Aging&Vision A publication for Practitioners, Researchers and Educators Volume 17 Number 1 Spring 2005 Lighthouse centennial Logo International Issues in Low Vision Services and Vision Rehabilitation by Cynthia Stuen, DSW The triennial international conference on low vision, Vision 2005, is being held April 4-7 in London, hosted by the Royal National Institute of the Blind. This issue of Aging & Vision addresses some of the conference themes that will be presented by hundreds of vision rehabilitation practitioners, researchers and educators in attendance. Reflecting the theme "Advances in technology, designing and constructing for an inclusive environment," we present two articles of interest: Dr. John Gill's synopsis of current electronic vision systems and Dr. William Mann and his rehabilitation science doctoral students' overview on home safety and modification for older adults with vision impairment. In addition, Dr. Jill Keeffe, a keynote speaker at Vision 2005, addresses another conference theme, "Epidemiology and world blindness," in her article about the need for low cost optical and adaptive devices worldwide. And in the issue's final article, Dr. Amy Horowitz concentrates on the psychosocial dimension of Vision 2005's theme "Clinical care and integrating rehabilitation," in her discussion of depression and age-related macular degeneration. Vision 2005, under the auspices of the International Society for Low Vision Research and Rehabilitation (ISLRR) will be the venue for the release of the Oslo Invitational Workshop report, "Toward a Reduction in the Global Impact of Low Vision." Lighthouse International through our annual Schupf Scientific Symposium and ISLRR sponsored the invitational meeting of 25 diverse professional experts from six continents in fall, 2004. We created an international Call to Action to raise awareness of low vision, increase resources for low vision research and development, education and rehabilitation, and integrate these into global initiatives. After its release in April, the report will be available at HTTP://www.lighthouse.org and also on HTTP://www.visionconnection.org. Cynthia Stuen, DSW, Senior Vice President for Education, Lighthouse International (sidebar) In This Issue - Electronic Vision Systems - Home Safety and Modification for Older Adults with Vision Impairment - The Need for Low Cost Optical and Adaptive Devices Worldwide - Depression and Age-Related Macular Degeneration Electronic Vision Systems by John Gill, OBE, FIEE For many years scientists have addressed the problem of how to use electronic systems to replace some of the functions of the human eye. Up to recently these were just interesting laboratory experiments, but new developments in electronics and wearable computers could turn these prototypes into devices of practical benefit at affordable prices. The three main approaches are: - Vision enhancement - Vision substitution - Vision replacement Vision Enhancement Vision enhancement involves input from a camera, processing of the information, and output on a visual display. In its simplest form it may be a miniature head-mounted camera with the output on a head-mounted visual display (as used in some virtual reality systems). However, modern fast wearable computers make feasible sophisticated processing of the information in real time, and it is this factor which could transform interesting research projects into products of practical benefit for blind and partially sighted people. For instance, a more sophisticated system might incorporate a combination of visual and ultrasonic cameras. The ultrasonic camera can provide information about the distance of an object from the camera. The user could then instruct that he or she is only interested in viewing items less than two metres away. The processor would then delete all data at a distance of more than two metres, which would significantly reduce the clutter on the visual display. Another possibility could be that the user is looking for a post box, for example, which he knows is painted bright red. He could request that anything which is not red is shown with lower brightness. Yet another option is for the user to instruct that only the edges of objects should be displayed. There are many other possibilities for processing the information to meet the specific needs of an individual at that moment. Research is needed to determine what facilities are required and how to optimally design the user interface. This is an important research task since users will have little understanding of what facilities could be offered and the types of user interface which could be utilised. However, without the research being done systematically, progress on electronic vision systems will be slow and fragmentary. Vision Substitution Vision substitution is similar to vision enhancement but the output is non-visual — typically tactual or auditory or some combination of the two. Since the senses of touch and hearing have a much lower information capacity than vision, it is essential to process the information at a level that can be handled by the user. Vision Replacement Vision replacement involves displaying the information directly to the visual cortex of the human brain or via the optic nerve. Considerable research has been done on how to interface to the brain, but problems have been experienced in obtaining a reliable link of sufficient bandwidth, as well as with the human brain interpreting the data it is receiving. Vision enhancement systems have already