Digital Reader vs Print Media

The Role of Digital Technology in Reading Accuracy in Age-Related Macular Degeneration

K Gill; A Mao; AM Powell; T Sheidow


Eye. 2013;27(5):639-643. 

In This Article

Abstract and Introduction


Purpose To compare patient satisfaction, reading accuracy, and reading speed between digital e-readers (Sony eReader, Apple iPad) and standard paper/print media for patients with stable wet age-related macular degeneration (AMD).

Methods Patients recruited for the study were patients with stable wet AMD, in one or both eyes, who would benefit from a low-vision aid. The selected text sizes by patients reflected the spectrum of low vision in regard to their macular disease. Stability of macular degeneration was assessed on a clinical examination with stable visual acuity. Patients recruited for the study were assessed for reading speeds on both digital readers and standard paper text. Standardized and validated texts for reading speeds were used. Font sizes in the study reflected a spectrum from newsprint to large print books. Patients started with the smallest print size they could read on the standardized paper text. They then used digital readers to read the same size standardized text. Reading speed was calculated as words per minute by the formula (correctly read words/reading time (s)·60). The visual analog scale was completed by patients after reading each passage. These included their assessment on 'ease of use' and 'clarity of print' for each device and the print paper.

Results A total of 27 patients were used in the study. Patients consistently read faster (P<0.0003) on the Apple iPad with larger text sizes (size 24 or greater) when compared with paper, and also on the paper compared with the Sony eReader (P<0.03) in all text group sizes. Patients chose the iPad to have the best clarity and the print paper as the easiest to use.

Conclusions This study has demonstrated that digital devices may have a use in visual rehabilitation for low-vision patients. Devices that have larger display screens and offer high contrast ratios will benefit AMD patients who require larger texts to read.


Age-related macular degeneration (AMD) is a disease of the central macular function that has significant and severe impact on a patient's central acuity, resulting in a dramatic decrease in the ability with which they accurately read and the speed with which reading occurs.[1] In the past several years, the use of antivascular endothelial growth factor agents has greatly advanced our management of AMD and has had a profound impact on visual outcomes for patients with these diseases.[2,3] Studies such as ANCHOR[4] and MARINA[5] have shown significant benefits and improvement in patient's quality of life following treatment of wet AMD. Although improvement in quality of life can be achieved, these improvements are relative to the baseline level of visual acuity and unfortunately do not represent a return to normal function. As such, many patients treated for wet macular degeneration are left with vision that does not allow them to read in a normal manner.

The general public, non-ophthalmic physicians, and ophthalmologists who treat patients with AMD markedly underestimate the quality-of-life loss associated with this condition.[6] Patients with moderate AMD reported a 40% decrease in quality of life, with very severe AMD patients reporting a decline of 63% in quality of life.[6]

The impact on quality of life has been found to be independently associated with vision loss.[7] It is recommended that patients with mild AMD (visual acuity worse than 6/12) can have significant improvements in their quality of life with a referral to a low-vision service.[7]

Three studies related to the epidemiology of vision impairment list macular degeneration as the leading cause of vision impairment in the developed world.[8,9,10] Most low-vision clinics attract AMD patients as they tend to notice a decline in central vision acuity more quickly and it has detrimental effects on everyday visual activities.[11]

The Wilmer low-vision clinic study showed that 64% of patients indicated that 'reading' was their chief complaint, whereas other activities were identified in <8% of patients. Thus, most AMD patients are referred to low-vision clinics with a concern of reading.[11]

Reading rehabilitation in low-vision clinics relies on tools that can measure reading speed effectively and have a high index of reliability. Both the Minnesota Reading Test (MNREAD) and Radner devices contain single and relatively short sentences to gauge reading acuity and magnification needs. However, both tests lack longer text passages to effectively measure and record improvements in reading speed.[12] More recently, reading passages with standardized texts were created to assess reading speed during repeated measurements and across languages for normal subjects and low-vision patients.[12] Through the Hahn group, standardized texts to measure reading speeds were developed and named International Reading Speed Text (iREST). These passages were developed in Germany in 2006 and have been standardized for content (reading material at a sixth grade level), length (830±2 characters), syntactic complexity, and spacing. These reading texts have been proven to be an invaluable diagnostic tool in low-vision research and in the comparison of different low-vision reading aids in visual rehabilitation in patients with AMD.[12,13]

Low-vision studies demonstrate that patients receive benefits from magnification, improved contrast, and augmented lighting, all of which may impact the patient's ability to read. Recently, digital technology products have become available to access the growing online digital media world. Only about 1.5% of the approximately two million books currently in print are available in large print format.[13]

Books, magazines, and online articles are becoming more available for patients, increasing access to those who are able to utilize them. Furthermore, these digital readers have the ability to modify the degree of brightness and contrast, as well as the size of the type, making them ideal to consider for patients with some lower visual needs. Electronic books as visual aids have been postulated by many low-vision experts as the next wave in visual rehabilitation with our aging population.[14,15]

The purpose of this study was to compare patient satisfaction, reading accuracy, and reading speed between digital e-readers (Sony eReader (Sony, New York, NY, USA), Apple iPad (Apple, Cupertino, CA, USA)) and standard paper/print media.