Lighting the Way for the Eye with Macular Degeneration
by Maryellen Bednarski, M.S., M.Ed., C.L.V.T.
Coordinator of Rehabilitation Services for the Offices of Dr. Jean Astorino, Low Vision Specialist
We have all heard of Albert Einstein’s famous equation: E=mc². In this article, I would like to introduce you to a new equation. The equation was developed by Dr. Jean Astorino, a low vision optometrist with several vision rehabilitation sites in the greater Philadelphia area. And so I call this the Dr. Astorino equation:
Proper lighting + Proper magnification = Success
In other words, as an individual with macular degeneration, you need the proper lighting AND the proper magnification devices in order to succeed in reading, in hobbies, and in distance viewing. In most cases, it is not enough to have one or the other. That is to say, proper lighting without proper magnification may very well result in frustration. And proper magnification without proper lighting can also result in frustration.
What are Magnification Devices?
Before moving into the focus of this article — lighting the way for the eye with macular degeneration — I would like to briefly discuss what we mean by magnification devices. When we refer to magnification, we are referring to a variety of devices that can enlarge the image and thus make it easier for someone with macular degeneration to identify that image. The image may be that of a near task, such as words on a page or a crossword puzzle or directions on food packaging or your prescription refill number. For such a task, you may need a higher power in your bifocal, but more commonly you may need high powered reading lenses or hand held magnifiers or possibly stand magnifiers, which are magnifiers with a flashlight type handle. Many magnifiers today have LED lighting sources, which provide bright light over the surface of the viewing area. Or the image in question may involve an intermediate task, such as your knitting or woodworking or dominoes or playing cards. For such tasks, mounted telescopic lenses (i.e., binocular glasses) may be appropriate. Or the image may involve a distance task such as seeing faces of loved ones, or your grandchildren in a play or sporting activity, or TV, or shelf tags at the grocery store. For those tasks, a hand held telescope (a small scope you hold before your better eye and focus on the desired image) or mounted telescopic lens may provide the magnification you require.
Low Vision Specialist
A low vision specialist will work with you in the course of a low vision examination in order to prescribe the most appropriate device for your own unique reading, intermediate, and distance tasks.
In our opinion, it is absolutely in your best interest to obtain periodic low vision examinations. In that way, your low vision specialist can provide you with the proper magnification devices for your needs; and he or she can update you on new devices that may be useful for you.
How to Get Low Vision Devices
Some individuals obtain low vision devices through mail order catalogs, and then become frustrated because the device they ordered was not powerful enough- or may be too powerful- to meet their needs and it is difficult to return the device. Just as you would not tell your family doctor what medication is the right one for you for a given medical problem, we feel you are best served by obtaining the low vision devices best matched to your individual needs from a low vision specialist. Your eye care specialist should be able to direct you to a low vision specialist in your area.
Why does the macular degeneration patient need special lighting? First of all, macular degeneration is generally a disease of “chronologically gifted”, or older, individuals. And it is a physiological fact that the older eye needs more light. Why is this? For one thing, pupil size diminishes as we age, and so less light is allowed into the eye. Secondly, the lens becomes thicker and more absorptive, again decreasing the amount of light reaching the retina. The result is a reduced perception of color and contrast. It has been estimated that a 60 year old needs three times as much light as a twenty year old to properly distinguish the color and contrast in a given target.
When macular degeneration is added to this situation, the result is that even more light is required. Macular degeneration damages the cone cells of the eye, the ones that detect detail and color and contrast. And so it makes sense that the individual with macular degeneration will need more light than the average person.
It should be noted that there is no one “best” lighting solution that works for ALL individuals with macular degeneration. Instead, lighting needs are unique to each individual. We have had patients who tell us that their family members have insisted that the lighting in their home- both general and task lighting- is “very bright”, or “absolutely perfect”. We gently remind those patients, and their loved ones, that one cannot decide what lighting is best for someone else. We encourage our patients, “LET YOUR EYES DECIDE!”
