  • Next, fill the container to within an inch from the top. That inch is so water or rain falling has somewhere to go. If the container is full of soil to the rim, water might wash away seeds or the top layer of soil.

Planting the Seeds

  • Plant your seeds, following instructions for spacing. Try planting seeds and small plants in the same container. You can enjoy the small plants while the seeds are germinating and sprouting. Planting lettuce or spinach "sets" and seeds in the same container means your lettuce crop will come in over time.
  • Use labels in large print or braille to mark containers. You can place the labels on the containers or on wood or metal markers that you can purchase at garden stores or make from Popsicle sticks. Use waterproof tape and markers to create your own large print labels.

Your Gardening Tools

  • If you have low vision, look for commercially-produced garden tools with brightly colored handles that contrast with the ground or with your plant bench.
  • You can also apply contrasting tape or paint to the handles of your favorite tools or paint the tines of your rake to help with locating your tools and identifying your work area.
  • Use an apron, utility belt, or plastic carryall container to hold your gardening tools.
  • Use protective techniques to protect your face and eyes from injury when bending down in the garden.

Additional Gardening Information

Social Life and Recreation
Low Vision
Readers Want to Know

My Top Book-Reading Apps for Braille Users by Scott Davert, AppleVis Editorial Team

Scott Davert head shot

Guest blogger Scott Davert, M.A., VRT, is an AppleVis Editorial Team Member and a Senior Instructor in the Adaptive Technology Department and Communications Learning Center at the Helen Keller National Center for Deaf-Blind Youths and Adults.

Most recently, Scott compiled his top picks for news apps that are user-friendly and accessible to braille users. This week, Scott reviews his personal picks for the top book-reading apps for braille users.

Says Scott, "During the past year, many book retailers have made their content accessible. Some apps, however, have distinct advantages in terms of braille access; thus, here are my personal 'top four' book-reading app picks."

1. Take It "To Go"

The Read2Go app, developed by Benetech, provides access to the Bookshare collection of digital e-Books.

One problem with iDevices is that they do not support continuous reading of books via braille displays. A helpful option in the Read2Go app, however, is the ability to read by section. This means that to turn the page, you will need to go forward only when you have finished reading a chapter instead of having to press space with "o" to turn each page – or an equivalent command, depending upon your braille display.

There is also the option to read by page, but if you're like me, the less scrolling I have to do, the faster I can read. The other nice thing about this app is that you can search the Bookshare collection from within the app, download your chosen content, and be reading within a couple of minutes.

Read2Go is available for $19.99 in the United States iTunes App Store. The subscription to Bookshare and the one-time fee for Read2Go will pay for themselves quickly if you're a qualifying user and avid reader (like me), since all Bookshare content is free.

2. Apple Has an App for That

Apple, a mainstream eBook provider, makes the iBooks app. The app and its content are almost entirely accessible to readers who use speech and/or braille, both contracted and uncontracted.

You can download and purchase content and begin reading immediately after the book has downloaded. One problem I have with the iBooks app is that when I reach the end of a page, I find that I'm moving into the menu located to the right of the displayed text. To go to the next page, I need to pan back left, and then press space with "o."

You can also read Bookshare content through iBooks. You'll need to download and install Dropbox to do this, and have it set up on whatever device you use to download Bookshare content. This will not work if you are only using an iDevice. You will also need to install the free Dropbox app on your iDevice.

These are the steps to follow:

  1. Download the Digital Accessible Information SYstem (DAISY) text-only format of the book you want to convert.
  2. Unzip the files to a location/folder that you select.
  3. Go to that folder and open the .xml file. This should open in a web browser. If it doesn't display correctly, rename the .xml file to an .htm extension and then open it.
  4. Press Control+A on Windows or Command+A on the Mac to select "all"; press Control+C or Command+C to copy; then open a word processor and paste the content into the new document.
  5. Save the file in .rtf, Word, or plain text, and then head on over to RoboBraille and follow the steps to convert to the ePub format. Once complete, the attachment will be e-mailed to the address you supplied.
  6. Download the attachment and place it in a Dropbox folder you can access on your iDevice.
  7. On your iDevice, launch the Dropbox app, find the file, and press a cursor routing button on it. Wait about 30 seconds, and then press space with "dots 4-5-6" to get to the export button on the lower right corner of the screen.
  8. Choose "open in iBooks" and after a delay, the length of which depends on the size of the book, your Bookshare book will be added to your iBooks library and will open in the iBooks app.

Please note that it is legal to convert files for personal use only. The act of file-sharing copyrighted material is not something I condone and it is illegal if the content is copyright-protected. You can read more about this issue at Bookshare's Support Center and FAQs, where Bookshare seems to indicate this is a legitimate use of their books for personal use.

3. Braille from the Amazon

Amazon's Kindle app is one example of a job quite well done by a mainstream eBook reader app.

The Kindle app has a unique feature that makes reading more enjoyable for braille users than with iBooks or the Nook app. Once you open a book, the only thing on the screen is the text of the book itself. Thus, while you will still have to turn pages, you won't have to worry about being slowed down by (a) having to predict where the end of the page will be, or (b) scrolling left from the menu. As soon as you get to the end of the page, you'll know it's time to move to the next one.

The downside to this app is that purchasing Kindle books involves either logging into the mobile site with Safari on your iDevice or purchasing it through a PC or Mac. You can even import documents, Bookshare content, or any other word processing files into the Kindle app by converting them to a supported format and then following the instructions, using the Kindle Personal Documents Service.

4. No Scrolls BARD

BARD Mobile is an app that gives qualifying patrons of the National Library Service for the Blind and Physically Handicapped (NLS) access to all of their content, downloadable to your iDevice using their app. This includes files in digital braille format.

The BARD Mobile app allows viewing of braille files in contracted braille only. You will not be able to use this app to read anything in uncontracted braille. You can learn more about the Braille and Audio Reading Download (BARD) service at the NLS website.

You can download content directly from the NLS braille collection very quickly, and can then read the book or magazine right away. Once you are in a book, be sure that "eight-dot mode" is on, which can be toggled by pressing space with "g" to turn contractions off. Press space with "dots 2-3-6" to toggle eight-dot mode on.

The iOS app also allows for book-marking, remembers your place when you exit the app, and has many other keyboard shortcuts that make it a unique option. Even better still, once you start reading a book, there is no page turning involved for the braille user.

For additional details, consult Chapter 7 of the BARD Mobile Application User Guide. You can also import .brf files from other sources if you copy them to your Dropbox folder. For a guide on this process, read Importing BRF files to the BARD Mobile app using Dropbox.

Additional Information

For more information, you can contact Scott at

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