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A Powerful New Report from the National Academies of Sciences, Engineering, and Medicine: Making Eye and Vision Health an Imperative for All Americans

the NASEM logo

The National Academies
of Sciences, Engineering,
and Medicine logo

Several recent United States-based eye and vision research projects, including the Los Angeles Latino Eye Study and the Philadelphia Glaucoma Detection and Treatment Project, have highlighted significant disparities in the quality and equity of eye care throughout the country, including barriers within the health care and public health systems, inadequate prevention and screening strategies, and insufficient concerns with patient quality of life.

On September 15, 2016, in response to these ongoing — and increasing — concerns, The National Academies of Sciences, Engineering, and Medicine (NASEM) released Making Eye Health a Population Health Imperative: Vision for Tomorrow, a comprehensive and powerful report that proposes an all-encompassing framework "to guide action and coordination among various—and sometimes competing—stakeholders in pursuit of improved eye and vision health and health equity in the United States."

About the National Academies of Sciences, Engineering, and Medicine

The National Academies of Sciences, Engineering, and Medicine (NASEM) are private, nonprofit institutions that provide expert advice on significant challenges facing the nation and the world. Their work helps to shape policies, inform public opinion, and advance the pursuit of science, engineering, and medicine.

The foundation for NASEM was established in 1863, when President Abraham Lincoln signed a congressional charter that formed the National Academy of Sciences to meet the government's need for an independent adviser on scientific matters. As science began to play an increasingly important role in national priorities and public life, the National Academy of Sciences expanded to include the National Research Council in 1916, the National Academy of Engineering in 1964, and the National Academy of Medicine in 1970.

Some Background for the NASEM Report

Excerpted from the NASEM website (with emphasis added):

"Despite the importance of eyesight, millions of people grapple with undiagnosed or untreated vision impairments—ranging from mild conditions to total blindness—and eye and vision health remain relatively absent from national health priority lists. Vision loss in adults is associated with increased risk of falls and injuries, social isolation, depression, and other psychological issues and can amplify the adverse effects of other chronic illnesses, increasing the risk for mortality. Similarly, undiagnosed or uncorrected refractive errors and other visual disorders in children can lead to developmental, academic, and social challenges, and in some cases permanent vision loss, which has lifelong implications.

In 2014, the Health and Medicine Division of The National Academies of Sciences, Engineering, and Medicine convened a multidisciplinary committee to "examine the core principles and public health strategies to reduce visual impairment and promote eye health in the United States," including short- and long-term strategies to prioritize eye and vision health through collaborative actions across a variety of topics, settings, community stakeholders, and levels of government.

This report [published on September 15, 2016] proposes a population health action framework to guide action and coordination among various—and sometimes competing—stakeholders in pursuit of improved eye and vision health and health equity in the United States.

This report also introduces a population-health approach that promotes eye and vision health far beyond the clinical setting, with an emphasis on minimizing preventable and uncorrected impairment. It is also a model for action that highlights different levels of prevention activities across a range of stakeholders and provides specific examples of how population health strategies can be translated into areas for action at federal, state, and local levels."

Highlights of the NASEM Report

Edited and excerpted from Making Eye Health a Population Health Imperative: Vision for Tomorrow – Report in Brief (PDF) (with emphasis added):

Eyesight affects how human beings perceive and interpret the world and is used for everyday communication, social activities, educational and professional pursuits, the care of others, and the maintenance of personal health, independence, and mobility.

As increased risk for poor eye health is associated with certain social, economic, cultural, health, and environmental conditions, these factors contribute to inequities that already affect populations with lower socioeconomic status and poor health. Moreover, the economic and social costs of vision impairment to patients, the healthcare system, and society are considerable. Yet vision impairment remains notably absent from many population health agendas and community programs.

NEI image of how someone with macular degeneration sees: overall blurriness with a blind spot in the center

What a person with AMD sees

No reliable data exist on the number of people affected by all causes of vision impairment in the United States. One model estimates that more than 142 million adults over the age of 40 in the United States experienced vision problems attributable to vision impairment, blindness, refractive error, age-related macular degeneration (AMD), cataract, diabetic retinopathy, and glaucoma.

Uncorrectable vision impairment affects an estimated 6.42 million people in the United States. Uncorrected vision impairment affects millions more people in the United States, with estimates for uncorrected refractive error alone ranging from 8.2 million to 15.9 million.

A number of factors contribute to the absence of focused and sustained programmatic investment that would translate into widespread action, including a lack of focus on prevention and underlying social and environmental determinants, inadequate information about the state of eye health, the segregation of eye care from the rest of medicine, minimal cross-discipline training, scant public health resources, and a lack of coordination within or across federal entities and among partner organizations.

Many public and private health insurance coverage policies, including Medicare, exclude eye examinations for asymptomatic or low-risk patients, corrective lenses, and visual assistive devices. Thus, in many cases, people must purchase additional vision insurance or shoulder costs out of pocket, exacerbating overall health inequities among populations least able to afford care. Moreover, effective interventions exist to improve or maintain the functioning of people with vision impairment, but information about, and access to, these services is often limited.

You can read Making Eye Health a Population Health Imperative: Vision for Tomorrow – Report in Brief (PDF) in its entirety at the NASEM website.

