7.0 My Favourite Reading Magnifiers

You can put a dozen low vision rehab specialists in a room and they’ll argue for hours about which magnifiers are best for what. YMMV, but I’d like to highlight some of my personal favourites — kind of my ‘Desert Island’ LVAs.

Most of these magnifiers count as favourites because they are suited to the task of fluent reading, (which you might have gathered is kind of my ‘thing’). When it comes to spot reading tasks I’m generally not too fussed.

Magnifier Lamps: Have a high speed limit for early AMD, mild-to-moderate VA. Low magnification, wide field of view, excellent illumination, and both hands can hold the book.

Task Lamps: Amazing how often these are neglected. High speed limit for early AMD, and about the best thing you can do for late Geographic Atrophy with a ring scotoma.

Handheld Magnifiers: For a portability and spot-reading tasks, not so much for reading books (but can be good for newspaper). Make sure you use one that has illumination.

CCTVs: Contrast enhancement and wide field of view means a high speed limit even with moderate-to-high AMD, and still really useful for independence and quality of life well into late vision impairment. Can be a great investment even in early vision impairment.

Portable CCTVs: High speed limit up to moderate AMD, very suited to column text, but not so great for books.

Tablets: Pagination and their book-like form factor makes them awesome for fluent reading well into vision impairment. I should totally have Apple shares (I don’t). None of the manufacturers offer accessibility controls that really ‘get’ low vision though, so advise your patients to get familiar with using tablets early.

Scanning CCTVs: Not just for text-to-speech, their text-reformatting powers allow a high speed limit at higher magnification than just about anything else. So far nobody has introduced a pagination option, but sooner or later they’ll figure it out.

Talking Books: They’re not for everyone, but they should always be an option in the mix. Make sure you know what talking books libraries and players are available in your area.

Magnifier Lamps

I never used to prescribe many magnifier lamps, but in recent years they’ve become my most-prescribed LVA. The particular models I use are a floor-mount and a desk-mount under the brand ‘Triumph’, but there are many other good ones on the market.

Here’s why I like magnifier lamps so much:

• They make very effective task lamps. For many tasks which are close to threshold, good light is all that’s needed, so it’s just a matter of having a decent lamp in a practical location, with an easy-to-position arm to get the light close to the page. The floor lamp is easy to position right next to the patient’s favourite chair, or next to the bed, and the arm is long and flexible enough to easily pull down to concentrate the light on the page, with the head angled so none of the LED bulbs are directly in the patient’s line of sight to cause glare. For use by a patient in a chair, the base should be positioned about half way between the patient’s hip and their knee. The Triumph has a flexible arm that doesn’t need locking in position, but it doesn’t require a lot of arm-strength to bend it.
• Using the magnifier and the illumination together is powerful. The combination of the illumination and the (mild) magnification vectors tend to push effectively into the visual volume, away from the most common problems of too small and too dim. Whether the patient has mild or severe low vision, all patients will encounter tasks that are challenging but become easy with the magnifier lamp.
• They are hands-free. That means for patients who use them for reading, they still have both hands to hold the book or newspaper, and they just need to move the book around under the magnifier. They can also be used for other two-handed tasks, such as clipping fingernails or changing batteries in other devices. Don’t underestimate the practical value of hands-free, it can make a huge difference.
• The field of view is wide,  and binocularity can be maintained.
• They don’t tend to cause glare, because the bulbs are not visible, there are no reflections of the bulbs off the lens, and the illumination is only in the magnified area (so the area outside of the macular field is not exposed to bright light).
• All of this adds up to a high speed limit. For many patients who still have good VA, a magnifier lamp may be all that’s needed to push book and newspaper print well into their Optimal Visual Volume, allowing comfortable reading.
• The switch is on the head of the lamp. Especially when the patient has mobility problems, accessibility of the switch is important. Some have the switch half way down the stand, which isn’t too bad. Some have a foot-switch on the base, which can be a huge practical barrier. And the Triumph’s switch is a big push-button model — even though it requires moderate finger strength, it doesn’t require a lot of dexterity, so even patients with arthritis can usually manage it.
• They’re affordable. High-end magnifier lamps can cost a lot (although, let’s face it, still a lot less than a high-end pair of glasses). The Triumph floor mounts are only around $100, the desk only around $60. Most patients will get a floor mount and a desk mount.

