Adapting to AMD can be challenging. Changes in vision may be disorienting, especially when they first occur. Sometimes learning to better understand and use your vision can be helpful. This booklet presents ways to optimize how you use both your vision and other resources to accomplish daily goals.

     If you are reading this book on a computer monitor, you may want to increase or decrease the font size for easier viewing. To do this, press and hold the "Control" key in the lower-left corner of your keyboard. While holding, press the "+" (plus) key to make the print larger, or press the "-" (minus) key to make the print smaller.

     PLEASE WRITE A REVIEW: Do you think this booklet might be helpful to you or someone you know who has AMD? If you try these lessons, please write a brief review so that others may be guided by your comments. What was helpful? What was not helpful? Your comments may help others to decide whether or not the book might be useful in their particular circumstances. You may email your comments to me at leslieburkhardt@gmail.com.

Thank you.

Leslie Burkhardt, MSLVR
Los Angeles, California

Who Can Use This Workbook

    These lessons help people use their vision better to see objects, to read and to write. They do this by helping people become more aware of ways to use their vision. This workbook is for people who have age-related macular degeneration and:

1) have had a marked change in their ability to read in the past two years,

2) notice that words or parts of words sometimes vanish or dim when reading,

3) can read this print, with or without a magnification device, well enough to finish this page in less than 5 minutes. (A low vision rehabilitation service can help to find the best device for you.)

Introduction

    Age-Related Macular Degeneration (AMD) affects visual abilities. It causes a blank spot (scotoma) in the center of a person’s field of view. That center area is normally the area where vision is the sharpest, so even when a very small blank spot occurs in the center, the vision becomes less clear, even when a person wears eyeglasses that focus vision as well as possible. The larger the center blank spot is, the less clear the vision will be. When the blank spot is only in one eye, the person uses the other eye to see as clearly as possible. When the blank spot is in both eyes, the brain usually uses only the eye with the smallest blank spot when it is trying to see something as sharply as possible.

    When AMD affects both eyes, nothing can make a person’s vision clearer. However, if an object or print is too difficult to see, sometimes it helps if the object can be changed so that it appears larger, bolder and stands out from its background.

    AMD particularly affects reading ability. Even with a small central blank spot in the better eye, people will usually have difficulty with long reading tasks like reading a newspaper or magazine article, or a chapter in a book. They are reading much more slowly than they were before AMD, and their eyes get tired much more quickly even when the print is enlarged to the best reading size. This occurs even after people learn to use their vision as well as possible either on their own or using lessons provided by a low vision rehabilitation specialist. If the blank spot gets larger, the print will need to be larger for the person to see it. If the print size needs to be larger, reading speed is slower and people’s eyes get tired faster.

    Usually, a person with moderate to severe macular degeneration can still see very large, bold print. However they may use their vision to read only when the task is very important and very short, such as a phone number, an address or a price tag. Even tasks like these are read with great effort. Some people who are able to read large print, still prefer to have someone read their mail to them, because it is much easier and faster. They use audio sources, like recorded books or personal assistance, for longer reading tasks.

How to Use This Workbook

    Your eyes may tire using this workbook, so rest often:

Work / Rest / Work / Rest

    If you work just 10 – 15 minutes a day with this book, on and off, you will start to learn new visual habits.

    You may also prefer to have a friend or family member read aloud the part of the text that provides learning information, and then view the text yourself only when visual exercises are presented.

    Another option is to have your computer read the text to you. Nearly all computers have this option, which can be activated in the "Accessibility" section of your control panel. Other commercial programs are also available that read displayed text aloud. Some are simple-to-use and available for free without trial expiration dates. Check with a low vision rehabilitation specialist for more information.

    If you are viewing the printed version of this book, you may want to put it on a reading stand, music stand or clipboard so that it is in front of your face at your best reading distance, and at a good reading angle. Try to sit up straight as you read.

    If you are viewing this book on a computer monitor, you will need to download and print out the worksheets from:

Your Toolbox

• An object should be only as large as is needed to see the object with as much detail as is needed.
  
  
• If an object is twice as close to you, it appears twice as big. However, most adults over the age of 40 need reading glasses or a magnifier to focus on objects that are closer than an arm’s distance away from the eye. The closer the object, the more powerful the lens needs to be.
  
  
• Magnifiers, eyeglasses, telescopes and electronic magnification systems such as closed-circuit televisions (CCTVs) can make an object seem bigger so that it is easier to see. A low vision rehabilitation service can help you find the best device for the task that you are trying to do.
  