The Lighting in Your Home
We encourage you to begin by considering general lighting around your home. Do you have enough light to move around safely without bumping into things or tripping over things? If not, please consider purchasing brighter bulbs or additional lamps, or possibly have an electrician install new lighting fixtures in dim areas around your home. Some folks have told us, “But I always have had my home arranged in a certain way, and I have always been just fine with 40 watt bulbs in each lamp. I shouldn’t have to make any changes, should I?” Of course, our answer is that you should experiment to see if brighter bulbs do improve your safety and comfort. Recently, a woman with macular degeneration had an electrician come in to install several fixtures in her basement. She told us that when he had finished his work and she saw how bright the basement was, she cried tears of joy.
Lighting Safety Issues
As you think about the lighting in your home, here are some safety issues to keep in mind.
DO NOT use a bulb whose wattage is above the rated wattage limit of the lamp or fixture.
Use dimmer switches ONLY for lamps or fixtures that are designed for this purpose. Compact fluorescent bulbs (which are sold as a cost effective alternative to incandescent bulbs) should NOT be used with a dimmer switch unless they are designed for this purpose.
Be careful as far as the placement of lamp cords, as improper placement can create the risk of falling.
In evaluating the general lighting in your home, be sure that you have enough light in each area of your home. We encourage you to experiment to find the best combination of general and task lighting to meet your needs. In the area of general lighting, pay special attention to transitional areas such as hallways and stairs. If they are not bright enough, by all means add light to enhance your safety! Also, consider the entrances to your home, as well as your walkways. Are they adequately lit at night? If not, consider walkway lights or patio lights along your driveway, and consider adding light at entrances.
Be careful to balance light levels from one area of the home to the next, as the older eye cannot adapt as quickly to changes in light levels.
Effects of Glare
As you evaluate your lighting, take some time to consider the effects of glare and contrast on your safety and visual performance. Glare decreases our comfort and cuts down our visual performance. It can be controlled in a number of ways.
Various window treatments- blinds, shades, curtains, and drapes- can be used to block the glare from bright sunlight streaming through the window.
Shiny surfaces can be covered- e.g., use a desk blotter on a shiny desktop, or a table runner or tablecloth on a high luster tabletop.
Beware that reflected light is not keeping you from seeing your computer or TV screen. If so, move the lamps or fixtures that cause the reflections, or adjust your window treatments to prevent these reflections. Some folks have told us that they positioned a lamp to shine directly on their TV screen, because they felt the colors were “washed out”. We were able to demonstrate to them that shining light directly onto the screen only washes out the colors even more!
Effects of Contrast
Contrast is absolutely invaluable for many individuals with macular degeneration, and it can greatly increase one’s safety and decrease one’s frustration. As noted earlier, macular degeneration diminishes one’s ability to detect contrast. But there are many simple strategies that can help.
Your low vision specialist can work with you to evaluate whether tinted lenses - especially lightly tinted yellow, orange, and amber lenses - enable you to see items inside the home more clearly. Such lenses may also cut glare and thus increase your visual comfort. The tint can be incorporated into your regular prescription, or can be achieved with a clip on or fitover pair of lenses.
Varied simple adaptations around the home can make a huge difference:
- Use a cutting board with two colors, and use the light side for slicing tomatoes and dark objects, while the dark side can be useful for slicing onions or celery
- Place potatoes and corn and chicken on a dark plate, while steaks are quite visible on on light plate.
- Use a contrasting placemat under your plate so that you can easily see the edges of the plate.
- Paint doorjambs and step edges a color that contrasts well with the walls or the rest of the steps.
- Place a white doily on a dark coffee table so that you do not walk into it.
- Put a towel over your shower or bathroom door, so that you can better see yourself as you comb your hair.
- Replace your switchplates with ones that contrast with the wall.
- Place your toothbrush on a dark washcloth.
Lighting in Each Area of Your Home
Now, let’s think about varied areas of the home, and let’s consider how to use lighting in each area to enhance visual performance and personal safety.
Stairs, hallways, entryways, and outdoor walkways must be adequately lit. Design your lighting to provide bright, even lighting all along the hallway, walkway, or stairs. In addition, keep these areas free of clutter to minimize the risk of falls! You may need to move a favorite decorative item such as a basket of flowers, in order to prevent falling over it! And keep a flashlight nearby when it is time to take out the trash. It may help in those dimmer areas of the yard. Also, a flashlight may help in setting the thermostat.