The NASEM Report Recommendations

Excerpted from Making Eye Health a Population Health Imperative: Vision for Tomorrow — Recommendations (PDF) (with emphasis added):

  • "The Secretary of the U.S. Department of Health and Human Services should issue a call to action to motivate nationwide action toward achieving a reduction in the burden of vision impairment across the lifespan of people in the United States. Specifically, this call to action should establish goals to (a) eliminate correctable and avoidable vision impairment by 2030; (b) delay the onset and progression of unavoidable chronic eye diseases and conditions; (c) minimize the impact of chronic vision impairment; and (d) achieve eye and vision health equity by improving care in underserved populations."
  • "The Secretary of the U.S. Department of Health and Human Services, in collaboration with other federal agencies and departments, nonprofit and for-profit organizations, professional organizations, employers, state and local public health agencies, and the media, should launch a coordinated public awareness campaign to promote policies and practices that encourage eye and vision health across the lifespan, reduce vision impairment, and promote health equity."
  • "The Centers for Disease Control and Prevention (CDC) should develop a coordinated surveillance system for eye and vision health in the United States. To advise and assist with the design of the system, the CDC should convene a task force comprising government, nonprofit and for-profit organizations, professional organizations, academic researchers, and the health care and public health sectors."
  • "The U.S. Department of Health and Human Services should create an interagency workgroup, including a wide range of public, private, and community stakeholders, to develop a common research agenda and coordinated eye and vision health research and demonstration grant programs that target the leading causes, consequences, and unmet needs of vision impairment."
  • "The U.S. Department of Health and Human Services should convene one or more panels—comprising members of professional organizations, researchers, public health practitioners, patients, and other stakeholders—to develop a single set of evidence-based clinical and rehabilitation practice guidelines and measures that can be used by eye care professionals, other care providers, and public health professionals to prevent, screen for, detect, monitor, diagnose, and treat eye and vision problems."
  • "…professional education programs should proactively recruit and educate a diverse workforce and incorporate prevention and detection of visual impairments, population health, and team care coordination as part of core competencies in applicable medical and professional education and training curricula."
  • "State and local public health departments should partner with health care systems to align public health and clinical practice objectives, programs, and strategies about eye and vision health…"
  • …"the Centers for Disease Control and Prevention should prioritize and expand its vision grant program, in partnership with state-based chronic disease programs and other clinical and non-clinical stakeholders, to (a) design, implement, and evaluate programs for the primary prevention of conditions leading to visual impairment; (b) develop and evaluate policies and systems that facilitate access to, and utilization of, patient-centered vision care and rehabilitation services, including integration and coordination among care providers; and (c) develop and evaluate initiatives to improve environments and socioeconomic conditions that underpin good eye and vision health and reduce eye injuries in communities."
  • "Communities should work with state and local health departments to translate a broad national agenda to promote eye and vision health into well-defined actions. These actions should encourage policies and conditions that improve eye and vision health and foster environments to minimize the impact of vision impairment, considering the community’s needs, resources, and cultural identity."

You can read Making Eye Health a Population Health Imperative: Vision for Tomorrow — Recommendations (PDF) in its entirety at the NASEM website.

Additional Information


Topics:
Cataracts
Cultural Diversity
Diabetes and diabetic retinopathy
Glaucoma
Health
In the News
Macular Degeneration
Planning for the Future
Public Policy

What's New in iOS 10 Accessibility for Blind, Low Vision, and Deaf-Blind Users Part 2: Scott Davert, AppleVis Editorial Team

Scott Davert head shot

Guest blogger Scott Davert, M.A., VRT, is an AppleVis Editorial Team Member and the Coordinator of the New York Deaf-Blind Equipment Distribution Program, administered by the Helen Keller National Center for Deaf-Blind Youths and Adults.

The Program provides no-cost communication and technology training to persons with significant combined vision and hearing loss who meet federal income guidelines. Equipment can include smartphones, tablets, computers, screen readers, braille readers, and adaptive software.

In past reviews, Scott has compiled his personal picks for book-reading apps and iDevice apps that are user-friendly and accessible to braille, and also speech, users.

Says Scott, "As a power user of braille devices on iOS, it's very liberating to me, as a deaf-blind person, to be able to take full advantage of the technology we have in our society today. Just a decade ago, my access to resources was much more limited if braille was my only means of accessing the world. Today, with the help of technology, I can be just as well-informed about what's going on around me as my sighted and hearing counterparts."

This week, Scott is reviewing the new iOS 10 release from Apple, with an emphasis on accessibility features for individuals who are blind, have low vision, and/or are deaf-blind. iOS is Apple's mobile operating system, or OS. Originally developed for the iPhone, it has since been extended to support other Apple devices, such as the iPod touch and iPad. In June 2010, Apple rebranded the iPhone OS as simply iOS.

In Part 1 of his review, Scott discusses the new SiriKit, automatic image descriptions, voicemail transcription, VoiceOver enhancements, auditory validation, and a number of other accessibility enhancements. In Part 2, Scott discusses additional accessibility enhancements, including braille, low vision, and hearing/TTY updates.

About the iOS 10 Release

Another fall is upon us, which means football season has started, temperatures are starting to drop, and a new version of iOS is coming out. Another seemingly established tradition is that another article from me, discussing the new accessibility features, is in order. Just like the past several years, there are many changes to iOS that are mainstream and will be welcome changes. Some of the new features include a revamped Music app; a new Home app; new 3D Touch functionality in Apple apps; and much more.

Many articles will be covering these changes, but the aim of this piece is to cover accessibility changes that are specific to blind, low vision, and deaf-blind users. Please note that this review is not intended as a comprehensive guide to iOS; rather, it is designed to document the changes in iOS 10.

Jumping Through Messages Means Action!

The way in which message threads in the Mail app are displayed has changed. Instead of having each message in its own window in Portrait view, now all of the messages in a thread show on the same screen. A new Rotor option called "Messages" allows you to jump quickly from message to message to help VoiceOver users more efficiently navigate among messages with this change. This Rotor option will simply show up when you have the option to organize by threads enabled. Braille users should be aware of a bug, which you can find listed below in the "Braille" section of this review.

Speaking of Mail, the way in which previews are shown has changed. Previously, VoiceOver would simply read the previews of messages. As of iOS 10, you now have to perform a three-finger single tap to get VoiceOver to read the preview.

Braille

3D Braille!

With iOS 10, you can now press space with dots 3-5-6 on a braille display to perform a 3D Touch action. This comes in handy when you want to launch a menu for an app, but have your iPhone stored in your pocket.

Note that if you are running a device that is not capable of 3D Touch, this command will not work. If 3D Touch is disabled, this command will perform a double tap and hold gesture.

You Can Work with This

Contracted braille users may have noticed that this heading contains only those words that are contractions. This is in recognition of the fact that Braille Screen Input users will now receive spoken feedback when they type using contracted braille. This was not possible in either iOS 8 or iOS 9, where only uncontracted braille feedback was given.