appeared on the market, but are often limited to systems providing image enhancement. It is anticipated that they will gradually incorporate more options for image processing. Vision substitution systems already exist, mainly as developments of electronic mobility devices, but it is likely to be some years before they come into widespread use. Appropriate training will also be necessary for these systems. Affordable vision replacement systems are farther into the future since much more needs to be known about how to optimally connect to the visual cortex. Since this will involve a surgical procedure, there will need to be stringent testing to ensure there are no adverse effects. Over the next few years it will be important to differentiate advertising hype from the real benefits some people can receive from the appropriate use of these systems. There is a tendency to dismiss developments if they do not live up to the stories in the news, but it would be unwise to dismiss these systems even if claims are made that they "solve the problems of blind people." John Gill, OBE, FIEE, Chief Scientist, Royal National Institute of the Blind (sidebar) New developments in electronics and wearable computers could turn prototypes into devices of practical benefit at affordable prices. Home Safety and Modification for Older Adults with Vision Impairment by Shin-yi Lin, Megan Witte, and Patricia Belchior with William Mann, OTR, PhD Introduction Vision loss is a significant issue for older adults. While people over the age of 65 represent 12.8% of Americans, older adults disproportionately constitute 30% of people with visual impairment in the United States.1 The four main causes of visual impairment or blindness among older adults are cataracts, age-related macular degeneration, glaucoma, and diabetic retinopathy. Vision impairment can result in dependency in activities of daily living (ADLs & IADLs),2,3,4 increased risk of falls and fractures,5,6 and psychosocial difficulties.7,8 Assistive technology devices (AT) and environmental interventions (EI) are effective compensatory strategies to help older people with vision impairment to maintain independence. The most common AT device for older adults with low vision is prescription glasses. Over 90% of people over the age of 70 use eyeglasses. Still, 14% of the older adults between 70 and 74 years of age have difficulty seeing even with eyeglasses. This increases to 32% for those over 85. Only fewer than 2% of the older adults with visual impairment above the age of 70 use other vision devices, such as readers or computer equipment. In addition to a variety of low and high technology vision aids for reading and ADLs, EI can maximize performance and ensure safety. In the following paragraphs, basic principles of home modification and injury prevention are discussed. AT devices that promote safety in the home for older adults with visual impairments are also introduced. Home Modifications Home modifications create a safer and more accessible home environment, and increase competence in task performance, by adapting a home to promote independence in activities of daily living.9 Even minor, low-cost changes can have a positive impact on a person's safety and ability to perform routine everyday tasks.10 Home modifications also provide caregivers with a more supportive environment, making their caregiving tasks easier to complete. The risk of accidents such as falls can be reduced with even very simple, no-cost modifications. Depending on the type of adaptation, home modifications may involve architects, builders, vision rehabilitation therapists, and occupational therapists, and most importantly, the residents and their caregivers. Mann and colleagues11 studied home environmental problems among older adults and found that the kitchen, bathroom, and bedroom were the three most problematic areas in the home. Common problems in other areas, such as the hallway, stairs, and dining and living rooms, included clutter, unsafe carpets and extension cords, inadequate lighting, and chairs and couches that posed difficulties for sitting down or getting up. Common, simple home modifications include:12 -nightlights in hallways and/or bathroom; -non-skid strips in bathtub or shower; -higher wattage light bulbs; -lever handle faucets and doorknobs; -non-slip strips on stairways, and; -secured carpets and throw rugs (using double-sided tape). More expensive home modifications include: - installation of light switches at the top and bottom of stairwells; - adding a bathroom and/or bedroom to the first floor of a 2-story home to make the first floor livable; - addition of handrails to both sides of stairways; - installation of handrails and/or grab bars in the bathroom; - widening of doorways, and - addition of a ramp or stair lift. Injury Prevention People with sensory deficits have an increased risk for injuries. Low vision impedes appropriate detection of hazards in the home. A person with impaired vision can take several steps to increase safety in the home. One basic tip is to decrease clutter throughout the home and make sure all drawers and cupboard and closet doors are closed when not in use in order to avoid slips and trips. Further, worn or torn carpeting should be replaced; rug corners and edges should be tacked or taped down; and, linoleum or wood floors should not be waxed. Increasing color contrast throughout the house and increasing lighting while decreasing glare can also prevent injury, especially in areas like stairwells. Slips