evaluation and management strategies of pediatric patients with visual impairment

Evaluation and Management Strategies of Pediatric Patients with Visual Impairment

Evaluation and Management Strategies of Pediatric Patients with Visual Impairment

Catherine L. Heyman, O.D., F.A.A.O.

Assistant Professor

Course GoalsCourse Goals

Understand how vision loss effects Understand how vision loss effects developmentdevelopment

Understand the role of the low vision Understand the role of the low vision optometrist in treating children with visual optometrist in treating children with visual impairmentimpairment

VISIONVISION

Vision is the primary learning modality and source of information for most children.

No other sense can stimulate curiosity, integrate information or invite exploration of the world in the same way, or as efficiently and fully, as VISION does!

BackgroundBackground

Loss of vision can cause global delays Loss of vision can cause global delays CognitionCognitionSpeechSpeechMotor Motor PsychologicalPsychologicalSelf-CareSelf-Care

Pediatric Low Vision OptometristPediatric Low Vision Optometrist

Manage primary vision concernsManage primary vision concerns Co-manage ocular health concernsCo-manage ocular health concerns Help the parentsHelp the parents navigate the unfamiliar navigate the unfamiliar

territory of special needsterritory of special needs Collaborative consultation with Rehab TeamCollaborative consultation with Rehab Team

Pediatric Low Vision OptometristPediatric Low Vision Optometrist

Knowledge of childhood developmentKnowledge of childhood development Knowledge of pediatric examination Knowledge of pediatric examination

techniquestechniques Knowledge of low visionKnowledge of low vision Knowledge of special populationsKnowledge of special populations

Purpose of a Pediatric Low Vision EvaluationPurpose of a Pediatric Low Vision Evaluation

To establish a baseline visual acuity To establish a baseline visual acuity measurement and visual functioning levelmeasurement and visual functioning level

To help parents and teachers better To help parents and teachers better understand their child’s visual condition understand their child’s visual condition and visual functioning, i.e., “how” he/she and visual functioning, i.e., “how” he/she seessees


To determine if there is a refractive error To determine if there is a refractive error and whether the refractive error is and whether the refractive error is significant enough to warrant corrective significant enough to warrant corrective lenseslenses

To provide information and assistance, as To provide information and assistance, as needed, in the process of determining the needed, in the process of determining the most appropriate learning and literacy most appropriate learning and literacy mediamedia


To determine if low vision devices, To determine if low vision devices, technology equipment, or other technology equipment, or other adaptations and accommodations will adaptations and accommodations will likely enhance the student’s functioning likely enhance the student’s functioning level in school and/or communitylevel in school and/or community

To assess visual skills in terms of whether To assess visual skills in terms of whether or not vision loss is likely to be a major or not vision loss is likely to be a major factor when there are concerns about factor when there are concerns about other developmental areasother developmental areas


To assist the educational team members To assist the educational team members with patient management as well as trial with patient management as well as trial and/or acquisition of recommended and/or acquisition of recommended devices or equipmentdevices or equipment

To assess if other related services are To assess if other related services are indicated (e.g., orientation & mobility)indicated (e.g., orientation & mobility)

To assess vision in terms of acquiring an To assess vision in terms of acquiring an instructional permit or driver’s license instructional permit or driver’s license when appropriatewhen appropriate


To provide timely reevaluation to To provide timely reevaluation to determine if visual functioning is determine if visual functioning is improving, remaining stable, or otherwise improving, remaining stable, or otherwise changingchangingIf vision is changing, to determine what If vision is changing, to determine what

those changes may indicate in terms of those changes may indicate in terms of other programming needs; and whether other programming needs; and whether the need for devices or other the need for devices or other accommodations has changedaccommodations has changed

EvaluationEvaluationEvaluationEvaluation

Case HistoryCase History Visual AcuityVisual Acuity Motor AlignmentMotor Alignment Refractive StatusRefractive Status Sensory StatusSensory Status Ocular Health evaluationOcular Health evaluation Vision ReportVision Report

Case HistoryCase History

Obtain information/ findingsObtain information/ findingsClinical findingsClinical findings

OphthalmologistOphthalmologistEducational/ Functional findingsEducational/ Functional findings

Teacher of the visually impairedTeacher of the visually impairedClassroom teacherClassroom teacherOrientation & mobility specialistOrientation & mobility specialistOccupational therapistOccupational therapistParents- developmental Parents- developmental

milestonesmilestones

Case HistoryCase History

Establish visual goalsEstablish visual goals What does the student need to do?What does the student need to do?

