Effective rehabilitation of reading by training in the
technique of eccentric viewing: evaluation of a 4-year
programme of service delivery
Shelagh Palmer, 1 David Logan, 1 Shahriar Nabili, 2 Gordon N Dutton 2,3,4
ABSTRACT
Background/aims Central visual loss caused by
conditions such as age-related macular degeneration
(ARMD) is the commonest cause of blindness in the UK.
Eccentric viewing training aims to teach patients how to
utilise the functioning areas of macula or adjacent retina
and establish a ‘pseudofovea’. This technique has yet to
gain acceptance in the UK despite evidence of success.
Subjects with ARMD in Glasgow, UK, have received such
training, and the outcome of training for this group is
described.
Methods Retrospective analysis auditing the outcome of
eccentric viewing training to read was carried out in 300
subjects with ARMD.
Results The data for 300 patients were reviewed. Fifty-
eight subjects were excluded due to incomplete final
data. Reading speed, font size, degree of
comprehension, duration of reading, and age and number
of lessons were recorded before and after training. The
mean age was 75.4 (SD 12). The mean number of 1-h
lessons required was 3.8 (SD 1.6). The starting mean
number of corrected words per min (WPM) reading
speed was 48 (SD 35) and this increased to 71.9 (SD
30.5) (p¼0.000). The starting Arial font size that could
be read fluently was 14.3 (SD 7.6) and this improved to
11.5 (SD 2.4). The starting mean duration of comfortable
reading was 1.7 (SD 2.0) min. This increased to 15.8 (SD
14.6) min. The mean percentage of material read that
was understood by the patients was 73.7 (SD 36.9)%.
This improved to 92.7 (SD 16.2)% (p¼0.000). Overall,
the majority of patients exhibited improvement in one or
more of the vision-related tasks measured.
Conclusion Eccentric viewing training is successful in
improving the reading ability of individuals with a central
scotoma. This paper shows evidence of the success of
training provided by the voluntary sector and funded by
adult literacy funding. The results are comparable with
those reported in the literature.
INTRODUCTION
The leading cause of visual impairment in the
developed world is age-related macular degenera-
tion (ARMD). 1 2 ARMD is a major public health
problem that has a devastating effect upon patients
and marked adverse financial consequences for the
economy. 3
The aim of rehabilitation is to facilitate inde-
pendence by optimising use of persisting visual
function and training in alternative strategies.
Without provision of training a large proportion of
low vision aids are not used. 4 Eccentric viewing, in
which an area of the peripheral vision adjacent to
the pathological scotoma is employed for reading
was first described in 1976. 5 Subsequent work
in Sweden 6 7 provided convincing evidence that
training in eccentric viewing culminates in signifi-
cantly enhanced reading ability and reading speed.
This process entails the development of a preferred
retinal locus (or loci); 8 this necessitates a process of
oculomotor adaptation, 9 with a shift of attention
and reading ability to the new preferred location in
the visual field. 10
We report the results of a retrospective audit of
a training programme in eccentric viewing that has
been in operation in Glasgow, UK, for a period of
4 years.
METHODS
The data collected for 300 patients who had
undergone training were analysed. Fifty-eight
patients were excluded because of incomplete
final data. The data collected included age, read-
ing speed, font size, final maximum duration of
comfortable reading and percentage of compre-
hension. An improvement in reading was con-
sidered as an increase in reading speed, reduction
of font size and/or improved duration of reading.
SPSS V. 17 (SPSS, Chicago, Illinois, USA) was
used for statistical analyses. The paired Student t
test was used to test significance and linear re-
gression was used to analyse associations.
Eccentric viewing training develops the skill of
eccentric fixation. Evidence from scanning laser
ophthalmoscopy shows that people can be taught
to optimise the use of their remaining vision by
visually fixating with a point on the retina, known
as a preferred retinal locus (PRL). 8
11
Eccentric
viewing training leads to more stable eccentric
fixation and the development of an optimal PRL. If
the person does not have a PRL, then training is
required to establish a trained retinal locus (TRL).
