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PART ~ Looking to the Future After many decades of research on the aging eye, vision scientists are on the threshold of significantly improving the working conditions of older employees. Investigators are devoting more time to studies of suit- able procedures for screening the vision of older workers, the basic visual abilities needed to perform visually guided tasks, and long-term research documenting how eyesight changes with age. Scientists are also exam- ining how retirement decisions are affected by company policies. These research efforts run the gamut from laboratory studies to home surveys, examination of tasks at the workplace, and analysis of large statistical data bases such as those kept by the U.S. Bureau of the Census. In conjunction with these efforts, research on normal changes in vision with age may indicate the most pressing visual problems of older people and their impact on working. Says Sara Czaja, "We need to . . . allow for developmental changes which occur as a natural function of the aging process. Therefore we need data on the type and extent of these changes and their implications for the performance of everyday tasks and activities." Such information is vital to implementing changes in the workplace that would benefit older people. Although data on the impact of basic changes in vision, such as reduced visual acuity, increased sen- sitivity to glare, loss of peripheral vision, and reduced color perception, are available, little ofthat information has been related to daily activities or specific tasks at work. In addition, few if any records are kept on employees with deteriorating eyesight, most of whom are older and have only minor visual impairment. These people usually accept their reduced vision as an inevitable part of aging. Yet laboratory studies and on-the job experience suggest a variety of methods for retaining these people as pro- ductive members of the work force. Researchers have found that eye examinations which take into account the type of lighting and visual tasks encountered at work may be This section includes material presented at the conference by Richard Burkhauser, Pauline Robinson, Corinne Kirchner, Hilda Kahne, Joseph Maino, Ronald Wilson, Harold Sheppard, and Arnold Small. 31

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most effective in treating the older employee. A portable, high-intensity desk lamp has brightened the work life of many older workers, whose smaller pupils dramatically reduce the amount of light reaching the retina. Placing nonreflective material on desktops and over video display terminals reduces glare, to which older people are particularly sensitive. And both laboratory and workplace studies indicate that older workers can be trained to improve their performance on some visual tasks. t iDo Companies Want? A basic problem with implementing retraining programs and proposed design changes is that many companies are simply not inter- ested in retaining older workers, and not all workers wish to stay on. Early retirement plans are common, especially among larger businesses. Companies that continue medical insurance coverage after workers leave the job may inadvertently encourage early retirement. Disincentives to continue working include restrictions on increasing pension benefits after normal retirement age. With so many other predisposing factors, the extent to which age-related decline in vision affects the decision to retire is unknown. Most companies cite cost savings as the main reason for early or mandatory retirement policies. Businesses point to the higher salaries earned by older employees, the obsolescence of their skills, increased absenteeism, and the disadvantages of holding back the careers of younger employees. Many of these reasons for retiring workers are questionable; for example, studies show that absenteeism is not signifi- cantly higher among older workers than it is among younger employees. Economics may force companies to retain more older workers as the turn of the century approaches. The smaller population of younger people following the baby boom, the dramatically smaller percentage of men in the work force, and an expected leveling off of the number of women in the job market all point to a shortage of workers in the coming decades. Older workers may become more valuable, and the advent of flexible, part-time work plans may keep many aging employees on the payroll. At present, however, efforts to extend the work life of older people with impaired vision may be most successful in those firms that recognize the economic advantage of retaining them. According to Pauline Robinson, formerly with the Andrus Geron- tology Center, most surveys that seek to identify such firms reveal little, simply because the threat of an age discrimination suit makes companies reluctant to give unfavorable opinions about older workers. Surveys that describe pension and benefit incentives for workers may be more infor- mative of a company's attitude toward older workers. Harold Sheppard of the International Exchange Center on Geron- tology, University of South Florida, told conferees that the ideal condi- tions for continued employment of older workers would include a high 32