and trips are not the only injuries possible in the home for those with low vision. People with low vision can also take steps to decrease the likelihood of poisoning. Pillboxes can be valuable aids. Color coding medications with high contrast colors or utilizing a tactile cue such as wrapping a rubber band around the pill bottle to equal the number of doses needed a day are two simple ways to avoid potential hazards when taking medications. Electric alarms and buzzers are also available to cue people to take their medications. Devices that vibrate or have flashing lights are available for people with sensory impairments.13 Food poisoning can be a concern as well, especially when cooking directions are often in fine, hard-to-read print. New technology is being developed that can read RFID (Radio Frequency Identification) tags on a food product, automatically set up the correct cooking protocol, and speak to the user about the food product. When this device is commercialized, it could alert the user about foods with ingredients to which the user has allergies. Proper cooking would ensure that the user does not consume undercooked food. While still in prototype stage, high tech devices like this will be available in the future. Other Devices for Safety Various products for household or personal use exist with large print or voice output features. In the kitchen, a simple liquid level indicator that produces a buzz sound when overfilling a cup can prevent scald. A large-print or talking room thermostat can ensure a comfortable room temperature. Health monitoring products such as blood sugar or blood pressure monitors are both available in large print and talking models. For emergencies and accidents, a personal emergency response system (PERS) allows older adults to issue an immediate call for help by simply pushing a button on a body-worn transmitter to activate an automatic dialing mechanism. Outside the home, hand-held electronic travel aids (ETAs) can help detect objects in the walking path. An ETA works like a radar system that detects obstacles in the environment and produces a sound or vibration warning signal. Usually, ETAs are used to provide additional information about the nearby environment to supplement traditional travel aids such as a white cane or guide dog. The number of older adults with visual impairment will significantly grow in the next two decades and beyond. The majority of older adults will "age in place." Vision problems affect not only activities related to reading and seeing, but also other daily activities and social participation. Through the use of AT and EI, older adults with vision and other impairments can live more independently and safely in their home environment. A wide variety of low vision aids are designed especially for people with vision impairment to compensate limitations in reading, as well as activities in other domains. Shin-yi Lin, Megan Witte, and Patricia Belchior are PhD students in the Rehabilitation Science PhD Program, University of Florida. William Mann, OTR, PhD, is Professor and Director of the PhD Program in Rehabilitation Science and Director of the Rehabilitation Engineering Research Center on Aging at the University of Florida. References 1. Desai, M., Pratt, L.A., Lentzner, H., & Robinson, K.N. (2001). Trends in Vision and Hearing Among Older Americans. Aging Trends; No.2. Hyattsville, Maryland: National Center for Health Statistics. 2. Raina, P., Wong, M., & Massfeller, H. (2004). The relationship between sensory impairment and functional independence among elderly. BMC Geriatrics, 4:3. 3. Ivanoff, S.D., Sonn, U., Lundgren-Lindqvist, B., Sjostrand, J., & Steen, B. (2000). Disability in daily life activities and visual impairment: A population study of 85-year-old people living at home. Scandinavian Journal of Occupational Thearpy, 7, 148-155. 4. Keller, b.K., Morton, J.L., & Thomas, V.S. (1999). The effect of visual and hearing impairments on functional status. Journal of the American Geriatrics Society, 47, 1319- 1325. 5. Cox, A., Blaikie, A., MacEwen, C.J., Jones, K.T., Holding, D., Sharma, et al (2004). Visual impairment in elderly patients with hip fracture: causers and associations. Eye, 1, 1-5. 6. Ivers, R.Q., Cumming, R.G., Mitchell, P., & Attebo, K. (1998). Visual impairment and falls in older adults: the Blue Mountains Eye Study. Journal of the American Geriatrics Society, 46:58-64. 7. Lindo, G. & Nordholm, L. (1999). Adaptation strategies, well-being, and activities among people with low vision. Journal of Visual Impairment & Blindness, 93, 434-446. 8. Lamoureux, E.L., Hassell, J.B., & Keeffe, J.E. (2004). The determinants of participationin activities of daily living in people with impaired vision. American Journal of Ophthalmology, 137, 265-270. 