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The First Stem Cell Clinical Trial for Wet Macular Degeneration Is Underway in London

retina with wet AMD

A pioneering clinical trial of a new treatment derived from embryonic stem cells for people with wet age-related macular degeneration (AMD) has been initiated at Moorfields Eye Hospital in London, following a successful operation on a 60-year-old woman. She is the first of 10 persons with wet AMD who will receive the stem cell treatment as part of an 18-month clinical trial to test the safety and effectiveness of this procedure.

In the United States, Ocata Therapeutics has revealed positive results from its small (18-patient) early-stage clinical trials of human embryonic stem cells (hESC) for the treatment of dry age-related macular degeneration and Stargardt disease.

Nevertheless, despite these encouraging – although admittedly very early – results, a clinical trial for stem cell treatment of wet AMD has remained elusive – until now.

 London Project to Cure Blindness logo

This initial operation is a key component of the London Project to Cure Blindness, which was established ten years ago with the goal of curing vision loss in persons with wet AMD. The Project is the result of a partnership that includes Moorfields Hospital, the University College London (UCL) Institute of Ophthalmology, the National Institute for Health Research, and Pfizer Inc..

The London Project to Cure Blindness

Excerpted from About Us at the London Project to Cure Blindness website:

The London Project to Cure Blindness has, for the past 10 years, been developing cell-based treatments to cure blindness associated with age-related macular degeneration (AMD). The group has been culturing embryonic stem cells, which give rise to all human cell types, to grow patches of retinal cells for transplant.

The project aims to bring stem cell therapy for retinal diseases, especially for AMD, to the clinic as rapidly as possible. We believe stem cell-based therapies for these conditions have the greatest chances of preventing blindness, restoring sight, and improving quality of life in the future.

The stem cell approach aims to replace cells in the eye that are either damaged or missing. In AMD the main cells that are initially affected are the retinal pigment epithelium cells (RPE). In the first of the trials developed by the London Project, we are using human embryonic stem cells (hES) that have been transformed into RPE cells. These RPE cells will then be transplanted under the patient's retina on a specially engineered patch that the London Project has developed.

[Editor's note: Retinal pigment epithelium (RPE) cells are the deepest cells of the retina. The RPE helps to maintain the health of the retinal photoreceptor cells, called rods and cones. These photoreceptor cells are triggered by light to set off a series of electrical and chemical reactions that helps brain to interpret what the eye sees. The degeneration of the RPE cells also leads to the death of the rods and cones and, ultimately, vision.]

More recently, The London Project has secured funding to examine the use of induced pluripotent stem cell (iPSC) technology for transplantation. This allows the original cells to be taken from the person with the disease themselves and not from another source, such as an embryo.

[Editor's note: Pluripotent refers to a stem cell that has the power to develop into any type of bodily cell or tissue ("pluri" = many; "potent" = having power). An induced pluripotent stem cell (iPSC) is a type of pluripotent stem cell that can be generated directly from adult cells.]

Another important arm of the project is to develop the technology by which stem cells can be transformed into photoreceptors (primarily cones and rods) and transplanted into patients. It is believed that the photoreceptors are lost after the RPE cells have degenerated.

This first clinical trial, which has been granted permission by the UK regulatory authority, will be for severe wet degeneration, and if successful, will then be also used in dry macular degeneration.

More about Age-Related Macular Degeneration (AMD)

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

What a person with AMD sees

Age-related macular degeneration (AMD) is gradual, progressive, painless deterioration of the macula, the small sensitive area in the center of the retina that provides clear central vision. The fovea is located in the center of the macula and provides the sharpest detail vision.

Damage to the macula impairs the central (or "detail") vision that helps with essential everyday activities such as reading, preparing meals, playing card and board games, and needlework and sewing.

AMD is the leading cause of vision loss for people aged 60 and older in the United States. According to the American Academy of Ophthalmology, 10-15 million individuals have AMD; approximately 10% of people who are affected have the "wet" type of AMD. For more information about vision loss from AMD, see How Does AMD Affect Vision? by Lylas G. Mogk, M.D.

Wet Macular Degeneration

In wet, or exudative, 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.

In wet AMD, abnormal blood vessels develop under the macula and break, bleed, and leak fluid. This damages the macula and, if left untreated, can result in rapid and severe loss of central vision. The most effective treatments to date for wet AMD are several "anti-angiogenic" drugs.

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 called 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.