School tasks/ IEP or IFSP GoalsSchool tasks/ IEP or IFSP GoalsCommunity/ vocational tasksCommunity/ vocational tasksIndependent travelIndependent travel

What does the student want to do?What does the student want to do?Reading leisure materialsReading leisure materialsAvocational activitiesAvocational activities

Visual AcuityVisual Acuity

ObservationObservationHow child interacts with environmentHow child interacts with environmentObserve them in different settingsObserve them in different settings


InformalInformalObservations made during assessmentObservations made during assessmentUse familiar objects to evaluate VAUse familiar objects to evaluate VAOpen hand thrust in front of faceOpen hand thrust in front of face


FormalFormalUse testing method appropriate for Use testing method appropriate for

developmental leveldevelopmental levelTeller Acuity cardsTeller Acuity cardsCardiff CardsCardiff CardsLea SymbolsLea SymbolsFeinbloomFeinbloomVEPVEP

OptometristOptometrist

Visual AcuityVisual Acuity Lea Visual AcuityLea Visual Acuity


Visual AcuityVisual Acuity Teller AcuityTeller Acuity


Visual AcuityVisual Acuity Cardiff Visual AcuityCardiff Visual Acuity

Clinical PearlClinical Pearl

May need to measure in gaze other than primaryMay need to measure in gaze other than primary No VA test used in isolation can accurately and No VA test used in isolation can accurately and

completely assess visual functioning completely assess visual functioning Doctor must combine Doctor must combine

Data from history & outside reportsData from history & outside reportsData from observationsData from observationsData from formal and informal acuity Data from formal and informal acuity

measuresmeasures Remember that resolution tests overestimate VA Remember that resolution tests overestimate VA

Report should reflect how patient would Report should reflect how patient would perform on Snellenperform on Snellen

Motor Alignment Motor Alignment

Cover TestCover Test

Motor AlignmentMotor AlignmentMotor AlignmentMotor Alignment

Hirschberg/KappaHirschberg/Kappa BrucknerBruckner

Refractive StatusRefractive StatusRefractive StatusRefractive Status

Refractive errorRefractive error

MyopiaHyperopiaAstigmatism

Sensory StatusSensory StatusSensory StatusSensory Status

Lang I & IILang I & II Randot Stereo Smile I & IIRandot Stereo Smile I & II

Ocular HealthOcular HealthOcular HealthOcular Health

Parent education need two eye doctorsParent education need two eye doctors

Color VisionColor Vision

Color namingCognitive level 3-4 years

Color preferenceDetermines if visual responses

increase to certain colorsUseful for vision stimulation techniques

Red and yellow are often used

Color VisionColor Vision

Detection of color vision defectsDetection of color vision defectsColor Vision Testing Made EasyColor Vision Testing Made Easy

Glare Assessment / Filter evaluationGlare Assessment / Filter evaluation

Children rarely complain Children rarely complain Rely on doctors expertise and objective Rely on doctors expertise and objective

findingsfindingsChoose a filter have child wear it Choose a filter have child wear it

outside watch for decreased outside watch for decreased squinting or other signs e.g., facial squinting or other signs e.g., facial relaxationrelaxation

ManagementManagement

Adaptations Adaptations Relative distance magnificationRelative distance magnification

Hold the material closer to the eyeHold the material closer to the eyeAngular magnificationAngular magnification

Low vision deviceLow vision deviceElectronic magnificationElectronic magnification

CCTV, computer softwareCCTV, computer softwareRelative size magnificationRelative size magnification

Enlarged printEnlarged print


Prescriptive Low Vision DevicesPrescriptive Low Vision DevicesBe sure to choose aids with a need in Be sure to choose aids with a need in

mindmindConsider cognitive abilityConsider cognitive abilityConsider motor abilityConsider motor abilityConsider visual ergonomicsConsider visual ergonomics

Slant boardSlant boardClassroom seatingClassroom seating


Preschool-Early Elementary AgePreschool-Early Elementary Age Mild to moderate impairmentMild to moderate impairment

SRx, Reading addSRx, Reading add““Paperweight” stand magPaperweight” stand magFiltersFiltersClassroom modificationsClassroom modifications

Moderate to severe impairmentModerate to severe impairmentSRxSRxCCTVCCTVFiltersFiltersClassroom modificationsClassroom modifications


Older Elementary AgeOlder Elementary AgeMild to moderate impairmentMild to moderate impairment

Hand held TelescopeHand held TelescopeModerate to severe impairmentModerate to severe impairment

Portable Video magnificationPortable Video magnification


Middle school to High school ageMiddle school to High school ageMild to moderate impairmentMild to moderate impairment

BiopticBiopticLaptopLaptop

Moderate to severe impairmentModerate to severe impairmentPortable video magnificationPortable video magnificationLaptop w/ video magnificationLaptop w/ video magnificationVideo recorderVideo recorder

Vision ReportVision Report

Include InformationInclude InformationVisual AcuityVisual AcuityRefractive statusRefractive statusSensory statusSensory statusOcular healthOcular healthRecommendationsRecommendations