  
• When an object is smaller, it can be seen in relation to the objects around it, and sometimes this can help identify an object.
  
  
• When an object is smaller, it can be seen without moving the eyes as much, so the eyes will not tire as quickly. This also lessens the possibility of motion sickness.
  
  
• If you are reading larger print, and start to feel a bit queasy, stop reading until the feeling passes. To avoid that queasy feeling, move print in front of your face more slowly.
  

• Find the best focus distance of your reading eyeglasses when you look at something close to you. For bifocals, raise your chin, so you look through the lower lens. Use the “A” below as a target. Put the “A” on your nose, then slowly move it away from your face until it is in the sharpest focus.

  A
  

  Now lower your chin, so you are looking at the “A” with the top half of your eyeglasses. Does it get fuzzier? If it helps you to see better, use reading glasses at their best focus distance.
  
  

• Check to see if your distance eyeglasses help you to see better. Sit 3 to 4 feet from a TV. Look at the TV with and without your distance eyeglasses (or the top part of your bifocals). Try this also at 6 – 8 feet from a TV. If the TV is sharper when you use distance eyeglasses, wear them when you need to look at distant objects.
  

• Objects are seen better when they stand out from the background.
  
  
• If the object is light colored, put it on a dark background. If it is dark, put it on a light background.
  
  
• Avoid backgrounds (like a table cloth or a plate) that have patterns or prints.
  
  
• Choose pens that make a thick, black line.
  

• Vision is eyesight, memory and logic working together. When eyesight is less clear, memory and logic do more work.
  
  
• The more you work at identifying objects that look fuzzy, the more able you will be to identify them using your eyes, memory and logic together.
  
  
• When you cannot identify an object, ask yourself what belongs where you are looking. (Example: Knowing that an object is a toaster, because it is in a kitchen.)
  
  

7. PERSONAL HELP

    People can help you to get things done and learn new skills. There is a difference between dependence and inter-dependence. Think about the difference between these two words. Inter-dependence can be a helpful skill to learn. It is the building block of all great nations.

8. THE BEST EYE POSITION

• If you have a blank, dim or distorted area in the center of your field of vision, that area can block what you are trying to see.
  
  
• Some areas in your field of vision see more clearly than other areas. When your vision changes, you must learn to find the new area of best vision. These areas will not be as clear as the center area used to be.
  
  
• The clearest vision is often at the edge of the center blank spot.
  
  
• The larger the blank spot is in the center of your vision, the less clear your vision will be, and the larger the print needs to be for you to see it. When a person has age-related macular degeneration, the center blank spot usually does not get any bigger than the central 20% of a person’s total visual field.
  
  
• It is easy for your gaze to drift away from a new area of best vision, but the more you work on finding the best spot and staying on that spot, the easier this will become.
  
  
• Learning to find your best area of vision is something that will be covered in the lessons that follow.
  

TRY THIS:

Look at this book with the different lamps in your home. Move each lamp close to the book and then far away, to the left and then to the right. Look at the book in the sun. Where is the best light for you to read?

Gather any sunglasses and hats that you own. Put them on, in your house, in a market, in bright sun, in shade, and when you ride in a car. What tint do you wear, in what type of light, to see the best? Notice which sunglasses give you better glare protection, and which sunglasses allow you to see more sharply.

Stand across the room from an object like a vase of flowers or a picture. Look at it, then move two steps closer and look again. Keep doing this until you are right next to the object. Where do you stand to see most clearly?

Set your table with different colors of placemats, plates and cups. Add types of food: carrot sticks, potato chips, coffee or milk. What color combinations help you see most clearly?

Sit 3 or 4 feet from a TV. With your eyes closed, change the channel, then listen until you make a picture in your mind of what you hear. Open your eyes and compare the picture you see with the one in your mind. Do this again with 3 more channels.

Call a phone number that you know well. Use only touch to enter the number on the phone keys. Remember that the numbers start at the top:

1    2    3
4    5    6
7    8    9
*    0    #

You can stick a bump on the 5, and find the bump with your middle finger. Your index finger pushes 1, 4, 7. Your middle finger pushes 2, 5, 8. Your ring finger pushes 3, 6, 9. The thumb pushes the bottom row: *, 0, #. Try this many times before you really call. If this is just too much work sometimes, you can push “0” and ask the operator to call the number for you. This is a free service for people with vision problems. Call your phone company for more information.

Pick out an outfit to wear. Then get dressed and groomed. Now ask someone: How do I look? Does anything need fixing?