Lucentis, Avastin, and Eylea

At present, these drugs are administered by injection directly into the eye after the surface has been numbed. The needle is very small and is inserted near the corner of the eye — not the center. During the injection procedure, the doctor will ask the patient to look in the opposite direction to expose the injection site, which also allows the patient to avoid seeing the needle. Anti-angiogenic drugs currently in use include Lucentis, Avastin, and Eylea.

More about the Stem Cell Clinical Trial

The ongoing clinical trial at Moorfields Eye Hospital in London is investigating the safety and effectiveness of transplanting RPE cells derived from stem cells to treat people with sudden severe visual loss from wet AMD. These cells are used to replace those at the back of the eye that are diseased in AMD. This is done using a specially engineered patch inserted behind the retina in an operation lasting one to two hours.

In total, the trial will recruit 10 patients over a period of 18 months. Each patient will be followed for a year to assess the safety and stability of the cells and the degree to which their vision is restored.

The first surgery was performed in August 2015 and there have been no reported complications to date. The surgical team hopes to determine the outcome, in terms of initial visual recovery, by early December 2015.

VisionAware will continue to report the results of this clinical trial as they become available.

Additional Stem Cell Information from VisionAware

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Macular Degeneration

Is Glaucoma a Genetic Disease? New and Innovative Genetic Research Shows Promise in the Treatment of Glaucoma

Molecular Cell logo

New glaucoma research from the United States and China indicates that a genetic interaction may prove to be a key component in the development and progression of open-angle glaucoma. Although this genetic research has been conducted only with laboratory mice, the concept shows great promise for developing and identifying effective therapies for treating – and even preventing – glaucoma.

Molecular Cell: the Research

The research, entitled P16INK4a [a type of gene] Upregulation [increased response] Mediated by SIX6 [also a type of gene] Defines Retinal Ganglion Cell Pathogenesis [i.e., disease development] in Glaucoma (explained and decoded below), has been published online ahead of print in the September 10, 2015 edition of Molecular Cell, a division of Cell Press. Molecular Cell publishes original, peer-reviewed research in molecular biology, including papers that open new avenues of research, report unexpected findings, or change established thought about biological processes.

The lead authors are Dorota Skowronska-Krawczyk and Ling Zhao, along with a research team representing an interdisciplinary mix of United States- and China-based institutions: Shiley Eye Institute, the Department of Reproductive Medicine, the Institute for Genomic Medicine, and the Howard Hughes Medical Institute from the University of California, San Diego; Sichuan University, Sichuan China; JiaoTong University, Shanghai, China; and Sun Yat-sen University, Guangzhou, China.

About Open-Angle Glaucoma

Glaucoma is a group of eye diseases that damage the optic nerve and is one of the leading causes of vision loss and blindness. Open-angle glaucoma is the most common form of glaucoma.

The eye continuously produces a fluid, called the aqueous (or aqueous humor), that must drain from the eye in order to maintain healthy eye pressure. Aqueous humor is a clear, watery fluid that flows continuously into, and out of, the anterior (or front) chamber of the eye, which is the fluid-filled space between the iris and the cornea. It is the aqueous that helps to bring nutrients to the various parts of the eye.

Aqueous fluid drains from the anterior chamber through a filtering meshwork of spongy tissue along the outer edge of the iris (called the trabecular meshwork), where the iris and cornea meet, and into a series of "tubes," called Schlemm's canal, that drain the fluid out of the eye. Problems with the flow of aqueous fluid can lead to elevated pressure within the eye.

In primary open-angle glaucoma (POAG), the filtering meshwork may become blocked or may drain too slowly. If the aqueous fluid cannot flow out of the eye, or flow out quickly enough, pressure builds inside the eye and can rise to levels that may damage the optic nerve, resulting in vision loss.

Most eye care professionals define the range of normal intraocular [i.e., within the eye] pressure (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.

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

Vision Loss from Glaucoma

Glaucoma results in peripheral (or side) vision loss initially, and as this field loss progresses, the effect 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. The damage to the optic nerve from glaucoma cannot be reversed.

About the Glaucoma Genetic Research

Excerpted from Identified Genetic Interaction Offers Possible New Target for Glaucoma Therapy from Health Canal:

Primary open-angle glaucoma (POAG) is the most common form of glaucoma, affecting more than three million Americans, primarily after the age of 50. Pressure inside the eye … and age are the leading risk factors for POAG, resulting in progressive degeneration of retinal ganglion cells, optic nerve damage and eventual vision loss.

[Editor's note: Retinal ganglion cells (RGCs), are neurons, or nervous system cells. They are located near the inner surface of the retina and give rise to optic nerve fibers that transmit information from the retina to several regions in the brain.]

