1040-5488/12/8909-1276/0 VOL. 89, NO. 9, PP.

1276–1281 OPTOMETRY
AND VISION SCIENCE Copyright © 2012 American Academy of Optometry

ARTÍCULO ORIGINAL

Accesibilidad de texto por personas con reducida

La sensibilidad de contraste

Michael D. Crossland * † y Gary S. Rubin *

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ABSTRACTO
Propósito. sensibilidad al contraste se reduce en las personas con enfermedades de los ojos, y también en los adultos mayores sin enfermedad ocular. En este artículo, se compara el
contraste del texto presentado en formatos impresos y digitales con valores de sensibilidad de contraste para una gran cohorte de sujetos en un estudio basado en la población de adultos
mayores (la evaluación Salisbury Eye).
Métodos. los valores de sensibilidad de contraste se registraron para 2520 adultos de 65 a 84 años que viven en Salisbury, Maryland. La proporción de la muestra
probable que sea incapaz de leer el texto de diferentes formatos (libros electrónicos, papel de periódico, libros de bolsillo, impresión láser, y los monitores de ordenador
LED) se calculó utilizando los niveles de reserva de contraste publicada necesarios para realizar lectura puntual, a leer con fluidez, alta fluidez, y en condiciones óptimas.

Resultados. El uno por ciento de esta muestra tenía la sensibilidad al contraste menor que la requerida para leer el periódico con fluidez. Texto presentado en un monitor de
ordenador LED tuvo el mayor contraste. El noventa y ocho por ciento de la muestra tenía la sensibilidad al contraste suficiente para alta lectura fluida de texto (por lo menos
160 palabras / min) en un monitor. Sin embargo, el 29,6% eran todavía poco probable que sea capaz de leer este texto con fluidez óptima.

Conclusiones. contraste reducido de impresión accesibilidad límites de texto para muchas personas en el mundo desarrollado. La presentación de texto en un formato de alto
contraste, como el negro de impresión láser en una página blanca, aumentaría el número de personas que pueden acceder a dicha información. Además, por lo que el texto
disponible en un formato que puede ser presentado en un monitor de ordenador LED aumentará el acceso a los documentos escritos. (Optom Vis Sci 2012; 89: 1276-1281)

Palabras clave: la lectura, la sensibilidad al contraste, baja visión, la accesibilidad

artículo, Whittaker y Lovie-Kitchin revisión de la bibliografía sobre la lectura y

UN istradas por ser legalmente ciego, y una 2.4million aún tienen baja visión. 1 Sin
embargo, se proximadamente
sabe que un número mucho
900.000 mayor de
personas en personas que
los Estados han reducido
Unidos son REGla visión sin
estar registrado, 2 y que el error de refracción no corregidos y el envejecimiento normal
presentaron la “reserva de contraste” que se necesita para leer el texto en
absoluto, y para leer con fluidez, con una alta fluidez, y en condiciones óptimas
(Tabla 1). 15 The contrast reserve is the ratio of the text contrast to the contrast
pueden reducir la visión de las personas sin ningún tipo de enfermedad ocular identificado. 3,4 sensitivity. In this article, we analyze the contrast sensitivity data from a large
epidemiological study investigating visual function in a population of older adults

La sensibilidad de contraste es un aspecto de la función visual que disminuye con la edad 3 así living in Maryland (the Salisbury Eye Evaluation [SEE]). The SEE study was a
como con enfermedades de los ojos. 5,6 Reducción de la sensibilidad al contraste es conocido population-based evaluation of adults aged between 65 and 84 years living in the

por estar asociado con dificultades en la lectura, 6-8 Reconocimiento facial, 9 reconocimiento de
objetos, 10 movilidad, 11,12 y la comunicación en personas con audición reducida. 13 Poorer
sensibilidad al contraste también aumenta el riesgo de estar involucrado en una colisión del
vehículo de motor “en-defecto”. 14
Para leer con fluidez, el texto debe ser presentado en varias veces mayor contraste
que el umbral de sensibilidad al contraste. 7 En una clave
community. 16
We use these data to determine what proportion of the population would be able to
read text presented in different formats, assuming that the visual acuity criterion is
met (i.e., the text is large enough to be comfortably resolvedwith the current
spectacle prescription).

