Seminars in Ophthalmology, Early Online, 1–9, 2015 ! Informa Healthcare USA, Inc. ISSN: 0882-0538 print / 1744-5205 online DOI: 10.3109/08820538.2015.1045151
ORIGINAL ARTICLE
Usage of Accessibility Options for the iPhone and iPad in a Visually Impaired Population Joshua L. Robinson1,2,3, Vanessa Braimah Avery1,2,3, Rob Chun1,2,4, Gregg Pusateri2, and Walter M. Jay4 1
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Illinois College of Optometry, Chicago, IL, USA, 2Spectrios Institute for Low Vision, Wheaton, IL, USA, Chicago Lighthouse for People Who are Blind or Visually Impaired, Chicago, IL, USA, and 4Department of Ophthalmology, Loyola University Chicago, Chicago, IL, USA
ABSTRACT Purpose: The iPad and iPhone have a number of low-vision accessibility features including Siri Voice Assistant, Large Text, Zoom Magnification, Invert Colors, Voice Over, and Speech Selection. We studied their usage within a low-vision population. Methods: Patients were recruited to participate in an IRB-approved survey regarding their usage of the iPad and/or iPhone. Participants met one of the following criteria: best corrected visual acuity (BCVA) of 20/60 or worse, or significant peripheral visual field defects. Results: Thirty-three low-vision patients agreed to participate (mean age 54.3 years). There were 18 different diagnoses represented and the average visual acuity of respondents was 20/119 in the right eye and 20/133 in the left eye. The most commonly used vision accessibility features were Zoom Magnification and Large Text. Conclusions: Although many patients are using the low-vision accessibility features, few are receiving training or recommendations from their eye care specialist. Keywords: Accessibility features, activities of daily living, low vision rehabilitation, smartphones, tablet computers
INTRODUCTION
are made problematic by vision loss, as a study by Woods and Stagunam2 indicates that the majority of visually impaired users have difficulty watching videos on handheld devices. Advances in low-vision accessibility features allow the iPhone and iPad to be used more efficiently by the visually impaired. The Apple iPad and iPhone (examples of a tablet device and smartphone, respectively) were selected to be used in this study due to the ease of the user interface. All models of the iPhone are the same across different wireless carriers, making for straightforward instruction of the patient on the use of the low-vision accessibility features. Rana and Rana3 conducted a focus group of 15 visually impaired patients in which a series of tasks were performed using the iPhone. At the end of the session, a questionnaire revealed that 80% of participants felt confident using the iPhone user interface. Confidence when using the interface is
Millions of people worldwide are diagnosed with vision impairment resulting from a wide range of ophthalmic conditions. Having impaired vision can make it difficult to perform activities of daily living (ADLs) such as reading and communicating with others, which in turn can cause a dramatic decline in one’s quality of life.1 However, technological advances have made these tasks and interpersonal interactions easier for individuals with vision impairments. The use of portable electronic devices has allowed visually impaired patients to maintain a level of independence not previously possible. Further, both normally sighted and visually impaired people use handheld electronic devices for leisure activities such as watching videos or playing games. These activities
Received 2 December 2014; revised 28 January 2015; accepted 19 March 2015; published online 8 July 2015 Correspondence: Joshua Robinson, OD, Spectrios Institute for Low Vision, 219 East Cole Ave, Wheaton, IL 60187, USA. E-mail: [email protected]
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TABLE 1. Categories of vision accessibility features. Audio Options
Visual Options
Voiceover Screen Reader Speak Selection Siri Voice Assistant
Zoom Magnification Large Text Invert Colors
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Each accessibility option is categorized as either audio- or visually based.
essential because it determines the likelihood that a patient will use the device to complete necessary tasks. Much of one’s interaction with an iPad or iPhone is visually based, so even the slightest reduction in visual acuity or contrast sensitivity can lead to difficulty when using these devices without vision accessibility features. Since many people’s personal and vocational interactions are highly dependent upon technological connectivity, an inability to effectively use smartphones and tablets can become a hindrance to one’s productivity. It is therefore important that these devices be available to those with vision impairments so that they may be positive, contributing members of society. There are few studies that emphasize the use of tablets and smartphones to assist in activities of daily living. This may be due to this technology being relatively new and therefore not yet being fully incorporated into practitioners’ arsenal of options for their low-vision patients. With so many visually impaired people owning the iPad and iPhone, quantifying how the accessibility features are being used can be helpful in the initiation of care and recommendation of appropriate devices or features. These results may allow the eye care specialist community to better incorporate the technology offered through these devices into low-vision evaluations, especially if the patient already owns these tools. The Apple operating system (iOS7) has six primary, built-in, low-vision accessibility features which allow the visually impaired to more fully utilize their devices. This investigation was completed prior to the introduction of iOS8; all six of the basic accessibility features included in the study are still present in iOS8. These features can be grouped into two categories (Table 1). The audio-based features include VoiceOver Screen Reader (VoiceOver), Speak Selection, and Siri Personal Assistant (Siri). The visually based features include Zoom Magnification, Large Text, and Invert Colors. Using some or all of these features allows visually impaired individuals to more easily place and receive phone calls, compose and read text messages and e-mails, obtain directions, access websites, and perform other tasks which are integral to one’s daily life. VoiceOver describes aloud what appears on the screen, so the device can be used without actually seeing it. This feature tells the user about each item on
FIGURE 1. VoiceOver Screen Reader. Photo showing the various settings available when using VoiceOver.