Genetics also plays a role. Recent [gene] studies have identified two genes – SIX1-SIX6 and p16INK4a – as strongly associated with POAG. SIX6 is required for proper eye development. P16INK4a irreversibly arrests cell growth, a phenomenon called senescence.

In their new paper, principal investigator Kang Zhang, MD, PhD, professor of ophthalmology and chief of Ophthalmic Genetics at Shiley Eye Institute, and colleagues report that some variants of the SIX6 gene boost the expression of p16INK4a, which in turn accelerates senescence and death of retinal ganglion cells. "We also show that high intraocular pressure in glaucoma increases expression of p16INK4a, making it a key integrator (or combiner) of genetic and environmental risk factors that can result in glaucoma," said Zhang.

The research findings suggest that inhibiting p16INK4a could offer a new therapeutic approach for glaucoma, which is currently treated by drugs that lower intraocular pressure. "Although lowering intraocular pressure can slow the worsening of the disease, it does not stop it and prevent further cell death or possible blindness," said [co-author] Robert N. Weinreb, MD.

More about the Research from Molecular Cell

Excerpted from the article discussion, with the full article available online:

Glaucoma is the leading cause of blindness, affecting tens of millions of people worldwide. Despite its prevalence, its etiology and pathogenesis [i.e., development] are poorly understood, and treatment is limited to lowering intraocular pressure (IOP). Despite aggressive IOP-lowering therapies, most patients have progressive loss of visual function, and some eventually become legally blind. The relationship of raised IOP and retinal ganglion cell (RGC) death is poorly understood.

Cellular senescence is a state of irreversible growth arrest. When senescent cells accumulate in the tissue, their impaired function can result in a predisposition to disease development and/or progression. In the present study, we show that SIX6 directly regulates expression of p16INK4a, an indicator of cell senescence and aging. Furthermore, we show that upon acute IOP elevation, p16INK4a expression is upregulated, which, in turn, can be a cause of RGC death.

Our hypothesis can help explain how IOP, the most common risk factor, can cause glaucoma. Moreover, it provides a molecular link between genetic susceptibility and other factors to the pathogenesis [i.e., development] of glaucoma. Our study suggests that cellular senescence plays a critical role in the pathogenesis of glaucoma.

Taken together, our study shows that SIX6 variant increases p16INK4a expression upon increased IOP, which in turn causes RGCs to enter into a senescent state and which may lead to increased RGC death in glaucoma. Our study provides important insights into the pathogenesis of glaucoma and suggests future therapeutic strategies based on targeted inhibition of p16INK4a-induced cell senescence to prevent and treat glaucoma.

Additional Glaucoma Information from VisionAware

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Good Nutrition and Eye Health: They're Connected!

Audrey Demmitt and her dog guide

Guest blogger Audrey Demmitt, RN, BSN, is a nurse diabetic educator, VisionAware Peer Advisor, AFB Career Connect mentor, and author of the VisionAware multi-part blog series on diabetes and diabetes education.

At age 25, Audrey was diagnosed with retinitis pigmentosa and continued to work as a nurse for 30 years with her visual impairment.

She has worked as an Adjustment to Blindness Counselor and Diabetic Educator for Vision Rehabilitation Services of Georgia and as a school nurse providing in-service training for school staff and developing care plans for newly-diagnosed students and their families.

Nutrition and Eye Health: the Basics

During Healthy Aging Month, it's appropriate to emphasize the link between nutrition and your eyes, including research studies that demonstrate a clear connection between good nutrition and eye health. Two landmark clinical trials, the Age-Related Eye Disease Study (AREDS) and AREDS2, provided evidence that a combination of specific nutrients in specific amounts reduced the risk of developing advanced AMD in participants who had already-existing moderate to advanced dry or wet macular degeneration (AMD).

Along with this growing evidence that specific nutrients have a positive and protective effect on eye health are growing numbers of nutritional supplements that offer a variety of formulas for healthy eyes. We all want to preserve our vision, but it can be confusing and overwhelming to interpret research studies and determine what is truly best for our individual situations.

Foods, Nutrients, and Eye Health

a range of vegetables

When it comes to nutrition, it is best to get your nutrients from foods. The good news is we have many wholesome foods available to us. It is all about making healthy choices.

Choosing the freshest forms of colorful fruits and vegetables, lean meats and fish, whole grains and nuts, and low-fat dairy and eggs will ensure a diet rich in many of the nutrients that promote healthy eyes and preserve vision.