For patients with reasonable acuity, the floor-mounted magnifier lamp is a good practical option for reading books or newspapers. For patients with worse acuity, the magnification won’t be enough for reading articles, but can still be enough for scanning newspaper article headlines, and then switching over to a stronger (but less ergonomically comfortable) LVA for reading any articles that pique their interest. Any object that a patient can almost see can be brought over to the magnifier lamp for a better view.

The desk-mounted magnifier lamps has a smaller field of view, but it’s lightweight and can be cordless (running off AA batteries). That makes them particularly effective as a simple task light. Common uses are in the kitchen, positioning over a chopping board, or on a table to illuminate wordsearch puzzles or large-print crosswords. Because the lens is smaller, it’s more suitable for spot-reading tasks, such as looking at the expiry date or heating instructions on food packets, for reading the next step in a large-print recipe, or for reading the dial on a set of scales.

It doesn’t make a lot of sense for optometrists to stock and sell magnifier lamps. They’re quite bulky, and there isn’t a lot of profit in them given the space they take up. I think it’s best to go down to your local lighting shop, find a model you like, and then ask them to keep it in stock. Whenever you have a patient who needs one, give them a prescription to take down to the lighting shop. Sure, it means you don’t make any money out of that transaction, but at least it means you’re effective. And not many patients get only a magnifier lamp, it’s just one of the devices they need. Anyway, the business side of low vision is a topic for another time.

You should arrange to have an example of your chosen mag-lamp in your consulting room to demonstrate. You’ll find it’s very useful, not just for low vision — for instance, being able to get a good look at eyelid and facial rashes, and epilating ingrown lashes or removing foreign bodies when the patient can’t be positioned on the slit-lamp.

Task Lamps

As mentioned above, my most commonly-prescribed task lamp is a magnifier lamp — even if they mostly need it as a lamp-only, at least the magnifier part is there for the occasional fiddly task. But sometimes they really need only a lamp, or they need even brighter illumination than the magnifier lamp can provide (yeah, I’m looking at you, patient with advanced geographic atrophy and foveal-sparing).

“If the only tool you have is a hammer, you tend to see every problem as a nail.” Abraham Maslow.

As optometrists, we spend so much of our time learning about lenses and optics that it seems kind of… wrong to be thinking of an intervention that doesn’t include a lens. It’s not unreasonable that we spend so much time on lenses, because optics is quite complicated (knowledge of lens optics is the ‘special sauce’ that optometrists bring to any multidisciplinary team). But we should remember, optometrists are trained to be experts in all aspects of vision, not just optics, and in low vision rehab our training in lights and illumination is just as important.

In Maslow’s terms, we are trained to use a whole toolbox, so don’t feel bad when the job doesn’t need a hammer.

The choice of task lamp deserves serious consideration. There are heaps of suitable lamps available, but even more that aren’t at all suitable. I think we owe it to our patients to be able to recommend a specific model, so the patient doesn’t end up with something impractical. After all, you wouldn’t tell your patient to ‘just get a magnifier’, you’d tell them which one. If you can’t tell them a specific model of lamp, at least tell them which features to look for.

The one I prescribe a lot is the Sara lamp, in both floor and desk versions.

It doesn’t hurt that it’s available in a range of colours. That sort of thing isn’t a practical consideration, but for many people their home decor is important, they don’t want something in their living room that looks ugly.

The main points for an effective task lamp:

• Easy-to-position arm with good reach, so the lamp can be positioned right above the page.
• Opaque shade so it doesn’t become a glare-source.
• Switch accessible while sitting down (no floor-switches).
• Switch easy to turn on with arthriticky fingers.

It’s important to prescribe a suitable bulb too. LED bulbs are good because they give excellent illumination but don’t produce much heat, which is important when the lamp’s going to sit close to the patient’s head for an extended period. Just as with magnifier lamps, it’s probably not worth selling lamps in your optometry practice — come to an arrangement with a local lighting shop, and they can help you choose a good lamp/bulb combination to prescribe (and that they can make sure is always in stock).

