Transcript Assessing Functional Vision in Children with Visual

Flavia Steiner-Viggiani, M.Ed. COMS. CLVT
Michigan AER, 2009
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Understand the difference and implications of
visual functioning and functional vision.
Explore some of the connections between the
brain and the process of vision.
Discuss some of the most common
disabilities associated with visual impairment
and their implications in functional vision
Learn strategies and techniques to observe
and assess functional vision in children with
VI and Multiple Disabilities.
“Visual functions depend on
ocular, refractive, ocular-motor
status and the integrity of the
primary visual pathway.
Visual functions are clinically
evaluated during a low vision
examination by a medical
Professional”.
Luisa Mayer, Ph.D., Anne Fulton, MD “Perspectives on Cortical Visual
Impairment, 2005”
Functional Vision
represents vision mediated
performance of tasks
required for daily living.
Cooking, reading, walking,
choosing between pictures,
are all examples of
activities that can be
visually guided.
Luisa Mayer, Ph.D., Anne Fulton, MD “Perspectives on
Cortical Visual Impairment, 2005
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A Holistic view of how a student uses his/her
vision.
Is “Vision within a Context”.
It never occurs in isolation. It has a purpose
and a motivation.
It is impacted by cognition, emotions,
language, physical abilities and educational
opportunities.
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“The student appears to detect objects, both
familiar and unfamiliar, when they are
presented on the lower, right field on a
contrasting surface”
“There is an alternating Esotropia both at
distance and at near when looking at a
moving target”.
What do you think?
Clinical or Functional?
It is a functional
observation!
•The student is being
observed in a learning
environment
•Statements include
observations about the
environment, contrast
in a variety of
situations.
•It does NOT include a
diagnosis.
It is a clinical finding!
The student is being
diagnosed and evaluated
clinically.
There is a definitive
diagnosis.
Measurement of an eye
deviation (turn) is part of
a comprehensive low
vision evaluation
performed by a medical
professional.
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Communication
Expressive language
Receptive language
Learning media
Use of other senses to
communicate
◦ Environment conducive
to communication
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Cognition
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Acquisition of concepts in the classroom
Functional skills
Pre-literacy or literacy skills
Computation or mathematical skills
Access to materials
Combination or learning medias
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Social/Emotional integration
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Choice making
Friendships
community involvement
Integration of family in the social process.
Ownership of routines and schedule for the day.
“Vision is an emotional sense” (Mary Morse Ph.D.)
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Orientation and Mobility
Spatial awareness and navigation
Depth perception
Orientation
Ability to recognize landmarks and familiar
places
◦ Ability to use mobility devices
◦ Use of visual skills to remain oriented and safe
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Motor Development
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Fine motor skills
gross motor development
Posture
gait and body balance
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Physical disabilities (Cerebral Palsy)
Neurological insults or brain abnormalities
Brain trauma or stroke
Chromosomal abnormalities
Genetic conditions
Hearing Impairment
Learning disabilities
Cognitive impairment
Cerebral Palsy means
“Brain Paralysis”. It
occurs when areas of
the motor areas don’t
develop properly or
are damaged due to a
neurological insult,
complications during
pregnancy or delivery
or in smaller
proportion to trauma.
Functional Vision
Decreased Visual
Attention
Eye-hand
coordination
Poor visual skills
Most common
visual
challenges in
children with
Cerebral Palsy
Oculo-Motor
Impairments
Strabismus
Nystagmus
Refractive errors
Amblyopia
Optic Atrophy
Visual Field
Defects
Retinal
Abnormalities
Additional disabilities
CVI
Developmental delays
Sensory integration
difficulties
1. Children who experienced asphyxia,
abnormalities with brain development or
maturation, cerebral bleeding, infections either
pre birth or at birth.
2. It includes children with acquired permanent
brain damage, such as: shunt failure, asphyxia,
injury or trauma or stroke.
3. Nearly always have additional disabilities.
4. They can have Cerebral Palsy, but not all
children with Neurological vision loss have
Cerebral Palsy.
5. Visual acuity and visual field can be severely
damaged but not in all cases.
6. It can include children with visual acuity loss,
visual field impairment and visual perceptual
problems (or visual dysfunctions)
7. Children with normal acuity, normal fields but
experiencing perceptual problems.
Dr. Gordon Dutton, Scotland , UK
The human brain
Common terms in
the visual brain
Cerebral Cortex (grey matter)
2 Hemispheres connected
Corpus Callosum
4 Ventricles
Cerebrospinal fluid
Brain Stem
Cerebellum
4 Cerebral Lobes
•Frontal
•Temporal
•Parietal
•Occipital
•Lateral Geniculate Nucleus
•Ventral and Dorsal Stream
•Optic radiations
• Coordination
of
movement
• Motor activities
• Learning and
remembering
physical skills
The Brain Stem
• Main motor and sensory
innervations to the face and
neck via the cranial nerves.
