- Email: [email protected]
Assessing the iPad as a tool for low-vision rehabilitation
Assessing the iPad as a tool for low-vision rehabilitation Zale Mednick, BA, MD,* Atul Jaidka, BSc,† Robert Nesdole, M.Ed, PhD,* Mark Bona, MD, FRCSC* ABSTRACT ● Objective: It has been demonstrated consistently that patients with poor vision have a reduced quality of life and functional status and higher rates of psychologic distress. This study aims to assess whether the iPad has potential as a visual aid in patients with low vision. Design: Qualitative study with key-informant interviews. Participants: Patients who identified as having impaired vision were recruited from a low vision ophthalmology clinic. Methods: Patients participated in a 4-session iPad training course. The goal of the course was to teach patients with low vision how to operate an iPad, with a particular emphasis on how to optimize iPad settings and accessibility features in response to some of the challenges faced by patients with low vision. Three interviews were conducted with each participant: before the course, immediately after the course, and 3 months after the course. The purpose of the interviews was to gain an understanding of their experience with low vision and to assess if and how the iPad had influenced this experience. A grounded theory qualitative approach was used for analysis. Results: Six patients took part in the study and were divided into 2 separate courses to minimize course size. Participants had favorable views regarding the course. Five of the 6 participants were using the iPad on a daily basis 3 months after the course. Thematic analysis revealed that use of the iPad led to both a heightened sense of independence and improved social connectivity. It is theorized that use of the iPad as a low-vision aid may enhance a patient’s sense of self-worth. Conclusions: With proper training, the iPad has the potential to be a valuable tool for low-vision patients. Its features help patients to gain independence and to stay connected within their social circles. Further research with a larger patient population and quantifiable endpoints should focus on these themes.
The burden of low vision is significant for many patients who have eye disease. Vision loss due to age-related macular degeneration adversely affects reading, emotional health, mobility, participation in activities of interest, and general quality of life.1,2 Patients with low vision have been shown to have poorer functional status relating to activities of daily living (ADLs) and instrumental ADLs (IADLs).3 Significant emotional and psychologic burdens also plague patients with visual impairment.3,4 Common tools used by low-vision patients include optical devices such as spectacles, magnifiers, and telescopes, as well as digital magnifiers, which include closedcircuit televisions and more portable digital magnifiers. A variety of heterogeneous multidisciplinary low-vision rehabilitation programs3 also have been documented previously. Currently available visual rehabilitation services aim to use a multidisciplinary approach comprising a combination of optical and digital aids, orientation and mobility training, as well as a variety of strategies used by low-vision therapists, occupational therapists, social workers, optometrists, and ophthalmologists,3 among others. Unfortunately, many of the current low-vision aids are expensive and often stigmatize the patient. Patients with low vision typically are older, have limited disposable income, and find it challenging to justify the expense of an
assistive device despite its purported benefit. Studies also suggest that low-vision patients have fears of having a stereotype applied to them; assistive devices encourage this fear because they are a symbolic of vision loss.5 Furthermore, the efficacy of current training programs for lowvision patients has not been demonstrated consistently across all domains.3 The systematic review by Binns et al3 concluded that current visual rehabilitation efforts improve patients’ visual function and ability to perform ADLs. In the domains of general quality of life, psychologic health, and emotional well-being, however, there is a paucity of evidence to support any true benefit of these programs. Studies have been unable to demonstrate a true effect on “generic health related quality-of-life.”3 Electronic tablets, such as the iPad, may have widespreading potential for the low-vision community. With a better understanding of how to optimize the iPad’s (Apple Inc.) settings and how to use certain applications (apps), the iPad may represent a novel way to improve patients’ quality of life. What makes the iPad so unique is its accessibility and commonplace use in society. In contrast to many other aids, the iPad has the potential to make the low-vision patient feel more included in mainstream society, as opposed to making them feel further excluded from mainstream culture when forced to use technologies
& 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2016.05.015 ISSN 0008-4182/16 CAN J OPHTHALMOL — VOL. ], NO. ], ] 2016
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iPad use in Low Vision Rehabilitation—Mednick et al. Table 1—Descriptions of Various iPad Functions Particularly Beneficial to Patients with Low Vision iPad Function Pinch zoom 3-Finger zoom 4-Finger application switcher 5-Finger close Spotlight search Speak selection Speak auto-text VoiceOver Siri
Description of Its Capability By placing 2 fingers on the screen and spreading them together or apart, the screen is zoomed in or out. Double tap 3 fingers to zoom; drag 3 fingers to move around the screen; double-tap 3 fingers, and drag to change zoom. Using 4 fingers in the middle of the screen, pushing up will take you to the “app switcher” where you can close apps or quickly switch to the one you want. By taking 5 fingers in the middle of the screen you can “close” an application and return to the home screen. Swipe 1 finger down the iPad screen to bring up a search screen. Allows you to highlight text and have it read to you across all websites and apps that support the function. Allows the device to speak auto correction suggestions and auto capitalizations. An in-depth screen reader primarily for users who are blind. VoiceOver changes all of the typical gestures of the device to require more input to ensure correct selections. Allows you to make verbal commands so the iPad performs desired functions. Using this button also allows for dictation instead of typing.
that are nonubiquitous and identify them to the public as blind. Moreover, the iPad has the added benefits functionality: it can be used for a variety of tasks, as well as being able to adapt over time in response to a patient’s progressive vision loss. The purpose of this pilot study is to assess the effects of an iPad teaching module on patients with low vision. Specifically, we would like to determine whether appropriate iPad training is able to have a positive impact on the quality of life of patients with low vision, and if so, in what ways.
METHODS Study Design
This pilot project is a qualitative study with keyinformant interviews. Patients participated in a 4-part iPad training course during a 2- or 4-week period. The study investigators conducted 3 interviews with each participant: before the course, immediately after the course, and 3 months after the course. The course was run twice during the study period.
