Clinical Low Vision Evaluation: An Integral Part of Student Success in School and Beyond through the Lens of a Low Vision OT Susan Garber, OTR/L,CLVT Center for the Visually Impaired

It is estimated that 0.2% of school-age children in the United States are visually impaired, with approximately 16% of these children considered functionally or totally blind. American Academy of Optometry

IDEA is a Federal law that ensures each student with a disability receives a free appropriate public education (FAPE) to meet his or her unique learning needs. Under federal law, students with visual impairments are guaranteed to have the same opportunities for an education following the regular curriculum with the necessary supports and services to students ages 3 through age 18 or 21.

What is the least restrictive educational environment? Often, the use of low vision devices, prescribed by an optometrist or ophthalmologist trained and experienced in low vision rehabilitation, constitutes the least restrictive approach to allowing access to printed materials. Corn, AL & Ryser, GR. Access to print for students with low vision. J Vis Impair Blind 1989;83(7):340-9.

Georgia Rules for Special Education CLVE should be completed by the time the student is 10 unless other factor apply such as severe cognitive or physical disability Strongly recommended that student be accompanied by parent and TVI Georgia Department of Education has developed a pre-clinic screening from to be completed by TVI prior to CLVE

Comprehensive clinical low vision evaluation should be completed as a visual impairment has been identified and the student is able to participate in the doctor examination. Recommend that the student have the CLVE when entering primary school so that the child can have the same opportunity as other students their age, better use their vision and allow student to maximize usable vision on all Activities of Daily Living (ADL’s) and allow for a smoother transition into school.

CLVE should continue throughout Kindergarten – 12 th grade and into adulthood as the students needs change as they advance through school into post secondary school or employment. CLVE’s are very important at transition times, such as when student moves from elementary to middle to high school, when school work becomes more demanding such as entering 4 th grade, as well as when students are preparing to enter college or a vocational training program.

Who is on the CLVE team?

Low Vision Optometrist or Ophthalmologist Occupational Therapist (OTR/L) Certified Low Vision Therapist (CLVT) Certified Orientation & Mobility Specialist (COMS) Teacher of the Visually Impaired (TVI) Classroom Teacher(s) Student Parent(s)

Orientation & Mobility Specialist Contribution to the low vision evaluation Has the student begun orientation and mobility training? What has been accomplished? What are the goals ? Is the student motivated? Technology?

Teacher of the Visually Impaired Contribution to the low vision evaluation Has TVI services been initiated What training is currently being provided Where are the successes? struggles? Has technology been assessed? outcomes? How often are services provided? Student motivation Student follow-through

Classroom Teacher Contribution to the low vision evaluation How does the child represent himself /herself in the classroom? Engaged or disengaged? Self Advocate? Grades? Use technology in classroom?

The Student The student’s level of participation and motivation in the CLVE process will directly impact the outcomes. (Internally motivated)  Can the student effectively communicate  Challenges  Successes  Goals  Independent thinking  Motivation

The Parent(s) Type of Parent Supportive or enabling? Allowing the student to speak independently? Parent talking about what can help student or what can help the parent? Identify What child is saying at home – about school Time devoted with homework Motivation Frustrations

What a CLVE is NOT Does not diagnosis eye diseases Does not assess eye health Does not monitor progression of eye disease That is why it is critical that student is followed by a traditional eye care professional yearly.

What is a Clinical Low Vision Evaluation?

Medical Examination from an Ophthalmologist or Optometrist – Provides information on distance, near and intermediate vision to determine optical and non- optical tools that will help the student's ability to complete near, intermediate and distance tasks. – Assess visual acuity at ranges, visual fields, refraction, contrast sensitivity – The specialist will identify potential low vision devices based on the goals of the student along with the acuity. Prescribed devices for near, intermediate, and distance activities will be identified. – Outline need for compensatory strategies and therapies – Sets the stage for patient participation in therapy – Establishment of coordination of care between team members. – The majority of special education programs across the United States require an eye report from an ophthalmologist/optometrist in order to initiate special education services for a child with a visual impairment. – One of the most beneficial results of the low vision evaluation is the link made between medical and functional aspects of vision loss.