Go to a market and try to find the food that you need. Can you find ketchup, mustard, mayonnaise and pickle relish at the market? They are all related, so they will be near to each other. Do you remember what part of the store they are in? Can you find them by the color or the shape of the jar? Slowly scan the shelves from top to bottom, and left to right, so you do not miss anything.

Your Toolbox Checklist

Think about and use each of these tools during each lesson. Review this section as you do the lessons to help you remember the information.

Lighting

Object Size

Eyeglasses

Contrast

Other Senses

Memory & Logic

Personal Help

Eye Position

Lesson 1: Seeing Objects

Find a coffee mug with writing or a picture on it for this first lesson.

1. Place it on a table in front of you, a full arm’s distance away.

2. Do you need to adjust the lighting, or put a placemat of a different color under the mug so that it does not blend into the background?

3. Cup your hand over the eye with less vision. Does the mug seem more clear? If so, block this eye when you need to see more clearly.

4. Do any blank or dim spots in your field of vision block the mug? The blank spots will move as you move your eye. If you move your gaze up, any spots will also move up.

5. Watch the mug as you move your gaze up, down, to the left and to the right of the mug. Does the mug appear more clear when your eye is in a certain position? You are trying to avoid the blank or dim areas of vision, and find the clearest area.

6. Try to remember where you need to look to see the mug as clearly as possible.

7. Hold the mug about 10 inches from your face and repeat steps 3 - 6 looking through your reading glasses.

Lesson 2: Reading

1. Can you block the word or a part of the word with a blank or dim spot in your field of view?

2. Try to move the blank spot just above the word by looking upwards. Is the word more clear when you do this? You need to pay attention to the word, and not the blank spot.

3. On the same grid, try to move the blank spot:


• just to the left of the word
  
  
• just above and to the left of the word
  
  
• just below and to the left the word
  
  
• just below the word
  
  
• just below and to right of the word
  
  
• just to the right of the word
  
  
• just above and to the right of the word
  

4. Is the word more clear when you move your blank spot to one of these areas? Remember where you looked to best see the word.

TIP: If you see just as clearly no matter where you place your blank spot, place the blank spot just above the word. This will let you read from left to right, and from the top of the page down in the easiest way.

5. On the next grid, read the words from left to right. Try to see each word as clearly as possible.






6. Read each word on this next grid. Where do you look to see each word the best?







READING FROM LINE TO LINE

• When you have a blank spot in the center of your vision, you may lose your place as you read, and skip or repeat lines. To avoid this, try reading in a new way:
  
  
1. READ THE FIRST LINE OF A STORY

2. SCAN BACK TO THE START OF THE SAME LINE

3. DROP YOUR GAZE DOWN TO THE NEXT LINE

4. READ THE NEXT LINE.



• If you practice reading like this, soon you will read this way without thinking.
  
  
• Use your finger or the edge of a black pocket comb to keep your place if this helps.
  

TRY THIS:


Read the next story using the four steps above. Since you will need to think about HOW you are reading, not WHAT you are reading, do not worry if you do not understand the meaning of the story as well as usual:




Excerpts from “Rhyme and Reason”
from The Phantom Tollbooth
© 1961 by Norton Juster



        "It has been a long trip," said Milo, climbing onto the couch where the princesses sat; "but we would have been here much sooner if I hadn't made so many mistakes. I'm afraid it's all my fault."

        "You must never feel badly about making mistakes," explained Reason quietly, "as long as you take the trouble to learn from them. For you often learn more by being wrong for the right reasons than you do by being right for the wrong reasons."

READING EASY WORDS


• This book may be easier for you to read than most. Because most of the words are easy words, you just need a glance to know them.
  
  
• The more words or letters that you can read with quick glances, the faster you can read.
  
  
• When you read, practice to see how many words or letters you can read with quick glances. See if you can increase the number with practice each day.
  
  
• Guess at common words that you are almost able to see. You may often be right. It is less effort to read this way, and you will guess better with practice.
  
  
• How much you can read in one glance may be limited by the size or number of blank spots in your field of view, so use a number of quick glances to piece a word or phrase together if you need to.
  

