Low Vision Rehabilitation of the Pediatric Patient Suleiman Alibhai, O.D.
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Transcript of Low Vision Rehabilitation of the Pediatric Patient Suleiman 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