• Guides nerve connections
of the motor and sensory
systems from the main part
of the brain to the rest of the
body
• “Primitive brain” acts
without any input on our
part.
• Important role in the
regulation of cardiac and
respiratory function.
• Regulates the central
nervous system, and is
pivotal in maintaining
consciousness and
regulating the sleep cycle.
2 Lateral Ventricles
• Located in the hemispheres
• Communicates with the 3rd. Vent.
Third Ventricle
• Located in the middle of the
cerebral cavity
• Communicates with the lateral
ventricles.
Fourth Ventricle
• Located in the most inferior
portion of the brain
• Communicates with the central
canal of the brain stem
All ventricles are filled with
cerebrospinal fluid which travels
throughout the cerebral cavities
and the spinal cord.
The Cerebral Hemispheres
Left
• Task analysis
• Mathematical
operations
• Logical
interpretation
of information
• Sequence
• Symbolic
information
• Abstraction
• Reasoning
Right
• Holistic
Functioning
•Processing
multisensory
information
•Provides us with
a more complete
picture of the
environment
• Language
processing
Frontal
Parietal
Temporal
Occipital
•Motor Function
•Movement:
•Motor patterns
•Voluntary motion
• Motor speech
•Problem Solving
•Memory and cognition
•Language
•Judgment
•Impulse control
•Social and sexual behavior
•Ability to concentrate and
attend to a task
Processing and discrimination
of sensory input.
Spatial Processing
Tactile recognition
Localizes objects around us
and directs movement in
space
Visually guided movements
Body orientation
Involved in processing pain
and touch
Auditory receptive area
Expressed behavior
Receptive speech
Perception of melodies
Reading facial expressions
Visual object recognition and
categorization. Image library
Processing details or
individual units
Processing auditory input
Long term storage of sensory
input
Where?
What?
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Difficulties with seeing details in a complex visual scene. (crowding, visually
overwhelmed)
Difficulties engaging visually while doing other tasks
(sensory overwhelmed)
Impaired visual attention (challenges with fixation)
Impaired visually guided movements of the upper or lower limbs, or both
(difficulties with depth perception, stairs, curbs, eye-hand coordination
tasks)
Difficulties placing objects or people in relation to self or among them (visual
skills, scanning, tracking, mapping, remembering lay outs)
Reading, finding a place on the page. (slower reading fluency, organization,
processing written information)
Organization of space and spatial layouts (inability to identify and remember
landmarks, lack of orientation, bumping and tripping, difficulties with
writing)
Dr. Gordon Dutton, “CVI Summit, 2005
Impaired
 Object, shapes or face recognition
 Ability to recognize facial expressions
 Animal recognition
 Route finding or reversals
 Word recognition (alexia)
 Color naming (color anomia)
 Letter and word recognition
Dr. Gordon Dutton, “CVI Summit, 2005”
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
1. Be quiet
2. Be still
3. Be patient.
4. Be 100% present in that moment.
5. Be open to discoveries instead of
assumptions.
Michigan AER Conference, 2009
Environment:
Complexity, contrast, glare, lighting
Processing of sensory information
Use of other senses, sensory selectiveness
or defensiveness, ability to integrate sensory
input. Can vision be combined?
Levels of assistance
degrees of independence and motivation
Communication:
concrete symbols,
pictures, verbal, multi sensory.
Intentional and unintentional
Emotional behavior
Frustration levels, stamina, advocacy
Community traveling skills
What do I know about the student?
Preparation and Observation
What do I need to find out?
Thinking, wondering and evaluating
How do I use the information gathered?
Communicating and Moving Forward
What do I know about the student?
Concerns or questions:
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From teachers, specialists and parents.
Records:
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Ocular and Medical reports (if available)
Observation:
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Near Tasks: Lunch, table work, snack, reading,
art, science.
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Intermediate Tasks: Recognizing people, reading
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close signs, social interactions
Distance Tasks: Traveling, reading signs,
recognizing people without sound input, looking
at traffic signals, being visually attentive at a
distance greater than 3 feet.
What areas do I need to evaluate further after observing the
student?
What areas of functional vision do I need to assess better?
How will I structure the environment?
Complexity, lighting, familiar people, brakes
contrasting surfaces, team approach with other professionals
What materials are appropriate for this student?
Age, interests, salient features of objects, size, textures
cognitively meaningful.
How can I maximize the student’s use of vision?