the screen or about a specific item as it is selected. Upon opening a new screen, VoiceOver (Figure 1) plays a sound, then selects and speaks the first item on the screen (typically in the upper-left corner). Speak Selection (Figure 2) enables any text that is highlighted by a user to be read aloud. Once the text is highlighted, the dialect and speaking rate can be adjusted. Siri (Figure 3) is the intelligent personal assistant that helps a user to get things done just by talking into their device. Siri can be used to write and send a message, set a reminder, place a call, get directions, and more. Siri will ask a question if it needs clarification or further information, and is integrated with VoiceOver so that Siri’s responses will be audible to the user. Zoom Magnification (Figure 4) allows a user to magnify the entire screen of any application to the needed level of magnification. This is achieved by double-tapping the screen with three fingers or dragging up and down with three fingers. Large Text (Figure 5) increases the text size in certain functions of the device such as alerts, calendars, contact lists, messages, and notes. Invert Colors (Figure 6) is a feature that allows a user to change from black text on a white background to white text on a black background, resulting in a screen resembling a photographic negative. Introduction to, and training with, these features can be beneficial in meeting a patient’s goals. Through Seminars in Ophthalmology
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Accessibilty Options for the iPhone and iPad
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FIGURE 2. Speak Selection. Photo depicting the process of highlighting and reading text using Speak Selection.
the use of a telephone survey given to users of the iPad and iPhone, we aimed to investigate how these vision accessibility features are being used by visually impaired patients.
MATERIALS AND METHODS Patients were recruited to participate in a survey regarding their usage of the iPad and iPhone. This survey was approved by the Institutional Review Board (IRB) at the Illinois College of Optometry in Chicago, Illinois. The IRB is a committee which reviews proposed research involving human subjects to ensure that it in conducted in accordance with all federal, institutional, and ethical guidelines. Patients were eligible to participate if they were 18 years of age !
2015 Informa Healthcare USA, Inc.
or older, reported owning an iPad and/or iPhone, and met one of the following criteria: best-corrected visual acuity of 20/60 or worse, significant peripheral visual field defects, or a combination of both. Patients with significant peripheral visual field defects were tested on Goldmann perimetry and had monocular visual fields of less than 60 degrees using a size III4e Goldmann target. A chart review uncovered 35 patients from the Chicago Lighthouse and Spectrios Institute who met the inclusion criteria for the study. These patients were contacted by telephone and asked to participate in a 10–15 minute telephone survey. The 33 patients (94%) who agreed to participate were consented and asked to report the following: how long they have owned the device, how frequently they use each device/feature (0–7 days per an average week), the
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FIGURE 3. Siri. Photo showing examples of helpful assistive tasks able to be carried out by Siri.
reported benefit of using each feature (on a scale from one to 10), and their own self-assessed proficiency in using each feature (on a scale from one to 10). They were also asked which features they would be more interested in learning to use, if they had received any form of training in using the devices/features, and whether a healthcare professional recommended the device or features.
RESULTS Thirty-three low-vision patients agreed to participate in the survey (15 males, 18 females). The mean age of the respondents was 54.3 years, ranging from 26 to 87. There were 18 different diagnoses represented, with
Stargardt disease (5), oculocutaneous albinism (4), retinitis pigmentosa (3), and retinal detachments (3) being the most common (see Table 2). Six of thirtythree (18%) patients owned an iPhone, 12 (36%) owned an iPad, and 15 (45%) owned both devices (see Figure 7). The average visual acuity of respondents was 20/ 119 in the right eye and 20/133 in the left eye. Twentyone patients (64%) had reduced central visual acuity, six (18%) had peripheral visual field defects, and six (18%) had some combination of both. The most commonly used vision accessibility features were Zoom Magnification with 28 patients (84.8%) and Large Text with 27 patients (81.8%) (see Figure 8). The feature shown to be most beneficial was Large Text, with 37% of users ranking it number one, while Speak Seminars in Ophthalmology
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Accessibilty Options for the iPhone and iPad
FIGURE 4. Zoom Magnification. Series of photos demonstrating the capability of Zoom Magnification.
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FIGURE 5. Large Text. Photos depicting the magnification capabilities of Large Text.
FIGURE 6. Invert Colors. Photos showing normal contrast and reversed contrast using Invert Colors.
Selection exhibited the lowest values for both proficiency and benefit of use, with 42.8% of users ranking it last. Twenty-one patients (63%) were self-taught in the use of their device(s), four (12%) received training in an eye care professional’s office, four (12%) received training from an Apple store associate or comparable service, and four (12%) utilized some combination of these methods. Five (15%) patients reported having the iPad or iPhone recommended to them by a healthcare professional.