Here is a list of nutrients that play a beneficial role in keeping our eyes healthy:

Lutein and Zeaxanthin

  • These important antioxidants may reduce the risk of chronic eye diseases, including age-related macular degeneration. They protect against the damaging effects of sunlight, cigarette smoke, and air pollution. Zeaxanthin appears to be the most active antioxidant in the macula specifically.
  • Foods to eat: green leafy vegetables like spinach, kale, and collards. Also found in eggs, broccoli, pumpkin, and bright-colored fruits like kiwi and grapes. The richest source of zeaxanthin is goji berries (also called wolfberries), which are available in health food and some grocery stores, in dried form and in juices and teas.
  • Please note: According to WebMD, goji berries could interact with certain drugs, including those for diabetes, blood pressure, and blood thinners. If you take any of these drugs, talk with your doctor before consuming goji berries in any form.

Vitamin A

  • The A vitamins, which include beta-carotene, help the retina, cornea, and other eye tissues to function properly. They are known for helping with night vision.
  • Foods to eat: beef liver, fish, milk, eggs, spinach, pumpkin, sweet potatoes, and carrots.

Vitamin C

  • This antioxidant may lower the risk of developing cataracts and slow the progression of AMD.
  • Foods to eat: oranges, berries, red and green peppers, cauliflower, broccoli, papaya, cantaloupe, and Brussels sprouts.

Vitamin E

  • This powerful antioxidant seems to protect cells of the eyes from the damage caused by free radicals, which destroy healthy tissue.
  • Foods to eat: sweet potatoes, almonds, pecans, sunflower seeds, wheat germ oil, fortified cereals, vegetable oils, and peanut butter

Essential Fatty Acids

  • Fats are essential in the diet. There are two types of omega-3 fatty acids: the plant-based ALA and the oily fish-based EPA and DHA. They play an important role in visual development and retinal function. Low levels of DHA, found in the retina, have been linked to dry eye syndrome.
  • Foods to eat: tuna, salmon, mackerel, anchovies, trout, green vegetables, vegetable oils, and walnuts.


  • This essential trace mineral helps bring vitamin A from the liver to the retina in order to produce melanin, a protective pigment in the eyes. It is found in high concentrations in the retina and the vascular layer underneath the retina.
  • Foods to eat: eggs, oysters, crab legs, red meat, poultry, baked beans, and whole grains.

More about Nutritious Foods from Lylas G. Mogk, M.D.

Lylas G. Mogk, MD

Dr. Mogk is the author of Age-Related Macular Degeneration on the VisionAware website and founding director of the Center for Vision Rehabilitation and Research, part of the Department of Ophthalmology at the Henry Ford Health System in Michigan. Here are her recommendations:

Studies suggest that eating antioxidant-rich foods, such as fresh fruits and dark green leafy vegetables (kale, collard greens, and spinach, for example), may delay the onset or reduce the severity of dry AMD. These types of vegetables contain lutein, which may protect the macula from sun damage, just as it protects the leaves of these vegetables from sun damage.

Eating at least one serving of fatty fish per week may also delay the onset or reduce the severity of AMD. These types of fish are high in omega-3 fatty acids, which help decrease inflammation and promote eye health.

Avoid packaged foods as much as possible. It's important to keep a balance between omega-6 fatty acids and omega-3 fatty acids in our diets. Virtually every food in a package contains omega-6 fatty acids in the form of vegetable oil. We need to increase our intake of omega-3s and decrease our intake of omega-6s.

Avoid artificial fats. Low-fat foods are good options if they've achieved their low-fat status through a process that physically removes the fat. Skim milk and low fat cottage cheese are examples of these types of good low-fat foods.

A low-fat cookie or a no-fat cake, however, is a nutritional contradiction. Usually a low-fat or no-fat label on baked goods doesn't mean less fat was used in the production of the food, but that an artificial fat was used, usually partially hydrogenated vegetable oil. These types of fats are artificial ingredients made in a laboratory and our bodies can't metabolize them. So it's best to eat real cookies - just don't eat the whole dozen!

More from Audrey: When to Use Supplements

Supplementation may be necessary when the diet is inadequate or in cases in which a disease process already exists. Some nutrients are actually toxic to the body in large amounts, and "more is not always better." And there are some nutritional supplements that may interact with medications and cause problems. So if you are considering a nutritional supplement for your eyes, it is important to talk to your eye doctor and discuss which formula is best suited for your overall health.

Maintaining a healthy diet and body weight also has protective benefits against diseases that can cause vision loss, such as diabetes, stroke, and eye vessel occlusions. Aging eyes need good nutrition. This will require more than nibbling on vegetables! Begin by including the healthy foods listed above in your diet whenever possible. Eat the foods that will keep your eyes happy and improve your quality of life.