The exact position of PRL is dependent on the size
and site of the scotoma; however, recent publica-
tions favour the superior retina as the retinal area of
choice. 12 13 Mastering eccentric reading depends on
being able to use the PRL and consistently employ
a technique known as the steady eye strategy. The
technique requires the image of the text to be
moved across the PRL/TRL, which is possibly the
most challenging element of the steady eye
strategy. It involves the patient keeping the head
still while moving the text in front of their eyes
from right to left and back. In addition, the text
needs to be held within a short reading distance of
2.0e6.5 cm, consistent with the use of high
magnification.
1 Visibility, Glasgow, UK
2 Tennent Institute of
Ophthalmology, Gartnavel
General Hospital, Glasgow, UK
3 Department of Vision Sciences,
Glasgow Caledonian University,
Glasgow, UK
4 The Royal Hospital for Sick
Children, Yorkhill, Glasgow, UK
Correspondence to
Dr Shahriar Nabili, Tennent
Institute of Ophthalmology,
Gartnavel General Hospital,
Great Western Road, Glasgow
G12 0YN, UK; nabili@hotmail.
com
Accepted 17 August 2009
Published Online First
12 October 2009
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group.bmj.com on May 30, 2012 – Published by bjo.bmj.com Downloaded from
The essential components of the training programme are listed
as follows.
< Identification of the preferred eye for reading
Usually the eye with the better visual acuity and the least
affected by the central scotoma is the preferred eye for reading.
< Determination of the PRL
The PRL ideally views an area below the scotoma or sometimes
above. 12 (Using the area of visual field above the scotoma means
that the scotoma occludes text which has already been read.) A
suitable PRL is determined by the optometrist, normally by
using an Amsler chart as previously described by Qui and Leat. 14
< Optimal magnification and refractive correction
Eccentric viewing learners require an appropriate low vision aid.
Typically they are issued with a spectacle-mounted aspheric
hyperocular low vision aid, with a magnification range of
between ×4 and ×12. Optical eccentric correction can also
improve the resolution acuity. 15 The level of magnification was
assessed by the optometrist during a low-vision assessment prior
to training.
< Lighting
Optimal task lighting is vital and is provided at the training
sessions.
< Training
Training entails identification of a suitable PRL. This leads to
visual fixation with the PRL followed by the implementation of
the steady eye strategy.
< Homework
Individualised exercises are provided to allow trainees to practice
the technique at home.
Description of eccentric viewing training
During the training session the correct fixation distance is
determined by asking the patient (using appropriate magnifica-
tion) to bring the text up to their nose and then slowly moving
it away until the text appears clearly. Fixation practice is often
done using fixation lines above or below the text thus encour-
aging the subject to look up or down. The patient is asked to
keep the eye and the head steady while moving the text slowly
to the left. The patient will often start to turn their head to the
right from the middle of the text and again move it quickly back
to the left at the end of a sentence. This is discouraged.
A trainer with experience in tutoring adults in areas such as
adult literacy and numeracy and who can motivate learners has
been identified as an essential element. At each session, the tutor
observes the reading technique, and offers coaching for
improvement, as appropriate. The role of the tutor is to
constructively develop the technique, which necessitates a deli-
cate balance between correction of difficulties and encourage-
ment to progress. This is a key element, especially for
minimising anxiety and fear of failure, and promoting confi-
dence and motivation to achieve.
Training consists of weekly, one-to-one sessions with the
tutor. Each session lasts about an hour and on average, three to
four sessions are required. Regular review and recording of
progress towards goals takes place throughout training.
The total number of sessions is dependant on progress.
Following each training session, homework tasks (appropriate to
the current levels of motivation aptitude and ability) are
provided for daily practise, for a maximum of 20 min per day
and for only a few minutes at a time, until the next lesson. In
addition to the homework tasks, learners are encouraged to try
reading tasks around the house and to keep a diary/record of
their achievements.
Progress is monitored by measuring the font size that can be
comfortably read, the speed and duration of reading at each visit.
An exact definition for success is difficult as it tends to vary
significantly among patients. (Someone who can read only one
font size smaller may be delighted with their achievement,
whereas someone who can read newsprint for 30 min may be
still dissatisfied.) At the first training session an individualised
learning plan is decided on and realistic goals and end-points are
encouraged. The setting of an individualised definition of success
is standard practise in the context of adult education, but
hampers the collection of data in order to evaluate potential
population benefit.