Yes, I Remember Who It's From!

With the release of every new software comes bugs, or what the technology community affectionately refers to as "unwanted features." For braille users who use the Mail app, there is certainly one unwanted feature present. Whenever you organize messages by thread, the number of the message you are currently reading is displayed on each line, along with the name of the sender. This includes the header information as well as the body of the email. If you disable "Organize by Thread," you will only see information about who the message is from. For example, if I have my messages organized by thread, and the first line of the message says "Hello Jim," braille users will see the following: "Message 1 of 1 Scott Davert Hello Jim." All of the information preceding the word "hello" will be shown on each line of the message.

I have started using Outlook for iOS to circumvent the reading of email messages. However, there is a bug that prevents the proper editing of emails I am writing, so I have decided to read my email in one app, and reply in the default Mail app. It works quite well with braille, though there seems to be no efficient way to navigate among messages when sorted by thread with Outlook. I hope Apple will fix this bug soon, so that I don't have to use two apps to manage my email.

A Bug Squashed!

In iOS 9, speech users of VoiceOver did not lose the ability to know which Wifi connection they were currently connected to. Braille users, however, only saw the signal strength followed by "SSID" instead of the actual name of the network. This has been resolved in iOS 10.

Low Vision

While I have taken the information presented in this section from the feedback of several low vision testers, I cannot attest to its accuracy. I am sure that any errors are on my part, and would strongly encourage users with low vision to check out iOS 10 on another device before installing it on their own to ensure the new operating system will work for them.

More Magnification

Among the enhancements to iOS 10 for low vision users is the addition of a magnifier. Find it under Settings > General > Accessibility > Magnifier. As the name implies, you can use your device's camera to magnify items in your environment. It also joins the features you can turn on and off with the Accessibility Shortcut (triple-clicking the Home button), though I'm not able to turn it on with Siri.

The software behind the Magnifier seems to resemble that of the Photos app; as such, auto-stabilization appears to be only as good as in the Photos app, and the same is true of autofocus. This could have interesting implications for the new dual cameras found on the back of the new iPhone 7 Plus, as all of these features could be affected by having dual lenses.

There is also an auto brightness function which can automatically adjust contrast and brightness according to lighting conditions. It's also possible to use any sort of filtering or other visual settings you have applied to iOS, which opens up a lot of possibilities. My conclusion from all of this information is that the new Magnifier feature is going to be a welcome one, but will not replace a dedicated video magnifier.

More Mixing of the Old and New

A new menu under the "Vision" heading is the Display Accommodations menu. This contains several options, but also new features. Invert Colors and Grayscale have been moved here, but otherwise appear to be unchanged. New in iOS 10 are a new series of color filters; these filters are designed to assist individuals who are color blind in differentiating text on the screen. It's also possible to adjust the intensity and hue of the filter to further accommodate this need.

An older option, Reduce White Point, was moved from the Increase Contrast menu and placed under Display Accommodations. In iOS 9, you could turn this on or off, but now White Point is an adjustable item which gives you more control over just how much it is reduced.

Covering More Highlights

When "Speak Selection" is turned on, there are new options for highlighting content when it is spoken. In older versions of iOS, this could only be turned off or on. It now has several ways in which you can specify what is spoken. You can choose to highlight words, sentences, or both words and sentences. You can also choose if you'd rather have the highlight style be with the text underlined or with the background color.

I Need Further Feedback

Once you navigate to Settings > General > Accessibility > Speech, you will find a new icon called "Typing Feedback." Within this menu, you can get feedback on what you type independent of VoiceOver. You can have each character, word, and auto-text. While auto-text has been an option previously, the other two are new. Also added to this menu is the ability to have predictions spoken if this feature is enabled. If you tap and hold on the prediction, it will be spoken aloud.

The Pronunciation Dictionary I covered in great detail in the VoiceOver section of Part 1 applies to the "Speak Screen" functionality as well. Any entries that you add to one location will also apply to the other.

Hearing

TTY Comes To the iPhone!

iOS 10 brings a new set of features to the iPhone for users of TTY. What this means is that the user cannot only call from TTY to TTY, but can also use Relay services, such as 711. Find the settings for this under Settings > General > Accessibility > Hearing > TTY. You can learn more about TTY services at AboutTTY.com.

TTY on the iPhone has two components: Software and Hardware. The Software TTY option allows the user to utilize the TTY software built into iOS 10. The Hardware function allows the user to connect a TTY they may already have and to use the iPhone to make TTY and text relay calls. Note that a TTY adapter is required to connect the iPhone to an external TTY.

It's worth noting that the iPhone 7 does not have a built-in 3.5 mm headphone jack, which is required to use the external TTY functionality; it's unclear at the time of writing whether the included lightning adapter will then allow for the same type of connectivity with an external TTY.

Looking at the Software option, you have the ability to (a) set up a number to call access relay services, (b) send text as you type it or send as one larger block of text, and (c) set up your iPhone so that it always answers with TTY, regardless of whether the person calling you also has a TTY. However, if you select this option and receive a voice call, it will not be forwarded to the relay number configured in the appropriate settings. If the TTY Software option is turned on, but not the feature to always answer calls as TTY, there appears to be no way to accept a TTY call – at least with VoiceOver.

Making a TTY call could be easier. To make a call, after turning the TTY Software Option on, launch the Phone app and dial the number. Tap Call when you are ready, and a pop-up will appear asking if you would like to place a voice, TTY, or relay call. After selecting TTY or relay, the call will then go through, with the keypad and time elapsed on the call shown.

To begin using the TTY functionality, it's necessary to hide the keypad, then select the TTY button to begin the conversation. It would seem to make more sense to begin the TTY call immediately, instead of making the person hide the keypad first and then select TTY, but maybe there is a reason for this that I'm not aware of.

Once the call is connected via TTY or relay, as a visual user familiar with TTY, the text experience is much the same, as far as I can tell, as long as you have the option to send the text immediately enabled. If disabled, you will receive messages in larger chunks, but they will still continue to appear in the same block of text until the other person in the conversation types something. There is also a set of abbreviations at the bottom of the screen which may be helpful for new TTY users.