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demand for labor, inadequate retirement benefits, rejection of the stere- otyped image of diminishing work capability associated with aging, job satisfaction, and good health. Beyond these basics, Sheppard said, are needed "special interventions ranging from education and persuasion of employers, unique labor-managment agreements, tailor-made training MICROSCOPES, TELESCOPES, AD IN BETWEEN For many people with impaired vision, bifocals supple- mented by focused lighting and other environmental changes may be enough to improve work performance. For others, special eyeglasses with extra powerful lenses may be needed. There is a variety from which the worker and the eye specialist can choose. Microscopic eyeglass lenses improve vision for people who can read print no more than an inch away. Depending on their strength, these lenses bring into sharper focus images that lie any- where from 13 inches to a quarter of an inch from the eyes. The thicker the lens, the closer to the eye that objects must be held. Since the magnification of these eyeglasses is the product of the magnification of the lens and the enlargement inherent in viewing an object closeup, overall magnification can be very great. Telescopic spectacles, on the other hand, allow extremely nearsighted people to read material comfortably at a distance. The telescopic portion is usually mounted on the top of a person's normal eyeglasses. The wearer looks through the standard lens to move about but uses the telescopic attachment to read distant detail, such as a street address or bus number. One advantage is that newspapers no longer have to be held close to the face, but these lenses reduce the amount of light reaching the eye and narrow the field of view. A telemicroscope combines a telescopic distance lens with a reading lens that magnifies. These devices, which sometimes feature a zoom lens, focus on both near and far objects. They allow a comfortable distance for close work as well as the ability to watch television and sporting events. Because partially sighted people often see better with one eye than the other, specialists may prescribe a low-vision device solely for the stronger, more easily correctable eye. In addition to eyeglass attachments, there are hand-held and freestanding magnification instruments that aid in addressing envelopes, reading menus and fine print, and other close visual tasks. Closed-circuit television systems that magnify print, talk- ing calculators, and large-print computers are other options in the workplace. 33

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techniques for the elderly, and creative technologies that make it easier for the handicapped to work." The cost-effectiveness of these interven- tions, among other considerations, are only just beginning to be explored. The Need for More Information Another obstacle to retaining the older employee with impaired vision is the paucity of data on the number of people affected. There are many uncertainties and only a few estimates of the number of workers with reduced visual function, the percentage who are unemployed, and the number no longer seeking work due to impairment. Most ofthe data are on people with severe impairment; those with vision better than legal blindness (20/200 vision or worse in the better eye) often fall through the cracks of government record keeping. Even data on people who are legally blind are outdated and unreliable accord- ing to the main source, the National Society to Prevent Blindness. The most up-to-date information on visual impairment is pro- vided by the National Center for Health Statistics (NCHS), Bethesda, Maryland; the Social Security Administration, Washington, D.C.; and the U.S. Bureau of the Census, Washington, D.C. The NCHS conducts annual health surveys; between 1966 and 1981 these included questions on color blindness, prevalence of eye diseases such as cataracts and glaucoma, and problems seeing with eyeglasses. (Vision questions were dropped from the annual survey in 1981.) Special NCHS surveys in the early 1960s and 1970s also assessed visual ability. A series of studies by the Social Security Administration, the latest conducted in 197S, relates vision impairment to the workplace, but these studies have not yet been analyzed. A ~ 976 study by the Census Bureau included items on employment of the visually handicapped. Although it asked people who had "serious difficulty seeing or were blind" just one question whether or not they considered themselves handi- capped the study was answered by a large number of people and provides detailed socioeconomic data. It is estimated that in 1976, 86 million Americans wore glasses and 800,000 were visually handicapped. What We Do Know from Statistics According to Corinne Kirchner of the American Foundation for the Blind, New York City, data from the Census Bureau and NCHS surveys show several trends, although percentages differ by source. To determine the current and future prevalence of visual impairment, Kirchner projected data collected from the decade-old surveys to the years 1985, 1990, and 2000. All of the surveys found that visual impairment was more com- mon among people aged 45 to 64 than among younger persons (l ~ to 441. The age gap was largest for moderate impairment, and Kirchner esti- 34