TRY THIS:


In the next story, try to read each group of words in quick glances:



More from “The Phantom Tollbooth”
© 1961 by Norman Juster



"You may        not see        it now,        said the

Princess of        Pure Reason,        looking

knowingly        at Milo's        puzzled face,

"but whatever        we learn        has a purpose

and whatever        we do        affects everything

and        everyone else,        if even in         the

tiniest way.        Why,        when a housefly

flaps his wings,        a breeze        goes round

the world;        when a speck        of dust falls

to the ground,        the entire planet        weighs

a little more;        and when you        stamp

your foot,

the earth moves        slightly off

its course.        Whenever you laugh,

gladness spreads        like the ripples        in a

pond;        and whenever you're sad,

no one anywhere        can be really happy.

And it's much        the same thing

with knowledge,        for whenever you

learn something new,        the whole world

becomes that much richer.”


READING HARD WORDS


• Long words or less common words often cannot be read at a glance. They must be read letter by letter.
  
  
• If you work too hard reading each letter, you may forget the meaning of the thought.
  
  
• You may want to skip some hard words as you read, or go back and read them at the end of a thought.
  
  
• For example, you may want to read:
  

“Mr. Tochioka from Chatanika walked toward the crowd.” as: “Mr. T from C walked toward the crowd.”

TRY THIS:


The next drill helps you to read letter-by-letter when you need to. Each line of letters has a letter at the start. Draw a line under each letter as you find it. This worksheet may be downloaded and printed out from:

www.mdsupport.org/worksheets.pdf



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Worksheet #1
Draw a line under this letter:    n

n m m n    n m n m    m m n n    m n m n    n n m m

Draw a line under this letter:    o

o u o u    o u c o    u u u o    o u c u    u c o u

Draw a line under this letter:    v

v y v v    w y v w    v w v v    y v w w    v y v w

Draw a line under this letter:    s

s a s a    s s s a    a a s a    a s a s    s a a s

Draw a line under this letter:    f

f f t t       t t t f       f t f t       t f t f       f f f t

Draw a line under this letter:    h

h h h b    h b b h    h h h b    b b h h    h b h b

Each line of numbers has a number at the start. Draw a line under each of these numbers as you find them.

Draw a line under this number:    7

7 7 2 1    7 1 2 7    2 7 1 7    1 7 7 2    2 1 7 2

Draw a line under this number:    3

3 3 8 8    3 8 3 8    8 3 3 3    8 8 8 3    3 8 8 8

Draw a line under this number:    9

8 9 4 9    9 4 8 9    9 8 9 4    4 4 9 9    9 4 8 4

Draw a line under this number:    6

5 6 6 5    8 6 5 5    5 5 6 8    6 5 5 8    6 6 8 6



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The more you practice reading, the less you will think about HOW you are reading. You will start to read by habit. Then you can think more about WHAT you are reading.

READING IN THE REAL WORLD

When you are trying to read mail and other writing, many things will affect if you are able to read, such as:


• Line and letter spaces. Read the next few words:
  


Now read the same words with more space between each line and letter:



• Space between each letter can be condensed, normal or expanded. Expanded spacing is easiest to read.
  
  
• Contrast will also make a difference. Here is a sentence that may be harder to read because the print and the background are similar:
  


Most people with partial vision prefer contrast combinations that are bright against dark or visa versa, like black and white, or yellow and black.

TRY THIS:


Some styles of print, called fonts, are easier to read then others. On the next page is a poem, printed in different fonts. If you have read it before, it will be easier for you to make sense of some of the fonts that are more difficult to read. If you have not read it before, the repeated words and the rhymed words will be easier to read. Most of the poem is single-space printing, so you may want to use a ruler, your finger or other guide to keep your place. Remember: Rest your eyes when they tire!









TIP: Most print is not large print. A low vision rehabilitation service can help you find a magnification device that will help you read print that is this size:



Here is standard, 12-point print. Extra space between lines and task lighting also helps reading.

It is not unusual for magazines and newspapers to use 10-point print. It’s very small!


In standard dictionaries, CD notes, clauses in legal contracts or medicine instructions, the print size can be 8 points or smaller.

TRY THIS:


Look at your mail each day. Can you tell who it is from? Can you find and read the most important parts?

Try to read a TV guide. This print is very small, and the letters are close together.

Try to read a take-home restaurant menu before you go out.

Take a magnifier to a store to read labels and price tags. Use it only when you must. Items that you buy again and again will be easy to spot, and you may not need to know the price.



READING WITH YOUR EYES OR EARS?