When working with a braille display, I turned off the option to send immediately, since I was working with an eighteen-cell braille display. As noted above, when you receive multiple messages using this format, they will appear immediately after the last message. For example, if I type "Good afternoon" and then send it, followed by "How's the weather in Charlotte today?", if the other party on the line has not typed anything, the two messages will appear on the same line, even though they were sent at different times.

The problem with this, for a braille user, is that if you are reading along and do not get the cue to go ahead, once you have panned past what has already been written, you will be back in the area where you can type a text. If you need to scroll back to see if further messages have been sent, you first have to scroll past everything you have already read to get to the new content. If you send a short text, such as "OK," the new block of text will appear separate from the old one, since you have sent a short message.

The other issue for braille users specifically is this: While it may be easy to read the text visually while the other person or relay operator is typing, it is not easy for a braille user to follow the conversation. This is because when the other person is typing, you see "top of document" or "bottom of document" shown on the braille display. This makes reading what is being typed an issue, which can decrease the pace of an already slow process of utilizing the phone system. I can tell you from experience that even under the most ideal conditions, business owners and people who are not familiar with the way relay works tend to hang up on relay calls if they are slow.

I have provided the above feedback to Apple with the hope that it will lead to a better user experience for braille users. I commend Apple for taking an old technology (TTY) and modernizing it to make it a solution again.

My Conclusions

Just as in previous iOS releases, whether you should upgrade or not depends on (a) whether the bugs present in the new release will have an impact on you that is more than you can tolerate, and (b) whether you feel the new features are worth the upgrade.

To check out a list of bugs related to VoiceOver and braille, you can go to the AppleVis website.

To download the update over the air, go to Settings > General > Software Update and follow the prompts onscreen. Alternatively, you can update your device through iTunes.

For more information, you can contact Scott at scott.davert@hknc.org.

More Information


Topics:
Assistive Technology
Helpful Products
In the News
Low Vision
Online Tools
Personal Reflections
Reading
Technology
Web Accessibility

What's New in iOS 10 Accessibility for Blind, Low Vision, and Deaf-Blind Users Part 1: Scott Davert, AppleVis Editorial Team

Scott Davert head shot

Guest blogger Scott Davert, M.A., VRT, is an AppleVis Editorial Team Member and the Coordinator of the New York Deaf-Blind Equipment Distribution Program, administered by the Helen Keller National Center for Deaf-Blind Youths and Adults.

The Program provides no-cost communication and technology training to persons with significant combined vision and hearing loss who meet federal income guidelines. Equipment can include smartphones, tablets, computers, screen readers, braille readers, and adaptive software.

In past reviews, Scott has compiled his personal picks for book-reading apps and iDevice apps that are user-friendly and accessible to braille, and also speech, users.

Says Scott, "As a power user of braille devices on iOS, it's very liberating to me, as a deaf-blind person, to be able to take full advantage of the technology we have in our society today. Just a decade ago, my access to resources was much more limited if braille was my only means of accessing the world. Today, with the help of technology, I can be just as well-informed about what's going on around me as my sighted and hearing counterparts."

This week, Scott is reviewing the new iOS 10 release from Apple, with an emphasis on accessibility features for individuals who are blind, have low vision, and/or are deaf-blind. iOS is Apple's mobile operating system, or OS. Originally developed for the iPhone, it has since been extended to support other Apple devices, such as the iPod touch and iPad. In June 2010, Apple rebranded the iPhone OS as simply iOS.

About the iOS 10 Release

Another fall is upon us, which means football season has started, temperatures are starting to drop, and a new version of iOS is coming out. Another seemingly established tradition is that another article from me, discussing the new accessibility features, is in order. Just like the past several years, there are many changes to iOS that are mainstream and will be welcome changes. Some of the new features include a revamped Music app; a new Home app; new 3D Touch functionality in Apple apps; and much more.

Many articles will be covering these changes, but the aim of this piece is to cover accessibility changes that are specific to blind, low vision, and deaf-blind users. Please note that this review is not intended as a comprehensive guide to iOS; rather, it is designed to document the changes in iOS 10.

Mainstream Stuff Impacting Accessibility

Wow, Siri Can Do That?

One of the major enhancements in iOS 10 is the development of SiriKit. Specifics about this functionality aren't known just yet, since SiriKit-enabled apps are only being released alongside the public version of iOS 10. However, what we do know is that there are many potential benefits to SiriKit. For example, if Uber were to implement SiriKit, one could simply tell Siri, "Book an Uber for me to go to Central Park." In theory, at least, Siri should now be able to carry out that exact action.

According to First hands-on demo of Siri's app integration doesn't disappoint, apps that will utilize SiriKit on the day iOS 10 is released are WhatsApp, LinkedIn, WeChat, Pinterest, Vogue Runway, Pikazo, Square Cash, Monzo, Slack, Looklive, Lyft, Fandango, and The Roll. It's not possible to know how each app will utilize Siri Kit; however, I'm sure it will be covered in greater detail by the time you are reading this article.

Describe it for Me, Please?

Another major change is that iOS will now attempt to add automatic image descriptions to your photos. According to a presentation as part of the World Wide Developer Conference, iOS performs eleven billion calculations per picture to determine what objects are in your photos. In addition to detecting objects, it also performs facial recognition, which can then compare pictures in your lists of contacts to tag people automatically. Indeed, it is now included as part of the information on each photo in my library. While Apple indicated that your photos are not sent to a server for recognition—meaning that it's all done on your device—it's not yet clear to me how long it takes for these descriptions to appear.

Press Home to Unlock

In iOS 10, you can now unlock your iDevice simply by pressing the "Home" button. While this was always possible on Touch ID-equipped devices, it is now possible on non-Touch ID devices as well. If you do not have a passcode set up, pressing the "Home" button, waiting for a second, and then pressing it again will now land you on the Home Screen of your device. If you find that you prefer the older way of unlocking your device, you can still do this. Head over to Settings > General > Accessibility > Home Button > and turn on "Rest Finger to Open."

