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

2. Definitions Vision 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

3. 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.

4. 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

5. Impact of the Vision Disorder Parents - denial, anger, depression, acceptance Child - none, confusion, apprehension, determination Society - what accommodations or treatments can be provided

6. 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

7. 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

8. 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!

9. 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

10. 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

11. 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

12. 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

13. 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?

14. 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

15. 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

16. 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

17. 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

18. 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?

19. 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

20. 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

21. Questions for Anthony Pre and Post CE Emotional adaptation Distance strategies Intermediate strategies Near reading strategies Lighting considerations Orientation and Mobility