Participant Recruitment
Participants were recruited on a rolling basis from the pool of patients who attended the low-vision clinic at Hotel Dieu Hospital (Queen’s University, Kingston, Canada). Eligible patients were approached regarding potential inclusion in the study, either via telephone or in-person during a clinic visit. Inclusion criteria were open to any patient with a visual acuity r6/15 and who thought that the course could benefit their functional ability. For the first of the 2 courses, it was required that patients have access to an iPad. For the second run of the course, the hospital’s Department of Ophthalmology partially funded iPads for patients who did not yet have one. Patients were excluded from the study if cognition was decreased to the point that they need a power of attorney to consent in study participation, or if visual function was expected to have a rapid decline during the study period.
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iPad Training Course
The iPad training course was divided into 4 sessions. The same instructor led all sessions, and medical students and occupational therapy students were present for the sessions to provide additional one-on-one support for the participants. The course designer and instructor was a special education teacher with extensive experience in lowvision training, having served as the special education coordinator of blind and low-vision services for a regional school board. Furthermore, the iPad course was supervised by an ophthalmologist specializing in low vision, who had assessed each of the patients in clinic prior to study enrollment. The iPad training modules had a structured curriculum with each subsequent lesson building on the previous lesson’s concepts. Early sessions focused on optimizing iPad tools thought to be particularly helpful for low-vision patients. A variety of Gestures and Zoom functions were reviewed, in addition to Speak Functions, such as Speak Selection, Speak Auto-Text, and VoiceOver (Table 1). Participants were shown how to alter contrast settings, text sizes and fonts, and colour schemas, to customize their screens for optimal vision. Latter sessions centred on ways to use the iPad to communicate with others, a recurrent theme that presented during the course of patients’ low-vision assessments. Different facets of iMessage were taught, including the ability to use zoom functions to read incoming messages and to utilize voice commands to dictate messages. FaceTime was introduced as another vehicle to enhance communication. Participants were shown how to use the Alarm and Timer functions and were taught how to navigate some of the intrinsic iPad apps such as checking the weather. In the final session, participants were instructed to use the iPad to access information, such as a newspaper or a traffic report. Several apps specific to low vision also were introduced to the participants. Patients were given homework assignments in addition to the classroom modules to help reinforce concepts and improved proficiency. For example, patients were asked to connect with each other via iMessage. This activity encouraged them to practice inputting contact information, accessing contacts, and communicating through
iPad use in Low Vision Rehabilitation—Mednick et al. Table 2—Baseline Demographic Characteristics of Patients Included in the iPad Training Courses
Diagnosis Age (y) Sex VA in best seeing eye
Patient A
Patient B
Patient C
Patient D
Patient E
Patient F
Pituitary adenoma 31 Female 20/60
RP 50 Female 20/1394
AMD 83 Female 20/50
MS 29 Male 20/400
Ischemic optic neuropathy 66 Male 20/60
MS 50 Female 20/50
AMD, age-related macular degeneration; MS, multiple sclerosis; RP, retinitis pigmentosa; VA, visual acuity
iMessage while using hand gestures, VoiceOver, and other accessibility features. A comprehensive iBook was provided to participants as part of the course. This manual included text, pictures, and videos that walked through the steps of the accessibility features that had been taught in the course. The intent was that this iBook could be a supplement for patients to help review the material covered during class time. Participant Interviews
One-on-one key-informant interviews were performed to understand better the functional, psychologic, and emotional experience of a patient with low vision, and how the iPad course influenced this experience. During some interviews, a family member was present. The interviews were termed “semi-structured.” Although there were preset questions, flexibility was imparted to the interviewer to deviate from the script as necessary to ask appropriate follow-up questions and to take cues from the participant. The interview questions are outlined in Appendix 1. Interview questions were formulated to capture best the experience of patients who have low vision. The first interview focused on patients’ ADLs, sense of independence, and quality of life, including social and psychologic well-being. The Low Vision Quality-of-Life Questionnaire,6 The Impact of Vision Impairment Profile,7 and the National Eye Institute Visual Functioning Questionnaire258 were used to help frame the interview questions to address prominent themes in low-vision research. The second and third interviews were specific to the iPad and the nature of the course itself. Questions prompted participants to explore if and how the iPad had influenced their functional ability. Data Analysis
A grounded theory qualitative approach was used to analyze the interviews. The interviews were all audiorecorded and transcribed into text. The transcripts were reviewed 3 times by the lead investigator. Coding was used, with subsequent categorization and thematic generation.
RESULTS Six patients in total participated in the course, 3 each time the course was run. The first course was run during a
4-week period, while the second course was run for 2 weeks. Fifty-four consecutive patients from the lowvision clinic were approached regarding participation in the study. Our response rate was 11% (6/54). Reasons cited by patients who decided not to participate included lack of available transportation to the hospital, unavailability during the proposed course dates, a level of satisfaction with the low-vision aids they were currently using, a discomfort with technology, financial limitations, and a general lack of interest. The 6 patients had variable degrees of visual limitation and diverse causes of their low vision (Table 2). Visual acuity in the better-seeing eye ranged from 20/50 to 20/ 1394. Ocular diagnoses included retinitis pigmentosa, agerelated macular degeneration, pituitary adenoma, optic neuropathy secondary to multiple sclerosis, and nonarteritic ischemic optic neuropathy. Thematic Analysis
Coding and categorisation of the interview transcripts revealed 2 main themes: independence and social connectivity. From these themes, the theory was generated that in low-vision patients, use of the iPad may help to elevate a patient’s sense of self-worth. Independence
Participants identified a wide range of functions and activities that were hindered due to low vision. Some activities became impossible due to their vision, while others were still feasible but required much more time and effort to complete. For those who were still in the workforce when their vision deteriorated, their occupational roles were either reduced in nature, or they were not able to continue working at all. IADLs such as shopping, reading, paying bills, playing games, and partaking in sports and other social activities all became more difficult, if possible at all. For one patient, even getting dressed in the morning was a challenge, as she could not see well enough to match her clothes. Codes relating to food were prominent in the interview transcripts. Patients experienced difficulty grocery shopping because they were unable to read fine print labels and expiry dates. Cooking and baking became cumbersome, as
How has low vision affected patient independence?
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iPad use in Low Vision Rehabilitation—Mednick et al.