I Read You Loud and Clear, Mostly

Another new feature in iOS 10 is the introduction of Voicemail transcription. For those who can't hear their voice messages, or for those who don't want to listen to the phone, it's no longer (mostly) required. However, it is necessary to play the message to make the transcription show up. You will find the transcribed text next to the "More Info" button. The transcription is fully accessible with VoiceOver and braille, but comes with the same caveats as any automatic transcription: It's not 100% accurate and any kind of noise or accent will greatly decrease transcription accuracy.

Raise to Shut Up?

There is a new feature in iOS called "Raise to Wake," which wakes up your phone each time you pick it up. It will also sometimes wake up when you don't want it to. While this may be a welcome feature for many, especially for VoiceOver users utilizing speech, it may also be annoying. If you like, you can turn off "Raise to Wake" under Settings > Display & Brightness.

VoiceOver

Moving Apps is No Longer a Drag!

When you get to your Home screen with iOS 10 and VoiceOver is enabled, you will now hear that there are Rotor actions available; these options relate to moving apps. Rotor over to the "Actions" item, then flick up or down to the "Arrange App" action and double tap. This puts you in "Screen Edit" mode, just as if you had used the old "double tap and hold" method to begin editing apps.

Next, find an app you wish to move, then flick up or down once to specify your desire to move this app. (You can also perform a two-finger double tap on an app to mark it as being ready to be moved.) Now, you can freely move around your Home screen, even changing pages if you prefer, until you find exactly where you would like to move the app you chose.

Once you locate the place where you would like to put the app, flick up or down to see different options: You can move it to the right of the app VoiceOver is focused on; move it to the left of VoiceOver's current position; create a folder with those two apps; or cancel the move entirely. Canceling will place you on the page you are currently editing, and the app you're canceling to move will return to its original place. (Pressing the "Home" button to exit Screen Edit mode will also cancel any app move you had in progress.) Even better is the fact that this system works great with both Bluetooth keyboards and braille displays!

You Say "To-mot-to," I Say "To-ma-to"

However you'd like VoiceOver to pronounce words, you can now customize this with the new Pronunciation Dictionary. Find it under Settings > General > Accessibility > VoiceOver > Speech > Pronunciation. If you have not created any pronunciation entries yet, you will only find an "Add" button. Double tap this to begin creating your first entry. You will then land on the "Phrase" text field. This is where you type the word VoiceOver reads but doesn't pronounce the way you'd like.

For example, the Alex voice pronounces my last name without the "a" sound, so I would type "Davert" in this field. Next to the "Phrase" field you will find the "Substitution" text field. This is where you can try to make VoiceOver pronounce the word the way you prefer, so in my case I would type "Dav-virt."

Flicking one more item to the right, you will find an option to dictate how you'd like the phrase to be pronounced by saying or spelling it out. To the right of this option, you will see a "Languages" button; double tapping this will allow you to choose which languages the pronunciation applies to. Going back to the previous screen and continuing to the right of the "Languages" button, you will find a "Voices" button; double tapping this button will present you with all available voices for that language that you can apply the pronunciation to, or you can choose "All."

In the above example, Alex is the only voice that mispronounces my name, so I can double tap on that voice, and it will only change the pronunciation for Alex. It's also possible to adjust whether the substituted phrase applies to upper or lowercase letters, and the apps in which the pronunciation is used. This could come in handy in certain circumstances, because you can adjust what VoiceOver says, based on context.

If you turn off "Apply to all Apps," a list of the apps installed on your device will appear below this under the "Assign to" heading. Note that once you add words to your Pronunciation Dictionary, the additions will then be available on all devices connected to your iCloud account when everything has been synced. When you have finished creating an entry, activate the "Back" button. In the main Pronunciations screen, after the "Add" button, you will now see all of your entries listed in alphabetical order. You can then double tap on any entry to edit it, or flick down and double tap to delete it.

Tom? Present! Fred? Accounted For! Allison? Ready for Action!

iOS 10 brings a host of new voices to users of features related to accommodations that utilize speech such as Speak Screen and VoiceOver, as well as to third-party apps that have the ability to use built-in iOS voices like Voice Dream Reader. These voices are familiar to Mac users, who have had them available for several years. The new U.S. English voices now on iOS include Fred, Tom, Allison, Ava, Victoria, and Susan.

To check out these new voices, go to Settings > General > Accessibility > VoiceOver > Speech. Once you find the "Speech" button, activate it and you will now see a button labeled "Voice," followed by the name of the voice you are currently using. Flick to the right, and you will find the "rotor languages" heading—below which are listed any secondary languages you have configured.

If you want to have just one voice onboard and available quickly, you will only need to set up the default option. If you are finding file sizes along with the voice name, this means that voice is not currently downloaded to your device. Double tap the download button to the right of the voice name to begin the download. As has been the case in the past, you will need to be connected to Wifi to download any voices not currently on your device besides Fred.

Once the download has completed, double tapping the name of the voice will then present you with a few options. Next to the heading of the voice you will find an "Edit" button. This will allow you to delete the voice you have put on your system. You can also achieve this by flicking up wherever VoiceOver indicates that there are actions available. Flicking down one more time will allow you to hear a spoken sample. Unfortunately, this option is present only when you have already downloaded that particular voice. It would be nice if it was possible to hear a sample prior to downloading.

Continuing to flick right, you will also see the options to do the specified rotor action items listed above as icons on the physical screen. If you choose the name of the voice that is just to the right of the "edit" button, you will choose the default version of the voice. After the "Speak Sample" button for the default voice, you will find the "Enhanced" flavor of the voice. At the time of this writing, it's not possible to use the default voice after deleting the enhanced version.

VoiceOver Settings, Expanded and Reorganized

Many of the options in the "Settings" screen have been moved around. This is also true of the VoiceOver settings. One new sub-menu is called "Verbosity"; this series of options now contains the "Speak Hints" option which we all already know. It also has a new feature called "Emoji Suffix," which speaks the word "Emoji" after telling the user what the Emoji is.