Occupational Therapist Exam Certified Low Vision Therapist Exam Collaborative History from all members of the low vision team Parent Student Teachers TVI & COMS Medical doctor IEP Identify List of Challenges – In school – At home Identify a list of goals – In school – At home – Post high school Secondary education Employment NEAR READING INTERMEDIATE WRITING COMPUTER DISTANCE TASKS SEEING THE BOARD VIEWING TEACHER MOBILITY AT SCHOOL IN THE COMMUNITY RECREATION & LEISURE LIGHTING GLARE SEATING ADL’s Post Secondary Testing: SAT, ACT GVRA

Identify Current Status Utilize information provided by the team: – Technology within current school – Adaptive Techniques and Modifications – Services provided within school (TVI,COMS) – Referrals for services within the state (GVRA) – Recommendations for post secondary planning and technology.

Identify Current Challenges Reading in various distances Reading at home vs. reading at school Homework Writing Computer Mobility Glare

Identify Goals Utilize information provided by the team as a starting point for setting goals: – What are the Learning goals? – What are Technology goals? – What are Adaptive Techniques and Modifications goals? – Recreation Goals? – Post secondary goals; education? Employment?

Determine Accommodations

The doctor recommends devices and technology that incorporate best corrective glasses and magnification requirements to meet the students needs. The occupational therapist/CVLT, using doctors prescription, determines the best devices and technology through training and trials. The OT also educates on adapted techniques and compensatory strategies as well as educates on resources and regulations.

Assistive technology is an umbrella term that includes assistive, adaptive, and rehabilitative devices for people with disabilities and also includes the process used in selecting, locating, and using them. Assistive technology - Wikipedia, the free encyclopedia In the case of low vision students: Goal Increase, maintain, or improve functional abilities of student

Assistive Technology Assessments Technology assessments address a student's need for such equipment as screen readers, screen magnification, scanners, adaptive keyboards, closed circuit televisions, audio communication and braille equipment. Assessment in these areas is fundamental to make sure the correct match of technology to student's needs.

Assistive Technology: History What has worked or not worked What assistive technology (AT) has been employed in the past or is currently used with the student? Discontinued AT for reasons: lack of training lack of interest other reasons If the student is currently using assistive technology what is being used location level of effectiveness trained staff

OTHER CONSIDERATIONS When making recommendations Classroom space Student can freely move around without too many restrictions Some students, despite being seated in front of the room, may need to go up to the board Location The student with low vision may be seated in front of the room, which means that a CCTV could be in the visual path of other students sitting behind him/her. Outlets

4 Types of Magnification Relative-size: makes the print larger Relative-distance: material presented closer to the student Angular: lens-based magnifiers – standard magnifiers: hand held, stand, domes Projection: electronic magnifying devices – CCTV : desktop or portable – E- readers: iPads

As with near-vision optical devices, it is important to encourage your child to use any prescribed distance-vision optical devices at home and school and in the community. The earlier your child is prescribed these devices and learns to use them, the more a part of his life they will become.

Projection electronic Magnification

High Technology CCTV Magnification up to 60 times High contrast white on black or black on white Moveable line markers to help keep reading position Full color Selectable foreground & background colors Desktop Require outlet Battery operated Near-intermediate-distance Portability Size Portable Ease of use Screen Size Screen Readers (OCR) Magnifies Reads text Specialized lighting-lamps and lights with various types of illumination may enhance the visibility of the working surface. Material positioning devices-page holders, book holders, or book stands, and slant boards enable better positioning of the material to decrease distance, angle or glare. Audio support-software or hardware that gives information through auditory channel in addition to the primary channel whether it be visual or tactile. Text-to-Speech- software that converts digital text into audio. It is implemented in talking programs, like word processors, or is part of read aloud imported text. Portable reading devices- Hardware that supports various formats of audio text. Information may be stored either as audio files on media cards, or as soundtracks on CDs.

eBooks Smart Boards are typically connected to PCs so that the contents of the PC screen is displayed on the Smart Board. Join.Me is a FREE solution that allows a teacher to share the screen of their PC, and thus the contents of the Smart Board, so it can be viewed on an iPad. Students can then view the information using the low-vision features of the iPad such as zoom and color inversion. Audio: Have the text read aloud using the device’s screen reader Book Share: Allowing students to electronically read text books.

