University of Iowa Health Care

Ophthalmology and Visual Sciences

Evaluation and Management of Children with Visual Impairments

Mark E. Wilkinson, OD, FAAO

Length: 16:52

Posted May 9, 2021

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Slide 1

This is Mark Wilkinson from the University of Iowa Department of Ophthalmology and Visual Sciences. In this presentation we will discuss how to evaluate and manage children with visual impairments.  

Slide 2

We will be discussing the importance of incorporating clinical vision rehabilitation evaluation findings in the educational planning for all children with visual impairments. Literacy issues for this population. The use of large print and Braille materials in school and educational accommodations for this population.

Slide 3

Data in the United States typically estimates that 0.2% of the school age population is comprised of children with low vision or blindness. Of these, only 10-15% are considered to be functionally or totally blind. Despite the low prevalence of visual impairment in the school age population, childhood vision impairment is a significant public health problem because it affects children across their lifespans.

Slide 4

The Service Model for pediatric vision rehabilitation services should be a collaborative one that uses clinical information and findings from the low Vision Practitioner along with ophthalmologic information. This clinical information will be combined with the educational and functional information and findings from the child's Teacher of the visually impaired, Classroom teacher, Orientation & mobility specialist and the child's Parents.

Slide 5

Functional and Educational Outcomes must be focused on the individual needs of the student.   We need to determine what does the student need to do, not only at School, but in the community as well as vocationally as they mature. We also need to consider their ability to travel independently, an important skill as the child matures and becomes more independent of their parents.  We must not forget to also consider what the student wants to do? Are they able to read leisure materials when away from school?  Also, it important to find out what avocational activities they are interested in. 

Slide 6

Let's review the purposes of providing a Clinical Vision rehabilitation Evaluation for all children who are visually impaired.  A primary purpose is to establish a baseline of acuity measurements and general visual functioning level, for all students who are visually impaired.  This will help the student's parents and teachers better understand their child's visual condition and visual functioning abilities.   Simply said, they will want to know how is my child able to see. 

The clinical vision rehabilitation evaluation will also be used to determine if there is a refractive error and whether the refractive error is significant enough to need corrective lenses. 

The clinical vision rehabilitation evaluation will provide information and assistance, as needed, in the process of determining the most appropriate learning/literacy media.

Slide 7

The clinical vision rehabilitation evaluation will be used to determine if low vision devices, technology equipment, or other adaptations and accommodations will likely enhance the student's functioning level in school and/or community.

This information will assist the educational team members with the trial and/or acquisition of recommended devices, equipment, or strategies.

The clinical vision rehabilitation evaluation will be used to assess the child's visual skills in terms of whether or not vision loss is likely to be a major factor when there are concerns about other developmental areas.

Slide 8

As the child ages, the clinical vision rehabilitation evaluation will be used to assess vision in terms of acquiring an instructional permit or driver's license when appropriate.

Timely reevaluations are important to determine if the child's visual functioning is improving, remaining stable, or otherwise changing.  If vision is changing, the clinical vision rehabilitation evaluation will help to determine what those changes may indicate in terms of other programming needs; and whether the need for devices or other accommodations has changed.

Slide 9

A Primary Consideration when evaluation a child who is visually impaired is to determine what they need to be literate.  Literacy is defined by Webster's New World Dictionary as the state or quality of being literate, specifically, the ability to read and write.

Slide 10

Taking Literacy, a bit further, the full complement of literacy components should include the ability to both Read and Write, with the ability to read and write in a legible way so the child can communicate with both themselves and with others.  If the child cannot read their own writing, and no one else can read their writing, they are not able to communicate and so do not have full literacy skills.  
Additionally, to be fully literate, the child needs to be able to access and acquire information.

Slide 11

An educational term you should be aware of this the primary learning medium.  The primary learning medium is the medium most frequently used during classroom instruction for reading and writing purposes.

The primary learning medium should allow access to the greatest variety of educational materials.  Additionally, the primary learning medium should be able to be easily utilized in a wide variety of settings including Academic, Non-academic and Vocational settings.