Another new VoiceOver settings sub-menu in iOS 10 is called "Audio." In the "Audio" menu, you will find some familiar options, since "Use Sound Effects" and "Audio Ducking" have both been moved here. A new feature, called "Auto-Select Speaker in Call," will allow you to control whether call audio automatically gets routed to your speaker when you move your phone away from your ear. Turning this off will prevent the audio from auto-switching to the speakerphone.

Under the sub-menu called "Channels," you can determine which channels will be heard through your connected Bluetooth or other audio output method. You can choose to have either your speech or the system sounds routed to one channel or another – it's not possible to deselect both channels. Also, if you have a mixer or DJ controller that supports it, you now have the ability in this menu to configure whether VoiceOver uses your mixer or another sound source for speech output.

Auditory Validation

In iOS 10, there are new sounds specifically associated with VoiceOver for several events. When you lock your screen, there will now be a sound instead of the verbal confirmation that the screen is locked. (As an aside, there is also a new screen lock sound in iOS 10.) If you press the "Home" button, and Touch ID does not recognize your fingerprint, there will also be a different sound played than when it does recognize it.

What's New in iOS 10, Part 2

In Part 2 of his review, Scott discusses more iOS 10 accessibility changes, including braille, low vision, and hearing/TTY updates. For more information, you can contact Scott at scott.davert@hknc.org.

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New and Ongoing Research: A Drug-Dispensing Contact Lens that Effectively Lowers Eye Pressure Associated with Glaucoma

Cover of the journal Ophthalmology

Several recent eye research projects have addressed the potential of contact lenses as a way to (a) deliver ocular drugs directly to the eye, (b) measure blood glucose levels, and (c) monitor intraocular (within the eye) pressure. Two prominent examples are the FDA-approved Triggerfish contact lens, which monitors intraocular pressure related to glaucoma, and Google's prototype "smart contact lens", proposed as a way to monitor blood glucose levels for people with diabetes.

Now, researchers from Harvard Medical School and the School of Medicine at Mount Sinai, New York have developed a contact lens – using animal models – to deliver eye pressure-lowering glaucoma medication, with the goal of preventing vision loss. Currently, most glaucoma medications are administered as eye drops, which can cause stinging and burning, be difficult to self-administer, and thus are associated with low compliance.

Please note: Although this glaucoma research has produced interesting results in laboratory animals thus far, it must be subjected to additional, longer-term, rigorous study and human clinical trials, encompassing many more years of research.

From the Journal Ophthalmology

This latest glaucoma contact lens research, entitled Latanoprost-Eluting [i.e., extracting or dissolving the drug latanoprost] Contact Lenses in Glaucomatous Monkeys, has been published online ahead of print in the August 29, 2016 edition of Ophthalmology, the official journal of the American Academy of Ophthalmology. Ophthalmology publishes original, peer-reviewed research in ophthalmology, including new diagnostic and surgical techniques, the latest drug findings, and results of clinical trials.

The authors are Joseph B. Ciolino, MD; Amy E. Ross, MSc; Rehka Tulsan, MSc; Amy C. Watts, OD; Rong-Fang Wang, MD; David Zurakowski, PhD; Janet B. Serle, MD; and Daniel S. Kohane, MD, PhD, who represent the following institutions: Massachusetts Eye and Ear Infirmary and Boston Children's Hospital, Harvard Medical School, Boston, MA; and the Icahn School of Medicine at Mount Sinai, New York, NY.

Latanoprost and Prostaglandin Analogs: Eye Drops for Glaucoma

a view of the eye to check for glaucoma

Prostaglandin analogs are the most widely prescribed eye drops. Prostaglandin is a naturally-occurring blood protein that can lower intraocular [i.e., within the eye] pressure (IOP), in addition to having many other therapeutic effects.

Analogue, or "analogous," means that the drug is comparable, or similar, to prostaglandin, but has a slightly different chemical composition.

Thus, prostaglandin analogues (PGAs) are drugs that are used in the treatment of open-angle glaucoma or ocular hypertension. At specific dosages, they lower intraocular pressure (IOP) by increasing the outflow of aqueous humor from the eye.

Some of the more common PGAs include

  • Xalatan (generic name: latanoprost)
  • Travatan (generic name: travoprost)
  • Lumigan (generic name: bimatoprost)
  • Zioptan (generic name: tafluprost)

About the Glaucoma Contact Lens Research

Edited and excerpted from Drug-dispensing contact lens effectively lowers eye pressure in pre-clinical glaucoma model, via the Massachusetts Eye and Ear Newsroom:

A contact lens designed to deliver medication gradually to the eye could improve outcomes for patients with conditions requiring treatment with eye drops, which are often imprecise and difficult to self-administer. A team of researchers has shown that a novel contact lens-based system, which uses a strategically placed drug polymer film to deliver medication gradually to the eye, is at least as effective, and possibly more so, as daily latanoprost eye drops in a pre-clinical model for glaucoma.

"We found that a lower-dose contact lens delivered the same amount of pressure reduction as the latanoprost drops, and a higher-dose lens, interestingly enough, had better pressure reduction than the drops in our small study,” said [study co-author] Joseph B. Ciolino, M.D. "Based on our preliminary data, the lenses have not only the potential to improve compliance for patients, but also the potential of providing better pressure reduction than the drops."

Contact lenses have been studied as a means of ocular drug delivery for nearly 50 years, yet many such lenses are ineffective because they dispense the drug too quickly. The authors of the Ophthalmology study designed the contact lens to allow for a more controlled drug release. The researchers had shown in a previous study that the lens is capable of delivering medication continuously for one month.

The researchers designed a contact lens that contains a thin film of drug-encapsulated polymers in the periphery [i.e., the outer edges]. The drug-polymer film slows the drug coming out of the lens. Because the drug film is on the periphery, the center of the lens is clear, allowing for normal visual acuity, breathability, and hydration. The lenses can be made with no refractive power or with the ability to correct the refractive error in nearsighted or farsighted eyes.

… the effect of this drug-eluting contact lens was assessed in four monkeys with glaucoma. The researchers showed that the contact lens with lower doses of latanoprost delivers the same amount of eye pressure reduction as the eye drop version of the medication. The lenses delivering higher doses of latanoprost had better pressure reduction than the drops.

