Flavia Steiner-Viggiani, M.Ed. COMS. CLVTMichigan AER, 2009

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 visionexamination 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

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.

“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.

Communication◦ Expressive language◦ Receptive language◦ Learning media◦ Use of other senses to

communicate◦ Environment conducive

to communication

Cognition◦ Acquisition of concepts in the classroom◦ Functional skills◦ Pre-literacy or literacy skills◦ Computation or mathematical skills◦ Access to materials◦ Combination or learning medias

Social/Emotional integration◦ 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.)

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

Motor Development◦ Fine motor skills◦ gross motor development◦ Posture◦ gait and body balance

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.

Most common visual

challenges in children with

Cerebral Palsy

Oculo-Motor ImpairmentsStrabismusNystagmus

Refractive errorsAmblyopiaOptic AtrophyVisual Field DefectsRetinal Abnormalities

Functional Vision

Decreased Visual AttentionEye-hand coordinationPoor visual skills

Additional disabilities

CVIDevelopmental delaysSensory 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 brainCommon terms in the visual brain

Cerebral Cortex (grey matter)2 Hemispheres connectedCorpus Callosum4 VentriclesCerebrospinal fluidBrain StemCerebellum4 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 RightLeft

• Task analysis• Mathematical operations• Logical interpretation of information• Sequence• Symbolic information• Abstraction• Reasoning

• 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?

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 % Observation20% 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

1.Be quiet2.Be still 3.Be patient. 4.Be 100% present in that moment.5.Be open to discoveries instead of

assumptions.

Environment: Complexity, contrast, glare, lighting

Processing of sensory informationUse 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 behaviorFrustration 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: From teachers, specialists and parents.Records: Ocular and Medical reports (if available)Observation: 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, 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, brakescontrasting surfaces, team approach with other professionals

What materials are appropriate for this student?

Age, interests, salient features of objects, size, texturescognitively 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)

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.

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

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• 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.

• Sometimes responses are NOT visual!• Pay attention at the distance where vision is at its maximum

potential. (longest amount of fixation and attention time)

• 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.

• Place objects in different portions of the surface to observe patterns of reaching or awareness.

• Present objects in different sections of the visual field.

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!

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”

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?

◦ 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 AlignmentEsotropia (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

flaviasteiner63@hotmail.com