Low Vision Rehabilitation of the

Pediatric PatientSuleiman Alibhai, O.D

DefinitionsVision Disorder: nystagmus, optic nerve hypoplasia, aniridia

Vision Impairment: reduced acuity, loss of visual field, central scotoma

Vision Disability: seeing the board, reading a book, bubbling a scantron sheet

Vision Handicap: preferred seating in classroom, extra time to take test, books on tape

Road to Rehabilitation

Parent - first to notice

Ophthalmologist - make the diagnosis

Educators - propose an IEP

Rehabilitation team - itinerant vision teachers, OT, low vision specialist, O&M

Advocacy resources - NAPVI, FFB, AFB etc.

Role Of The Low Vision Specialist

Referral from MD, school, state rehab program, parents in search

Careful history - expectations, parent and child’s understanding, vision report from MD

Exam - emphasis on what can be seen: acuity, field, contrast, reading especially

Visual aids - distance, near, intermediate

Non-visual aids - tapes, canes and mentors

Impact of the Vision Disorder

Parents - denial, anger, depression, acceptance

Child - none, confusion, apprehension, determination

Society - what accommodations or treatments can be provided

Measurement of the Visual Impairment

Role of visual acuity: 20/200 is NOT blind!

ETDRS chart at 2m, 1m or even 0.5m

Contrast sensitivity - the quality of vision measured by MARS, Pelli Robson or LEA

Visual field - likely to be unreliable, use observation and understanding of disorder

Reading ability - letters vs words, serifs, spacing, learning disability

Aids to overcome the Vision Disability

Try the glasses first!

Telescopes for distance: monocular, binocular, bioptic - goal of 20/40

Options to read: accommodate and get closer, bifocal with high adds, reading glasses, magnifiers, CCTV’s

Other considerations: filters for contrast and glare, lighting and lamps

White cane for mobility

Visual Handicap(how much accommodation will

be necessary)Books will need to be enlarged - font size?

Recorded and/or braille books will be provided

More time for examinations, quizzes and tests

Transportation alternatives - will never drive!

Case 1 Kathryn (7)

• Vision Disorder: nystagmus, OCA – still in kindergarten

• Vision Impairment: OD 20/400 OS 20/320

• Rx OD +2.50-2.00X180 OS +1.75-1.00X180

• Contrast 1.44 log MARS

• Reading OD 2.0M @ 12cm, 1.6M @12cm

• VF: FTFC OD and OS

Functional Vision and Learning Media Assessment by Itinerant

Vision Teacher

• Emotional development: advocates and discusses

• Near functioning: discrimination of details in pictures in age appropriate book, completes a maze, matches coins

• Intermediate functioning: reaches for objects on table, picks up paperclips scattered desk

• Distance functioning: imitates body movements at 10 feet

Functional Vision and Learning Media Assessment by Itinerant

Vision Teacher continued...

• Distance functioning: read 2 inch letters at 4 feet from whiteboard

• Lighting sensitivity: outdoors wears glasses, okay indoors

• Orientation and Mobility: travels confidently in school: playground, steps, grass vs asphalt

• Recommends: trial of visual aids

Vision Disability Strategies

• 4x monocular telescope to see the board

• +5.00 add single vision reading glasses to read – achieves 1.0M more comfortably

• Jupiter dome stand magnifier for spot reading

• NOIR U21 tint wraparound over glasses for glare sensitivity

Vision Handicap

• Too young yet to tell

• Probably need transportation alternative to driving but might qualify for bioptic driving in VA if 20/200

• Can reading be sustained into college years or will audio substitution become necessary?

Case 2 Brian (17)

• Disorder: Bardet Biedel, RP like

• Impairment OD 20/250 OS 20/100

• Rx: OD -0.75-4.50X180 OS -2.75-3.75X170

• Contrast 0.48 log MARS

• Reading OD 8.0M @ 10cm, 0.8M @10cm

• VF < 10 degrees

Functional Vision Assessment by Itinerant Vision Teacher

• Emotional assessment: does not use cane at school, visual fatigue and strain, HA’s, relies on others

• Near functioning: relies on enlarged print, cannot see details in pictures or map, needs bold print, relies on Zoom-text for PC

• Intermediate functioning: scans and reaches for coins on table

Functional Vision Assessment by Itinerant Vision Teacher cont..

• Distance functioning: imitates body movements at 10 ft, can read clock at 8 ft and 1 inch letters at 4 ft, relies on brother to find bus

• Light sensitivity: difficulty with transitions in different light conditions, OTT lamps used

• Orientation and mobility: looks down when walking and does bump into objects

Learning Media Assessment

• Reading speed with basic words: 62 wpm @ 10 point, 90 wpm with bold 14 point

• Reading speed with grade appropriate text silent reading: 48 wpm @ 10 point, 64 wpm with bold 14 point. Comprehension 80%

• Writing: bold pen, 6 inch working distance, loses place - does not take notes in class

Disability Strategies

• Acrobat zoom reader to see board

• CCTV reverse polarity to read: My Reader 2

• Kurzweil and Zoomtext for PC

• White cane for mobility

• Mother helps with schoolwork (Grade 10)

• Braille?

Vision Handicap

• Likely to lose further vision based on diagnosis

• Auditory substitution likely - learn braille?

• Transportation accommodation definite – needs to learn good cane travel or use a dog

• Technological adaptations at workplace

• Might even pursue disability if learning disability prevents further education

Case 3: Anthony (14)

• Knobloch syndrome: high myopia, risk of RD and vitreoretinal changes

• Myopia: -22.00, acuities: 20/200 to 20/400

• PSC OU S/P CE 2009: PC IOL’s OU 20/320

• CSF 0.96 log MARS

• Reading with +12 add 2.0M @ 6-cm

• Full visual fields

Questions for AnthonyPre and Post CE

• Emotional adaptation

• Distance strategies

• Intermediate strategies

• Near reading strategies

• Lighting considerations

• Orientation and Mobility