Fig. 1 — A snapshot of the coding used to generate themes from the participant interviews. This particular block of coding illustrates how terms related to food and the outdoors represented an underlying issue of loss of independence.
it was hard to access and read recipes, as well as to distinguish between spices and other ingredients in the kitchen. Eating at restaurants was a challenge; one participant explained that reading the menu was too frustrating, and instead of trying to browse the menu for something she really wanted to eat, she would just order something she knew had a high likelihood of being on the menu. A snapshot of the coding framework used to identify themes from the interviews is featured in Figure 1, which specifically highlights coding related to food and outdoor activities. Similar coding was done for all facets of the interviews to generate thematic and theoretic concepts. The participants’ difficulty and inability to complete all of the above tasks unanimously led to a feeling of constant reliance on others. The loss of their driving abilities particularly was difficult for patients and was cited as a major reason for their dependence on family and friends. Such dependence led to frustration, embarrassment, and the feeling of being a burden on others. A participant who had optic neuropathy bluntly expressed, “My independence is gone,” elaborating that “I’d like to be able to do more, but I can’t. I put a burden on other people and I don’t like that. I have to rely on other people. I was independent and people relied on me before.” How has the iPad contributed to increased independence?
Immediately after and then 3 months after the course, 5 of the 6 participants used the iPad on a daily basis. The iPad’s zoom functions allowed patients to read labels easily when shopping and cooking and to do their own online banking. By using the VoiceOver and Speak Selection, patients were able to have information read to them, instead of actually having to focus on reading everything themselves. Siri was relied heavily on by some patients
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because it obviated the need to type; a patient could simply ask Siri to look something up with a verbal command, making it very easy to navigate the Internet and the iPad itself to access information, be it a recipe or an article. The patient with optic neuropathy who described a lack of independence said that after the course, although he still relied on his wife for certain things, the iPad was “starting to increase my percentage of doing things,” citing an example of how he was able to take family pictures with his iPad during the holidays. A woman with retinitis pigmentosa explained, “I can message somebody and get a quick reply from them. It’s given me freedom from being so dependent on people.” The patient who had anxiety at restaurants felt significant relief with the iPad, explaining “Because I can read the menu now, I wouldn’t just be ordering a cheeseburger or a club house and fries because every menu has it.”
Social Connectivity
The theme of social isolation was both explicitly and implicitly evident in the interviews. Patients who had to give up their jobs missed the collegial atmosphere of the workplace. Socially, participants partook in fewer activities with friends and family, partly because they did not want to be an inconvenience and burden, and also because their vision limited the extent to which they could actually take part in the activities. For example, one patient could no longer join poker nights due to difficulty seeing the cards, while another patient stopped watching sports with friends because he could not see the hockey puck on the TV screen and thus could not join in commentary about the
How has low vision affected social connectivity?
iPad use in Low Vision Rehabilitation—Mednick et al. game. Entertaining guests also was a logistical challenge, further limiting social interaction. Several patients spoke about facial recognition, commenting that they could no longer see faces clearly, including those of their grandchildren. The patient with retinitis pigmentosa expressed that “the most frustrating thing for me is not being able to read or see someone smile or see the reaction on their face.” This speaks to an even deeper-rooted social isolation; even when spending time with people, establishing a meaningful connection can become more difficult if vision is impaired. How has the iPad contributed to improved social connectivity?
iMessage and FaceTime were 2 of the most popular-used features cited by the participants. It allowed for easier and more frequent interaction with friends and family. The combined use of Siri enabled iMessages to be sent easily without having to physically type. Patients felt more connected to their loved ones and were able to expand their social circles to people with whom they had lost touch. In the first interview after the course, one patient explained “Now I FaceTime my grandchildren. FaceTime —it’s like they are next door; it’s wonderful.” Three months later, when asked if the patient’s quality of life had improved since the course, the same patient said the following: “Definitely, especially the FaceTime, the texting. I would never be able to text my kids. How I do it, I use the text when I think somebody is sleeping or busy and find out if they are busy or free. The nice thing about texting is that you’re not sort of imposing.” This is in stark contrast to a comment from the patient’s first interview, in which he stated “I put a burden on other people, and I don’t like that.” Another patient similarly described the merits of text messaging, explaining that texting is an easy way to keep in touch and “keeps me connected. I don’t feel alone.” Siri, VoiceOver, and general accessibility features made it easier for patients to navigate the Internet. Being more connected to the news and social media increased their sense of connectivity to the world at large. A patient with optic neuritis secondary to multiple sclerosis explained in her first interview that she “feels as though she misses a lot by not reading.” After the course, this same woman said that she was able to read books again and explained that she was better equipped to navigate websites by using the various zoom functions. Self-Worth
The overarching idea of self-worth ties together the themes of independence and social connectivity that were derived from interviews. We theorize that use of the iPad, with appropriate training, may help to increase confidence and sense of purpose in patients with low vision. This theory was both inferred by thematic analysis and
explicitly expressed by several participants. Apart from being able to accomplish more tasks independently and staying better connected, participants described a great sense of pride in being able to operate the iPad. Participants felt motivated to challenge themselves and try new things after experiencing the breadth of opportunities that the iPad could make possible. Regarding the iPad, one participant explained, “If I can do that, I just need to figure out how I can do this.” Several participants developed a greater sense of purpose in life and a feeling of pride that they could now contribute to society by transferring their skills to others. The patient with multiple sclerosis explained that she “feels more useful because she can help other people.” In her 3-month interview, she described having “more confidence in myself.” She referred to the iPad as her “second left hand; it’s always with me.” The woman with retinitis pigmentosa said, “I feel a lot better about myself. It’s an eye opener for me. I feel like a new person in a way.” Patients thought that with the iPad, their visual difficulties no longer defined them to the same extent. Because the iPad is so commonplace and not a specific low-vision device, they could be using their iPad for a visual-related task without anybody knowing that they were actually visually impaired. A young male participant with multiple sclerosis explained that he is no longer so stressed at needing to have his magnifier at all times, because the iPad takes its place and does so much more.
Reflections on the Course
Overall, participants were very satisfied with the 4 sessions, and at the 3-month follow-up point, all but 1 of the patients felt quite comfortable using the iPad. Most patients commented that learning to use the iPad had a significant effect on their lives. The patient with a pituitary adenoma had the most difficult time incorporating the iPad into her life; comorbidities including a lack of manual dexterity and restricted verbal communication limited her ability to access the various features on the device. Participants enjoyed the small group size, the accompanying iBook, and having medical students and occupational therapy students provide one-on-one assistance while the lead instructor was running the sessions. Most participants thought the course was not long enough, however, and would have preferred more sessions to practice and implement the concepts that were being taught. Patients also advocated increase homogeneity of group members, in terms of baseline vision and prior knowledge of the iPad. Particularly, patients with much poorer vision benefited more from VoiceOver/Vision Substitution training, while patients with better vision preferred to spend more time learning about other iPad features.
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iPad use in Low Vision Rehabilitation—Mednick et al. DISCUSSION Although current low-vision aids provide benefits to patients in several domains, it is unclear whether such aids actually enhance patients’ overall quality of life.3 Furthermore, devices may be expensive, lack portability, and typically are not ubiquitous. As patients identified during their interviews, many of the low-vision aids that they had been using prior to the course made them stand out as being visually impaired, further allowing their blindness to define them in public settings. Several studies have shown that the iPad is a useful reading aid for patients with poor vision, in regards to reading speed and the quality of the text appearance.9,10 Another study has validated the use of an iPad reading chart as a means of testing contrast sensitivity.11 Reading speed, reading accuracy, and contrast sensitivity, however, are narrow ways of characterizing the potential impact of the iPad as an assistive device on patients with low vision. The results of this study provide optimism that the iPad may have even wider-spreading potential in the low-vision community. Patients of a variety of ages, sexes, and visual function found benefit from the program. Participant interviews globally suggested that patients experienced gains in multiple domains by using the iPad, ranging from increased independent functioning to improved emotional well-being. Although Apple itself offers one-on-one iPad training to patients with low vision, our framework is unique in that the course is run by an ophthalmologist and a low-vision technology specialist. More importantly, significant benefit was derived from the fact that low-vision patients congregated to form a shared experience of learning this technology. As one participant described, “I enjoyed going there and meeting everyone. It’s a morale booster.” A limitation of this study was its low sample size and lack of quantifiable endpoints. However, this study was designed intentionally as qualitative in nature to gain a more thorough understanding of the low-vision experience and how the iPad might influence this. Our interviews afforded a greater opportunity to delve into themes of low vision and the iPad, which may have been missed by simply administering a generic low-vision questionnaire. The benefits of qualitative research in the field of ophthalmology have been outlined by Murthy and Gupta.12 A qualitative study allows for a more comprehensive understanding of each individual’s experience. Based on our keyinformant interviews, we have established thematic concepts that would be helpful in creating a larger study with quantifiable endpoints to validate the iPad as an effective visual rehabilitation tool. The authors do not purport that this study serves as sufficient validation of the iPad as a tool for low vision rehabilitation. Rather, the encouraging results of this study serve as a basis for which the iPad should be explored further in this group of patients, in studies with larger sample sizes and quantifiable measures. Further studies
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also should seek to assess the varying impact of iPad training on patients with different degrees of low vision. The present study’s participants were made up of patients whose best-corrected visual acuity ranged from 20/50 to 20/3094. Although it is promising that the full range of patients found benefit from the program, a larger study would be better equipped to stratify further the effects of iPad training in different patient groups. The way patients were recruited into the study allowed for an inherent selection bias. Specifically, motivated patients with strong social supports, financial means, and transportation access were more likely to sign up for the course. However, a prevailing theme in low-vision rehabilitation is that its success is predicated by a patient’s motivation. Whether it relates to an iPad or a simple magnifier, the patient must be determined and surrounded by a supportive social network if low-vision rehabilitation is to be successful. In this respect, the selection bias reflects the nature of rehabilitative medicine and works to our advantage; the pilot project was administered on patients with the greatest potential for success. Feedback from the participants should be incorporated into future versions of such a course. Similar courses should entail small class sizes and ensure that support staff is present to provide one-on-one assistance in addition to a lead instructor. As much as it allows, course participants should be as homogenous a group as possible, in terms of baseline vision and prior iPad knowledge. The number of sessions should be increased, with designated time for practice and review of previously taught concepts. Overall, this study provides encouraging qualitative data supporting the iPad as a potential low-vision aid. Many participants emphatically endorsed the iPad and the training course as a way to enhance communication and independence. The iPad’s accessibility, magnification functions, and wide array of apps provide a host of unique features that helped patients optimize their daily functioning. In many cases, patients explicitly commented that their quality of life had improved since using the iPad and that their self-esteem was heightened. Based on this pilot project, future studies certainly would be appropriate in further validating the iPad as a low vision aid.
APPENDIX Supplementary material
Supplementary data are available in the online version of this article at http://dx.doi.org/10.1016/j.jcjo.2016.05.015 REFERENCES 1. Hassell JB, Lamoureux EL, Keeffee JE. Impact of age related macular degeneration on quality of life. Br J Ophthalmol. 2006;90:593-6. 2. Brown MM, Brown GC, Sharma S, et al. The burden of age-related macular degeneration: a value-based analysis. Curr Opin Ophthalmol. 2006;17:257-66.
iPad use in Low Vision Rehabilitation—Mednick et al. 3. Binns AM, Bunce C, Dickinson C, et al. How effective is low vision service provision? A systematic review survey of ophthalmology. Surv Ophthalmol. 2012;57:34-65. 4. Burggraaff MC, van Nispen RMA, Knol DL, Ringens PJ, van Rens GHMB. Randomized controlled trial on the effects of CCTV training on quality of life, depression, and adaptation to vision loss. Ophthalmol Vis Sci. 2012;53:3645-52. 5. Southall K, Wittich W. Barriers to low vision rehabilitation: a qualitative approach. Journal of Visual Impairment & Blindness. 2012;106:261-74. 6. Wolffsohn JS, Cochrane AL. Design of the low vision quality-of-life questionnaire (LVQOL) and measuring the outcome of low-vision rehabilitation. Am J Ophthalmol. 2000;130:793-802. 7. Hassell JB, Weih LM, Keeffe JE. A measure of handicap for low vision rehabilitation: the impact of vision impairment profile. Clinical and Experimental Ophthalmology. 2000;28:156-61. 8. Mangione CM, Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD. Development of the 25-item National Eye Institute Visual Function Questionnaire. Arch Ophthalmol. 2001;119(7):1050-8. 9. Walker R. An iPad app as a low-vision aid for people with macular disease. Br J Ophthalmol. 2013;97:110-2. 10. Gill K, Mao A, Powell AM, Sheidow T. Digital reader vs print media: the role of digital technology in reading accuracy in age-related macular degeneration. Eye. 2013;27:639-43.
11. Kollbaum PS, Jansen ME, Kollbaum EJ, Bullimore MA. Validation of an iPad test of letter contrast sensitivity. Optom Vis Sci. 2014;91: 291-6. 12. Murthy GV, Gupta SK. Qualitative research in ophthalmic sciences. Indian Journal of Ophthalmology. 1999;47:257-64.
Footnotes and Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article. From the *Department of Ophthalmology; †School of Medicine, Queen’s University. Originally received Apr. 27, 2016. Accepted May. 13, 2016. Correspondence to Mark Bona, MD, FRCSC, Queens University Ophthalmology Hotel Dieu Hospital, 166 Brock Street, Room 2-227A, Kingston, Ontario K7L 5G2 Canada; [email protected]
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The burden of low vision is significant for many patients who have eye disease. Vision loss due to age-related macular degeneration adversely affects reading, emotional health, mobility, participation in activities of interest, and general quality of life.1,2 Patients with low vision have been shown to have poorer functional status relating to activities of daily living (ADLs) and instrumental ADLs (IADLs).3 Significant emotional and psychologic burdens also plague patients with visual impairment.3,4 Common tools used by low-vision patients include optical devices such as spectacles, magnifiers, and telescopes, as well as digital magnifiers, which include closedcircuit televisions and more portable digital magnifiers. A variety of heterogeneous multidisciplinary low-vision rehabilitation programs3 also have been documented previously. Currently available visual rehabilitation services aim to use a multidisciplinary approach comprising a combination of optical and digital aids, orientation and mobility training, as well as a variety of strategies used by low-vision therapists, occupational therapists, social workers, optometrists, and ophthalmologists,3 among others. Unfortunately, many of the current low-vision aids are expensive and often stigmatize the patient. Patients with low vision typically are older, have limited disposable income, and find it challenging to justify the expense of an
assistive device despite its purported benefit. Studies also suggest that low-vision patients have fears of having a stereotype applied to them; assistive devices encourage this fear because they are a symbolic of vision loss.5 Furthermore, the efficacy of current training programs for lowvision patients has not been demonstrated consistently across all domains.3 The systematic review by Binns et al3 concluded that current visual rehabilitation efforts improve patients’ visual function and ability to perform ADLs. In the domains of general quality of life, psychologic health, and emotional well-being, however, there is a paucity of evidence to support any true benefit of these programs. Studies have been unable to demonstrate a true effect on “generic health related quality-of-life.”3 Electronic tablets, such as the iPad, may have widespreading potential for the low-vision community. With a better understanding of how to optimize the iPad’s (Apple Inc.) settings and how to use certain applications (apps), the iPad may represent a novel way to improve patients’ quality of life. What makes the iPad so unique is its accessibility and commonplace use in society. In contrast to many other aids, the iPad has the potential to make the low-vision patient feel more included in mainstream society, as opposed to making them feel further excluded from mainstream culture when forced to use technologies
& 2016 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2016.05.015 ISSN 0008-4182/16 CAN J OPHTHALMOL — VOL. ], NO. ], ] 2016
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iPad use in Low Vision Rehabilitation—Mednick et al. Table 1—Descriptions of Various iPad Functions Particularly Beneficial to Patients with Low Vision iPad Function Pinch zoom 3-Finger zoom 4-Finger application switcher 5-Finger close Spotlight search Speak selection Speak auto-text VoiceOver Siri
Description of Its Capability By placing 2 fingers on the screen and spreading them together or apart, the screen is zoomed in or out. Double tap 3 fingers to zoom; drag 3 fingers to move around the screen; double-tap 3 fingers, and drag to change zoom. Using 4 fingers in the middle of the screen, pushing up will take you to the “app switcher” where you can close apps or quickly switch to the one you want. By taking 5 fingers in the middle of the screen you can “close” an application and return to the home screen. Swipe 1 finger down the iPad screen to bring up a search screen. Allows you to highlight text and have it read to you across all websites and apps that support the function. Allows the device to speak auto correction suggestions and auto capitalizations. An in-depth screen reader primarily for users who are blind. VoiceOver changes all of the typical gestures of the device to require more input to ensure correct selections. Allows you to make verbal commands so the iPad performs desired functions. Using this button also allows for dictation instead of typing.
that are nonubiquitous and identify them to the public as blind. Moreover, the iPad has the added benefits functionality: it can be used for a variety of tasks, as well as being able to adapt over time in response to a patient’s progressive vision loss. The purpose of this pilot study is to assess the effects of an iPad teaching module on patients with low vision. Specifically, we would like to determine whether appropriate iPad training is able to have a positive impact on the quality of life of patients with low vision, and if so, in what ways.
METHODS Study Design
This pilot project is a qualitative study with keyinformant interviews. Patients participated in a 4-part iPad training course during a 2- or 4-week period. The study investigators conducted 3 interviews with each participant: before the course, immediately after the course, and 3 months after the course. The course was run twice during the study period.
Participant Recruitment
Participants were recruited on a rolling basis from the pool of patients who attended the low-vision clinic at Hotel Dieu Hospital (Queen’s University, Kingston, Canada). Eligible patients were approached regarding potential inclusion in the study, either via telephone or in-person during a clinic visit. Inclusion criteria were open to any patient with a visual acuity r6/15 and who thought that the course could benefit their functional ability. For the first of the 2 courses, it was required that patients have access to an iPad. For the second run of the course, the hospital’s Department of Ophthalmology partially funded iPads for patients who did not yet have one. Patients were excluded from the study if cognition was decreased to the point that they need a power of attorney to consent in study participation, or if visual function was expected to have a rapid decline during the study period.
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iPad Training Course
The iPad training course was divided into 4 sessions. The same instructor led all sessions, and medical students and occupational therapy students were present for the sessions to provide additional one-on-one support for the participants. The course designer and instructor was a special education teacher with extensive experience in lowvision training, having served as the special education coordinator of blind and low-vision services for a regional school board. Furthermore, the iPad course was supervised by an ophthalmologist specializing in low vision, who had assessed each of the patients in clinic prior to study enrollment. The iPad training modules had a structured curriculum with each subsequent lesson building on the previous lesson’s concepts. Early sessions focused on optimizing iPad tools thought to be particularly helpful for low-vision patients. A variety of Gestures and Zoom functions were reviewed, in addition to Speak Functions, such as Speak Selection, Speak Auto-Text, and VoiceOver (Table 1). Participants were shown how to alter contrast settings, text sizes and fonts, and colour schemas, to customize their screens for optimal vision. Latter sessions centred on ways to use the iPad to communicate with others, a recurrent theme that presented during the course of patients’ low-vision assessments. Different facets of iMessage were taught, including the ability to use zoom functions to read incoming messages and to utilize voice commands to dictate messages. FaceTime was introduced as another vehicle to enhance communication. Participants were shown how to use the Alarm and Timer functions and were taught how to navigate some of the intrinsic iPad apps such as checking the weather. In the final session, participants were instructed to use the iPad to access information, such as a newspaper or a traffic report. Several apps specific to low vision also were introduced to the participants. Patients were given homework assignments in addition to the classroom modules to help reinforce concepts and improved proficiency. For example, patients were asked to connect with each other via iMessage. This activity encouraged them to practice inputting contact information, accessing contacts, and communicating through
iPad use in Low Vision Rehabilitation—Mednick et al. Table 2—Baseline Demographic Characteristics of Patients Included in the iPad Training Courses
Diagnosis Age (y) Sex VA in best seeing eye
Patient A
Patient B
Patient C
Patient D
Patient E
Patient F
Pituitary adenoma 31 Female 20/60
RP 50 Female 20/1394
AMD 83 Female 20/50
MS 29 Male 20/400
Ischemic optic neuropathy 66 Male 20/60
MS 50 Female 20/50
AMD, age-related macular degeneration; MS, multiple sclerosis; RP, retinitis pigmentosa; VA, visual acuity
iMessage while using hand gestures, VoiceOver, and other accessibility features. A comprehensive iBook was provided to participants as part of the course. This manual included text, pictures, and videos that walked through the steps of the accessibility features that had been taught in the course. The intent was that this iBook could be a supplement for patients to help review the material covered during class time. Participant Interviews
One-on-one key-informant interviews were performed to understand better the functional, psychologic, and emotional experience of a patient with low vision, and how the iPad course influenced this experience. During some interviews, a family member was present. The interviews were termed “semi-structured.” Although there were preset questions, flexibility was imparted to the interviewer to deviate from the script as necessary to ask appropriate follow-up questions and to take cues from the participant. The interview questions are outlined in Appendix 1. Interview questions were formulated to capture best the experience of patients who have low vision. The first interview focused on patients’ ADLs, sense of independence, and quality of life, including social and psychologic well-being. The Low Vision Quality-of-Life Questionnaire,6 The Impact of Vision Impairment Profile,7 and the National Eye Institute Visual Functioning Questionnaire258 were used to help frame the interview questions to address prominent themes in low-vision research. The second and third interviews were specific to the iPad and the nature of the course itself. Questions prompted participants to explore if and how the iPad had influenced their functional ability. Data Analysis
A grounded theory qualitative approach was used to analyze the interviews. The interviews were all audiorecorded and transcribed into text. The transcripts were reviewed 3 times by the lead investigator. Coding was used, with subsequent categorization and thematic generation.
RESULTS Six patients in total participated in the course, 3 each time the course was run. The first course was run during a
4-week period, while the second course was run for 2 weeks. Fifty-four consecutive patients from the lowvision clinic were approached regarding participation in the study. Our response rate was 11% (6/54). Reasons cited by patients who decided not to participate included lack of available transportation to the hospital, unavailability during the proposed course dates, a level of satisfaction with the low-vision aids they were currently using, a discomfort with technology, financial limitations, and a general lack of interest. The 6 patients had variable degrees of visual limitation and diverse causes of their low vision (Table 2). Visual acuity in the better-seeing eye ranged from 20/50 to 20/ 1394. Ocular diagnoses included retinitis pigmentosa, agerelated macular degeneration, pituitary adenoma, optic neuropathy secondary to multiple sclerosis, and nonarteritic ischemic optic neuropathy. Thematic Analysis
Coding and categorisation of the interview transcripts revealed 2 main themes: independence and social connectivity. From these themes, the theory was generated that in low-vision patients, use of the iPad may help to elevate a patient’s sense of self-worth. Independence
Participants identified a wide range of functions and activities that were hindered due to low vision. Some activities became impossible due to their vision, while others were still feasible but required much more time and effort to complete. For those who were still in the workforce when their vision deteriorated, their occupational roles were either reduced in nature, or they were not able to continue working at all. IADLs such as shopping, reading, paying bills, playing games, and partaking in sports and other social activities all became more difficult, if possible at all. For one patient, even getting dressed in the morning was a challenge, as she could not see well enough to match her clothes. Codes relating to food were prominent in the interview transcripts. Patients experienced difficulty grocery shopping because they were unable to read fine print labels and expiry dates. Cooking and baking became cumbersome, as
How has low vision affected patient independence?
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iPad use in Low Vision Rehabilitation—Mednick et al.
Fig. 1 — A snapshot of the coding used to generate themes from the participant interviews. This particular block of coding illustrates how terms related to food and the outdoors represented an underlying issue of loss of independence.
it was hard to access and read recipes, as well as to distinguish between spices and other ingredients in the kitchen. Eating at restaurants was a challenge; one participant explained that reading the menu was too frustrating, and instead of trying to browse the menu for something she really wanted to eat, she would just order something she knew had a high likelihood of being on the menu. A snapshot of the coding framework used to identify themes from the interviews is featured in Figure 1, which specifically highlights coding related to food and outdoor activities. Similar coding was done for all facets of the interviews to generate thematic and theoretic concepts. The participants’ difficulty and inability to complete all of the above tasks unanimously led to a feeling of constant reliance on others. The loss of their driving abilities particularly was difficult for patients and was cited as a major reason for their dependence on family and friends. Such dependence led to frustration, embarrassment, and the feeling of being a burden on others. A participant who had optic neuropathy bluntly expressed, “My independence is gone,” elaborating that “I’d like to be able to do more, but I can’t. I put a burden on other people and I don’t like that. I have to rely on other people. I was independent and people relied on me before.” How has the iPad contributed to increased independence?
Immediately after and then 3 months after the course, 5 of the 6 participants used the iPad on a daily basis. The iPad’s zoom functions allowed patients to read labels easily when shopping and cooking and to do their own online banking. By using the VoiceOver and Speak Selection, patients were able to have information read to them, instead of actually having to focus on reading everything themselves. Siri was relied heavily on by some patients
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because it obviated the need to type; a patient could simply ask Siri to look something up with a verbal command, making it very easy to navigate the Internet and the iPad itself to access information, be it a recipe or an article. The patient with optic neuropathy who described a lack of independence said that after the course, although he still relied on his wife for certain things, the iPad was “starting to increase my percentage of doing things,” citing an example of how he was able to take family pictures with his iPad during the holidays. A woman with retinitis pigmentosa explained, “I can message somebody and get a quick reply from them. It’s given me freedom from being so dependent on people.” The patient who had anxiety at restaurants felt significant relief with the iPad, explaining “Because I can read the menu now, I wouldn’t just be ordering a cheeseburger or a club house and fries because every menu has it.”
Social Connectivity
The theme of social isolation was both explicitly and implicitly evident in the interviews. Patients who had to give up their jobs missed the collegial atmosphere of the workplace. Socially, participants partook in fewer activities with friends and family, partly because they did not want to be an inconvenience and burden, and also because their vision limited the extent to which they could actually take part in the activities. For example, one patient could no longer join poker nights due to difficulty seeing the cards, while another patient stopped watching sports with friends because he could not see the hockey puck on the TV screen and thus could not join in commentary about the
How has low vision affected social connectivity?
iPad use in Low Vision Rehabilitation—Mednick et al. game. Entertaining guests also was a logistical challenge, further limiting social interaction. Several patients spoke about facial recognition, commenting that they could no longer see faces clearly, including those of their grandchildren. The patient with retinitis pigmentosa expressed that “the most frustrating thing for me is not being able to read or see someone smile or see the reaction on their face.” This speaks to an even deeper-rooted social isolation; even when spending time with people, establishing a meaningful connection can become more difficult if vision is impaired. How has the iPad contributed to improved social connectivity?
iMessage and FaceTime were 2 of the most popular-used features cited by the participants. It allowed for easier and more frequent interaction with friends and family. The combined use of Siri enabled iMessages to be sent easily without having to physically type. Patients felt more connected to their loved ones and were able to expand their social circles to people with whom they had lost touch. In the first interview after the course, one patient explained “Now I FaceTime my grandchildren. FaceTime —it’s like they are next door; it’s wonderful.” Three months later, when asked if the patient’s quality of life had improved since the course, the same patient said the following: “Definitely, especially the FaceTime, the texting. I would never be able to text my kids. How I do it, I use the text when I think somebody is sleeping or busy and find out if they are busy or free. The nice thing about texting is that you’re not sort of imposing.” This is in stark contrast to a comment from the patient’s first interview, in which he stated “I put a burden on other people, and I don’t like that.” Another patient similarly described the merits of text messaging, explaining that texting is an easy way to keep in touch and “keeps me connected. I don’t feel alone.” Siri, VoiceOver, and general accessibility features made it easier for patients to navigate the Internet. Being more connected to the news and social media increased their sense of connectivity to the world at large. A patient with optic neuritis secondary to multiple sclerosis explained in her first interview that she “feels as though she misses a lot by not reading.” After the course, this same woman said that she was able to read books again and explained that she was better equipped to navigate websites by using the various zoom functions. Self-Worth
The overarching idea of self-worth ties together the themes of independence and social connectivity that were derived from interviews. We theorize that use of the iPad, with appropriate training, may help to increase confidence and sense of purpose in patients with low vision. This theory was both inferred by thematic analysis and
explicitly expressed by several participants. Apart from being able to accomplish more tasks independently and staying better connected, participants described a great sense of pride in being able to operate the iPad. Participants felt motivated to challenge themselves and try new things after experiencing the breadth of opportunities that the iPad could make possible. Regarding the iPad, one participant explained, “If I can do that, I just need to figure out how I can do this.” Several participants developed a greater sense of purpose in life and a feeling of pride that they could now contribute to society by transferring their skills to others. The patient with multiple sclerosis explained that she “feels more useful because she can help other people.” In her 3-month interview, she described having “more confidence in myself.” She referred to the iPad as her “second left hand; it’s always with me.” The woman with retinitis pigmentosa said, “I feel a lot better about myself. It’s an eye opener for me. I feel like a new person in a way.” Patients thought that with the iPad, their visual difficulties no longer defined them to the same extent. Because the iPad is so commonplace and not a specific low-vision device, they could be using their iPad for a visual-related task without anybody knowing that they were actually visually impaired. A young male participant with multiple sclerosis explained that he is no longer so stressed at needing to have his magnifier at all times, because the iPad takes its place and does so much more.
Reflections on the Course
Overall, participants were very satisfied with the 4 sessions, and at the 3-month follow-up point, all but 1 of the patients felt quite comfortable using the iPad. Most patients commented that learning to use the iPad had a significant effect on their lives. The patient with a pituitary adenoma had the most difficult time incorporating the iPad into her life; comorbidities including a lack of manual dexterity and restricted verbal communication limited her ability to access the various features on the device. Participants enjoyed the small group size, the accompanying iBook, and having medical students and occupational therapy students provide one-on-one assistance while the lead instructor was running the sessions. Most participants thought the course was not long enough, however, and would have preferred more sessions to practice and implement the concepts that were being taught. Patients also advocated increase homogeneity of group members, in terms of baseline vision and prior knowledge of the iPad. Particularly, patients with much poorer vision benefited more from VoiceOver/Vision Substitution training, while patients with better vision preferred to spend more time learning about other iPad features.
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iPad use in Low Vision Rehabilitation—Mednick et al. DISCUSSION Although current low-vision aids provide benefits to patients in several domains, it is unclear whether such aids actually enhance patients’ overall quality of life.3 Furthermore, devices may be expensive, lack portability, and typically are not ubiquitous. As patients identified during their interviews, many of the low-vision aids that they had been using prior to the course made them stand out as being visually impaired, further allowing their blindness to define them in public settings. Several studies have shown that the iPad is a useful reading aid for patients with poor vision, in regards to reading speed and the quality of the text appearance.9,10 Another study has validated the use of an iPad reading chart as a means of testing contrast sensitivity.11 Reading speed, reading accuracy, and contrast sensitivity, however, are narrow ways of characterizing the potential impact of the iPad as an assistive device on patients with low vision. The results of this study provide optimism that the iPad may have even wider-spreading potential in the low-vision community. Patients of a variety of ages, sexes, and visual function found benefit from the program. Participant interviews globally suggested that patients experienced gains in multiple domains by using the iPad, ranging from increased independent functioning to improved emotional well-being. Although Apple itself offers one-on-one iPad training to patients with low vision, our framework is unique in that the course is run by an ophthalmologist and a low-vision technology specialist. More importantly, significant benefit was derived from the fact that low-vision patients congregated to form a shared experience of learning this technology. As one participant described, “I enjoyed going there and meeting everyone. It’s a morale booster.” A limitation of this study was its low sample size and lack of quantifiable endpoints. However, this study was designed intentionally as qualitative in nature to gain a more thorough understanding of the low-vision experience and how the iPad might influence this. Our interviews afforded a greater opportunity to delve into themes of low vision and the iPad, which may have been missed by simply administering a generic low-vision questionnaire. The benefits of qualitative research in the field of ophthalmology have been outlined by Murthy and Gupta.12 A qualitative study allows for a more comprehensive understanding of each individual’s experience. Based on our keyinformant interviews, we have established thematic concepts that would be helpful in creating a larger study with quantifiable endpoints to validate the iPad as an effective visual rehabilitation tool. The authors do not purport that this study serves as sufficient validation of the iPad as a tool for low vision rehabilitation. Rather, the encouraging results of this study serve as a basis for which the iPad should be explored further in this group of patients, in studies with larger sample sizes and quantifiable measures. Further studies
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also should seek to assess the varying impact of iPad training on patients with different degrees of low vision. The present study’s participants were made up of patients whose best-corrected visual acuity ranged from 20/50 to 20/3094. Although it is promising that the full range of patients found benefit from the program, a larger study would be better equipped to stratify further the effects of iPad training in different patient groups. The way patients were recruited into the study allowed for an inherent selection bias. Specifically, motivated patients with strong social supports, financial means, and transportation access were more likely to sign up for the course. However, a prevailing theme in low-vision rehabilitation is that its success is predicated by a patient’s motivation. Whether it relates to an iPad or a simple magnifier, the patient must be determined and surrounded by a supportive social network if low-vision rehabilitation is to be successful. In this respect, the selection bias reflects the nature of rehabilitative medicine and works to our advantage; the pilot project was administered on patients with the greatest potential for success. Feedback from the participants should be incorporated into future versions of such a course. Similar courses should entail small class sizes and ensure that support staff is present to provide one-on-one assistance in addition to a lead instructor. As much as it allows, course participants should be as homogenous a group as possible, in terms of baseline vision and prior iPad knowledge. The number of sessions should be increased, with designated time for practice and review of previously taught concepts. Overall, this study provides encouraging qualitative data supporting the iPad as a potential low-vision aid. Many participants emphatically endorsed the iPad and the training course as a way to enhance communication and independence. The iPad’s accessibility, magnification functions, and wide array of apps provide a host of unique features that helped patients optimize their daily functioning. In many cases, patients explicitly commented that their quality of life had improved since using the iPad and that their self-esteem was heightened. Based on this pilot project, future studies certainly would be appropriate in further validating the iPad as a low vision aid.
APPENDIX Supplementary material
Supplementary data are available in the online version of this article at http://dx.doi.org/10.1016/j.jcjo.2016.05.015 REFERENCES 1. Hassell JB, Lamoureux EL, Keeffee JE. Impact of age related macular degeneration on quality of life. Br J Ophthalmol. 2006;90:593-6. 2. Brown MM, Brown GC, Sharma S, et al. The burden of age-related macular degeneration: a value-based analysis. Curr Opin Ophthalmol. 2006;17:257-66.
iPad use in Low Vision Rehabilitation—Mednick et al. 3. Binns AM, Bunce C, Dickinson C, et al. How effective is low vision service provision? A systematic review survey of ophthalmology. Surv Ophthalmol. 2012;57:34-65. 4. Burggraaff MC, van Nispen RMA, Knol DL, Ringens PJ, van Rens GHMB. Randomized controlled trial on the effects of CCTV training on quality of life, depression, and adaptation to vision loss. Ophthalmol Vis Sci. 2012;53:3645-52. 5. Southall K, Wittich W. Barriers to low vision rehabilitation: a qualitative approach. Journal of Visual Impairment & Blindness. 2012;106:261-74. 6. Wolffsohn JS, Cochrane AL. Design of the low vision quality-of-life questionnaire (LVQOL) and measuring the outcome of low-vision rehabilitation. Am J Ophthalmol. 2000;130:793-802. 7. Hassell JB, Weih LM, Keeffe JE. A measure of handicap for low vision rehabilitation: the impact of vision impairment profile. Clinical and Experimental Ophthalmology. 2000;28:156-61. 8. Mangione CM, Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD. Development of the 25-item National Eye Institute Visual Function Questionnaire. Arch Ophthalmol. 2001;119(7):1050-8. 9. Walker R. An iPad app as a low-vision aid for people with macular disease. Br J Ophthalmol. 2013;97:110-2. 10. Gill K, Mao A, Powell AM, Sheidow T. Digital reader vs print media: the role of digital technology in reading accuracy in age-related macular degeneration. Eye. 2013;27:639-43.
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Footnotes and Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article. From the *Department of Ophthalmology; †School of Medicine, Queen’s University. Originally received Apr. 27, 2016. Accepted May. 13, 2016. Correspondence to Mark Bona, MD, FRCSC, Queens University Ophthalmology Hotel Dieu Hospital, 166 Brock Street, Room 2-227A, Kingston, Ontario K7L 5G2 Canada; [email protected]
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