Functional Low Vision Assessment for O/M Instructors

1. Functional Low Vision Assessment for O/M Instructors Evaluating, Communicating and Applying Results Flavia Steiner-Viggiani, M.Ed. COMS, CLVT Welcome Everybody! Michigan AER Conference, 2009

2. Goals for this workshop • Develop a better understanding of the components of a FVA and how they relate to a meaningful educational practice. • Gain experience in performing some of the assessment techniques. • Learn how to structure the information in a comprehensive report. • Explore some of the possible goals for a mobility program based on the results of the FVA • Get ideas on materials, toys and charts used. • Share challenges and ask questions Michigan AER Conference, 2009

3. Characteristics of a Meaningful Functional Vision Assessment Michigan AER Conference, 2009

4. A Meaningful FLVA is: 80 % Observation 20% evaluation, testing and structured activities A process that helps us grow as teachers and makes us look at students as completely unique individuals Michigan AER Conference, 2009

5. How does the process look like? 1. Preparation and Observation 2. Thinking, wondering and evaluating 3. Communicating 4. Moving Forward Michigan AER Conference, 2009

6. Preparation What do you know about the student? Concerns or questions From teachers, specialists and family members. Medical Records and/or Reports Ocular and Medical records, educational evaluations, previous educational concerns stated in the IEP Michigan AER Conference, 2009

7. Rules for a thoughtful Observation • Be quiet. Sit and observe without getting involved in anything else. Be 100% present in that moment. • Don’t assume. Just observe and learn. • Take your time to find the uniqueness of this particular student. • When you feel comfortable, start writing down some of your observations. Michigan AER Conference, 2009

8. NEAR TASKS: Lunch, table work, snack, reading, art, science. INTERMEDIATE TASKS: Recognizing people, reading close signs, social interactions DISTANCE TASKS: Traveling, reading signs, recognizing people without sound input, looking at traffic signals, circle time, copying from the board. Observing the student Michigan AER Conference, 2009

9. Observing the environment and relevant educational aspects Illumination: Levels and types of illumination, contrast and glare Environment: complexity and amount of sensory input Use of other senses: visual vs. tactile, auditory Levels of assistance: degrees of independence and motivation Communication: concrete symbols, pictures, verbal, multi sensory. Emotional behavior: Frustration levels, stamina, advocacy. Community traveling skills Levels of Independence, Orientation, Mobility skills, Visual awareness Michigan AER Conference, 2009

10. Ivan Cognitive delays Cerebral Palsy PVL Optic Nerve Atrophy TVI OM PT Speech and Language Michigan AER Conference, 2009

11. Thinking, Wondering and EvaluatingWhat do I need to know? What areas do I need to evaluate further after observing the student? Components of the FLVA How will I structure the environment? Complexity, lighting, familiar people, brakes, contrasting surfaces. What materials are appropriate for this student? Age, interests, salient features of objects, size, textures, cognitively meaningful. Michigan AER Conference, 2009

12. Planning and Evaluation General observation (ocular health) Near and Distance Vision (clinical, functional) Visual Fields (gross observation) Color awareness (matching, preference) Ocular Observations (alignment, motilities) Visual behaviors (visual skills) Michigan AER Conference, 2009

13. General Observation of Ocular Health • EYE APPEARANCE • Eyelashes • Conjunctiva • Cornea (opacity, cloudiness) • Rubbing, scratching, watering • Inflammation. Michigan AER Conference, 2009

14. Formal Visual Acuities at Distance and Near Formal or Clinical VA Uses clinically calibrated visual charts to obtain resolution acuity results (object identification) Require the cognitive ability to identify pictures or letters Usually designed for testing at 10 feet (distance) At near, they are designed to be tested at 40 cm. “At 10 feet of distance, Flavia was able to identify a 3.5 in. symbol, which represents an acuity of 20/200 using the Patti Pics Chart” “Flavia was able to identify a 4 mm. size letter at 10 inches” (functional notation) ALWAYS make a copy of the actual chart for a concrete representation Michigan AER Conference, 2009

15. Functional Visual Acuities Functional VA Used in very young children or students and adults with intellectual disabilities. Students who present challenges staying visually attentive or motivated. Uses real life motivating objects It is a good idea to start from a distance and move closer to identify the point when the student makes eye contact or reaches out. It is notated using the size of the object FIRST and then viewing distance. It specifies the conditions of the environment. “Flavia is able to identify a 2 in. tall, green cereal bowl from 5 feet when placed on the table on a black mat” Michigan AER Conference, 2009

16. Converting Formal Visual Acuities into Snellen Notation • The goal is to obtain a fraction with the number 20 in the numerator (top number) • For example, if the acuity is 5/80, by multiplying 5 times 4, we obtain a numerator equal to 20. • We use the same number 4 to multiply the bottom number 80 (denominator) • The Snellen acuity is: 20/320 • Incorrect: 20/60 at 5 feet. • Correct: 5/60. Visual acuity is: 20/240 Michigan AER Conference, 2009

17. Let’s Practice! An acuity of 10/100 is: 20/200 An acuity of 5/40 is: 20/160 An acuity of 5/400 is: 20/1600 An acuity of 10/15 is: 20/30 Michigan AER Conference, 2009