Further study is needed to confirm the finding in the higher-dose lenses. The researchers are currently designing clinical trials to determine safety and efficacy of the lenses in humans.

More About Glaucoma

The term "glaucoma" describes a group of eye diseases that can lead to blindness by damaging the optic nerve. It is one of the leading causes of vision loss and blindness. The human eye continuously produces a fluid, called the aqueous, that must drain from the eye to maintain healthy eye pressure.

Types of Glaucoma

In primary open-angle glaucoma, the most common type of glaucoma, the eye's drainage canals become blocked, and the fluid accumulation causes pressure to build within the eye. This increasing pressure can cause damage to the optic nerve, which transmits information from the eye to the brain. Vision loss is usually gradual and often there are no early warning signs.

In angle-closure glaucoma, also called "acute" glaucoma, the aqueous cannot drain properly because the entrance to the drainage canal is either too narrow or is closed completely. In this case, eye pressure can rise very quickly and cause an acute glaucoma attack. Symptoms can include sudden eye pain, nausea, headaches, and blurred vision. Acute glaucoma is a true ocular emergency and requires immediate treatment.

In normal-tension glaucoma, also called low-tension/low pressure glaucoma, individuals with the disease experience optic nerve damage and subsequent vision loss, despite having normal intraocular [i.e., within the eye] pressure (IOP).

Most eye care professionals define the range of normal IOP as between 10 and 21 mm Hg [i.e., millimeters of mercury, which is a pressure measurement]. Most persons with glaucoma have an IOP measurement of greater than 21 mm Hg; persons with normal-tension glaucoma, however, have an IOP measurement within the normal range.

Visual Field Loss

Glaucoma results in peripheral (or side) vision loss initially, and the effect as this field loss progresses is like looking through a tube or into a narrow tunnel. This constricted "tunnel vision" effect makes it difficult to walk without bumping into objects that are off to the side, near the head, or at foot level.

A living room viewed through a constricted visual field

A living room viewed through a constricted visual field.
Source: Making Life More Livable. Used with permission.

Glaucoma is an especially dangerous eye condition because most people do not experience any symptoms or early warning signs at the onset. Glaucoma can be treated, but it is not curable. At present, the damage to the optic nerve from glaucoma cannot be reversed.

You can learn more about the different treatments for glaucoma, including laser peripheral iridotomy (LPI), selective laser trabeculoplasty (SLT), and eye drops to lower eye pressure, on the VisionAware website.

Complying with Your Eye Medication Regimen

If you have been diagnosed with glaucoma, it is critical that you maintain the eye medication regimen prescribed by your ophthalmologist. In order for the medication to lower your intraocular pressure effectively, consistent daily adherence to your prescribed eye drop regimen is essential.

At times, compliance can be difficult because there can be some discomfort when administering your eye drops. If you have ongoing problems, such as pain, blurred vision, or headaches after taking your drops, talk to your doctor about using another type of eye drop.

Here is a set of helpful steps for administering drops, developed by The National Eye Institute:

  • Wash your hands.
  • Tilt your head back.
  • Hold the bottle upside down.
  • Hold the bottle in one hand and place it as close as possible to your eye.
  • With the other hand, pull down your lower eyelid. This forms a "pocket."
  • Place the prescribed number of drops into the lower eyelid pocket. If you are using more than one eye drop, be sure to wait at least five minutes before applying the next eye drop.
  • Close your eye or press the lower lid lightly with your finger for at least one minute. Either of these steps keeps the drops in the eye and helps prevent the drops from draining into the tear duct, which can increase your risk of side effects.

For additional tips, adaptations, and assistive devices to help you take your glaucoma medications, see Tips for Taking Glaucoma (and Other) Eye Drops by Ira Marc Price, O.D.

More About the Study from Ophthalmology

From the study summary and abstract:

Purpose: To assess the ability of latanoprost-eluting contact lenses to lower the intraocular pressure (IOP) of glaucomatous eyes of cynomolgus monkeys [i.e., macaques].

Participants: Female cynomolgus monkeys with glaucoma induced in 1 eye.

Methods: Latanoprost-eluting low-dose contact lenses and high-dose contact lenses were produced by encapsulating a thin latanoprost-polymer film within the periphery of a methafilcon hydrogel, which was lathed into a contact lens. We assessed the IOP-lowering effect of low-dose contact lenses, high-dose contact lenses, or daily latanoprost ophthalmic solution in the same monkeys.

Each monkey consecutively received 1 week of continuous-wear low-dose contact lenses, 3 weeks without treatment, 5 days of latanoprost drops, 3 weeks without treatment, and 1 week of continuous-wear high-dose contact lenses. On 2 consecutive days before initiation of each study arm, the IOP was measured hourly over 7 consecutive hours to establish the baseline IOP.

Results: Latanoprost ophthalmic solution resulted in IOP reduction of 5.4±1.0 mmHg [i.e., millimeters of mercury, which is a pressure measurement] on day 3 and peak IOP reduction of 6.6±1.3 mmHg on day 5. The low-dose contact lenses reduced IOP by 6.3±1.0, 6.7±0.3, and 6.7±0.3 mmHg on days 3, 5, and 8, respectively. The high-dose contact lenses lowered IOP by 10.5±1.4, 11.1±4.0, and 10.0±2.5 mmHg on days 3, 5, and 8, respectively.

For the low-dose contact lenses and the high-dose contact lenses, the IOP was statistically significantly reduced compared with the untreated baseline at most time points measured. The high-dose contact lenses demonstrated greater IOP reduction than latanoprost ophthalmic solution on day 3 (P = 0.001) and day 5 (P = 0.015), and at several time points on day 8 (P < 0.05).

Conclusions: Sustained delivery of latanoprost by contact lenses is at least as effective as delivery with daily latanoprost ophthalmic solution. More research is needed to determine the optimal continuous-release dose that would be well tolerated and maximally effective. Contact lens drug delivery may become an option for the treatment of glaucoma and a platform for ocular drug delivery.

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Our Readers Want to Know: What Causes Floaters and Should I Be Worried About Them?