Classroom accommodationsClassroom accommodations


JB was born full term at a birth weight of 6 lb 8 oz. JB is diagnosed with Dandy-Walker Syndrome (congenital brain malformation involving the cerebellum and surrounding fluid spaces), cardiomegaly (enlarged heart), hydrocephalus (build up of fluid inside the skull leading to brain swelling) s/p 14 ventriculoperitoneal shunt revisions (shunt surgically placed in the skull to relieve pressure secondary to hydrocephalus), and seizure disorder. JB is currently taking the following systemic medications: Prevacid, Nortriptyline, Enalapril, Lasix, Periactin, and Regulin


VISUAL ACUITYVISUAL ACUITYJB was able to respond to the 20/128 Cardiff acuity cards JB was able to respond to the 20/128 Cardiff acuity cards with both eyes open. However, it should be noted that with both eyes open. However, it should be noted that Cardiff acuity overestimates the visual acuity by Cardiff acuity overestimates the visual acuity by approximately three times. She showed equal objection to approximately three times. She showed equal objection to occlusion, which may indicate relatively similar acuities in occlusion, which may indicate relatively similar acuities in both eyes.both eyes.

REFRACTIVE STATUSREFRACTIVE STATUSThrough cycloplegic retinoscopy (objective measurement Through cycloplegic retinoscopy (objective measurement with drops administered to stabilize focusing system), JB with drops administered to stabilize focusing system), JB was found to have equal and mild hyperopic (far-sighted) was found to have equal and mild hyperopic (far-sighted) refractive errors in both eyes. refractive errors in both eyes.

STRABISMUS AND BINOCULAR VISIONSTRABISMUS AND BINOCULAR VISIONJB displayed an intermittent left hypertropia (eye turn JB displayed an intermittent left hypertropia (eye turn upwards). upwards).


ASSESSMENTASSESSMENTJB demonstrates cortical visual impairment that JB demonstrates cortical visual impairment that is not refractive in nature. JB was found to have is not refractive in nature. JB was found to have mild hyperopic refractive error (far-sightedness) mild hyperopic refractive error (far-sightedness) that is normal for her age. She is also seen to that is normal for her age. She is also seen to display a constant left hypertropia (left eye turns display a constant left hypertropia (left eye turns upwards) with a slow-moving, large amplitude upwards) with a slow-moving, large amplitude nystagmus (dancing eyes). JB compensates for nystagmus (dancing eyes). JB compensates for this eye turn and nystagmus with a preferred this eye turn and nystagmus with a preferred head turn to the right, head tilt to the left head turn to the right, head tilt to the left shoulder, and chin pointed downwards. Bilateral shoulder, and chin pointed downwards. Bilateral anterior and posterior segment health was within anterior and posterior segment health was within normal limits.normal limits.


INDIVIDUAL VISION PLAN (IVP)INDIVIDUAL VISION PLAN (IVP) JB was not prescribed spectacles at this visit as her hyperopic JB was not prescribed spectacles at this visit as her hyperopic

refractive error is minimal and normal for her age. refractive error is minimal and normal for her age. JB adopts a head turn and tilt to help her align her eyes and slow JB adopts a head turn and tilt to help her align her eyes and slow

her nystagmus. This allows her increase the time that her eyes are her nystagmus. This allows her increase the time that her eyes are still and improves her ability to see details. She should be allowed still and improves her ability to see details. She should be allowed to adopt this head position as needed. When in the classroom to adopt this head position as needed. When in the classroom setting she should be seated at the front of the room and to the left setting she should be seated at the front of the room and to the left of center. This will allow her to see the teacher while she adopts her of center. This will allow her to see the teacher while she adopts her preferred head position.preferred head position.

JB should continue care with her Pediatrician.JB should continue care with her Pediatrician. JB should receive VI services to aid her in her visual development JB should receive VI services to aid her in her visual development

and learning. This can be provided by Blind Children’s Learning and learning. This can be provided by Blind Children’s Learning Center or by Jenni’s school.Center or by Jenni’s school.

JB should continue to receive occupational therapy and physical JB should continue to receive occupational therapy and physical therapy, with heavy emphasis on speech/language therapy to therapy, with heavy emphasis on speech/language therapy to improve her communication skills. A one-on-one speech/language improve her communication skills. A one-on-one speech/language therapist is recommended.therapist is recommended.

JB should return for a full eye and vision assessment with Dr. JB should return for a full eye and vision assessment with Dr. Heyman in one year. Heyman in one year.

SummarySummary

The optometrist plays an integral role in the The optometrist plays an integral role in the transdisciplinary rehab team for children with transdisciplinary rehab team for children with visual impairmentvisual impairmentDiagnosis and management of ocular Diagnosis and management of ocular

diseasediseaseImpact of visual impairment on developmentImpact of visual impairment on development

Visual stimulationVisual stimulationVisual enhancement therapyVisual enhancement therapyVision TherapyVision Therapy

Provide prescriptive low vision devicesProvide prescriptive low vision devices

Destination… IndependenceDestination… Independence

evaluation and management strategies of pediatric patients with visual impairment

Documents

low vision devices

backgroundloss of vision

changingif vision

visual impairmentcatherine

visual impairmentvisionvision

visual skills

childs visual condition

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