    Many people with AMD say that they read only the information that they need and have to read with their eyes. This kind of information might include mail, labels and price tags. Reading with AMD is more work, and the larger the center blank spot is, the harder a person works to read. Because of this, you may find that you rely more on listening to recorded books, TV or radio for large amounts of information. This is OK! Use your eyes enough, though, that you keep the skills you have learned to do the tasks that you need to do. At least a total of five minutes of reading and writing each day will help retain skills.
    Remember also that reading with your ears also requires practice until you can do it without thinking about it. Practice active reading habits when you listen to a book. Push the stop button when your mind wanders or when you need to think about what you have just heard. You may need to re-read some parts to really understand them. Read an audio book the same way you used to read print books.

TRY THIS:


Find your nearest free library service for people with vision impairments by calling 1-800-882-1629. Apply for service, and order a recorded book. Order a book that you read long ago, but want to re-read. That is a good first project. Use earphones if you want to listen in private and hear better. You may not enjoy the first two or three books that you read, because you are learning new reading habits.

Watch three TV programs: News, a game show, a drama or sitcom. How much information did you get from each program? How much did you miss? How close do you need to sit to see best? Does it feel better sometimes to close your eyes and just listen?

If you really miss the information in a newspaper, call the National Federation for the Blind’s free Newsline service at 1-888-882-1629. Using the keypad on your phone, you can select any of over 200 newspapers to listen to. It takes practice to get used to the non-human voice, and to learn to use this service.




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Lesson 3: Writing


    Writing is a very useful skill. Also, because the sense of touch works with vision when writing, each sense helps the other work. This lesson has drills to help improve writing skills.

    As you do the drills, use a pen that has a bold line. When writing large print, use something similar to a Sanford brand “20/20” or “Sharpie” pen. These make a thick, black line. If you use a Sharpie, a blank page under the writing page will blot the ink. When you need a thinner line, use a medium-point, nylon-tip pen.

    If you see better when you are up close, put pillows or phone books below your writing surface, to raise it nearer to your face, or use a clip board or music stand to raise your task up to your face.



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Worksheet #2
Download and print out from
www.mdsupport.org/worksheets.pdf
Drill 1: Draw a Big “X” in Each Box


    If you get bored with Xs, try to draw a happy, sad or wow face. On the facing page, you may want to try using a pen with a thinner line, along with a magnification device or CCTV. Examples:







TIP: Visit a low vision rehabilitation service to select the best magnification device, and to learn how to use it.






Drill 2: Draw Zig-Zag Lines Between the Lines

    On the next page, you may want to try using a pen with a thinner line, and a magnification device or CCTV. Example:







TIP: Bold-line paper and writing guides are available from companies that sell products for people with vision impairments.






Drill 3: Practice Writing B-I-G

    If you have written one size and style most of your life, you will need to practice writing big. Block printing can be hard for someone who likes to write in script, but it is often easier to read. Use a pen with a thick line for this next drill. Copy this on the second line:






    You have more room to write big if you turn the paper sideways. Write a note to yourself:






Drill 4: Practice Math Problems

    Here are some sample math problems. Make up some of your own on the next page:




















Drill 5: Practice Your Signature

When you sign your name, it should be:

1. On or near the signature line.

2. Not easy for someone to copy.

3. The same each time.

4. Able to be done fast.

    Practice writing your signature again and again. You may want to use a writing guide or the edge of a credit card above or below your writing to guide you. If your signature has changed a lot since your vision has changed, give your bank a new copy of your signature.






---

TRY THIS:


Write a fake grocery list. Write it big, and then try to read it later.

Write a note to someone. Ask the person if the note can be read. Keep writing notes until people are able to read them.

Ask your bank about large-print checks. Most banks have them. Your bank can order large-print checks for you by calling Deluxe Check Printing Company at 800-335-8931, and asking for “Guideline Checks.”




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Final Notes



Charles Bonnet Syndrome

    This note is included, because people with AMD or any vision problem can have something called Charles Bonnet Syndrome (CBS). A person will “see” a visual image that the person usually knows is not real. Some people may not want to tell anyone that they are seeing strange visions out of fear that people might think they have a mental disorder. CBS occurs in about twenty percent of people who have vision loss. Though no accepted theory explains why this occurs, it is known to be related to vision loss, and not to a mental disorder. The images are only visual, uncontrollable, and vary as to how long and often they occur.

    Reported images include highly colored flowers, shapes or patterns, landscapes, animals, walls of brick, uniformed people and elves! If you have questions about CBS, take this booklet to your eye doctor, who can discuss it with you.



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Review This Booklet

    Good for you! You have completed the booklet. Now keep it nearby, and read it again now and then, especially if your vision changes.

    Also, a low-vision rehabilitation service can help you find the best ways to complete the tasks that you want to do. Find a service in your area.

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