Slide 12

The selection of Primary Learning Medium will consider the portability of reading skills, reading rates and accuracy, Visual fatigue and the Working distance required when reading.  

Slide 13

As the educational team works to determine the Initial Literacy Medium, they will gather objective information in these areas of how well the child uses their visual sense versus their tactile or auditory senses for information gathering.
The team will look at the sizes of objects and working distances the child needs to visually respond and the team will look at the influence of additional disabilities on the potential reading method.

Slide 14

In the past, and even some today, the use of large print has been the standard approach to use for any child who is visually impaired.   The problem with that approach is that a one size fits all approach is never appropriate.  Additionally, we know that reading speeds are slower in large print.

The total head-sweep needed to read large print is time-consuming and tiring.
Also, there are fewer large print books in publication than Braille books.

Slide 15

Other disadvantages of Large Print include Fractions, label on diagrams other non-standard printed items is not enlarged to large print size.

Large type materials are not readily available after school and there are Limited choices available in large print for pleasure and fun reading.

In general, a large print only reading high school graduate may be functionally illiterate in many situations including college and employment opportunities.

Slide 16

Given this, you might ask, so why is Large Print Provided? 
By providing large print, schools feel good about doing something for students who are visually impaired.  Additionally, It is what has been done for years.
There is also the Adult's perception of the value of large print ("my grandmother uses large print").

There are also Eye or other doctors recommend large print, often without ever measuring the child's near acuity

The general education teacher and/or parent wants it.

The teacher of the visually impaired does not have data to support a more appropriate choice.

Slide 17

The Principle of Least-Restrictive Materials is a good strategy to consider when determining the best learning media for a child who is visually impaired.   The principle states, Materials should be adapted only to the extent necessary for efficient learning. If regular materials can be used in conjunction with environmental adaptations or low vision devices, such an approach is preferable to using specialized materials. 

What this is saying is that using low vision devices, which are discussed more fully in the optical and low-tech devices and the high-tech devices presentations, is preferred, because it will allow the student access to all printed materials, versus having to wait for those materials to be enlarged. 

Slide 18

This slide shows what happened in my state of Iowa when we worked to examine every student in the state who was receiving large print.  Some of the students who were receiving large print did not need it and in fact never used it.  Many others were able to read regular size print with the use of low vision devices.  

Slide 19

This slide shows that the vast majority of students who are visually impaired have a Working Distance when reading of 6" or closer. This is a normal adaptation for a child who is visually impaired. The child is using relative distance magnification to be able to read. This closer reading distance should not be discouraged.  

For more on relative distance magnification and the different types of magnification used to enhance vision, watch the optical and low-tech devices presentation.  

Slide 20

As you work with each child's educational team to determine best Literacy medium for the child, you and the team will need to Consider the following questions. 

Does the visual condition indicate a stable condition?  Progressive loss? Unpredictability?

If there is a medically diagnosed expectation of visual deterioration in adolescence or early adulthood?  If yes, is there a need for instruction in a new primary literacy medium before the current medium is ineffective?

Slide 21

A few comments about Braille.

Some say "learn Braille now, because it may be useful in the future."  The problem with this approach is that it assumes the world is static.  No consideration is given to the technology advances that have and will continue to occur over time.   Additionally, no consideration is given to the gene and stem cell therapies that are anticipated to be available in single digit years.

Others say it is best to "learn both Braille and print reading."   The problem with this approach is that often Braille is only learned as well as the student can visually see it.  Additionally, a dual sensory approach can slow the development of visual reading speed as well as other educational areas because of the time it takes to develop a functional level of braille reading skills. 

Bottom line is this, those that need to learn Braille, will learn it.  It is simply not necessary for every child who is visually impaired to learn braille. 

Slide 22

There are many people who may be part of the Multidisciplinary Team that provides care to a child who is visually impaired.   Team members include the
Treating eye care professional, the Low vision rehabilitation clinician, the Teachers of students with visual impairments.  Also involved can be an Educational consultant, and a Technology consultant.  The child's Parents should always be involved as well.   For younger children, an Early childhood specialist is an important member of the team.  For children with additional disabilities, there are additional consultants available depending on the child's needs.  Orientation and mobility specialist are involved if there is concern about the child's vision loss affecting their ability to independently move from one environment to another.   The student's Classroom teachers will be part of the team and the Student themselves will be a team member when they reach the appropriate age. 