METHODS
* PhD
† MCOptom
The SEE identified adults aged between 65 and 84 years living in the
Salisbury, Maryland, metropolitan area, using the Health Care Financing
Visual Neuroscience, UCL Institute of Ophthalmology, London, United Kingdom, andBiomedical
ResearchCentre forOphthalmology, London, UnitedKingdom (both authors). Administration Medicare eligibility lists. In total, 4624 subjects were identified, of
whom 2520 received a compre-

Optometry and Vision Science, Vol. 89, No. 9, September 2012

 Text Accessibility by People with Reduced Contrast Sensitivity—Crossland and Rubin 1277

hensive visual assessment. As part of this assessment, contrast sensitivity was high fluency, and with optimal performance was calculated using the values
published by Whitaker and Lovie-Kitchin. 15
measured using the Pelli–Robson chart. 17 This test was performed monocularly
on each eye, at a distance of 1 m, in a well-lit room (chart luminance:
approximately 100 cd/m 2), using the optimal refractive correction. Credit was given RESULTS
for each letter read correctly. Data from the better eye are presented in this
Contrast sensitivity was recorded for 2507 subjects. Data were missing for
article. Participants were also asked a visual function questionnaire (the Activities
0.5% of the sample (14 of 2520). Mean age of participants was 71 years
of Daily Vision Scale). 18 One question on the Activities of Daily Vision Scale
(interquartile range: 68–76 years), and the median best corrected distance visual
specifically addresses reading newsprint: “Would you say that you read the
acuity was 0.02 logMAR (20/20 1, 6/6 1, interquartile range:
ordinary print in newspapers with: (a) no difficulty at all; (b) little difficulty; (c)
0.1 logMAR to 0.06
moderate difficulty; (d) extreme difficulty; or (e) you have not read a newspaper
logMAR). Visual acuity and contrast sensitivity were moderately linearly related (r
recently because of your vision?”
0.69).
Median contrast sensitivity was 1.60 log units (interquartile range: 1.50–1.70
log units). Fig. 1 shows the cumulative percentage of contrast sensitivity values.
Ethical approval was obtained for the study, informed consent was received
This figure shows the proportion of the population whose contrast sensitivity is
from all participants, and the study conformed to the Declaration of Helsinki.
at, or is poorer than, the value shown on the horizontal axis. Table 2 indicates
the Weber contrast values for the different formats of text.
Weber contrast values for different types of text were obtained by measuring
the luminance of the background (a blank area of white) and of print (a filled
area of black ink or print) using a photometer (CS-100, Minolta, Tokyo, Japan).
Fig. 2 andTable 3 show the proportion of the population unable to read text
This measurement was performed in a bright office (room luminance: 940 lux
presented in different formats at different levels of
[Testo
540, Testo, Lenzkirch, Germany]), although Weber contrast is invariant to
changes in background luminance. The contrast sensitivity required to read TABLE 2.
each text format at all, with fluency, with Weber contrast of different text formats

Background Print

TABLE 1. luminance luminance Weber

Task (cd/m 2) (cd/m 2) contrast
Contrast reserve required for different reading tasks Task
Electronic book (Sony 70 16 77%
Contrast reserve
PRS-505)
Spot reading 3:1 Newspaper 97.2 18.2 81.2%
Fluent reading (80 words/min) 4:1 Paperback book 109 15 86.2%
High-fluent reading (160 words/min) 10:1 Laser print 144 19.7 86.3%
Optimal reading 30:1 Computer monitor (Apple 177 4.06 97.7%
Cinema display)
Data from Whittaker and Lovie-Kitchin. 15

FIGURE 1.
Cumulative percentage of contrast sensitivity values for this population.