Additional Resources

Low Vision
Medical Updates
Macular Degeneration

What's New in iOS 9 Accessibility for Blind 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.

According to 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 Apple's new iOS 9 release, with an emphasis on accessibility features for users who are blind and 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 discussed VoiceOver enhancements and updates/changes in accessibility features. In Part 2, Scott discusses new gestures, braille screen input, and braille display changes.

The Need for Speed!

Along with the additional variants of speech in VoiceOver (see Part 1 for more information about additional VoiceOver Voices via the Siri speech synthesizers), it's now possible to speed speech up more than it had been in the past. You can do this quickly from anywhere in iOS if you have the speech rate option enabled in the rotor, or you can configure this under VoiceOver settings.

Is It Tap Tap, or Tap ... Tap?

With this new VoiceOver setting, called "Double-tap Timeout," the choice is yours. One of the issues I've encountered from time to time when teaching individuals on the touch screen is the inability to do the double-tap gesture fast enough due to lack of motor skills or limited dexterity. To reconfigure this setting, head over to the VoiceOver settings and find it near the very bottom of the screen.

Once you double tap this button, you will have the ability to control the period of time that elapses between the two taps, enabling VoiceOver to recognize the two taps as a double-tap gesture. If you do not wish to type in a value for the time period, flicking to the right once will give you a decrement button, followed by an increment button. The default is 0.25 seconds, but you can go way up from there as needed.

I Will Select Simplicity

A piece of feedback I and others have offered Apple over the years is that selecting text with the touch screen and the pinch gesture is a rather cumbersome, and not so effective, way to select text. In iOS 9, a new way to select text has arrived. You must first enable it in your rotor settings, by enabling text selection.

Once you have located the text you want to select, find the rotor option. Now, you can flick up with one finger to cycle through the list of choices. The options from top to bottom are Character Selection, Word Selection, Line Selection, Page Selection, and Select All.

After deciding which element type you would like to select, find the beginning of the text in whatever way is most comfortable for you. Then, begin flicking right to highlight text, and left to deselect it. I find this to be a much more manageable way of selecting text, and I suspect many who use the touch screen as their primary way of selecting will agree.

This will also be more efficient when trying to select text on a Bluetooth keyboard or braille display. One slight inconvenience of this feature is that you cannot select text when moving backward. So if you are reviewing a document, for example, and find something you want to delete, you have to go to the beginning of the text you wish to remove, and start your selection from there.

Caps Lock Becomes a Multipurpose Key

One of the complaints over the years, more so with the Mac than iOS, is that certain keyboard commands require the pressing too many keys at once. Apple has partially addressed this issue by adding the caps lock as a modifier key to the VoiceOver cursor. With older versions of iOS, it was necessary to press the Control and Options keys on a Bluetooth keyboard in conjunction with another key or two on the keyboard to carry out VoiceOver-specific commands.

You will find this new option, called "Modifier Keys," under the VoiceOver settings. Your options are Caps Lock, Control + Option, or both. Just like when you make the Caps Lock key the modifier on other screen readers, you can press the Caps Lock key twice quickly to toggle, whether you write in all capitals or not. It's worth noting that when you press the Caps Lock key twice, VoiceOver reports the wrong key setting. For example, if you hit the key twice, and VoiceOver reports that your Caps Lock is off, it's actually on.

Braille Screen Input (BSI): Just the Way You'd Like It to Be

Originally introduced in iOS 8, BSI has lacked the customizability that many users would like to have throughout the operating system. One of the issues for some has been the lack of clarity of what specific gestures are available when your device is set to BSI mode. No longer is this the case! If you have BSI enabled in your rotor, when you go to the Practice Gestures feature under the VoiceOver settings, you will now see two tabs: General and Braille Screen Input. This does not allow you to practice writing braille – it is only the gestures associated with BSI.

One of the new gestures that you will find is swiping up or down with three fingers. This will lock, or unlock, your screen orientation. This is handy if you are moving around but don't want your screen orientation doing the same.

Continuing with the new BSI features, you can now control where it shows up in your rotor. In iOS 8, BSI would follow you around the operating system, always being one rotor turn away. Now, you can put it wherever you desire within your rotor options, just like all of the other choices you have in the rotor. You can even have BSI behave as it once did by making it the first option within your rotor.