9. Duncan, R., Pynoos, J., & Sabata, D. (2003). Common Ground: What do we mean by home modification [Abstract]. Proceedings of the International Conference on Aging Disability and Independence, Washington D.C. 10. Hutchings, L., & Olsen, R. (2003). Aging in place with a developmental disability: An environmental intervention study [Abstract]. Proceedings of the International Conference on Aging Disability and Independence, Washington D.C. 11. Mann, W., Hurren, D., Tomita, M., Bengali., & Steinfeld,E. (1994). Environmental problems in homes of elders with disabilities. The Occupational Therapy Journal of Research, 14(3), 191-211 12. Bayer, A., & Harper, L. (2000). Fixing to stay. A National Survey of housing and home modification issues. AARP. Washington D.C. Retrieved October 24, 2004, from http://research.aarp.org/il/home_mod.pdf 13. Centers for Disease Control and Prevention (CDC; 1986), Perspectives in Disease Prevention and Health Promotion National Poison Prevention Week: 25th Anniversary Observance. MMWR 35(10): 149-152. (photo caption–pg 4) Closed-circuit television (CCTV) can magnify up to 60X (photo caption–pg 5) Color coding or tactile marking of medications can differentiate for safety The Need for Low Cost Optical and Adaptive Devices Worldwide by Jill Keeffe, PhD The most recent global estimate from the World Health Organization (WHO) of the number of people who have visual impairment is 161 million.1 Of these, approximately 9 million have no usable vision — they are blind. Over half of the remaining 152 million people who experience low vision to varying degrees could potentially have their vision improved or restored, mostly via cataract surgery. Despite this, at least 60 million people with low vision will not be able to have their vision improved. In addition to this number are those individuals who can have their vision restored, but who will not be able to have surgery, and, as a result, will need low vision care. Ninety percent of people who have impaired vision live in developing countries. Low Vision Services in the Developing World In countries such as the United States, Australia, and the UK, it is estimated that about 10% of people with low vision use vision-related clinical and/or rehabilitation services.2 The picture is much worse in the developing world. At the Asian Pacific Regional Low Vision Workshop in Hong Kong in 2001, countries from the region estimated that only between zero and 5% of people with low vision could or did access low vision services. Barriers to establishing low vision services or access to existing services were discussed. One of the major impediments to the provision of low vision care has been the lack of good quality, yet affordable, low vision devices. Some countries such as Pakistan and India have produced low vision devices locally, but these do not meet national or global demands. The availability of professionals trained in low vision care poses another major barrier. Recommendations from the Asian Pacific Regional Low Vision Workshop A number of recommendations, which centered on the nature and delivery of low vision services; the availability of special resources; human resource development including training, curriculum development, and advocacy to both professionals and the community, were developed during the Workshop. Another recommendation was to establish regional centers for training which would act as clearinghouses for low cost low vision technology. Following the Workshop, a Working Group on Low Vision (LVWG) was formed by the WHO. The members were selected so that the Working Group would represent all regions and would include the range of agencies, professionals, and consumers involved in low vision care. The Resource Centre and Low Vision Devices One of the first priorities of the Group was to set up a Resource Centre whose mission is to make available and distribute a comprehensive range of good quality affordable low vision devices to people in developing countries. The Centre, which now has a stock of approximately 80 different items, acts as a clearinghouse to centralize the purchasing and development of low cost low vision devices and assessment materials. The aim is to provide optical devices in the most commonly prescribed range of powers for children and adults. Though the Centre does not supply the very high power magnifiers that are not commonly prescribed, it stocks near magnifiers at incremental steps up to 12.5 times magnification and telescopes (hand-held and spectacle mounted) from three times to 10 times magnification. The Centre also holds in inventory illuminated and non-illuminated hand-held and stand magnifiers. Further development work is needed to complete the range of optical low vision devices at the Centre. Although spectacle magnifiers are being added to the range, electronic devices such as high quality affordable closed circuit apparatuses have yet to be included. Non-optical devices are not stocked since most of these devices, such as those that enhance contrast and illumination, can be readily purchased in most countries. To assist in the development of low vision care in developing countries, distance and near visual acuity charts are needed to assess vision for the prescription of devices. Since the cost of these charts can be prohibitive in setting up a low vision clinic, the Centre now offers high quality low cost chart models. Selection of Devices Devices were initially selected because of their optical properties and design durability. The Centre trialed and compared a selection of low vision devices with devices commonly prescribed in low vision clinics. People with low vision used both the low cost devices and the "gold standard" devices to read passages of print. No significant differences in performance or subjective preference were found between the two sets of devices. The simplest devices can be purchased for less than a dollar with the telescopes ranging from $13 – $16. Near magnifiers cost less than $6. Orders are placed through the web site of the Hong Kong Society for the Blind, www.hksb.org.hk, following the link to the Resource Centre. To make the Centre sustainable, a very small margin is added to the cost of devices, which allows for quality control and the