DISCUSSION Our study revealed that many patients who own an iPad or iPhone attempt to use the low-vision accessibility features, but are generally unfamiliar with their full capabilities. This may be due to several possible factors, including lack of clinician recommendations, lack of knowledge by the patient, and lack of the knowledge of these features by the doctor. Having been rated as the most commonly used feature and also the most beneficial feature, Zoom Seminars in Ophthalmology
Accessibilty Options for the iPhone and iPad
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Subject
Age
Diagnosis
Visual Acuity (OD, OS)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
72 79 54 55 52 52 66 61 45 85 43 30 38 48 60 28 38 55 72 38 59 26 71 78 85 70 44 32 39 39 35 87 58
Proliferative Diabetic Retinopathy Primary Open Angle Glaucoma Stargardt’s Macular Dystrophy Cone-Rod Dystrophy Albinism Retinitis Pigmentosa Myopic Degeneration Hemangiopericytoma Albinism Atrophic Macular Degeneration Optic Atrophy Cone-Rod Dystrophy Stargardt’s Macular Dystrophy Stickler Syndrome, bilateral RD Stargardt’s Macular Dystrophy Stargardt’s Macular Dystrophy Retinal Detachments Retinitis Pigmentosa NAION OD, retinal detachment OS BRVO OS, NAION OS, LTG OU Optic Atrophy Oculocutaneous Albinism Macular Degeneration (Atrophic) Macular Holes OU Macular Degeneration (Exudative) NAION OU Retinitis Pigmentosa Leber’s Congenital Amaurosis Keratoconus Stargardt’s Macular Dystrophy Oculocutaneous Albinism Primary Open Angle Glaucoma Toxic optic neuropathy secondary to chemotherapy
20/80, 20/160 20/160, 20/200 20/150, 20/150 20/120, 20/240 20/200, 20/200 20/200, 20/200 20/100, 20/100 20/50, 20/50 20/80, 20/80 20/60, 20/50 NLP, 20/60 20/120, 20/120 20/200, 20/120 20/200, NLP 20/360, 20/240 20/360, 20/400 20/100, NLP 20/200, 20/200 20/320, 20/280 20/40, 20/280 20/1600, 20/3000 20/120, 20/120 20/400, 20/40 20/160, 20/160 20/80, 20/100 20/120, 20/120 20/60, 20/60 HM, 20/200 20/120, 20/320 20/100, 20/100 20/200, 20/200 20/40, NLP 20/240, 20/120
List of all participants’ ages, diagnoses, and visual acuities.
Feature Ulizaon 28
30
iPhone (6)
Both (15)
iPad (12)
Number of Subjects
27
25 20
17
15
8
10
7
7
5
Magnification may be the most important feature to be initially incorporated into the low-vision rehabilitation plan by the practitioner. Since this study was completed, the functionality of Zoom Magnification has been improved through the introduction of the new iOS8 feature known as the Zoom Controller. This function allows the user to enable magnification and adjust the level of magnification with a single touch !
2015 Informa Healthcare USA, Inc.
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om
Te xt In
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i Sir
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Ov
Sp ea kS
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FIGURE 7. Device Ownership. Diagram depicting how many participants own each type of device.
er
0
Vo
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TABLE 2. List of subjects.
FIGURE 8. Feature Utilization. Graph showing how many participants reported using each feature.
through the use of a slider bar, potentially improving its ease of use for visually impaired individuals. VoiceOver was the number one feature that 11 out of 33 patients identified they would be motivated to
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use if they were more familiar with it. Speak Selection came in as the second most common feature that patients would use if they were more familiar with it (10 out of 33 respondents). Both of these features are auditory in nature and are often more complex to use than the magnification features. More users chose VoiceOver as being the most beneficial feature as compared to Speak Selection. This may be due to the higher acuity demand to utilize Speak Selection, which requires the user to locate and select a section of text to be read aloud. In comparison, VoiceOver reads the entire page without additional input. Siri is a versatile audio feature that surprisingly had the second lowest average proficiency of use, although over half of all patients reported using Siri. There is a general lack of public knowledge with regards to Siri’s full capabilities and potential benefits to a low-vision patient. Further, it takes time for a user to master the best tone of voice in which to communicate with Siri. Finally, it is important to adequately select the proper words and phrasing to use with Siri.4 Due to these details, the vast spectrum of Siri’s capabilities may be perceived as difficult to master by some patients. As time goes on, we anticipate that the functionality of Siri will continue to expand as both the technology and user performance with dictation features on mobile devices continually improve. There is currently no published research guiding clinicians in their recommendations of specific accessibility features based on a patient’s diagnosis and clinical findings such as visual acuity or visual field extent.5 It is our hope that the findings of this survey can lay the groundwork for future studies aimed at correlating clinical diagnoses and test results with the most advantageous features to be used by certain categories of patients. This can help to guide eye care specialists in their recommendations and training of patients in the use of these features. However, it is important to note that each individual patient has very specific needs with regards to their training in using these features, including but not limited to their age, initial level of comfort and familiarity with technology, manual and mental dexterity, and specific goals for using this technology. Once the initial assessment has been done, each patient should have an individualized program tailored to their specific needs. This study has several limitations including a small sample size gathered by convenience sampling from a small geographic area. This sampling error leads to findings which may not be representative of the entire population of visually impaired iPad and iPhone users. The study also includes patients with widely varying diagnoses, limiting the statistical conclusions which may be made. Our study indicates that many visually impaired patients are using low-vision accessibility features the
majority of the time when operating the iPhone and iPad. These features are being used to aid in instrumental tasks of daily living, and their ease of use allows patients across a wide range of ages and diagnoses to become proficient. We as practitioners must do a better job of encouraging the use of this technology in our management of patients, regardless of their age or level of vision, as it can prove to be highly beneficial in many cases. It is also our role to encourage our patients to seek further education in the use of these features, including focus groups or training sessions outside of a clinical setting. Doing so will allow us to advocate for our patients and help them to lead more productive and fulfilling lives.