You can now also control the amount of spoken feedback offered by VoiceOver as you are inputting text with BSI. Find this configurable setting in the VoiceOver settings under Typing Feedback. Your choices are Characters, Words, and both Characters and Words. This works great with uncontracted braille, but there still appears to be no speech feedback provided when inputting characters in contracted braille.

New iPad Features Bring New Gestures

With the new ability to run apps in split screen mode and a new feature called Slide Over, come new gestures, along with new Bluetooth and braille keyboard commands. Since I'm only documenting changes with accessibility in this review, I will not go into great detail about how to use these features, but I will cover the different ways in which you can interact with them.

Slide Over

Slide Over is available with all iOS 9 compatible iPads. This feature allows you to have an app consuming 1/3 of the screen to carry out some tasks quickly before switching back to where you were originally working. Note that you cannot use this with all apps, only those that are supported.

When in landscape mode, to launch the Side App Switcher, tap the status bar, and then swipe left with three fingers to bring up the new Side App Switcher. You can also achieve this on a braille display with the command "space with dots 1-6." The Side App Switcher will allow you to "pin" a supported app to that 1/3 of the screen.

There is then a "Divider" that sits between that 1/3 of the screen and the app with the main focus. To move between the two apps, tap your touch screen. If you're using a Bluetooth keyboard, you can move between the two apps and also hit the divider by using the commands "VoiceOver modifier" with [ (left bracket) VoiceOver modifier ] (right bracket). Using the [ will move you backwards, and the ] will move you forward. Pressing "space with dots 2-4" on a braille display will move focus to the left, while "space with dots 2-6" will move focus to the right. The Divider becomes important, as it allows you to control re-sizing and other options on an iPad that supports the Split View feature.

Split View

Split View functions similarly to Slide Over, in the sense that you can pin apps and move them around. However, Split View does add more functionality to the mix. It's only available on the iPad Air 2 and later, as well as the iPad Mini 4 and anything that comes after that.

Split View allows you to run two apps on the screen at once and also allows you to decide how much of the screen each app will consume. The way in which you re-size apps is controlled with the Divider. When focus is set on the divider, a new rotor option allows you to control how the Split View operates. The rotor will allow you to launch the Side App Switcher, resize the right-hand app to take half the screen, dismiss the right-hand app altogether, or maximize the right-hand app to eliminate the app on the left side of the screen.

Braille Display Specific Changes

Picking up Speed

This heading refers to text input with a braille display. For many users, it was very sluggish in iOS 8, particularly for those on older devices. I'm finding that iOS 9 is much more responsive in terms of typing braille, about as rapid as iOS 7 was, which is probably one of the biggest reasons for me to upgrade.

Slow Down Your Announcements!

VoiceOver gives you announcements, or flash messages, which appear on a braille display quite quickly. For a slower braille user, this leads to having to press "space with N" to read the announcement again, and then pressing "space with N" again to return to whatever they were doing. In other situations, the announcement would stay on the display for a much longer duration than a faster reader may desire.

Now you can control the speed of such announcements. In Settings, go to General > Accessibility > VoiceOver > Braille, and configure this setting to your preference under "Alert Display Duration."

Start and Stop It All

Since a few iOS versions ago, VoiceOver users have had a gesture (double-tap with two fingers), which performs a custom action. What it does depends on the context of the situation. For example, use this gesture to answer or hang up a phone call, launch dictation when in a text field, or start and stop recording in Voice Memos.

Bluetooth keyboard users have also had access to this in the form of the command "VO with – (dash)," but braille users have not – until now. To use this function on a braille display, press "space with dots 1-5-6."

Hold It

Double-tap and hold has been a gesture since the beginning of VoiceOver's existence on iOS. A couple of versions back, Bluetooth keyboard users were able to use this function by pressing "VO shift M." This feature, among other things, allows the user to move apps around their home screen, bypass VoiceOver gestures, and delete apps. It's now an option for users of braille displays as well. Do a double-tap and hold gesture on your braille display by pressing "space with dots 5-6-7-8."

Finally, Quicknav Works as Advertised!

In iOS 8.3, Apple decided to differentiate between the Quicknav keyboard commands for various actions and the Quicknav commands for navigational purposes for textual elements like headings, form controls, etc., known as "First Letter Quicknav." To activate First Letter Quicknav, a Bluetooth keyboard user presses "VO with the letter Q." With iOS 9, you can now finally use these commands directly from your braille display. Toggle this function with "space and dots 1-2-3-4-5-7."

My Conclusions

Just as in previous iOS releases, whether you should upgrade or not depends on whether (a) the bugs present in the new release will impact you on a greater level than you can tolerate, and (b) you feel the new features are worth your time. To check out a list of bugs related to VoiceOver and Braille, you can visit the AppleVis website.