employment of an individual who handles order distribution. The Centre has received and filled orders to all geographic regions. One of the actions for the LVWG over the 2004 – 2008 period is to consider and recommend the establishment of additional regional Resource Centres. Other Aims of the Working Group on Low Vision The other major aim of the LVWG was to develop curriculum and conduct training courses, both of which have commenced. During 2004, two intensive four-week courses were conducted in Hong Kong for National Focal Persons — those persons who will have an important role in establishing and supporting national low vision programs, and the low vision practitioners who will assist in establishing low vision services in developing countries. In the coming years, one of the outcomes to be monitored will be the increase in access to low vision care for the 95% of the world's population who have low vision. Our services will be evaluated to ensure the maintenance and improvement of quality of life for people with low vision. Jill Keeffe, PhD, Centre for Eye Research Australia, and Co-Chair, World Health Organization Low Vision Working Group References 1. Resnikoff S, Pascolini D, Etya'ale D, Kocur I, Pararajasegaram R, Pokharel GP, Mariotti S. Global data on visual impairment in the year 2002. Bulletin of the WHO 2004; 82:844-851. 2. Culham LE, Ryan B, Jackson AJ, et al. Low vision services for vision rehabilitation in the United Kingdom. British Journal of Ophthalmology 2002; 86:743-7. (sidebar_pg 8) - The most recent global estimate from the World Health Organization (WHO) of the number of people who have visual impairment is 161 million. - ... approximately 9 million have no usable vision — they are blind - Over half of the remaining 152 million people who experience low vision to varying degrees could potentially have their vision improved or restored ... - ... at least 60 million people with low vision will not be able to have their vision improved - Ninety percent of people who have impaired vision live in developing countries. (photo caption–pg 9) A hand-held telescope is useful for distance viewing Depression and Age-Related Macular Degeneration by Amy Horowitz, DSW The experience of clinically significant depression as a consequence of the functional and emotional impact of vision loss in later life is a very critical but often unidentified and overlooked problem among older adults with age-related macular degeneration (AMD). There is clear evidence from population-based studies that age-related vision impairment, often as a result of AMD, increases the risk of depression among older adults, even when other risk factors such as age, gender, and concurrent medical conditions are controlled. In fact, visually impaired adults are anywhere from two to three times more likely to experience depression than their non-visually impaired peers — making vision loss in later life a more potent risk factor for depression than many other common age-related health conditions. At the Arlene R. Gordon Research Institute of Lighthouse International, we have been engaged in a program of research on the prevalence, course, and consequences of depression among older people with vision loss due to age-related vision diseases with studies funded by the National Eye Institute, the National Institute of Mental Health, the National Institute on Aging, as well as several private foundations. Prevalence of Depression Similar to other investigations, we have found that approximately 7% of older adults with vision loss due to age-related vision diseases meet the criteria for a major depressive disorder compared to an estimated 1 to 4% of elders in the general community. Another 27% experience a subthreshold depression compared to 15 to 20% of medically ill older adults. Thus, one-third of all older adults with AMD can be expected to experience clinically significant depressive symptoms. The human side of these numbers is reflected in comments made by our research participants: When the first eye went, I was depressed. But, when the second eye went, I fell to pieces. — 86 year old female … very depressing … frustrating. Terrible feeling to lose vision, like the end of the world almost. I feel like people might feel if they had a terminal illness. — 75 year old male Interestingly, the research has found no evidence of a strong association between the objective severity of vision loss and the severity of depression. That is, older adults who are in the early stages of the disease and have only minimal vision impairment are at no less risk for depression than are those with more severe impairments. Predictors of Depression How then can we explain this extremely strong relationship between late life vision loss and depression? We propose three primary pathways: the functional link, the subjective experience, and the loss of valued activities. Functional Link First, vision impairment has the potential to result in substantial limitations in everyday activities. Disability and depression are intricately linked in old age with each feeding into the other in what has been labeled a "downward spiral." Without appropriate interventions, disability increases the risk of depression and depression further increases the risk of disability. Subjective Experience Second, on a subjective level, one of the most unique characteristics of vision loss is the intense fear it evokes. Loss of vision is viewed as an extraordinary event that threatens the very identity of the individual. Negative