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mates that this trend will continue through the turn of the century. Very minor impairments (difficulty seeing without glasses) and blindness were more evenly distributed across age groups. According to NCHS data from the 1970s, nearly 45 percent of people who were "severely visually impaired" had other handicaps as well. The percentage increased sharply with age. These statistics indicate that multiple impairments should be considered in any effort to retain the older worker with impaired vision. The surveys indicated that visually impaired people tend to be concentrated in blue-collar jobs, such as laborer or service worker. But there is little information available on another measure that might be useful for developing more comprehensive vision screening programs in the workplace the age at which visual impairment begins. Kirchner stresses that self-reports of the incidence of vision problems are highly suspect, because many people are reluctant to admit the onset of impair- ment and the disorder may have been developing unnoticed for years. Existing surveys should be supplemented with questions on vision and employment, she added. Driving as a Mode} for Working Results from research on driving provide the clearest information On potential screening procedures so far. Screening criteria under con- sideration for testing of older drivers include performance under high- and low-level lighting conditions, the impact of glare on road sign iden- tification, and the ability to distinguish details on a moving target. The efficacy of these proposed tests may suggest appropriate screening tests for older people in the workplace. New vision tests may make the difference between productive employment and loss of a job and may also help older workers keep their current position rather than face reassign- ment. Health experts also stress the importance of informing businesses that simple design changes and periodic eye checkups may boost the productivity of many older employees who do not even realize they have a vision problem. The key to success, according to some scientists, is for researchers to work hand in hand with companies that have a stake in the continued health of older employees. Efforts of Private Companies A number of companies, including IBM, AT&T, Hewlett-Packard, and Sears, make special efforts to retain or hire people who have lost some or all of their vision. IBM recently opened an information hotline for disabled employees and the general public. Sears offers a health care catalogue that features magnifying glasses and special eyeglasses for the visually impaired. Stories abound in the workplace about people who 35

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have retained jobs despite visual impairment. There's John B., a 42-year- old manager at IBM who developed retinitis pigmentosa four years ago; with the aid of a closed-circuit television system, he has been able to continue work and even merit a promotion. Instead of placing a visually impaired cable repairman on disability, Pacific Telephone in Santa Barbara retrained him for a desk job that used his skills to determine the proper cable needed for repair jobs. Some companies have also become more aware of the role of preventive eye care. For example, Levi-Strauss of San Francisco recently completed a pilot study of eyestrain among word processor operators. The employees worked with a local ophthalmologist to determine if eye exercises could prevent strain. This pilot study is just one example of the increased awareness of vision care in industry. There remains a challenge, however, to inform more businesses about the benefits ofthese programs and the low cost of design features that accommodate workers with impaired eyesight. Selie6~3i 3Resour6~s for Vision Care A number of resources are available to workers and employers interested in identifying, understanding, and treating the changes in vision that occur with age. VICTORS: A Resource for Veterans In the mid-1 970s, the Veterans Administration (VA) spearheaded a major new program to rehabilitate veterans with low vision. Known as VICTORS, the program draws upon a teem of optometrists, ophthalmolo- g~sts, social workers, and rehabilitation specialists to aid in the early identification and treatment of partially sighted ax-military personnel. The first of 12 planned VICTORS centers opened at the Kansas City VA Medical Center in ~ 979 and serves primarily people in Missouri, Kansas, Iowa, and Nebraska. A second program began operating at the West Side VA Medical Center in Chicago in 1987. According to Joseph Maino, a VA optometrist who helped found the program, VICTORS helps keep veterans in the work force by making the best of their remaining vision, helping to modify work conditions or job tasks to match the veteran's abilities, and referring veterans to state or VA rehabilitation centers for further help. VICTORS does not duplicate services already offered at the VA's Blind Rehabilitation Centers; it offers help to veterans who typically have considerably more partial sight than someone who is legally blind. Patients are given priority according to their employment ability, sever- ity of impairment, and sernce-related disability rating. Patients usually spend three days at a VICTORS center. During their stay, a special low-vision eye examination is conducted to determine the full extent of the problem. Additional testing, including a color 36