Overall, I'd say that iOS 9's first release is much more stable with fewer issues than what we have seen in earlier major releases. Apple earlier this year claimed that this version of the operating system would focus primarily on polishing up what is already there. This goal seems to have been achieved, as there are far fewer bugs in 9 than what were found in iOS 8. To download the update, go to Settings > General > Software Update, and follow the prompts. Alternatively, you can update your device through iTunes.

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What's New in iOS 9 Accessibility for Blind 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.

According to 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 Apple's new iOS 9 release, with an emphasis on accessibility features for users who are blind and 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 9 Release

It's September, which means that my annual reminder that I'm growing older (i.e., my birthday) has arrived. It also means that Apple is doing their annual "coming out with more new stuff," or in my case, birthday presents. The good news is that if you have been running iOS 8, your device is going to be able to run 9. As a general rule, 9 seems to run about as well as 8 has on other devices, so if you find that the features are worth an upgrade, go for it.

As in past years, there are many mainstream enhancements to iOS 9. Some examples include a new news app, a more advanced Notes app, a new low power mode, and many enhancements to iPad multitasking. This review, however, will focus on the changes related to the accessibility features for users who are blind or deaf-blind.

Without a doubt, there will be other features not documented here that people will discover as they get their hands on the new iOS. While I've been running the betas since June, I am certain I will learn even more things about it as the masses get their opportunity to play with it. Please note that this review is not intended as a comprehensive guide to iOS; rather, it is designed to document the changes in iOS 9.

Astute readers have probably noticed that I did not include low vision in the title of this review. This is not due to an error; rather, it is due to the fact that I did not receive what I felt was sufficient feedback from low vision users to comment on the changes related to low vision. To date, comments from the low vision community indicate that very little has changed, other than the new keyboard enhancement found under Settings > General > Accessibility > Interaction.

Some Mainstream Stuff

Search for It

One of my complaints about the Settings application is that it is very complex. For example, if I want to change a setting in braille that is not included in its set of commands, I previously had to navigate to Settings > General > Accessibility > VoiceOver > Braille. It was not even possible to ask Siri to open the settings for braille.

With iOS 9, once you go in to the Settings application, the first thing you are presented with is an optional search box. If you navigate past this option, you'll still find many of the settings you know and love the same way as before, but the search function can make some tasks much faster to carry out. Unfortunately, I still cannot go directly to braille settings; instead, I can type VoiceOver into the search box and get that option to come up. This is also good for people who cannot speak clearly who want a faster way to access certain settings that are hidden deep within this screen.

Hey Siri, Are You Understanding Me?

New in iOS 9 is the ability to have Siri better recognize when you say "Hey Siri" when this feature is enabled. When you first turn this feature on, you will be prompted to do a short set of voice exercises. In addition, thanks to new dedicated components inside the latest iPhone models, you can now have "Hey Siri" enabled even when you're not connected to AC power with the iPhone 6S and 6S Plus. I'm not sure if this function is to train Siri to recognize anyone saying the phrase, or if it's supposed to help it recognize just your voice, but time will tell.

What Are all of These Keyboard Commands on the iPad?

On the iPad, you can get a list of keyboard shortcuts while in an app, if the developer has put these together. You can launch "keyboard hints" by pressing and holding the command key for a few seconds. I tried this in the Mail and Notes apps and learned that VoiceOver will read only the function the keyboard command carries out, but not the actual keyboard command.

Also, not all commands are listed with VoiceOver. For example, in the Mail app, just like on the Mac, "command R" will reply to a message if you have an email open, "command shift D" will send your message, etc. While these keyboard commands also work on the iPod and iPhone, pressing and holding the command key offers no such keyboard hints.

Apple Maps Gets Public Transit Support

While it's only available in select cities at the time of release, you can now use the Maps app to plan routes using public transit. If you want step-by-step instructions as you go, this does have its limitations. When I used this to plan a route from Long Island to the Google Building in Manhattan, for example, the route planning worked well. However, as any New Yorker can tell you, getting cell service in the subway system is very challenging. So while it's helpful in terms of getting train information, it's not always useful. If you want directions to be updated as you travel, it's not possible without cell service.

VoiceOver Enhancements

Is that Siri or VoiceOver?

With iOS 9, all users of iDevices now have additional VoiceOver Voices in the form of the Siri speech synthesizers. This means, for example, two new American Voices, two new British Voices, two new Australian Voices, etc. Even better is the news that the Siri Voices will work on older devices, such as the iPhone 4S, iPod 5, and all devices that can run iOS 9 that have been released that do not have a 64-bit processor.