Kitchen
In the kitchen, provide good overall lighting, but supplement it as needed with task lighting. The term task lighting refers to any lamp or fixture that is meant to illuminate one defined area. A lamp over the sink or stove is a task light. So is an undercabinet light or a chandelier above the table.
Bathroom
In the bathroom, good overall lighting should be balanced with task lights as needed. A fixture above the mirror is a task light. Consider lighted mirrors or even lighted magnifying mirrors to enable you to examine your face and hair more closely. But be sure to “try before you buy”. Some lighted mirrors shine the light directly into the eye, thereby creating glare and preventing one from seeing well in the mirror.
Bedroom
The bedroom should have good general lighting to allow one to safely move about, with task lights as needed in reading areas and of course on the night tables. Lamps and switches should be placed so that one never needs to walk around in the dark. A flashlight can help in this situation, and can also be used to help distinguish colors of socks or slacks or shoes.
Den/Family Room
In the den or family room, be sure that you have sufficient lighting to move about safely, even when watching TV. It is true that most folks prefer lower overall light levels when viewing TV. But you do not want to trip when getting up to answer the phone or door while watching TV. Before rising from your seat, turn on the table lamp next to you or flip on the overhead lights.
Laundry Room and Workshop
In the workshop and laundry area, task lights can be a great help. A fixture placed directly over the working area, high enough so that the light does not shine directly into the eye, is recommended.
Close-up Work Lighting
Now let’s consider your lighting in the area where you sit and read, or do close work. Many patients have told us that they like to sit by a window during daylight hours in order to read. That is perfectly fine, as long as the sun is not shining into your eyes and creating glare. But since we often need to read at night or on dull days, most folks need a reading lamp as well.
Light Bulbs
When our patients evaluate reading glasses, we present them with a sample of large print newsprint (or Large Print Reader’s Digest) beside a large print story with black text on a white page. That gives them two different quality materials to use in comparing different types of bulbs. We ask them to evaluate which of the following types of light provides the greatest comfort and best performance as they view the reading samples: incandescent, fluorescent, halogen, and “natural daylight” or “full spectrum” bulbs.
Each bulb is presented separately; we also evaluate a combination lamp with both a fluorescent bulb and a screw in bulb (the screw in bulb may be a standard incandescent bulb, or it may be a “natural daylight” type incandescent bulb- e.g., a Philips Natural daylight bulb or a GE Reveal bulb. It may even be a compact fluorescent bulb with a screw in base.) In many cases, we find that our patients do indeed have a clear preference for a certain type of light. That preference is unique to each individual, and so we encourage all readers of this article to experiment to learn what type of light is best for them.
Lighting Evaluation
Your low vision specialist may be able to provide a lighting evaluation for you. If not, take some of your reading material with you to a lighting or office supply store. Be sure to have some material that is of poorer quality contrast along with high quality materials. View each sample under each type of lighting- incandescent, fluorescent, natural daylight or full spectrum, halogen, and a combination lamp- and decide what type of lighting is best for you. You will see that some bulbs are more yellowish, while others are brighter white or even bluish white.
What is best is completely unique to the individual. Even after deciding on a task lamp, you may wish to purchase several types of bulbs, in varied colors, in order to allow you to experiment in more detail at home and to determine what works best for you. In general, incandescent bulbs are warmer (redder) than fluorescent or daylight bulbs, which are bluer. But fluorescent bulbs come in a range of colors as well. They range from yellowish white (warmer) to white and bluish white (cooler). For instance, a “cool white” fluorescent will appear whiter than a standard incandescent bulb.
Task Lamps
We recommend a flex arm or gooseneck lamp, as you can position it in the exact position and at the exact angle that is best for you. As far as the type of bulb to use, we strongly suggest that you LET YOUR EYES DECIDE!
Another example of a task lamp is a flexible arm lamp (sometimes called an architect’s lamp) or a gooseneck lamp placed on the table. Such a lamp may be used to better illuminate one’s plate, or to sort one’s medications or review the mail. Yet another form of task lighting is a flashlight- consider keeping flashlights throughout the home to illuminate drawers, closets and cabinets, and the contents of storage bins. In the kitchen, some folks use flashlights to help in setting stove and microwave dials, and to find objects in cabinets.