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sensitivity examination, is also performed. After consultation with an optometrist to decide which low-vision aids are best suited for the veteran, a therapist begins training the patient in how to use the devices, which might include hand-held magnifiers, closed-circuit television systems that magnify print, or telescopic lenses mounted on the patient's eyeglasses. These devices are given on extended loan to the patient. A significant sidelight of the VICTORS program is its use as a training facility for optometrists specializing in low vision. The Kansas City center has a residency program affiliated with the optometry school of the University of California at Berkeley. dote Network Many organizations help visually impaired workers and employ- ers who want to hire or retain these workers. Among these is the Job Accommodations Network, which advises industry on techniques for accommodating the impaired workers, including those with vision loss. Often a firm will call the network with a handicapped person in mind for a job; the network then counsels both the prospective employee and the company representative. The network also provides information to rehabilitation therapists on job redesign, but it does not over a placement service. Set up in 1984 by the President's Council on Employment of the Handicapped, the network's toll-free number is 1-800-526-7234. An index for Jobs A resource for workers is the Job Index, an information telephone line begun by the American Foundation for the Blind in New York City. The service maintains files on more than 500 workers who have remained on the job despite visual impairment. Callers are educated about supplemental lighting and other changes in the workplace that aid people with visual disabilities. In addition to providing written informa- tion, the Job Index puts impaired workers in touch with others in a similar profession who have successfully adapted their visual skills. Remaining ore the dote in New York City The recently established National Center for Vision and Aging, also located in New York City, seeks to bridge the gap between agencies serving the elderly and those aiding the visually impaired. Educating the public about visual impairment among the elderly and promoting re- search that will improve rehabilitation efforts are two of its objectives. Through booklets and video cassettes, the center has begun educating businesses about efforts to hire or retain people who are visually im- paired. For example, the group discusses with medical directors of corporations the techniques of adapting the workplace to the needs of visually impaired workers. Sponsored by the New York Lighthouse for the Blind, the center is an advocate for people with considerable partial sight as well as those who are legally blind. 37

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Another offshoot of the New York Lighthouse, the Job Retention Service, aids both visually impaired workers and businesses in the New York metropolitan area. The service, in conjunction with the Lighthouse's low-vision clinic, refers workers for eye examinations, provides counseling, and visits the work site in order to suggest ways of ~ en. lancing exls ;lng vision. According to Neil Crouse, director of the retention service, people who contact his office tend to be clerical workers or managers, most in their 50s through mid-60s. His office helped about 20 people last year and expected to see about 50 in 1986. Crouse commented that the biggest fear among many impaired people is that of losing their job once their vision problem becomes known CATARACTS Cataracts are caused by a clouding of the eye's lens, which distorts and decreases available light. Although cataracts can occur at any age, even at birth, they are most common in the elderly. The National Society to Prevent Blindness estimated in the late 1970s that 41 million Americans over the age of 40 have cataracts. According to the National Eye Institute, about 5 million people have disorders that will progress to interfere seriously with normal vision, and 700,000 undergo surgery each year to correct the problem. The effects of a cataract on vision depend on its size, location, and density. A small cataract in the center of the lens will probably affect vision far more than a large cataract occurring away from the center. Among the symptoms are blurred or double vision and spots, problems with too little or too much illumination, change in the color of the pupil, and the sensation of having a film over the eyes or looking through a waterfall. In fact, cataracta is the Latin word for waterfall. Treating cataracts involves two steps. First the cloudy lens is surgically removed. Then an appropriate substitute special ' eyeglasses, contact lenses, or an artificial lens implanted in the eye is chosen to replace the damaged tissue. Laser cannot treat cataracts, but it may help disintegrate after-cataracts, remnants of the oval lens capsule, left in the eye after surgery. According to the National Eye Institute, 90 percent of cataract patients who undergo surgery report that they see better after the operation. Although there is a small risk of injury to the eye during or after surgery, this can generally be treated before serious damage occurs. 38