Positioning, instructions and use of language
General observation (ocular health)
Near and Distance Vision (clinical, functional)
Visual Fields Preference /Limitations
(gross observation)
Color awareness and relevance (matching,
preference)
Ocular Observations (alignment, motilities)
Visual behaviors (visual skills)
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Eye appearance:
◦ Appearance of eyelashes and conjunctiva
◦ Cornea (opacity, cloudiness)
◦ Eye rubbing, scratching, watering, inflammation.
◦ ALWAYS refer to the appropriate professional
and contact the family.
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Uses clinically calibrated visual
charts to obtain resolution
acuity results (object
identification)
Requires 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.
“Flavia was able to identify a 3.5
inches symbol at 10 feet 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
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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 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”
Considerations for evaluating Visual Acuity
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Sometimes 10 feet is too far away. Move closer.
If you are using concrete, tangible objects, start at 5 feet and
move closer until you see a visual response.
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Sometimes responses are NOT visual!
Pay attention at the distance where vision is at its maximum
potential. (longest amount of fixation and attention time)
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Frequently, using more than two symbols or objects is too
visually/cognitive overwhelming. Use only two symbols (square
and circle) or 2 or 3 cheerios, gold fish, pictures, or objects.
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Place objects in different portions of the surface to observe
patterns of reaching or awareness.
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Present objects in different sections of the visual field.
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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
DO NOT RUSH! Children with multiple disabilities
need additional time to spot a peripheral target
Let’s watch it!
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Use observational terms, not clinical diagnostic terms.
Flavia was able to identify the presence of the 4 cm multicolor
penlight on the right side of the peripheral field without
difficulties. However, when the target was presented inferiorly,
Flavia spotted the penlight when the object was reaching her
nose. 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 from the left side of her face. She did not
appear to have challenges identifying the penlight superiorly.
It should be noted that the peripheral target was moved very
slowly, providing Flavia with enough time to react and show
awareness of the peripheral field. The room was dimly lit and
numerous brakes were offered to rest”
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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)
◦ Preferred colors to use in materials
What materials can we use?
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Wheatley Kit with shapes and colors
Color squares (Paint catalogues)
Interactive games that include color (Candyland, Legos)
Color sticks or beads, Lightbox with translucent shapes
Ocular Alignment
Esotropia (eye turned in)
Exotropia (eye turned out)
Hypertropia (eye turned up)
Hypotropia (eye turned down)
Most infants who are developing
normally acquire binocularity or
stereopsis between 4 and 6 months
of age.
Ocular motilities refer to the ability of the eye muscles to
control eye movement, so that both eyes can move together as
a team.
What materials and activities can you do?
• Following a penlight or flashlight
• Following a finger puppet or a funny pencil top eraser
• Slinky or shinny object
• Key chains
• Encourage students to follow with their eyes without moving their
heads and make note of difficulties.
Shifting Gaze: Changing visual attention between two
objects with smooth, full and accurate movements.
Tracking: Following a moving target with efficiency
Scanning: Organized visual search pattern
Materials used: wooden beads, toys, M&M over a
contrasting surface, moving toy (car or ball), puppets or
illuminated toys without a sound
• General Report Information
• Overview of the child
•Age, grade, setting, services provided, number of adults, extracurricular
activities.
• Purpose of the assessment
• IEP requirements, concerns expressed by educators or parents
• Changes in vision or educational circumstances
• Determination of adequate placement
• Medical Information:
• Definition, implications and source of information, LEE, Devices used
• Assessment Information
• Number of sessions, times of the day, specific assessment used.
• Specific Modifications in the testing
• Brakes, familiar people present, environment, communication.
• Functional Vision Observations
• Near, Intermediate and Distance activities (if possible)
• Levels of frustration, stamina, assistance, social interactions, functional
use of vision along with other sensory information
• Visual Acuity (Functional or Formal)
• Specify the chart (if any) or materials you use, the distance and the
environmental conditions
• Eye movements (Ocular Motilities)
• Are both eyes moving together? Are there any challenges? When?
• Eye-hand coordination
• reaching, scanning and coordinating fine motor skills along with vision
• Ocular alignment
• By observing the child at various tasks, are both eyes aligned in all
positions of gaze? When? Is one of them or both turned or misaligned?
When?
• Visual Field
• Specify the size and type of the peripheral and central targets, the
conditions of the environment, behavioral observations and findings.
• Spatial/Movement coordination (as it relates to vision)
• How is the child using vision in the environment? Navigation in the
classroom and school or community. Any bumping or tripping? Is
positioning affecting vision when traveling?
• Summary and Recommendations
• Brief summary of the child and diagnosis. Description of the strengths
and challenges, recommendation in ALL areas: educational,
communication, mobility, social/emotional, planning and integrating
vision in all areas throughout the day.
Flavia Steiner-Viggiani
[email protected]