To check out these new voices, go to Settings > General > Accessibility > VoiceOver > Speech, or type VoiceOver in the new handy search box and it should take you past most of those menu options. Once you find the Speech button and activate it, you will now see the default language option, followed by rotor languages.

If you only wish to have one voice on board and available quickly, you only need to set up the default option. You will see a list of available speech synthesizers for your chosen language; double-tapping the option you want will switch to that choice, and if necessary, will download to your device. You will need to be connected to WiFi to download the new synthesizer.

It's also worth noting that each synthesizer has a "default" and "enhanced" option. The default option allows you to run the synthesizer as it is currently installed. The quality is lower, but it also consumes much less disk space and system resources. Double-tapping the option you want will activate it and will begin downloading the chosen selection if you are connected to WiFi.

If you want to add more speech synthesizers, you will need to flick past the option for the default speech setting and find the "add rotor languages" button. Just like with iOS 8, you will need to find and double-tap the language you wish to add to your rotor. Once you have done this, you will see other options such as "enhanced" versions of the default voice and Siri Voices.

Note that you can only use one variant for each language, other than the language you have set as your default as described above. So, for example, if you wish to have the Siri Mail Voice and the traditional Samantha Voice available on the fly, you can still do that by setting Alex as your default, adding the U.S. English voice to your languages rotor, and choosing U.S. English.

Changes in Accessibility

New Ways of Interacting

The Accessibility menu under Settings has again been reorganized with a new heading called Interaction. In addition to housing the Assistive Touch and Switch Control functions, this heading has a few new options. One of these new feature sets is called Touch Accommodations, which allows the user to adjust the sensitivity of the touch screen and limit input from unintended screen taps. The purpose of these settings is to assist the user with motor challenges who may have difficulty touching the screen. While I'm not familiar with each of these settings in great detail, here is a brief explanation of each setting:

  • Hold Duration: Allows the user to define a set amount of time to hold a screen touch before the touch is registered, which can help prevent unintended screen taps. iOS then recognizes the touch as a single gesture, instead of as multiple actions.
  • Ignore Repeat: Allows the user to set the amount of time during which a series of touches will be interpreted as one gesture. Multiple touches within the specified time duration are then treated as a single touch.
  • Tap Assistance: Allows the user to configure which kind of touch should be interpreted as a tap. It's quite flexible, as you can set it to use the Initial Touch Location on the screen or the Final Touch Location before raising your finger.

Keyboard Enhancements

Still under the Touch Accommodations heading, iOS 9 sports a few new options to help the keyboard function better for users with certain disabilities. Under the software keyboard setting, you will find the ability to show or not show lower-case keys. This setting will allow you to show lower-case letters in upper case, which may help some users with low vision to better see the on-screen keyboard.

With hardware keyboards (those connected via Bluetooth), iOS 9 has the following new assistive features:

  • Key Repeat: When turned off, allows keys to be held down without registering multiple presses of the same key.
  • Sticky Keys: Allows you to set certain keyboard combinations which will register without having to hold down multiple keys. Once enabled, Sticky Keys can be toggled by pressing the shift key five times, just like on Windows. You can also configure whether a sound is played when modifiers are set, which can be turned on or off as needed.
  • Slow Keys: Allows you to adjust how long you need to press and hold a key before iOS registers it as pressed.

Shake It Off!

The Touch Accommodations heading also contains a feature that can now be turned off. Some people love the Shake to Undo function which, when typing, allows you to shake the phone to undo the last action. However, not everyone is in love with it for various reasons. I do not enjoy Shake to Undo because if I'm in a moving vehicle that is on a bumpy road, for example, this feature may accidentally activate. In iOS 9, however, it's now possible to disable this function.

This Is Giving Me a Bad Vibe, Stop It!

I think the Disable All System Vibrations feature should have much more exposure than it does buried in the Accessibility menu, as it can potentially benefit everyone – not just users with disabilities.

For example, sometimes an individual may want to watch the time on their phone during a meeting while also demonstrating to the people in the room that they are paying attention to the meeting. To do this, the person may put their phone on the table. However, unless the phone is set to Do Not Disturb, the vibrations will still go off, even when the phone is muted. Now, you can choose to disable all system vibrations and still get notifications visually without any movement or noise from the phone.

What's New in iOS 9, Part 2

In Part 2 of his review, Scott discusses more iOS 9 accessibility changes, including new gestures, braille screen input, and braille display changes. For more information, you can contact Scott at

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