ACKNOWLEDGMENT The authors acknowledge support from the Illinois Society for the Prevention of Blindness (ISPB) Research Grant.
DECLARATION OF INTEREST The authors report no declaration of interest. The authors alone are responsible for the content and writing of the article.
REFERENCES 1. Walker R. An iPad app as a low-vision aid for people with macular disease. Brit J Ophthalmol 1996;97:110–112. 2. Woods RL, Satgunam P. Television, computer and portable display device use by people with central vision impairment. Ophthal Physl Opt 2011;31:258–274. 3. Rana MM, Rana U. Accessibility evaluation of iPhone’s user interface for visually impaired. The 13th International Association of Science and Technology for Development Conference on Internet and Multimedia Systems and Applications, IASTED-IMSA09, Honolulu, Hawaii, USA, 2009;164–167. 4. Bahal A, Gupta R. Advances in automatic speech recognition: From audio-only to audio-visual speech recognition. J Comput Eng 2012;5(1):31–36. 5. Irvine D, Zemke A, Pusateri G, et al. Tablet and smartphone accessibility features in the low vision rehabilitation. Neuro-Ophthalmology 2014;38(2):53–59.
APPENDIX Text of Questionnaire
DEMOGRAPHICS Name: Age: Gender: M/F Seminars in Ophthalmology
Accessibilty Options for the iPhone and iPad Race: Ocular Diagnosis: Vision Impairment Level/ICD-9 Code: Better Seeing Eye
Worse Seeing Eye
ICD-9 Code
Best-corrected visual acuity without the use of magnification:
Do you utilize any other accessibility features for the iPhone that I have not mentioned? If so, what? If patient is iPad user: I will now list some low-vision accessibility functions for the iPhone. Please tell me whether or not you utilize that specific function, and if so, how many days out of an average week you use the function: Accessibility Option
How many days in an average week do you use the following accessibility options?
Distance Near Visual Field (Full/Constricted/Scotoma in Field)
Voiceover Screen Reader Siri Voice Assistant Zoom Magnification Large Text Invert Colors (Contrast) Speak Selection
Never Never Never Never Never Never
OWNERSHIP
Do you utilize any other features for the iPad that I have not mentioned? If so, what? In what way did you learn to use the accessibility functions of your iPhone/iPad? – Self Taught – Formal instruction from an eye care provider or rehabilitation specialist – Consumer training; i.e., Apple Store – Other (describe) On a scale of 1 to 10, how proficient do you feel you are with the accessibility options you currently use? (ask specifically for the feature the patient says they use)
OD
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9
OS
Do you currently own an iPhone? Y / N If yes, what version? Do you currently own an iPad? Y / N If yes, what version? How long have you owned the device(s)? iPhone iPad
Do not own Do not own
51 year 51 year
1–3 years 1–3 years
43 years 43 years
USAGE How many days do you use your iPhone in an average week? Never use 1 2 3 4 5 6 7 How many days do you use your iPad in an average week? Never use 1 2 3 4 5 6 7 If patient is iPhone user: I will now list some low vision accessibility functions for the iPhone. Please tell me whether or not you utilize that specific function and, if so, how many days out of an average week you use the function: Accessibility Option
How many days in an average week do you use the following accessibility options?