Optometry and Vision Science, Vol. 89, No. 9, September 2012

People with Reduced Contrast Sensitivity—Crossland and Rubin

FIGURE 2.
Proportion of population able to read different text with different levels of fluency for (A) electronic book, (B) newsprint and (C) paperback book. 1278 Text Accessibility by

Optometry and Vision Science, Vol. 89, No. 9, September 2012

 Text Accessibility by People with Reduced Contrast Sensitivity—Crossland and Rubin 1279

FIGURE 2.
Proportion of population able to read different text with different levels of fluency for (D) laser print and (E) computer monitor.

TABLE 3.
Contrast sensitivity value required for each task and each fluency value, and the percentage of the population with this contrast sensitivity value

Percentage of population with this

Contrast sensitivity required (log units) contrast sensitivity

Spot Fluent High fluent Optimum Spot Fluent High fluent Optimum

Electronic book 0.59 0.72 1.11 1.59 99.08 98.88 96.93 44.71
Newsprint 0.57 0.69 1.09 1.57 99.08 99.00 97.16 44.71
Paperback 0.54 0.67 1.06 1.54 99.16 99.00 97.16 60.51
Laser print 0.54 0.67 1.06 1.54 99.16 99.00 97.16 60.51
Computer monitor 0.49 0.61 1.01 1.49 99.24 99.02 97.73 70.40

Note: contrast values are rounded up to the nearest 0.05 log units when calculating the percentage of the population with this contrast sensitivity.