Referrals to the programme are open and self-referral is
encouraged. Learners are invited to a pre-training discussion in
which the level of required magnification and suitability of the
eccentric viewing training for the individual is assessed. For
a minority of subjects, problems such as cognitive or physical
disabilities are identified that render the programme technically
too challenging.
RESULTS
There were 77 men and 165 women (female/male ratio of 2.14).
The mean age was 75.4 (SD 12) years. The mean number of
lessons required was 3.8 (SD 1.6). Table 1 gives a summary of all
variables at the beginning and the end of the training period.
Reading speed
Reading speed was measured by asking the subject to read out
loud from a prepared text for one minute, and counting the
number of words read. We started with very simple text such as
‘Billy went to the zoo. The zoo had lions, tigers and chimps.’
This level was accessible to anyone with even basic literacy
skills. Thereafter, we tended to increase the level of difficulty at
each session. We did not repeat texts for assessments: if we
wished to test at the same level, we use an alternative text. The
number of words varied from text to text but we calculated the
number of words as the number read over 1 min.
Figure 1 Graphical representation of percentages of patients with
improved function.
Table 1 A summary table of pre- and post-training variables
Pre-training Post-training
Reading speed (WPM) 48 (35) 71.9 (30.5)
Font size 14.3 (7.6) 11.5 (2.4)
Duration of reading (min) 1.7 (2.0) 15.8 (14.6)
Comprehension (%) 73.7 (36.9) 92.7 (16.2)
Values are mean (SD).
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The starting mean corrected WPM reading speed was 48 (SD
35) and this improved to a 71.9 (SD 30.5) (p¼0.000). The mean
improvement in reading speed was 23.9 (SD 27.6) WPM. Two-
hundred and four (82.6%) patients had an improvement of
between 1 and 135 WPM. Sixteen (6.5%) patients did not
achieve any improvement and 25 (10.1%) patients lost between
1 and 42 WPM in their reading speed.
Font size
Font size was assessed using Keeler N Series Near Vision Voca-
tional Test Chart. The N Series Near Vision Vocational Test
Chart contains font sizes from N48 to N5 as well as assessment
pages of reduced Snellen, and examples of music, drawings and
telephone directory print. The font style used was Arial.
The starting font size read was N14.3 (SD 7.6) and this
improved to N11.5 (SD 2.4). This was statistically significant
(p¼0.000). The mean improvement was N3.5 (SD 6.9).
Duration of reading
The patients were asked to read as much as they could
comfortably and the duration was recorded. The subjects were
then asked to record how long they were able to read comfort-
ably at home after the completion of the training.
The starting mean duration of reading was 1.7 (SD 2.0) min.
This again improved to a mean of 15.8 (SD 14.6) min. This
improvement was statistically significant (p¼0.000). Most
patients (n¼231 (95%)) managed to read for longer at the end of
the training period.
Degree of comprehension
The degree of comprehension was estimated by asking the
subjects four prepared questions on the text they had read and
awarding 25% for each correct answer.
The mean percentage of material read that was understood by
the patients was 73.7 (SD 36.9)%. This improved to 92.7 (SD
16.2)% (p¼0.000).
DISCUSSION
This audit study provides information concerning how well
learners of eccentric viewing (as a reading skill) performed at the
time of their final assessment in relation to their starting point
(figure 1). For many, the reading statistics showed significant
improvements in the measures of words read per min, text size
and duration of reading.
Wedidnotfindanystatisticallysignificantassociationbetween
the age of subjects and the degree of improvement. This must be
set in the context of the sample, which was drawn from an
essentially narrow age range of 70e90 years, with some outlying
data. However, even within this context, the sample matches the
results ofCrossland etal, 16 who reportedthat reading speed is not
fully correlated with acuity, age or size of scotoma.
There was no evidence that more than five lessons improved
performance and this is in accordance with the findings of
Nilsson et al. 7 Further studies will be required in order to
ascertain whether the skills learned are maintained in the long-
term, and in what proportion of individuals.
We found that high starting reading speeds were associated
with high finishing reading speeds. This is not surprising as
these learners probably had a better acuity and smaller scotoma.