Reading print is the use of hard copy print enlargement. Exclusive reliance on hardcopy large print, however, has been shown to result in slowed reading speeds and the inability to read when away from school, unlike the results for students using optical or electronic devices.

Audio The Johns Hopkins research, which started in 2002, shows a 38 percent increase in subject content acquisition among high school students who use our audio books. This statistic is based on measurable student performance in comprehension, recall, and retention of content presented in an audio format. A study at Rutgers University showed that students using audio textbooks in the inclusion setting improved their reading in general, and made gains in word recognition, reading rate and comprehension. – Text Books – Fiction and Non Fiction

Computer Keyboard Large print keyboard stickers – in order to make the keyboard labels more visible Large Print Keyboards – They come in three color versions – – white on black, or black on white, black on yellow Computer Software Built-in magnifier (PC), Zoom (Mac) – computer operating systems come with magnification accessibility features Text to Speech Software – ZoomText – Magic Speech Only – Jaws

Computer Dictation Speech recognition enables student to work smarter and more productively at school and at home. use your voice

Angular Magnification Dome Magnifiers: Near – Easy to use – Portable – Sturdy Hand Held Magnifier: Near – Portable – Use in community Telescope: Distance – Mobility – Spot Viewing in the Classroom

Bioptics What is a Bioptic? Bioptic systems combine prescription eyewear with a small telescopic system. The eyewear lens portion is deemed the carrier, which provides general vision while the telescope aids in quick spotting of detail for the visually impaired patient. The telescope can be fabricated for one or both eyes. Bioptic telescopic systems are specially designed eyeglasses that allow a person with low vision who meets certain qualifications to drive a vehicle. For some teens driving may be possible using a BTS.

Relative Size

Cell Phone and E-Books Near Reading – Textbooks – Fiction/non-fiction – Audio – Text to speech Intermediate/Distance – Camera

Increasing Size Large print text Larger computer screens Large keyboards Bold lined paper Large faced watches Larger cell phones Enhanced Computer Software

Relative Distance

Sitting Closer to the board Using iPhone or e-reader Sitting closer to the computer monitor Using lap desks or book stands

If your child is prescribed a magnifier, it is important to give him opportunities to use it, not only at school, both at home and in the community. Encouragement to use his magnifier is necessary as well as student’s internal motivation. If the student is embarrassed or does not want to stand out he may not want to use magnifier(s), then alternative solutions such as current technology needs to be evaluated.

Low Tech Aids non-optical High contrast (20/20) pen Bold line paper Typoscopes Lap Desk Talking watch Enhanced Lighting – Flashlights – Book lights – desktop Glare Management – Hats – Sunglasses

It is essential that children with visual impairments have access to ongoing clinical low vision care. Ongoing clinical low vision evaluations for an individualized approach to addressing the visual needs of students with visual impairments provides the best opportunity for successful growth from primary and secondary to post secondary education and/or employment.

Finally, all students, regardless of their visual status, should have ongoing eye health evaluations at the frequency recommended by their optometrist or ophthalmologist.

Transition Should begin no later than age 16 – Instruction in low vision and blindness skills Mobility Technology College preparedness Academic Achievement – Community Experience Volunteer Employment Recreation / Leisure – Employment and other post school activities Begin planning Provide experiences (community transportation & ADL training) – What is the students goal? What are they internally motivated to achieve secondary and post secondary?

Transition Checklist Career goals (realistic?) Community/work experience related to goal Academic coursework related to career goal Financial assistance availability / Income Internships Entrance exams Self advocacy skills Transportation options Socialization skills Personal Management skills / ADL and IADL skills Living Arrangements

PHONE: Susan Garber OTR/L, CLVT Center for the Visually Impaired