images of blindness abound in mythological, historical, and biblical literature. Just think of the expression, "the eyes are the windows to the soul," and many more like it. As a result, public opinion polls have found that "blindness" is the fourth most feared illness of Americans of all ages, following only AIDS, cancer, and Alzheimer's disease. Loss of Valued Activities Third, we are finding that psychological distress may stem, not only from the general limitations in everyday life caused by vision impairment, but also from the impact that vision loss has on especially valued activities. AMD, for example, affects two of the most common and valued activities of older adults — reading and driving. Losing the ability to read is clearly one of the most devastating consequences of vision loss for older adults. The loss is ubiquitous. Not only is reading for pleasure affected, but the inability to read newspapers and magazines can also psychologically break one's connection with larger society. Difficulty reading menus and prayer books, for example, may threaten the older adult's connection to the social community, and difficulty reading price labels, street signs, and medicine bottles further contributes to problems with everyday living. Perhaps even more psychologically stressful is the impact of vision impairment on the ability to drive. For older adults, driving is more than just a means to accomplishing daily activities. It is permeated with personal meanings including one's sense of autonomy, independence, and self-worth. Losing the ability to drive is symbolically associated with the first step towards dependency. Also, ex-drivers have significantly higher rates of depression. Again, in the words of our research participants: Not driving my car makes me feel so helpless and also as if I don't belong to the world. — 78 year old female I stopped driving to visit people. Now they must visit me. I stopped living … wish life would end. — 65 year old male Accessing Vision Rehabilitation Services Depression, like AMD, is a major public health concern. Individually and even more so in combination, these diseases are costly to society. Each significantly increases the risk of further medical complications and morbidity among older adults and depression carries the added increased risk of mortality. However, the experience of depression as a consequence of AMD is neither inevitable nor invariable. Access to vision rehabilitation services can play a critical role in reducing the risk of depression initially, as well as influencing declines in depression over time. In research at Lighthouse International, our findings indicate that vision rehabilitation significantly slows the decline in functional disability, which in turn, is associated with decreased depression. In a study of the impact of optical devices, we have found that greater use of these devices predicts a decline in both disability and depression at the six- month follow-up. Unfortunately, national data also indicate that most older adults who have vision problems are not aware of the availability of vision rehabilitation and/or do not use these services for financial and other reasons. To address these unmet needs, it is imperative to highlight the potential of vision rehabilitation for improving both the physical and mental health of older people with AMD and to continue to work towards increasing access to and coverage for these critical services. Amy Horowitz, DSW, Senior Vice President for Research and Evaluation, Director of the Arlene R. Gordon Research Institute, Lighthouse International Sections of this article were drawn from: Horowitz, A. (2003). Depression and vision and hearing impairments in later life. Generations, 27 (1), 32-38. Please see this article for citations. (sidebar pg 12) There is clear evidence from population-based studies that age-related vision impairment, ... increases the risk of depression among older adults, even when other risk factors ... are controlled. Aging&Vision Cynthia Stuen, DSW Senior Vice President for Education, Director of Lighthouse Center for Education Sarah Lloyd Director of Educational Publications Photos: Jayne DiGregorio, James LaBounty, Robert Lisak, and Peter Vidor Aging & Vision Editorial Board Cynthia Stuen, DSW, Chair Aries Arditi, PhD Eleanor E. Faye, MD, FACS Michael Fischer, OD, FAAO Kent Higgins, PhD Amy Horowitz, DSW Bruce Rosenthal, OD, FAAO Carol Sussman-Skalka, CSW, MBA Lighthouse International Barbara Silverstone, DSW President and CEO Lighthouse International is a leading resource worldwide on vision impairment and vision rehabilitation. Through its pioneering work in vision rehabilitation services, education, research, prevention and advocacy, Lighthouse International enables people of all ages who are blind or partially sighted to lead independent and productive lives. Founded in 1905 and headquartered in New York, Lighthouse International is a not-for-profit organization, and depends on the support and generosity of individuals, foundations and corporations. If you'd prefer not to receive Aging & Vision, please send a message to: unsubscribe_agingvision@webletter.lighthouse.org Lighthouse International does not sell its e-mail subscriber list to third parties. For more information, and additional opt out options, please read our privacy policy statement by following this link: lighthouse.org/about_privacy.htm E-mail delivery provided by DoubleClick's DARTmail. Click here for important privacy information: privacychoices.org