As you evaluate task lamps, you will find that there are varied supports for flex arm lamps. These include clamps, so that you can mount them on the table or on the wall; heavy table bases, that provide good stability when you extend the arm of the lamp (be very careful when moving heavy bases; it is no fun to drop one on your foot!); and floor stands, with or without wheels. If you purchase a lamp with a floor stand, be careful to grasp the lamp by sturdy upright portion of the floor stand when you wish to move it. In most cases, the lamp portion fits into the base, but can also be accidentally pulled out of the floor stand it you grasp it and then try to move the lamp.
When you have the desired lamp in your home, experiment to find the best placement of the lamp itself, and then the best positioning of the head of the lamp so that your task is adequately illuminated.
Safety Issues
Safety issues to consider — if you are using a task lamp, e.g., a gooseneck or flex arm lamp, be careful that the bulb does not come into contact with your hands or arms or face. This is especially true if you are using halogen or high intensity bulbs, but incandescent bulbs get hot as well. (For this reason, many individuals prefer a fluorescent bulb, as long as it is equally comfortable for their eyes.) Some lamps, especially halogen lamps, provide protection for the user by placing the bulb behind a translucent cover that prevents one from touching the bulb. If your lamp does not provide a protective cover for the bulb, be sure that the bulb does not protrude beyond the housing, as this increases the risk of glare. Position the lamp so that it is directed onto the task, not into your eye!
Natural Day light - Full Spectrum Lighting
Many lamp manufacturers have touted their products as providing “full spectrum” or “natural daylight” types of light. The Lighting Research Center of the Rensselaer Polytechnic Institute has investigated these types of light. They state that “full spectrum” and “natural daylight” are not technical terms, but rather are marketing terms. In general, the terms “natural daylight” and “full spectrum” refer to bulbs that provide even amounts of light across all wavelengths in the visible spectrum. They are meant to simulate natural sunlight. But it is very hard for full spectrum bulbs to truly mimic daylight because the spectrum of daylight varies constantly according to time of day and weather conditions. With that said, it is true that bulbs marketed as “full spectrum” and “natural daylight” do tend to be brighter and whiter than standard incandescent bulbs. They provide good color perception, and may provide psychological benefits. But the Lighting Research Center did not find that they provided any documented health benefits such as improving dental health, stimulating Vitamin D production, or providing better relief of symptoms of Seasonal Affective Disorder than other white light source. But “full spectrum” and “natural daylight” lamps are being heavily advertised, and many individuals with macular degeneration are happily and comfortably using them for reading, writing, and other close work. As we have stated before, LET YOUR EYES DECIDE what is best for you.
Fluorescent Bulbs
Compact fluorescent bulbs are widely advertised as a cost effective replacement for standard incandescent bulbs. It is important to note that today’s fluorescent bulbs are far superior to those of yesteryear. Fluorescent bulbs and tubes are available that do not flicker or buzz or cause headaches, so do not be afraid to try them!
Bulb Wattage
When comparing one bulb to another, we have always thought in terms of wattage- a 75-watt bulb provides more light than a 60 watt bulb. In truth, watts measure how much energy the bulb uses. Since 1995, all bulbs sold in the U.S. must be labeled with lumens, which is a measure of the amount of light emitted by a bulb. So if you are comparing different types of bulbs, look at lumens to see how much light they really are producing. For instance, a 100 watt incandescent or halogen bulb will provide about 1600 to 1700 lumens, while a 100-watt GE Reveal bulb produces 1250 lumens and a 100-watt Philips Natural Daylight bulb produces 1350 lumens. Yet a 25-watt compact fluorescent bulb with a screw in base produces 1750 lumens. Thus, you may wish to compare varied bulbs at approximately the same level of lumens, since you then can be sure that they are producing the same amount of light.
Computer Lighting
If you are working at a computer and referring to written text or correspondence, you may find it best to use dark text on a white background on your monitor. That way, your eyes do not need to adjust when your eyes move from the page to the screen and back. Use the same principle if you have a video magnifier next to your computer monitor. The text and background should be similar on both computer and video magnifier screen- whether you prefer light text on a dark background, or vice versa.