Again, perhaps it is not surprising that those with higher
starting reading speeds needed fewer lessons as they started out
with reading speeds closer to fluent reading speed than the other
learners.
Many people with ARMD want to read again without the
need for large print. Of the cohort, only six patients (2.5%) were
able to read text of font size or below N10 (using their hyper-
ocular readingaid)whentheycommencedthetraining. However,
on completion of thetraining, 85 (36%) patients could read a font
sizeN10orsmaller.Thisissignificantbecausemuchoftheprinted
materials of everyday life are in font size N10, which means that
more than one-third of the cohort were enabled to read ‘normal’
size print when they could not do so before they were trained.
The percentage of patients who were able to read font size
N12 or larger improved from 41.6% before the training to 85%
after training, and only 15 people finished their training unable
to read font size N14 or below.
Fifty-eight patients were excluded from the final analysis as
there were insufficient data (such as initial reading speed) at the
entry stage. The reason most of these people had no initial data
is that if someone presented as very anxious or reticent at the
initial meeting, it was often better to avoid the test element and
to focus on the practicalities of eccentric reading technique. All
of these patients completed the training and anecdotally,
reportedly benefited from the training. Even if it is assumed that
the 58 excluded patients did not have any improvement in their
reading speed, revised calculation reveals that a significant
proportion (47.8%) of the 300 patients would have still
improved their reading speed.
The training does not aim to improve distance visual acuity
and hence we did not include Snellen visual acuity. The aim of
training was to improve aided near vision function. The near
vision is what was measured, analysed and submitted.
The training scheme was set up to deliver a service, and
measures used for recording the duration of reading and degree
of comprehension were designed to give a basic index of the
efficacy of training as part of the service delivery. Both indices
show evidence of significant improvement.
The training programme was named ‘New View’ to avoid the
inevitable misinterpretation of the term ‘eccentric reading’ by
the layperson. The programme was developed as a person-
centred, community-based programme. The training combines
elements of adult education techniques with known eccentric
reading methods to produce a programme that empowers the
client to improve their reading/viewing ability. There is
a considerable degree of flexibility in the training protocol to
allow the clients to achieve their own individual goals.
Although we did not measure quality of life directly in this
study, we found during small session focus groups that client
satisfaction did not necessarily correlate with improvement in
reading speed. There were those whose change in reading statis-
tics did not show much improvement. However, when these
learners were asked what difference taking part in training had
madeto their lives, verypositive responses were given,with some
goingasfarastosaythatthishadbeenalife-changingexperience.
None of the trainees expressed dissatisfaction with the service
received or the outcome. This suggests that the focus on reading
parametersalonemayfailtoidentifythetruevalueofthetraining
programme to people with visual impairment. We are currently
collecting data on validated quality of life questionnaires.
Established macular degeneration is a chronic disability that
falls outside the remit of the acute medical sector. The New
View eccentric viewing programme was conceived as requiring
funding from education sources, to regain adult literacy, and its
only link with the hospital sector is the provision of low vision
aids. This study provides an audit of the results of eccentric
viewing training in a large series of subjects with ARMD, in the
context of a clinical service. It is therefore open to bias, as it is
496 Br J Ophthalmol 2010;94:494e497. doi:10.1136/bjo.2008.152231
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not a controlled trial. Notwithstanding, the uniformly positive
results of this audit indicate that the New View programme has
afforded sufficient benefit to the recipients of the service to
justify continuation in the long-term.
Our aim in submitting this audit of the new service for
publication is not only to evaluate the outcome of the service,
but also to report this novel and appropriate approach in which
service delivery for disability need not be implemented or
organised from a medical base.
Acknowledgements We would like to thank Visibility for allowing us to audit and
analyse their results.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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Br J Ophthalmol 2010;94:494e497. doi:10.1136/bjo.2008.152231 497
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doi: 10.1136/bjo.2008.152231
12, 2009
2010 94: 494-497 originally published online October Br J Ophthalmol
Shelagh Palmer, David Logan, Shahriar Nabili, et al.
delivery
evaluation of a 4-year programme of service
in the technique of eccentric viewing:
Effective rehabilitation of reading by training
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