Voiceover Screen Reader Siri Voice Assistant Zoom Magnification Large Text Invert Colors(Contrast) Speak Selection
Never Never Never Never Never Never
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use 51 1 use 51 1 use 51 1 use 51 1 use 51 1 use 51 1
2 2 2 2 2 2
3 3 3 3 3 3
4 4 4 4 4 4
5 5 5 5 5 5
6 6 6 6 6 6
7 7 7 7 7 7
Accessibility option(s) patient is currently using
use 51 1 use 51 1 use 51 1 use 51 1 use 51 1 use 51 1
2 2 2 2 2 2
3 3 3 3 3 3
4 4 4 4 4 4
5 5 5 5 5 5
6 6 6 6 6 6
7 7 7 7 7 7
Scale (1-novice 10-expert) 1 1 1 1
2 2 2 2
3 3 3 3
4 4 4 4
5 5 5 5
6 6 6 6
7 7 7 7
8 8 8 8
9 9 9 9
10 10 10 10
Please rank all of the features you currently use, from most to least beneficial: Do you currently use any downloaded low-vision applications for the iPhone/iPad? If so, please rank them from most to least beneficial: Please specify if there are features you would be motivated to use if you were more familiar with them, and rank them based on your interest level: Has your low-vision eye care professional or other healthcare professional ever recommended the iPhone/iPad to you? YES / NO Any particular features? YES / NO If ‘‘YES,’’ please describe:
ORIGINAL ARTICLE
Usage of Accessibility Options for the iPhone and iPad in a Visually Impaired Population Joshua L. Robinson1,2,3, Vanessa Braimah Avery1,2,3, Rob Chun1,2,4, Gregg Pusateri2, and Walter M. Jay4 1
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Illinois College of Optometry, Chicago, IL, USA, 2Spectrios Institute for Low Vision, Wheaton, IL, USA, Chicago Lighthouse for People Who are Blind or Visually Impaired, Chicago, IL, USA, and 4Department of Ophthalmology, Loyola University Chicago, Chicago, IL, USA
ABSTRACT Purpose: The iPad and iPhone have a number of low-vision accessibility features including Siri Voice Assistant, Large Text, Zoom Magnification, Invert Colors, Voice Over, and Speech Selection. We studied their usage within a low-vision population. Methods: Patients were recruited to participate in an IRB-approved survey regarding their usage of the iPad and/or iPhone. Participants met one of the following criteria: best corrected visual acuity (BCVA) of 20/60 or worse, or significant peripheral visual field defects. Results: Thirty-three low-vision patients agreed to participate (mean age 54.3 years). There were 18 different diagnoses represented and the average visual acuity of respondents was 20/119 in the right eye and 20/133 in the left eye. The most commonly used vision accessibility features were Zoom Magnification and Large Text. Conclusions: Although many patients are using the low-vision accessibility features, few are receiving training or recommendations from their eye care specialist. Keywords: Accessibility features, activities of daily living, low vision rehabilitation, smartphones, tablet computers
INTRODUCTION
are made problematic by vision loss, as a study by Woods and Stagunam2 indicates that the majority of visually impaired users have difficulty watching videos on handheld devices. Advances in low-vision accessibility features allow the iPhone and iPad to be used more efficiently by the visually impaired. The Apple iPad and iPhone (examples of a tablet device and smartphone, respectively) were selected to be used in this study due to the ease of the user interface. All models of the iPhone are the same across different wireless carriers, making for straightforward instruction of the patient on the use of the low-vision accessibility features. Rana and Rana3 conducted a focus group of 15 visually impaired patients in which a series of tasks were performed using the iPhone. At the end of the session, a questionnaire revealed that 80% of participants felt confident using the iPhone user interface. Confidence when using the interface is
Millions of people worldwide are diagnosed with vision impairment resulting from a wide range of ophthalmic conditions. Having impaired vision can make it difficult to perform activities of daily living (ADLs) such as reading and communicating with others, which in turn can cause a dramatic decline in one’s quality of life.1 However, technological advances have made these tasks and interpersonal interactions easier for individuals with vision impairments. The use of portable electronic devices has allowed visually impaired patients to maintain a level of independence not previously possible. Further, both normally sighted and visually impaired people use handheld electronic devices for leisure activities such as watching videos or playing games. These activities
Received 2 December 2014; revised 28 January 2015; accepted 19 March 2015; published online 8 July 2015 Correspondence: Joshua Robinson, OD, Spectrios Institute for Low Vision, 219 East Cole Ave, Wheaton, IL 60187, USA. E-mail: [email protected]
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TABLE 1. Categories of vision accessibility features. Audio Options
Visual Options
Voiceover Screen Reader Speak Selection Siri Voice Assistant
Zoom Magnification Large Text Invert Colors
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Each accessibility option is categorized as either audio- or visually based.
essential because it determines the likelihood that a patient will use the device to complete necessary tasks. Much of one’s interaction with an iPad or iPhone is visually based, so even the slightest reduction in visual acuity or contrast sensitivity can lead to difficulty when using these devices without vision accessibility features. Since many people’s personal and vocational interactions are highly dependent upon technological connectivity, an inability to effectively use smartphones and tablets can become a hindrance to one’s productivity. It is therefore important that these devices be available to those with vision impairments so that they may be positive, contributing members of society. There are few studies that emphasize the use of tablets and smartphones to assist in activities of daily living. This may be due to this technology being relatively new and therefore not yet being fully incorporated into practitioners’ arsenal of options for their low-vision patients. With so many visually impaired people owning the iPad and iPhone, quantifying how the accessibility features are being used can be helpful in the initiation of care and recommendation of appropriate devices or features. These results may allow the eye care specialist community to better incorporate the technology offered through these devices into low-vision evaluations, especially if the patient already owns these tools. The Apple operating system (iOS7) has six primary, built-in, low-vision accessibility features which allow the visually impaired to more fully utilize their devices. This investigation was completed prior to the introduction of iOS8; all six of the basic accessibility features included in the study are still present in iOS8. These features can be grouped into two categories (Table 1). The audio-based features include VoiceOver Screen Reader (VoiceOver), Speak Selection, and Siri Personal Assistant (Siri). The visually based features include Zoom Magnification, Large Text, and Invert Colors. Using some or all of these features allows visually impaired individuals to more easily place and receive phone calls, compose and read text messages and e-mails, obtain directions, access websites, and perform other tasks which are integral to one’s daily life. VoiceOver describes aloud what appears on the screen, so the device can be used without actually seeing it. This feature tells the user about each item on
FIGURE 1. VoiceOver Screen Reader. Photo showing the various settings available when using VoiceOver.