18. Peripheral Visual Field Assessment • Modified Confrontation with both eyes open • Best performed with two evaluators involved. • Functional and qualitative. Not clinical. • Uses 2 targets: one central and one peripheral. • Target needs to be symmetrical. • Flashlight or penlight • Lava flashlight • Toy and hanger • Small finger puppet Let’s do it! Michigan AER Conference, 2009

19. How do we communicate the results? • Use observational terms, not clinical diagnostic terms. • Flavia was able to identify the presence of the 1.5 in. yellow star on the right side of the peripheral field without difficulties. However, when the target was presented inferiorly, Flavia spotted the star when the object was almost at chin level. When the target was presented from the left side, Flavia had difficulties spotting the object until it reached a distance of 1 or 2 inches of her face. She did not appear to have challenges identifying the star superiorly” • If you have any difficulties testing or if the results are not consistent or reliable, or if there are no eye reports or visual field testing done in the past, always refer the student for more testing in a clinical setting. Michigan AER Conference, 2009

20. Color discrimination and awareness • Color helps us determine: • Contrasting surfaces • Type of print and color based on background • Challenges identifying objects around the environment • Predominant color for tactile symbols, maps, and objects in the environment (street signs, bus numbers, pedestrian signals, traffic lights) • What materials can we use? • Wheatley Kit with shapes and colors • Color squares (Paint catalogues) • Interactive games that include color (Candyland®, Legos®) • Color sticks or beads Michigan AER Conference, 2009

21. Ocular Observations • Are both eyes aligned? Are they deviated? When? • Observe if both eyes work as a team, move together in a steady fashion and remain centered when the child is looking “centrally” or in “primary gaze”. • Many children with multiple disabilities have eye turns or deviations, especially those with Cerebral Palsy. • What are some of the implications of eye turns? Michigan AER Conference, 2009

22. Ocular Motilities • Ability of the eye muscles to control eye movement. It is directly related to the ability of the eyes to move together as a team in all positions of gaze. • What materials do we use? • Follow a penlight • Follow an object without a sound (puppet, toy, shinny object, slinky, fun pencil erasers, key chains, etc) • Ask the student/client to follow the object with their eyes only without moving their heads. Make note of difficulties! Note: make sure that the only stimulus is visual, so that the student is not following the sound, but only the object. Michigan AER Conference, 2009

23. Visual Skills Shifting Gaze (changing visual attention between two objects) Tracking (following a moving target) Scanning (organized search pattern) Materials used: Wooden beads, toys M&M’s over a contrasting surface Moving toy (car or ball) Without a sound! Puppets Illuminated toys Michigan AER Conference, 2009

24. Thinking about a telescope? Consider these aspects: Visual field Visual acuity Physical/cognitive issues Michigan AER Conference, 2009

25. Thinking about incorporating a telescope • Look at the distance acuity • Calculate diopters • Divide by 4 to obtain the X power of magnification. • Example: Acuity: 20/400 • 400 divided by 20= 20Diopters • 20 divided by 4= 5X • Always star with something slightly below the magnification. For example, start with 4X telescope and evaluate functionally how it works. • Make sure that you share this information with the whole team, doctors and parents, so that everyone is on the same page. Doctors can also assess acuity using the telescope in the clinical setting and make other recommendations. Michigan AER Conference, 2009

26. Communicating your findings Writing the report: Always use observational statements “John appeared to be visually distracted by the activity in the classroom, the sounds of the environment and the visual stimuli” Include all aspects related to visual behaviors John was not using any communication method or system during the evaluation. It seems that he has difficulties focusing on two dimensional pictures. However, he did seem to be interested in concrete objects. Always include: cognition, communication ,emotional aspects and how they relate to vision. Michigan AER Conference, 2009

27. Thinking about O/M Goals • Language • How does the student communicate and understand? • What are some of the Speech and Language goals? • Physical Considerations: • What are the strenghts and limitations? • What are some of the PT goals? • Cognition: • What is the learning style of this student? • What are the academic goals? • Vision: • What is the learning media? (tactile, Braille, large print) • What are some of the Vision goals? Michigan AER Conference, 2009

28. Ivan’s IEP Goals • Speech: “Nori will increase the use of relevant language within the context of social interactions.” • Vision: “Nori will demonstrate tactile awareness and discrimination.” • O/M: “Nori will increase his orientation skills in familiar and unfamiliar environments” • Physical Therapy: “With the use of special adaptive equipment, Nori will improve his up-right posture and gait.” • Academics: “Nori will increase his understanding of ascending and descending numbers on a line from 0 to 100.” Michigan AER Conference, 2009

29. Ivan’s School Job Attendance Helper Skills: • Build a tactile map of the school building. • Determine routes and sequence of classrooms. • Cane practice • Social skills and use of language. • Development of tactile skills and recognition of raised numbers. • Increasing endurance, walking, posture and dexterity. Michigan AER Conference, 2009

30. “Nori will use a hand-made tactile map to find at least 3 destinations within the school building” “Nicholas will choose a desirable destination within the school building by choosing between 2 real pictures” Same Goal but Different Road Same goal: Understanding the layout of the school building Different Road: Tactile map vs. real pictures (learning media, functional vision) Complexity of the task (cognition) Amount of assistance (advocacy, cognition, emotional) Forced choice vs. more flexibility (cognition) Language vs. pointing (communication) Michigan AER Conference, 2009

31. Questions? Michigan AER Conference, 2009

32. flaviasteiner63@hotmail.com Michigan AER Conference, 2009