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at work. In one case that came to Crouse's ounce, a worker admitted her vision problem only after another secretary began using a closed-circuit television magnifier with the company's blessing. Quality of lighting is an important factor in work sites, Crouse notes. In one office, sunlight falling on a video terminal turned out to be a major source of glare for a visually impaired worker; the simple but effective solution was to turn the terminal away from a nearby window. At another company, rose-colored paper taped over a fluorescent ceiling light made it easier for a worker to see. Federally Sponsored Projects Some workers qualify for free visual aids provided by state commissions on blindness or state vocational rehabilitation services. These state groups, as well as nonprofit organizations like the Sensory Aids Foundation, may also provide free work-site consultations and counseling for the visually impaired worker. Since 1 96S, the Rehabilita- tion Services Administration of the federal government has funded Projects with Industry, a nationwide group of activities encouraging employment of the disabled. Most projects work directly with industry, and each activity has a local advisory group of ~ ~ to 25 business people. Among the 98 projects funded in 1984 were several that worked with advocacy groups and businesses, including the Rolm Telephone Com- pany, to hire people with impaired vision. . Helping the Partially Sighted The Center for Partially Sighted, located in Santa Monica, pro- vides information, guidance, and referrals to people with partial sight (less than 20/70 vision in the better eye) throughout the United States. In the Santa Monica area, the center provides a special low-vision examination that takes into account patients' objectives and vision- related problems in their daily environment. An optometrist then determines which visual aids, if any, will help meet these goals. Techni- cians or optometric interns train patients in the use of the Tow-vision devices that are prescribed. In addition, psychologists, counselors, and a speaker's bureau from the center educate patients and the public about [earning to cope with visual impairment. Since its inception in INS, the center has aided more than 3,500 partially sighted people. Optometry Schools Optometry schools are another resource. Many have low-vision clinics that aid partially sighted workers. The Pennsylvania School of Optometry in Philadelphia, for example, offers vision screening exams to businesses, nursing homes, and community groups. The State Univer- sity of New York College of Optometry evaluates vision screening programs and lighting requirements for some businesses in the New York metropolitan area. The University of Houston Optometry School 39

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THE AGING EYE: A PERSONAL VIEW Having been interested in vision all my life, it has been natural for me to observe what happens as ~ have gotten older. ~ am certain that my adaptation to darkness is now poor, and ~ have data to confirm that. When ~ go from outdoors to indoors, it takes me longer than any of my colleagues to adjust my eyes to see what's going on. More subjectively, ~ also notice that ~ have difficulty distin- guishing blue colors. Offhand, ~ can't tell whether something is pink or lavender, because ~ am uncertain whether the color has a little blue in it or not. ~ do guess the correct color by introspec- tion if I'm "truly certain," it's probably lavender; if I'm not cer- tain, it's probably pink. My general impression is that ~ don't see as well as ~ think ~ should. In some ways ~ know my limitations ~ expect to have trouble driving at night, so I've cut down on my night driving. On the other hand, ~ have great difficulty driving at twilight, espe- cially in picking out particular areas of the street scene that ~ need to make sense of to know where ~ am. I've got into the habit of making a dry run in the middle of the afternoon if ~ know ~ have to visit somebody's house in the evening or nighttime. That way don't get lost at twilight. ~ have also noticed that some typefaces are easier to read than others. ~ have more difficulty reading with small interIetter, interword, and interline spaces. ~ also have difficulty with low- contrast print and with printed pages with small borders. ~ find that placing a white typoscope a white paper with a rectangular window cut out of it improves the readability of both crowded and low-contrast print. The usual black typoscope also works, but not as well as a white one the object is to isolate the print rather than cut back on the luminance of the background. ~ want to stress that there is only a slight resemblance between the process of aging and chronological age. Older people are so diverse that just about anything you say about them applies to somebody, but often to no clear majority. Differences occur even among the young-old (65 to 74), the old (75 to 84), and the old-old (~5 and over). Meredith Morgan, 74, is professor emeritus and former dean of the School of Optometry, University of California, Berkeley. He has monitored his vision as well as that of countless patients for more than four decades. Meredith Morgan, O.D., Ph.D. 40