the screen or about a specific item as it is selected. Upon opening a new screen, VoiceOver (Figure 1) plays a sound, then selects and speaks the first item on the screen (typically in the upper-left corner). Speak Selection (Figure 2) enables any text that is highlighted by a user to be read aloud. Once the text is highlighted, the dialect and speaking rate can be adjusted. Siri (Figure 3) is the intelligent personal assistant that helps a user to get things done just by talking into their device. Siri can be used to write and send a message, set a reminder, place a call, get directions, and more. Siri will ask a question if it needs clarification or further information, and is integrated with VoiceOver so that Siri’s responses will be audible to the user. Zoom Magnification (Figure 4) allows a user to magnify the entire screen of any application to the needed level of magnification. This is achieved by double-tapping the screen with three fingers or dragging up and down with three fingers. Large Text (Figure 5) increases the text size in certain functions of the device such as alerts, calendars, contact lists, messages, and notes. Invert Colors (Figure 6) is a feature that allows a user to change from black text on a white background to white text on a black background, resulting in a screen resembling a photographic negative. Introduction to, and training with, these features can be beneficial in meeting a patient’s goals. Through Seminars in Ophthalmology
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Accessibilty Options for the iPhone and iPad
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FIGURE 2. Speak Selection. Photo depicting the process of highlighting and reading text using Speak Selection.
the use of a telephone survey given to users of the iPad and iPhone, we aimed to investigate how these vision accessibility features are being used by visually impaired patients.
MATERIALS AND METHODS Patients were recruited to participate in a survey regarding their usage of the iPad and iPhone. This survey was approved by the Institutional Review Board (IRB) at the Illinois College of Optometry in Chicago, Illinois. The IRB is a committee which reviews proposed research involving human subjects to ensure that it in conducted in accordance with all federal, institutional, and ethical guidelines. Patients were eligible to participate if they were 18 years of age !
2015 Informa Healthcare USA, Inc.
or older, reported owning an iPad and/or iPhone, and met one of the following criteria: best-corrected visual acuity of 20/60 or worse, significant peripheral visual field defects, or a combination of both. Patients with significant peripheral visual field defects were tested on Goldmann perimetry and had monocular visual fields of less than 60 degrees using a size III4e Goldmann target. A chart review uncovered 35 patients from the Chicago Lighthouse and Spectrios Institute who met the inclusion criteria for the study. These patients were contacted by telephone and asked to participate in a 10–15 minute telephone survey. The 33 patients (94%) who agreed to participate were consented and asked to report the following: how long they have owned the device, how frequently they use each device/feature (0–7 days per an average week), the
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FIGURE 3. Siri. Photo showing examples of helpful assistive tasks able to be carried out by Siri.
reported benefit of using each feature (on a scale from one to 10), and their own self-assessed proficiency in using each feature (on a scale from one to 10). They were also asked which features they would be more interested in learning to use, if they had received any form of training in using the devices/features, and whether a healthcare professional recommended the device or features.
RESULTS Thirty-three low-vision patients agreed to participate in the survey (15 males, 18 females). The mean age of the respondents was 54.3 years, ranging from 26 to 87. There were 18 different diagnoses represented, with
Stargardt disease (5), oculocutaneous albinism (4), retinitis pigmentosa (3), and retinal detachments (3) being the most common (see Table 2). Six of thirtythree (18%) patients owned an iPhone, 12 (36%) owned an iPad, and 15 (45%) owned both devices (see Figure 7). The average visual acuity of respondents was 20/ 119 in the right eye and 20/133 in the left eye. Twentyone patients (64%) had reduced central visual acuity, six (18%) had peripheral visual field defects, and six (18%) had some combination of both. The most commonly used vision accessibility features were Zoom Magnification with 28 patients (84.8%) and Large Text with 27 patients (81.8%) (see Figure 8). The feature shown to be most beneficial was Large Text, with 37% of users ranking it number one, while Speak Seminars in Ophthalmology
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Accessibilty Options for the iPhone and iPad
FIGURE 4. Zoom Magnification. Series of photos demonstrating the capability of Zoom Magnification.
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FIGURE 5. Large Text. Photos depicting the magnification capabilities of Large Text.
FIGURE 6. Invert Colors. Photos showing normal contrast and reversed contrast using Invert Colors.
Selection exhibited the lowest values for both proficiency and benefit of use, with 42.8% of users ranking it last. Twenty-one patients (63%) were self-taught in the use of their device(s), four (12%) received training in an eye care professional’s office, four (12%) received training from an Apple store associate or comparable service, and four (12%) utilized some combination of these methods. Five (15%) patients reported having the iPad or iPhone recommended to them by a healthcare professional.