Physical therapist and Occupational therapist may also be part of the team, again depending on the child's needs. 

Slide 23

Common Questions for certified orientation and mobility specialists are, Can my child Cross a street, Walk to school, Ride a bike, Ride a moped or even Drive a car. A certified orientation and mobility specialist will be able to do an assessment in both familiar and unfamiliar environments, under different lighting conditions to sort out the answers to these questions.

Slide 24

Technology Consultant are invaluable because of the myriad of options available to enhance functional abilities with the different technologies now available.  The technology consultant uses the SETT framework to determine what technology assistance will help the student at different stages of their lives. 

Slide 25

The SETT Framework looks at Student information, what is their Eye condition, what does the Clinical low vision rehabilitation report say, what was found during the Functional vision assessment and are there any other handicapping conditions.

Next, they will review the Environments the student needs to function in, both at Home and in School as well as Vocational and Community setting. 

The Tasks in which the student may need assistive technology is reviewed.

Finally, the Tools required by the student to function as independently, efficiently and competitively as possible are reviewed.

For more information about technology options, watch the high tech devices presentation.

Slide 26

It is important to know that 40 - 66% of children with visual impairments have additional disabilities.   Of this group, 75 - 80% have some useful vision.  Given this, both your examination and recommendations for devices to enhance visual functioning will need to take into considering the effect of the additional disabilities on the child's ability to be evaluated and to use the various devices available. 

Slide 27

An additional consideration is determining if the child has Cortical Visual Impairment, a brain processing visual information problem.  Or, is the visual impairment secondary to a more global Neurological deficit, where there are more widespread impairments in the functional abilities and cognition of the child.

Slide 28

A Report should be written and shared with the student's parents and educational team after each low vision rehabilitation evaluation.   That report should include the following, the current or working diagnosis, a realistic Prognosis, if known about the likely stability or possible progression of the vision loss.   Any Eye Medications recommended.   Any Color Vision Deficiencies found.
The best corrected Visual Acuity in the distance as well as at near.   When reporting near acuity, always note the Working Distance near acuity testing was performed at.   Report your recommendation for Reading Print Size.  Report and Visual field limitations.  

Slide 29

If Photophobia is present, is it only present outdoors, or is it present both Indoors and Outdoors. If photophobia is present, what is recommended to ameliorate the photophobia.  Are there any restrictions in Physical Education or Sports? Does the student have any special Contrast or Lighting Requirements?  If a Spectacle Correction is prescribed, what is it used for, General Use, Distance only or Reading only. Remember that many myopic children will want to look over the top or remove their glasses for near vision tasks. Their parents and teachers need to know this is the way the child sees their best when reading.  

Any Optical and/or Electronic Devices recommended should be noted along with the expected benefits from using these devices. 

Finally, note when the child should have their Next Evaluation with you.

Slide 30

In conclusion, it is important to remember that vision rehabilitation is the only non-surgical treatment modality for vision loss.  With this in mind, on-going vision rehabilitative assessment and care, provided by a vision rehabilitation practitioner, is an essential component in the educational planning for every child with a visual impairment.

Slide 31

The Low Vision Section of the American Academy of Optometry, published a Position Paper on Clinical Low Vision Evaluation and Treatment of Students with Visual Impairments for Parents, Educators and Other Professionals.  That document is an excellent Resource for Practitioners and Parents and can be found at the web address noted on this slide.

Slide 32

Additional Resource for Parents can be found at the NEI National Eye Health Education Program (NEHEP) website, and at the American Foundation for the Blind and National Association for Parents of Children with Visual Impairments: Family Connect website where you will find Common Questions Asked by Parents of Children Who Are Visually Impaired.

Slide 32

Now you know the issues and care consideration when evaluating and managing the vision rehabilitation needs of children who are visually impaired. 

Thanks for your attention. If you have any questions, you can contact me by email.  

last updated: 05/9/2021
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