Lighting When You Are Outside
So far, we have discussed lighting in the home. But when you are away from home, lighting is still important! We all spend at least some time outside during the day. Sunlenses and a hat with a brim can make all the difference in decreasing glare and increasing comfort.
Your low vision specialist can evaluate the proper shade and tint for you. There are 6 or 7 different colors and several shades of each, in evaluating sun protection for patients. As with other aspects of lighting in the home, what is best is unique to the individual. It is important for you to try varied colors and tints to see which provides you with the greatest glare reduction and contrast enhancement. You may find that you need two or three different shades of sunlenses, according to the weather conditions.
Be sure to evaluate various designs, as well. Wraparound sunlenses protect your eyes from glare coming from the side and possibly from above and below as well. Remember, the sun can reflect off surfaces such as water and sidewalks or snow, and thus glare can enter your eyes from below. A wraparound design that fits over your regular glasses and yet snugs up against the forehead and cheeks will provide the best glare reduction. A hat with a brim, or a visor, can be a great help in glare reduction as well. And a polarized lens will eliminate glare from horizontal surfaces such as car hoods and sidewalks or sand or water, thus increasing comfort.
Sunglasses
When choosing sunlenses, be careful that the lens is not too dark when you walk into shaded areas. This will eliminate the risk of falling. We recommend that you put on your sunlenses as you step out the door, and remove them as you step in. This decreases the amount of adjusting that your eyes need to do.
Some individuals find that they do very well with photochromatic lenses, which darken as you go outside and lighten indoors. However, many folks have difficulty when they first step indoors, as the lenses take some time to darken. In that situation, it is wise to step aside from the doorway and wait a minute or two for the lenses to lighten; then move ahead.
We have heard from many patients that bright sunshine is very difficult, as they find it creates much glare and areas of light and shadow. If you have a choice when walking outdoors, walk with the sun behind you or to the side. Many find it easier to walk down the shaded side of the street.
Restaurants and Offices
When in a restaurant or an office, you may find you are more comfortable if you sit with your back to a window, at the table or the area with the best overall light. Feel free to ask for light levels to be adjusted, if that will increase your comfort. And remember your flashlight! Keychain flashlights can be a great help in viewing restaurant menus or even the layout of the food on the plate. In addition, they can help in locating keyholes on a dark night.
For those who are working, feel free to approach your employer about adjusting the lighting in your workplace and in your specific area in order to meet your needs. In all likelihood, your coworkers will benefit from improved lighting as well! If you do not wish to discuss your vision problem with your employer, you may wish to obtain a task lamp for your use in your specific work area.
Other People’s Homes
When visiting friends or family members, feel free to ask them to adjust light levels and to open or close blinds or shades to enhance your comfort. Most people will be more than happy to accommodate your requests. That is part of being a good host.
In summary, I want to encourage you to take a fresh look at your lighting and make the changes that will enhance your safety and comfort. The changes you make can indeed make a great difference in your life and in coping with your macular degeneration. In addition, I wish to restate Dr. Astorino’s equation:
Proper lighting + Proper magnification = Success
And finally, I want to encourage all readers of this article to experiment to find what is best for their unique individual needs. As I have stated throughout this article, LET YOUR EYES DECIDE!
Note: The author found much helpful material for this article from the website of the Lighting Research Center at Rensselaer Polytechnic Institute.
Maryellen Bednarski is a Certified Low Vision Therapist with 17 years experience. She is currently the Coordinator of Rehabilitation Services at the offices of Dr. Jean Astorino. Dr. Astorino is a Low Vision Optometrist with a passion for providing quality patient care. Her offices are located in Media, West Chester, and Blue Bell, Pennsylvania.
Ms. Bednarski received a Masters in Vision Rehabilitation and a Masters in Education of the Visually Handicapped from the Pennsylvania College of Optometry. She previously served as Coordinator of Rehabilitation Services at both the Moore Eye Foundation Low Vision Center in Springfield, PA, and the William Feinbloom Vision Rehabilitation Center of the Pennsylvania College of Optometry in Philadelphia, PA. Ms. Bednarski brings a unique perspective to her work, as she has a vision impairment. She initiated two low vision support groups. She continues to lead the first group, which has been active since 1990; the other group was initiated in 1999 and is still active today.
Posted on June 25, 2007