Editor's note: One of the many benefits associated with an online information center and website, such as VisionAware, is the ability to track readers' search terms [i.e., information readers are seeking as they search online]. Of particular concern to many readers are the presence and disease implications of floaters, as evidenced by the following searches:

  • Do floaters go away after a while?
  • I've had a sudden onset of a shower of floaters. What does this mean?
  • I have floaters after laser treatment/eye injection/eye surgery. Is this a problem?
  • Can floaters cause a retinal tear?

An Answer from Mrinali Patel Gupta, M.D.

Dr. Mrinali Patel Gupta

Dr. Gupta graduated with distinction with a Bachelor of Science in Biology, summa cum laude and Phi Beta Kappa, from Duke University College of Arts and Sciences in Durham, North Carolina. She completed her M.D. degree at Duke University School of Medicine, where she was elected to the Alpha Omega Alpha academic honor society.

During medical school, she also completed a one-year research fellowship as a Howard Hughes Medical Institute/National Institutes of Health Research Scholar at the National Eye Institute in Bethesda, Maryland. She pursued internship training at Memorial Sloan-Kettering Cancer Center in New York.

Dr. Gupta completed her Residency in Ophthalmology at Harvard Medical School/Massachusetts Eye & Ear Infirmary, followed by a Fellowship in Vitreoretinal Diseases and Surgery at Weill Cornell Medical College/New York-Presbyterian Hospital in New York, NY. Currently, she is an Assistant Professor of Ophthalmology in the Vitreoretinal Surgery Service at Weill Cornell Medical College, where she combines an active clinical and surgical practice with research in retinal disease and education of residents and fellows.

What are Floaters?

As their name implies, floaters are usually small, black shapes that look like spots, squiggles, or threads, and "float about" in one's vision. They generally move as the eyes move, and are most noticeable against a plain bright background, such as a white or light-colored wall.

What Causes Floaters?

There are a number of conditions and changes within the eye that can cause floaters. These are the most common:

  • Changes in the vitreous: The inside of the back part of the eye is filled with a jelly-like substance called vitreous. The vitreous is attached to the retina, which is the thin, light-sensitive tissue that lines the inside surface of the eye. Much like the film of a camera, cells in the retina convert incoming light into electrical impulses. These electrical impulses are carried by the optic nerve to the brain, which finally interprets them as visual images.
  • As a person ages, the jelly-like vitreous becomes more liquefied and areas of the vitreous can condense and acquire a "stringy" consistency. These strings or strands of vitreous can be perceived as floaters.
  • Posterior vitreous detachment (PVD): As the vitreous liquefies, it also shrinks and pulls away from the retina. This process is called a posterior vitreous detachment, or PVD. Many people develop posterior vitreous detachments and never experience symptoms, whereas others may notice new floaters. In general, a vitreous detachment is not considered an ocular emergency.
view of the eye with vitreous

The vitreous: A side view of the eye with the vitreous gel (in blue)
filling the inside of the back part of the eye and attached to the retina.
Source: Courtesy Mrinali Patel Gupta, M.D.,
Weill Cornell Medical College, New York



view of the eye with posterior vitreous detachment

A posterior vitreous detachment (PVD): the vitreous gel (in blue)
shrinking and pulling away (detaching) from the retina.
Source: Courtesy Mrinali Patel Gupta, M.D.,
Weill Cornell Medical College, New York

  • Retinal tear or detachment: In some cases, as the vitreous is peeling away from the retina and detaching, it can pull so hard in areas of firm attachment that it tears the retina. Therefore, any person with a PVD should have a careful retinal exam to rule out an associated tear. As the retina tears, a retinal vessel may be torn or damaged, leaking blood into the vitreous. This blood, called a vitreous hemorrhage, may also produce floaters.

A tear in the retina is of great concern, because it can extend and allow fluid to enter through the tear and separate the retina from the underlying tissue. To picture how this happens, imagine a rip in the wallpaper in the bathroom. That is like a retinal tear. If the rip is not repaired, over time, steam from the bathroom shower can get behind the tear; eventually the entire sheet of wallpaper may begin to peel and fall off. A similar process occurs when a tear is untreated and the retina comes off, or detaches.

Anyone can develop a retinal tear and detachment, but they are more likely to occur in persons who are nearsighted, older, have recently undergone cataract surgery, or have sustained a trauma to the eyes.

Please note: Retinal tears often lead to retinal detachment. While retinal tears usually do not cause vision loss and can be repaired effectively through a non-incisional [i.e., no surgical cuts involved] laser or cold therapy (cryotherapy) procedure in the office without anesthesia, retinal detachments almost always cause vision loss and usually involve incisional surgical repairs in an operating room. Therefore, it is critical to be evaluated promptly, because diagnosis and treatment of a retinal tear before it results in a retinal detachment can be vision-saving.

What Should You Do if You Notice Floaters?

Anyone who notices new floaters should undergo a dilated eye examination. The doctor may use a Q-tip or small instrument to push gently on the eye to look at the far edges of the retina not visible through a routine examination.

Anyone with a prior history of floaters who notices a new shower of floaters, flashing lights, or a curtain or shade "coming down over one eye" should undergo a prompt dilated eye examination. These may be signs of a retinal tear or retinal detachment.

How are Floaters Treated?

  • In all cases, the underlying cause of the floaters should be treated. The underlying cause for any inflammation or bleeding should be identified and treated accordingly.
  • If the floaters are due to changes in the vitreous or to posterior vitreous detachment (PVD), no intervention is necessary. A dilated eye examination should be performed to rule out an associated retinal tear or detachment.
  • In addition, many eye doctors may perform a follow-up exam in several weeks to confirm that a new tear or break has not developed in the retina. Over time, the floaters may decrease, and in many cases, the brain learns to ignore these floaters.
  • The only effective way to remove floaters from the vitreous or from posterior vitreous detachment (PVD) is to surgically remove them. In rare cases, a vitrectomy can be considered if floaters are causing significant visual symptoms. However, it is important to weigh the risks versus benefits of such a procedure.

For more information about treatments for retinal tears and retinal detachments, see Floaters, Retinal Tears, and Retinal Detachments on the VisionAware website.

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