DISCUSSION Our study revealed that many patients who own an iPad or iPhone attempt to use the low-vision accessibility features, but are generally unfamiliar with their full capabilities. This may be due to several possible factors, including lack of clinician recommendations, lack of knowledge by the patient, and lack of the knowledge of these features by the doctor. Having been rated as the most commonly used feature and also the most beneficial feature, Zoom Seminars in Ophthalmology
Accessibilty Options for the iPhone and iPad
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Subject
Age
Diagnosis
Visual Acuity (OD, OS)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
72 79 54 55 52 52 66 61 45 85 43 30 38 48 60 28 38 55 72 38 59 26 71 78 85 70 44 32 39 39 35 87 58
Proliferative Diabetic Retinopathy Primary Open Angle Glaucoma Stargardt’s Macular Dystrophy Cone-Rod Dystrophy Albinism Retinitis Pigmentosa Myopic Degeneration Hemangiopericytoma Albinism Atrophic Macular Degeneration Optic Atrophy Cone-Rod Dystrophy Stargardt’s Macular Dystrophy Stickler Syndrome, bilateral RD Stargardt’s Macular Dystrophy Stargardt’s Macular Dystrophy Retinal Detachments Retinitis Pigmentosa NAION OD, retinal detachment OS BRVO OS, NAION OS, LTG OU Optic Atrophy Oculocutaneous Albinism Macular Degeneration (Atrophic) Macular Holes OU Macular Degeneration (Exudative) NAION OU Retinitis Pigmentosa Leber’s Congenital Amaurosis Keratoconus Stargardt’s Macular Dystrophy Oculocutaneous Albinism Primary Open Angle Glaucoma Toxic optic neuropathy secondary to chemotherapy
20/80, 20/160 20/160, 20/200 20/150, 20/150 20/120, 20/240 20/200, 20/200 20/200, 20/200 20/100, 20/100 20/50, 20/50 20/80, 20/80 20/60, 20/50 NLP, 20/60 20/120, 20/120 20/200, 20/120 20/200, NLP 20/360, 20/240 20/360, 20/400 20/100, NLP 20/200, 20/200 20/320, 20/280 20/40, 20/280 20/1600, 20/3000 20/120, 20/120 20/400, 20/40 20/160, 20/160 20/80, 20/100 20/120, 20/120 20/60, 20/60 HM, 20/200 20/120, 20/320 20/100, 20/100 20/200, 20/200 20/40, NLP 20/240, 20/120
List of all participants’ ages, diagnoses, and visual acuities.
Feature Ulizaon 28
30
iPhone (6)
Both (15)
iPad (12)
Number of Subjects
27
25 20
17
15
8
10
7
7
5
Magnification may be the most important feature to be initially incorporated into the low-vision rehabilitation plan by the practitioner. Since this study was completed, the functionality of Zoom Magnification has been improved through the introduction of the new iOS8 feature known as the Zoom Controller. This function allows the user to enable magnification and adjust the level of magnification with a single touch !
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s or ol tC ve r
om
Te xt In
La rg e
Zo
i Sir
o n ec el
Ov
Sp ea kS
ice
FIGURE 7. Device Ownership. Diagram depicting how many participants own each type of device.
er
0
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TABLE 2. List of subjects.
FIGURE 8. Feature Utilization. Graph showing how many participants reported using each feature.
through the use of a slider bar, potentially improving its ease of use for visually impaired individuals. VoiceOver was the number one feature that 11 out of 33 patients identified they would be motivated to
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use if they were more familiar with it. Speak Selection came in as the second most common feature that patients would use if they were more familiar with it (10 out of 33 respondents). Both of these features are auditory in nature and are often more complex to use than the magnification features. More users chose VoiceOver as being the most beneficial feature as compared to Speak Selection. This may be due to the higher acuity demand to utilize Speak Selection, which requires the user to locate and select a section of text to be read aloud. In comparison, VoiceOver reads the entire page without additional input. Siri is a versatile audio feature that surprisingly had the second lowest average proficiency of use, although over half of all patients reported using Siri. There is a general lack of public knowledge with regards to Siri’s full capabilities and potential benefits to a low-vision patient. Further, it takes time for a user to master the best tone of voice in which to communicate with Siri. Finally, it is important to adequately select the proper words and phrasing to use with Siri.4 Due to these details, the vast spectrum of Siri’s capabilities may be perceived as difficult to master by some patients. As time goes on, we anticipate that the functionality of Siri will continue to expand as both the technology and user performance with dictation features on mobile devices continually improve. There is currently no published research guiding clinicians in their recommendations of specific accessibility features based on a patient’s diagnosis and clinical findings such as visual acuity or visual field extent.5 It is our hope that the findings of this survey can lay the groundwork for future studies aimed at correlating clinical diagnoses and test results with the most advantageous features to be used by certain categories of patients. This can help to guide eye care specialists in their recommendations and training of patients in the use of these features. However, it is important to note that each individual patient has very specific needs with regards to their training in using these features, including but not limited to their age, initial level of comfort and familiarity with technology, manual and mental dexterity, and specific goals for using this technology. Once the initial assessment has been done, each patient should have an individualized program tailored to their specific needs. This study has several limitations including a small sample size gathered by convenience sampling from a small geographic area. This sampling error leads to findings which may not be representative of the entire population of visually impaired iPad and iPhone users. The study also includes patients with widely varying diagnoses, limiting the statistical conclusions which may be made. Our study indicates that many visually impaired patients are using low-vision accessibility features the
majority of the time when operating the iPhone and iPad. These features are being used to aid in instrumental tasks of daily living, and their ease of use allows patients across a wide range of ages and diagnoses to become proficient. We as practitioners must do a better job of encouraging the use of this technology in our management of patients, regardless of their age or level of vision, as it can prove to be highly beneficial in many cases. It is also our role to encourage our patients to seek further education in the use of these features, including focus groups or training sessions outside of a clinical setting. Doing so will allow us to advocate for our patients and help them to lead more productive and fulfilling lives.