The other ‘task lamp’ I prescribe a lot is a mini-torch (flashlight). Nowadays I tend to prescribe these in situations where previously I might have prescribed a folding magnifier — such as for looking at price tags and recognising products in the supermarket. Bringing the torch close (within 5cm) to the price tag gives a very nice spot of high illumination. Most of the time price tags are quite large and well-printed nowadays, so that brightness is sufficient for the purpose for many patients. And boosting the illumination can be enough to recognise colours and logos that distinguish certain products. Of course, having a torch with them is very useful from a safety point of view whenever a patient finds themselves having to walk through a poorly-lit area.

A variation on that theme is using your smartphone flash as a torch. Many patients have these already, and of course it’s something they tend to always have with them. Check that they know the operating system shortcut for turning it on and off.

Illuminated Handheld Magnifiers

Even though I love magnifier lamps, they’re not suitable to put in your pocket and carry around! And patients for whom a pocket torch isn’t enough in the supermarket will need something that gives magnification as well. As you’d expect from me, I give strong preference to any device that has illumination as well as magnification, so a good handheld illuminated magnifier can be brilliant for out-and-about.

The field of view and the need to devote one hand to holding the magnifier means they generally don’t have a high speed limit, so they aren’t as suitable for prolonged or fluent reading, but illuminated magnifiers are a top choice for spot-reading tasks. Their speed limit is higher for column text in the lower powers, so if the patient has a steady hand they might be good for newspaper.

I really like the Eschenbach 1510 Mobilux LED series, which has great LED illumination, relatively wide field of view and nice ergonomic handles. I prescribe a lot in the lower powers, 3x and 3.5x (+8D and +10D), and even up to 6x is usually well accepted. Above about 6x it can get too hard to hold the magnifier steady, so it’s probably better to use an illuminated stand magnifier (but nowadays a portable CCTV is a better option). Remember, if your patient has a tremor, you should be looking at other options straight away.

Note: Eschenbach, (like many magnifier manufacturers), uses confusing terminology to indicate the power of with their lower strength magnifiers. Their +8D and +10D magnifiers should be 2x and 2.5x, but they label them as 3x and 3.5x. The next power up is +16D, which is a significant jump from the +10D, but it you might not realise it is because the rated magnification only goes from 3.5x to 4x. I’m sure there’s a good reason for this inconsistency, but I really wish they’d keep to the one standard.

CCTVs

CCTVs used to be the magnifier of last-resort, something you’d turn to when nothing else works. Nowadays I recommend them a lot earlier, for two reasons:

• For patients who have a progressive condition that is likely to result in them needing a CCTV sooner or later, I think there’s an argument to be made that they should get it sooner. It’s easier to learn to use it while their vision is still not too bad, and in the meantime it’s going to make their life a lot easier.
• For patients who want to read for pleasure, a wide-screen CCTV can fit an average book page at 4-5x magnification without having to scroll sideways, which facilitates a very high speed limit. For column text (newspaper and magazines) they can have a high speed limit even on 8-10x. CCTV manufacturers seem to overlook this group of low vision patients, aiming their products instead at people who have very advanced vision loss. In fact, for every patient with advanced loss, there are many patients with less advanced loss but with significantly impaired reading fluency. Not everyone is prepared to spend that sort of money just to be able to return to the pleasure of books, but some are. Just think how much people spend on other hobbies, like fishing or golf — reading is no less important.
•  

These days there’s a lot more emphasis on ‘ageing in place’, trying to keep people independent in their own homes rather than going into a nursing home. Since having people in a nursing home costs governments a lot, there may be funding support available for purchasing CCTVs if it helps people stay at home. In Australia the MyAgedCare system will sometimes help patients get a CCTV if it’s needed for managing essential correspondence, checking medications, reading phone numbers and cooking instructions, etc. For patients under 65yrs, funding may be available through the NDIS. For patients who need a CCTV for employment reasons, look in the Employment Assistance Fund.

CCTVs are a very mature technology, and there are a lot of great options available. I think it’s best to get as large a screen as possible — even if it’s not quite necessary for the patient right then, it provides a degree of assurance that it will still be an effective option if the vision declines further.

My favourite CCTV at the moment is the Freedom Scientific Topaz HD 24″. It’s a nice basic CCTV with controls that are very easy to learn.

It’s good to get a CCTV with HD optics. The HD camera means it can show a good quality image at low magnification, which is really good for people who have more problem with luminance and contrast than with detail. It also means a better quality image of small print at high magnification.

The other one I really like is the Freedom Scientific Onyx PHD, paired with a large-screen HDTV as a monitor.

It’s a lightweight, portable CCTV, intended for connection to a laptop. But it also works with a direct connection to a monitor or a TV. By using a quite large (40″-50″) TV as a monitor, you can have a combination of high magnification and a wide field of view. Or, alternatively, position the TV further back than a normal CCTV monitor for reduced convergence demand and better comfort over prolonged periods, while still subtending the same screen angle as a normal CCTV monitor up close. The camera being in free-space is also really good for people working on crosswords, and working on tasks like craftwork or fixing/assembling equipment.

Aside: HDTVs make excellent low vision monitors, for computers as well. They don’t usually have fine enough pixels to be acceptable as monitors to people with normal vision, but for people with vision impairment they are quite suitable, and relatively cheap these days. It’s worth getting out the remote and adjusting the TV contrast and brightness settings to suit the user. Patients sometimes get a bit confused, thinking you mean them to use it as both a TV and a monitor, and may object (“I couldn’t watch TV that close!”), so they might need repeated reassurance that they should think of it just as a monitor. Sure, they could use it as a TV as well, but it’s a bit of a pain, as the they need to switch input, which is often a fiddly process. It’s simpler to have a TV and a magnifier monitor, and keep them quite separate.

Portable CCTVs

I love modern portable CCTVs. Whenever someone wants to read the newspaper, and a magnifier lamp isn’t good enough, the next thing I show them is a portable CCTV.

The great thing about modern portable CCTVs is that they have that angle relative to the page. With stand magnifiers, you can’t get around the fact that you have to either lean forwards to look down into the magnifier, or you need to put the document on an angled reading stand and rest the magnifier on it (which means you need to take the weight of the magnifier). Neither of those positions are very comfortable. In contrast, portable CCTVs can display the image at that comfortable angle while the page is flat on the table. The magnifier just sits on the page, so the patient doesn’t need to take its weight, just slide it around on the page.

Most have quite a large screen these days. 5″ is about the smallest, which is easy to carry but still gives a good field of view. The Humanware Explore 8 (my current favourite) has an 8″ screen, and I’ve seen portable magnifiers of a similar format with up to 13″ screens (small laptop size). As always, the larger the screen, the better the field of view, but if portability is needed then the larger ones might be too bulky.

For me, one of the first things I check with any new portable CCTV is whether its screen can fit a full column-width from my local newspaper. That was the problem with most of the earlier generations, they didn’t have magnification options low enough to allow a column to fit across the screen, which means slower reading speed and comfort.

I like the Explore 8 because it’s nicely designed. Its buttons are in a good position — buttons on the side are often accidentally pressed. The image quality is good. It starts up quickly, only a couple of seconds. And it’s quite a bit cheaper than some of its major competitors. But there are a lot of other great options out there too.

Portable CCTVs are excellent for reading newspapers and magazines. They’re not great for reading books though. Book pages don’t sit flat, and it’s awkward trying to slide a portable CCTV around on a book page, especially text on the bottom of the page (because the camera is at the top of the magnifier, so when it’s in line with the bottom lines the stand mostly isn’t sitting on the book, if at all). For books, I’m more likely to recommend a tablet.

Tablets

Tablets are awesome! They are revolutionising low vision care in so many ways, especially since it’s getting common to find that patients already have one. The particular use I want to highlight is using tablets as eReaders, because they are hands-down best device for fast-fluent immersive reading with low vision. You can buy electronic versions of just about any book these days, and you can even borrow eBooks from many libraries (just ask them about it). And in practical terms, they are cheap — even if your patient doesn’t already have one, there’s a good chance a family member might have an older model that they’re not using any more, and decent second hand tablets are widely available on sites like Gumtree.

There are many different apps. Personally I use an iPad, and use both Apple’s Books app and Amazon’s Kindle app. Whatever you use, the ability to display book print with high contrast and high magnification in a paginated format is the perfect way to read with high fluency with moderate-to-severe low vision.

Comment: Even if you have no interest in low vision, remember this: if you have a patient who is an avid reader, with pathology that is likely to progress to at least moderate low vision (such as AMD), one of the best things you can do for them is to encourage them to read at least one full book with a tablet. Many will object, saying they don’t need it yet. But if they wait until they already have more advanced vision impairment, it’s harder for them to learn how to use the tablet.

The first presentation of the iPad is really important.  In the Low Vision Clinic, we use a large screen (12.9″) iPad Pro, and we have it in an easy-grip case, like this:

It’s not just to protect the iPad from damage. It’s because when you first hand it to the patient, they instinctively hold it like a book, with their thumbs coming over as if to hold the page edges down. With a tablet, that touch on the screen always makes something happen. I present it to them with a book already open in iBooks, but if they rest their thumbs on the side of the screen it will turn the page, then do it again, and again and again and again — which means their very first experience of the iPad is mucking something up. The case gives them something secure to grip on to, while their thumbs don’t disturb the display.

That first presentation is with an eBook open. I usually use The Jungle Book, which is often familiar to our patients, and it’s not too hard a reading difficulty text. I set it on moderately high magnification, high contrast & brightness, in portrait format, with a clear sans-serif font. I demonstrate how we can make the print larger or smaller (I show them it going up to maximum, even if they don’t need nearly that magnification), and how we can reverse the contrast (which gets a very good response from anyone who is very glare-sensitive), and then I show them how to move on to the next page and come back again.

Sometimes the response is profound. The patient goes silent, deep in the experience of reading comfortably for the first time in years.

I might mention how you can use tablets for other things, but I think they are worthwhile as eReaders alone, even if they never use them for anything else (and you might even use the Guided Access settings to restrict to the one app for a while, just to make it more foolproof). If I show any other apps, the first one is usually the local newspaper app, in which you can get an exact digital copy of the newspaper, but in beautiful high contrast, and with zoomable print.

Scanning CCTVs

Text-to-speech is a less mature, more evolving technology.  The one we have in the LVC is the Humanware Prodigi Desktop, which I find very good. Freedom Scientific and Optelec have also been adding it into their CCTVs.

I have to say I’m not brilliant with text-to-speech options. I process visual information much better than I process audio information, so I sometimes have trouble making sense of the voice output (although it’s easier if I slow it down). That seems to be a common problem with our older patients — after seven or eight decades of getting information by (visually) reading it, it can be hard for a patient’s brain to take in the audio effectively. In contrast, younger patients with vision impairment tend to have better plasticity, and find these sorts of devices very helpful.

That being said, remember that these give a visual output as well as the speech output. As discussed earlier, there are some particular benefits to these as CCTVs, in that they can display a single continuous column of magnified text, removing the need for side-to-side image scrolling, and thereby allowing a reasonably high speed limit even at quite high magnification. When doing that, the voice is more of a distraction than anything, so best to turn the voice off.

Reading in a single continuous column is good, but it would be better if the text were paginated. It would be easy to do — most models already give options for continuous column, continuous line or sequential single word, so it would be just a matter of adding sequential pages as a display option — but so far I don’t think anyone has thought of it. If you find a model that offers that option, please let me know.

Talking books

Sometimes the only practical way to get immersed in a story is to use audio books. You can borrow these from most libraries, but in Australia there are at least a couple of large talking books libraries reserved for those with impaired vision, through Vision Australia and VisAbility. What often makes the difference is the player — standard CD players tend to have fiddly, low-contrast buttons which make the book hard to control. The patient is much better to have a proper low vision audio-book player, with large tactile buttons.

An emerging alternative is to use a smartphone or tablet, with downloaded audiobooks from sites such as Audible.com.

Tip: Sometimes older patients have poor hearing too, so it can be worth getting a pair of headphones — they can then blast the book as loud as they like without bothering anyone else.

I find it helps acceptance of the concept by reminding older patients that listening to books used to be quite commonplace. Many will remember sitting next to the wireless on a Sunday evening, looking forward to hearing the next chapter in whatever book the station was working through.

A common problem is that patients go to sleep while listening to audio books. It can certainly be very restful. My advice is for them to find something to do while they are listening — perhaps knitting, or listening while they are eating meals or doing housework. If they’ve got headphones, they might listen while pottering around the garden (but not while walking on the street, for safety reasons).

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