Optometry and Vision Science, Vol. 89, No. 9, September 2012

1280 Text Accessibility by People with Reduced Contrast Sensitivity—Crossland and Rubin
TABLE 4.
Self-reported reading difficulty and mean contrast sensitivity value
Mean (SD) contrast
No. sensitivity value
Self-reported reading difficulty responses (log units)
No difficulty at all 1836 1.60 (0.10)
Little difficulty 372 1.55 (0.15)
Moderate difficulty 86 1.50 (0.20)
Extreme difficulty 17 1.40 (0.25)
Have not read because of vision 191 1.30 (0.45)
SD, standard deviation.
fluency. The poorest performance was found for electronic books (Fig. 2A): only
44.71% of the population was expected to be able to read electronic books or
newsprint optimally. One percent of this population was unlikely to be able to
read newsprint with any level of fluency. LED computer monitors had the
highest contrast text: 99% of the population could read this fluently, yet more
than one person in four (29.6%) could not read this with optimal fluency.
One thousand eight hundred thirty-six participants (72.9%) did not report any
difficulty in reading newsprint, and 666 (26.4%) reported some level of difficulty
or had not read newsprint because of their vision. Data were missing for 18
participants (0.7% of the sample). Mean contrast sensitivity in those reporting no
difficulty was 1.6 log units, whereas in those reporting any level of difficulty, it
was 1.45 log units. Table 4 shows the mean contrast sensivity values for different
levels of self-reported difficulty in reading newsprint.
DISCUSSION
Reduced contrast sensitivity creates difficulty in reading text. Although the
proportion of the population who are unlikely to be able read text with fluency
because of low contrast sensitivity is relatively small, this translates to large
numbers of people. For example, 1% of our population was unlikely to read
newsprint with any fluency because of reduced contrast sensitivity. If this
population is representative, this indicates that 395,000 older people in the
United States and 768,000 older people in the European Union are unable to
read newsprint fluently because of its text contrast.
Laser print is relatively easy to read, although 0.8% of the population
(316,000 older Americans, 614,000 Europeans aged 65 years) is unable to read
laser-printed text even with the slowest “spot reading” fluency. If laser-printed
documents were instead sent electronically and viewed on a computer monitor,
an additional 0.08% of the older population would be able to read them. This
number may sound small, but it equates to 31,600 more people in the Unites
States and 61,400 more people in the EuropeanUnion being able to read them.
This is of clear importance for banks, utility companies, and government
agencies that send communication by post. Of course, presenting text on a
computer monitor is no guarantee that it will be easily readable by the end user:
color contrast, the boldness of text, and the ability to manipulate the format and
spacing of text are also important.
Optometry and Vision Science, Vol. 89, No. 9, September 2012
Use of self-reported visual function data indicated that declining contrast
sensitivity was related to an increased probability of reporting difficulty in reading
newsprint. Approximately one-quarter of our population reported difficulty in
reading newsprint. This is greater than the proportion we predicted to read the
newspaper with less than high fluency based on our contrast sensitivity model. Of
course, many other visual and nonvisual properties will affect newspaper reading
performance, including visual acuity, the presence of visual field loss, and
cognitive and neurological factors. However, the relationship between
self-reported reading performance and contrast sensitivity confirms the
importance of contrast sensitivity on reading ability.
Our Weber contrast values are higher than those previously reported by, for
example, Brilliant. 19 We suggest that this is because of advances in printing
technology, which has enabled print to be darker and paper to be brighter. It may
be that British newspapers and paperback books (which we have assessed in our
study) have higher contrast than the North American publications described in
many low vision textbooks. The population of the SEEmay not be truly
representative. This population is older (minimumage: 65 years; median: 71
years) and includes subjects of predominantly white and African American origin.
Furthermore, these data are from a population with Medicare insurance and
access to health care. As contrast sensitivity is significantly reduced in cataract,
lower values may be expected in a population with poorer access to health care
and without health insurance. These data are now several years old, but we have
no reason to doubt their applicability at present. The population is aging, and the
mean age of a random sample of older adults would be expected to be older,
increasing the prevalence of age-related eye disease. However, this aging will
bemitigated by recent advances in ophthalmology, such as anti–vascular
endothelial growth factor treatment for age-related macular disease. The data
presented in this article examine only the effect of text contrast on reading
performance, and have not considered visual acuity. As there is a moderate
relationship between visual acuity and contrast sensitivity, it would be expected
that many of the people unable to read print because of poorer contrast sensitivity
would also struggle with text size. There will be other individuals who have
sufficient contrast sensitivity to access text but who will not be able to resolve text
because of its size. These people are likely to respond well to magnification.
Reduced contrast sensitivity can only be ameliorated by electronic means, such
as the use of an electronic magnifier or by manipulating text presented on a
computer monitor.
We have only considered the eye with better contrast sensitivity in this
investigation. As there is some binocular summation of contrast in people with
good vision, 20,21 one might expect true binocular contrast sensitivity to be better
than the values presented here. However, as binocular contrast sensitivity was not
measured in the present study, and contrast summation is limited or reduced in
some people with eye disease, 22 we felt more comfortable using a measured
response than an inferred binocular contrast sensitivity value.
A final limitation of our work is that we have compared contrast sensitivity values
measured at 1 m using large characters to a reading task, typically performed with
smaller characters viewed from a distance of about 40 cm. This approach has been
used before, for
 Text Accessibility by People with Reduced Contrast Sensitivity—Crossland and Rubin 1281
example, byMohammed andDickinson. 23 By extending the viewing distance of a
Pelli–Robson chart, these authors found that contrast sensitivity did not vary
significantly with angular size of the letters on the chart.
CONCLUSIONS
Reduced text contrast restricts accessibility to the written word for a large
number of people in the developed world. Making text available in a format that
can be presented on an LED computer monitor will increase access to written
documents.
ACKNOWLEDGMENTS
The authors wish to thank GF Mueden for providing the motivation for this analysis. MDC is
supported by the National Institute for Health Research grant PDF/01/2008/011. This report
describes independent research arising from a grant supported by the National Institute for
Health Research. The views expressed in this publication are those of the authors and not
necessarily those of the NHS, the National Institute for Health Research or the Depart- ment of
Health.
Received January 5, 2012; accepted April 11, 2012.
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Michael Crossland
UCL Institute of Ophthalmology
11–43 Bath Street
London EC1V 9EL
United Kingdom
e-mail: m.crossland@ucl.ac.uk