ACKNOWLEDGMENT The authors acknowledge support from the Illinois Society for the Prevention of Blindness (ISPB) Research Grant.
DECLARATION OF INTEREST The authors report no declaration of interest. The authors alone are responsible for the content and writing of the article.
REFERENCES 1. Walker R. An iPad app as a low-vision aid for people with macular disease. Brit J Ophthalmol 1996;97:110–112. 2. Woods RL, Satgunam P. Television, computer and portable display device use by people with central vision impairment. Ophthal Physl Opt 2011;31:258–274. 3. Rana MM, Rana U. Accessibility evaluation of iPhone’s user interface for visually impaired. The 13th International Association of Science and Technology for Development Conference on Internet and Multimedia Systems and Applications, IASTED-IMSA09, Honolulu, Hawaii, USA, 2009;164–167. 4. Bahal A, Gupta R. Advances in automatic speech recognition: From audio-only to audio-visual speech recognition. J Comput Eng 2012;5(1):31–36. 5. Irvine D, Zemke A, Pusateri G, et al. Tablet and smartphone accessibility features in the low vision rehabilitation. Neuro-Ophthalmology 2014;38(2):53–59.
APPENDIX Text of Questionnaire
DEMOGRAPHICS Name: Age: Gender: M/F Seminars in Ophthalmology
Accessibilty Options for the iPhone and iPad Race: Ocular Diagnosis: Vision Impairment Level/ICD-9 Code: Better Seeing Eye
Worse Seeing Eye
ICD-9 Code
Best-corrected visual acuity without the use of magnification:
Do you utilize any other accessibility features for the iPhone that I have not mentioned? If so, what? If patient is iPad user: I will now list some low-vision accessibility functions for the iPhone. Please tell me whether or not you utilize that specific function, and if so, how many days out of an average week you use the function: Accessibility Option
How many days in an average week do you use the following accessibility options?
Distance Near Visual Field (Full/Constricted/Scotoma in Field)
Voiceover Screen Reader Siri Voice Assistant Zoom Magnification Large Text Invert Colors (Contrast) Speak Selection
Never Never Never Never Never Never
OWNERSHIP
Do you utilize any other features for the iPad that I have not mentioned? If so, what? In what way did you learn to use the accessibility functions of your iPhone/iPad? – Self Taught – Formal instruction from an eye care provider or rehabilitation specialist – Consumer training; i.e., Apple Store – Other (describe) On a scale of 1 to 10, how proficient do you feel you are with the accessibility options you currently use? (ask specifically for the feature the patient says they use)
OD
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OS
Do you currently own an iPhone? Y / N If yes, what version? Do you currently own an iPad? Y / N If yes, what version? How long have you owned the device(s)? iPhone iPad
Do not own Do not own
51 year 51 year
1–3 years 1–3 years
43 years 43 years
USAGE How many days do you use your iPhone in an average week? Never use 1 2 3 4 5 6 7 How many days do you use your iPad in an average week? Never use 1 2 3 4 5 6 7 If patient is iPhone user: I will now list some low vision accessibility functions for the iPhone. Please tell me whether or not you utilize that specific function and, if so, how many days out of an average week you use the function: Accessibility Option
How many days in an average week do you use the following accessibility options?
Voiceover Screen Reader Siri Voice Assistant Zoom Magnification Large Text Invert Colors(Contrast) Speak Selection
Never Never Never Never Never Never
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use 51 1 use 51 1 use 51 1 use 51 1 use 51 1 use 51 1
2 2 2 2 2 2
3 3 3 3 3 3
4 4 4 4 4 4
5 5 5 5 5 5
6 6 6 6 6 6
7 7 7 7 7 7
Accessibility option(s) patient is currently using
use 51 1 use 51 1 use 51 1 use 51 1 use 51 1 use 51 1
2 2 2 2 2 2
3 3 3 3 3 3
4 4 4 4 4 4
5 5 5 5 5 5
6 6 6 6 6 6
7 7 7 7 7 7
Scale (1-novice 10-expert) 1 1 1 1
2 2 2 2
3 3 3 3
4 4 4 4
5 5 5 5
6 6 6 6
7 7 7 7
8 8 8 8
9 9 9 9
10 10 10 10
Please rank all of the features you currently use, from most to least beneficial: Do you currently use any downloaded low-vision applications for the iPhone/iPad? If so, please rank them from most to least beneficial: Please specify if there are features you would be motivated to use if you were more familiar with them, and rank them based on your interest level: Has your low-vision eye care professional or other healthcare professional ever recommended the iPhone/iPad to you? YES / NO Any particular features? YES / NO If ‘‘YES,’’ please describe:
