What Did I Just See, and What Does It Mean

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What Did I Just See, and What Does It Mean?

• Darick Wright, M.A., COMS, CLVT
• Coordinator, New England Eye Clinic at Perkins
• Faculty UMass-Boston, Vision Studies Program
• New England College of Optometry

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FUNCTIONAL VISION ASSESSMENT
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Topics

• Components of a FVA
• Methods Materials
• Writing the report
• Recommendations to Goals
• Resources

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Indications of Visual Function

• Fixation (eyes only, eyes head/body)
• Alertness
• Directed eye movements (saccades)
• Eye-Hand (reaching, pointing)
• Pupil constriction
• More ???

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Observation - video
Mike
Katie
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WHAT is a Functional Vision Assessment

• A planned observation to determine how a person
  uses, or doesnt use, their vision when
  performing routine tasks in their normal
  environment.
• It utilizes information from clinical
  examinations and education/rehabilitation reports

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It is NOT..

• Diagnosis or Prescription for treatments
• patching, surgery, vision therapy
• Replacement for other assessments
• Learning Media Assessment
• OM Assessment
• Technology Evaluation

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WHY is it necessary

• To determine the current level of visual
  functioning in a real environment while
  performing routine tasks.
• To make appropriate device recommendations and
  environmental modifications that may increase
  visual functioning.
• To develop instructional goals and strategies

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WHERE is it conducted

• School
• Work
• Home Neighborhood
• Combination of areas

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WHEN should it be conducted

• When there is a diagnosed visual impairment
• When changes occur in visual function
• When transitioning to a new or more visually
  demanding area/grade
• When a previous assessment has not been conducted

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Functional Implications Worksheet Mary Mary Eye
Exam
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Mary Mary

• Background 18 year old girl enrolled in local
  public school
• Primary Concern Identification of modifications
  at school. Final evaluation prior to transition.
• Visual Diagnosis Hyperopia, Alt. Eso with
  nystagmus, Reduced visual acuities (glasses),
  Significant Peripheral Field Loss.
• OU 20/50
• OD 20/125, OS 20/125 With correction
• Additional Disabilities/Services Partial
  bilateral sensory neural hearing loss (wears
  aids). Enlarged print, preferential seating.
  Receives vision-related services

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Mary Mary

• Disease/Condition Hyperopia, Reduced Acuity,
  Nystagmus, Peripheral Field Loss OU
• Etiology unknown genetic?
• Portion(s) of anatomy affected
• Cornea, Lens, Retina?
• Resulting effect on Vision
• Resolution of details (sustained tasks)
• Visual skills (scanning, tracking)
• Light/dark adaptation
• Glare
• Spatial orientation

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Mary Mary

• Functional Vision Predictions
• Lose place while reading (crowding)
• Increased visual fatigue when resolving details
• Negotiating through crowded areas
• Locating obj. in dark, dim lit areas
• Safe travel outside in bright sunlight, night

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Road Trip!

• Prepare (get stuff together)
• Pick a destination
• Buy maps
• Plan route
• Pack the car
• Go!

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Plan Your Route
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Based on

• Anticipated areas of impact
• Primary concern(s) of TEAM
• Method of Observation
• Your familiarity of student
• Time

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FVA ComponentsErin, J. Paul,B. (1996) In
Corn, A.L., Koenig, A.J. (Eds.) Foundations of
Low Vision (chapter 9) New YorkAFB Press
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FVA Components(Erin Paul, chapter 9,
Foundations of Low Vision)

• History
• The Environment
• Eye structure/Reflexes
• Functional Visual Acuity
• Functional Visual Fields

Medical, Educational, Vocational Family patient
expectations Daily routine, Primary Concerns
Illumination, Contrast, Visual Complexity,
Safety
General appearance, Blink reflex, Pupil response
Light Perception Object Awareness Object
Identification Near, Intermediate Distance
Static Dynamic
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Components of a Functional Vision Assessment

• Motility/Visual Skills
• Color Perception
• Use of devices
• Recommendations

Alignment (tropias/phorias), Fixation,
Convergence, Saccades,Tracking (pursuits),
Scanning, Depth Perception, Eye
Dominance (preference)
Red, yellow, green, blue, purple, brown, white,
black
Assessment of prescribed devices Introduction of
new optical/non-opticals
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What can they see?Should they read Braille or
print?What size of print should they use?Are
we doing everything we need to be doing in the
classroom?
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What do you really want to know?
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• What can they see?

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What is the quality of the image?

• Visual Acuity
• Visual Fields
• Color discrimination

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How are they managing visual information?

• Eye Alignment
• Eye Movements
• Visual Skills (efficiency)
• Use of optical devices

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• Are we doing everything we need to be doing in
  the classroom?

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What is the impact of the environment on visual
function?

• Illumination
• Color Contrast
• Visual Complexity
• Other sensory stimuli
• Safety

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Assessment Plan Mary Mary
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Mary Mary

• ASSESSMENT SEQUENCE

• ASSESSMENT COMPONENTS
• History
• Environmental Characteristics
• Eye Structure
• Functional Distance Acuity
• Near Visual Acuity
• Visual Fields
• Motilities/Visual Skills
• Color Discrimination
• Use of Devices

• History
• Observe
• Environmental characteristics
• Eye Structure
• Functional Acuities
• Motilities/Visual Skills
• Use of Devices
• Pull-out
• Formal acuities
• Visual fields
• Motilities, visual skills
• Color screening
• Recommendations

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Conducting the Assessment
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General Observation (hallway)
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Dont Forget toLook Out The Window!
Environmental Worksheet
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Environmental Factors

• Illumination
• Glare
• Color Contrast
• Visual Complexity
• Student Position

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Illumination

• Factors to consider
• Type
• Amount (time of day)
• Position
• Control Method(s)
• Light and Dark Adaptation

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Amount of Light
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Light and Dark Adaptation

• For persons with low vision, the amount of time
  to adjust may take longer. Even small changes
  that go unnoticed to the normal eye may create
  problems

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Glare

• Glare is scattered light that isnt focused
  appropriately in the eye.
• Type of Glare
• Discomfort glare doesnt affect image quality
  but creates tiredness and pain over time
  (computer, snow)
• Disability Glare Affects image quality, makes
  it difficult to discriminate the target (dirty
  windshield, mirrored surface

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Glare
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Environmental Assessment (classroom)
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Environmental Assessment
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Environmental Assessment
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Environmental Assessment
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Environmental Assessment
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Documenting Observations

• Illumination
• Overhead florescent lighting
• Overhead florescent supplemented by natural light
  (glare)
• Illumination control, curtains
• Visual complexity
• Classroom, cluttered, visually complex
• Hallways, simplified, few objects
• Color Contrast
• Dark/Light tabletops
• Dark letters on light background
• Light hallway floors/walls, dark baseboard/doors
• Student Position
• Directly in front, approx. 8 feet from board

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Think About

• While factors are presented in isolation, in
  fact, they interact.
• Lighting can increase or decrease contrast.
• Contrast can increase functional vision.
• Visual Clutter/Complexity can result in visual
  fatigue or decreased performance.

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Visual Acuity
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Hierarchy of Visual Acuity

• Light Perception
• Light Perception with Projection
• Object Awareness (form perception)
• Object Identification (Resolution)

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(No Transcript)
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Formal Distance Acuities
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Documenting Formal Distance Acuity

• Betsys distance visual acuity is 10/60 using
  isolated Patti Pics symbols.

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Functional Distance Acuities
2004 Visual Conditions Functional Vision. FPG
Child Development Institute UNC Chapel Hill
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Documenting Functional Distance Acuity

• Betsy could identify a 3-inch object (toy bear)
  with reduced color contrast at a distance
• of 4-feet.

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Functional Distance Acuities
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Documenting Functional Distance Acuity

• Betsy could visually identify 2½ inch black
  letters on white board at 6 feet in the classroom
  with overhead florescent lighting

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Formal Near Acuities
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Documenting Formal Near Acuities

• Darick could identify 2.0M (2mm) size high
  contrast symbol at a preferred distance of 3
  inches with additional task lighting.

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Formal Near Acuities
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Documenting Formal Near Acuities

• Besty could identify 2.0M (2mm) size high
  contrast single symbol at a distance of 16 inches
  (40cm) with normal overhead florescent lighting.

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Functional Near Acuities
2004 Visual Conditions Functional Vision. FPG
Child Development Institute UNC Chapel Hill
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Documenting Functional Near Acuity

• Darick could identify 2mm size object (candy
  sprinkle) on a high contrast background at a
  distance of 6 inches.
• Darick could identify an isolated 1-inch square
  communication symbol at 16 inches.

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Functional Near Acuities
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Functional Near Acuities
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Gather Additional Information

• Current Letter/Symbol Characteristics
• Size (height of lower case letter in mm)
• Complexity (serf vs. san-serif, spacing)
• Threshold vs. Preferred/Functional
• Single Letter/Symbol vs. Continuous Text

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How Big? Critical Components?
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Notation
Dist. Equivalent
M-size
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Clinical Visual Acuity Notation

• Target Size (Goal)
• 1M _at_ 40 cm
• 1M regular print 1.45mm

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Functional Measurement of Near Visual Acuity

• Preferred Distance
• Size of Print
• Note smallest line read (threshold)
• Identify Functional Size
• Visual Reserve (2-3 times larger than
  threshold)
• Speed Comprehension

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Functional Near Acuity Notation

• Darick can identify a
• ½-inch object
• at 12 inches

Preferred Distance
Actual Size of Object
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Critical Components

• Letter/Object Size
• Viewing Distance
• Typeface Layout (complexity)
• Reading/Identification Speed
• Comprehension

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Serif Typeface

• Typeface that have tiny strokes or feet
  attached to the edges of letters. They help guide
  the eye from one letter to the other.
• Examples
• Times Script Bodoni

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Sans Serif Typeface

• Sans literally means the absence of (without)
  serifs. Often used in headlines and for visual
  impact.
• Examples
• Ariel Century Gothic Helvetica

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To Serif or Not To Serif!

• Sans Serif is better when reading close to
  threshold acuity.
• Letters too close or t o o f a r apart (kearning)
  may be difficult to read.
• The smaller the space between lines (leading) of
  print, the darker or visually complex the
  page appears.

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Selecting the Print Size

• Identify threshold (clinical/functional)
• Identify current print size reading duration
  required (target)
• Identify current environmental conditions
• Color contrast
• Illumination
• Measure reading speed, accuracy, comprehension,
  etc.

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Case 1 - 7 y/o, 1st grade

• Near Visual Acuity 2.5M at 40 cm
• Current Required Print Size 5mm
• Reading Duration average
• Environmental Conditions
• High contrast
• Normal illumination (no task lighting)

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Case 1 Compare

• Compare actual size (height)
• Clinical acuity (2.5M _at_ 40cm)
• Required print size (5mm)
• Which is larger?
• Can they access Required Print?
• Is Required Print Size Functional?
• If Required Print is 2 3 times larger than
• threshold acuity, magnification may not
• be required with equal reading distance.

Required Print Size
Yes
?
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Case 2 - 7 y/o, 1st grade

• Near Visual Acuity 3.2M at 40 cm
• Current Required Print Size 3 mm height
• Reading Duration average
• Environmental Conditions
• Low/medium contrast
• Normal illumination (no task lighting)

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3.2M
3 mm
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Case 2 Compare

• Compare actual size (height)
• Clinical acuity (3.2M _at_ 40cm)
• Required print size ( 3 mm)
• Which is larger?
• Required print size accessible?
• Possible functional print size (at 40cm)?

Clinical/Formal Acuity
No
6.3M
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Case 3 - 16 y/o, 11 grade

• Near Visual Acuity 4M at 40 cm
• Current Required Print Size 1.45mm
• Reading Duration average
• Environmental Conditions
• Low/medium contrast
• Normal illumination (no task lighting)

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4M
1.45 mm (1M)
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Case 3 Compare

• Compare actual size (height)
• Clinical acuity (4M _at_ 40cm)
• Required print size (1M 1.45mm)
• Which is larger?
• Required print size accessible?
• Possible functional print size (at 40cm)?

Clinical Acuity
No
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Visual Acuity Lab
Lab Sheet
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Ideas for Materials

• Real Objects
• Toys
• Environmental Objects (I-Spy, Tell me what you
  notice, material on chalkboard, etc)
• Small white board (you write on board)
• Formal materials
• Feinbloom Chart
• LEA distance/near charts, playing cards
• etc

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Think About

• Use real objects when possible
• Consider
• the environment
• Motivation
• Test with both eyes open
• Note both object size and viewing distance
• Refer to LV Specialist when appropriate

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Visual Fields
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Visual Field Testing

• Formal - quantifiable
• Peripheral or central (Amsler Grid)
• Automated (Humphrey)
• Informal functional
• Peripheral awareness
• Modified confrontation method

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Modified Confrontation Method
X
X
X
X
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Modified Confrontation Method
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Modified Confrontation Method
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Visual Field Testing
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Documenting Peripheral Visual Field

• Using the confrontation method with 2- inch
  peripheral target, Darick was aware of the object
  when presented in all quadrants. He does not show
  any decreased peripheral awareness at this time.

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Visual Field Testing
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Documenting Peripheral Visual Field

• Using the confrontation method with 1 ½ inch
  target, Luis showed decreased awareness when
  objects are presented from above, the right, and
  left sides. The left side showed greatest
  constriction.

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Visual Fields Lab
Lab Sheet
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Ideas for Materials

• wand or stick approx 2 feet in length
• Wire coat hanger
• Wooden dowel
• Peripheral targets (attached to wand)
• No larger than 1.5-inches in diameter
• Simple color(s)
• Key chains, pencil eraser
• Lighted objects

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Think About

• Use two person method when possible
• Consider
• the environment
• Motivating peripheral targets
• Test with both eyes open
• Use informal, observational terms for
  documentation (this is not a diagnosis)
• Refer to LV Specialist when appropriate

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Eye Movements/Visual Skills
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Visual Skills

• Eye alignment (gross)
• Fixation
• Convergence
• Saccades (shift attention)
• Tracking
• Scanning

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Visual Skills
2004 Visual Conditions Functional Vision. FPG
Child Development Institute UNC Chapel Hill
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Visual Skills
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Documenting Visual Skills

• Sharon demonstrated the ability
• to accurately and smoothly move her eyes in all
  positions of gaze. (formal)
• to maintain FIXATION on motivating objects at
  various distances.
• To horizontally/vertically TRACK a quickly moving
  2-inch target but with jerky fixation.
• To efficiently SCAN using a left to right
  pattern.

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Visual Skills
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EOMs/Visual Skills Lab
Lab Sheet
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Ideas for Materials

• Age-appropriate materials with multiple objects
  for gathering/sorting.
• Beads
• Counting bears
• Silverware
• CDs
• Box/Container for storage

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Think About

• Consider
• Environmental complexity
• Motivating, age-appropriate objects
• Increase number/complexity of objects
• Present objects in variety of positions
• Assess at distance and near
• Refer to LV Specialist when appropriate

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Color Screening
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Color Screening

• Formal
• Seeks to determine congenital vs. aquired
  deficiency
• Pseudo-isochromatic plates (figure-ground)
• Assembly style (cognitive physical)
• Informal Screening
• Primary Secondary colors
• Student may label, match, compare color targets

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CLASSIFICATIONS

• Tritan
• Blue/Yellow
• Deutran (moderate loss)
• Red/Green
• Protan (absence of red receptors)
• Red/Green
• Achromatopsia congenital absence of ability to
  see colors caused by cone defect or absence.

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Types of Color Tests

• Pseudo-isochromatic colored dots, differing in
  shade and hue, form numbers and patterns that
  cannot be distinguished by those with color
  vision deficits.
• Examples
• Ishihara Plates
• Color Vision Testing
• Made Easy (Wagonner)

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Types of Color Tests

• Arrangement patient is given a series of
  disks or caps and are asked to arrange them
  in a particular order.
• Examples
• Farnsworth D-15
• Precision Vision
• (PV-16)

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Types of Color Tests

• Functional Screening
• Matching basic colors
• Use large targets
• primary/secondary colors
• Several of each color
• Targets all same size, shape
• Beads
• Paint Samples
• Computer generated

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Are We There Yet ?
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Assessment Tools

• Check list
• variety
• well organized
• May be limiting
• Observation Notes
• can be individualized to student
• may lack organization
• difficult to synthesize
• Combination

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Functional Vision Assessment FormLevack, N.
(1991)Low Vision A resource guide. Texas School
f/t Blind and VI
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Sensory Channels FormKoenig Holbrook, (19??)
Learning Media Assessment
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Writing The Report
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• Organize observation notes
• Primary Concerns
• Materials used Performance
• Recommendations
• what would increase performance?
• Determine Report Format
• Reference other reports
• according to most recent reports available, Dr.
  ___ (3/06) states that
• Summarize observations by category
• Include specific recommendations

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• Patient Name
• D.O.B.
• Evaluation Functional Vision Assessment
• D.O.E. 30 March 2006
• Evaluator Name
• Background
• According to the most recent reports available
  (Wright 2/03)
• Primary Concerns/Reason for referral
• Assessment
• Documentation of assessment components
• Location of assessment
• Team members present
• Summary Recommendations
• Brief summation of background assessment
• findings
• Recommendations Referrals

Mary Mary FVA
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Writing Recommendations

• Follow the assessment sequence
• Consider areas of weakness
• Identify ways to increase functional
  vision/performance
• environmental modifications
• Additional training
• Referral for additional assessment
• Medical, educational

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Sample Recommendations

• Color contrast between walls and flooring and
  levels of general illumination is inconsistent.
  Stair nosings are not marked with high
  contrasting color on each step.

Task lighting, increased contrast achieved with
glare-free illumination will help reduce Visual
fatigue especially with sustained visual
tasks. All stair nosings (edges) should be
marked with high contrast color.
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Sample Recommendations

• Her teachers provide enlarged print (2mm 3mm).
  When provided a line guide, she was able to
  accurately read with greater fluency and
  preferred a sans-serif font.

Use of san-serif font style with minimum of 3mm
(14point size) and increased spacing between
lines for sustained visual tasks. Use of a
typoscope or line guide. This is critical when
she needs to read smaller print (4mm or less) or
when the space between lines is reduced.
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Sample Recommendations

• When reading her class notes on her laptop (12
  pt Times), she lost her place and could not
  quickly find specific information.

Use of san-serifed font style such as Ariel Black
with increased leading on her laptop with minimum
14 point size. Mary should work with her computer
teacher to find the best preferred default
settings.
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Sample Recommendations

• With both eyes open, she showed a significantly
  delayed reaction in all quadrants of peripheral
  visual fields. She did not detect the target
  until even with her face.

Formal visual field testing at her next
appointment to low vision clinic to further
examine observations made during this assessment.
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Think About

• Reference other reports
• Use specific, objective examples
• Include environmental characteristics!
• Include samples within text or as an attachment
• Justify recommendations in FVA data and summary
• Dont forget to sign the report!

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Recommendations to Goals
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Goal vs Objective

• Goal broad generalized statement about what is
  to be learned.
• Objective specific, measureable, short term,
  observable, student behaviors

Writing educational goals and objectives -
http//www.personal.psu.edu/bxb11/Objectives/index
.htm
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Writing Goals

• S specific
• M measurable
• A attainable
• R relevant
• T time-bound

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Writing Goals

• Who the student
• What desired outcome
• How measurement criteria
• When time frame

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Measurable Criteria - Examples

• At least 8 out of 10 trials
• At least 90 accuracy
• At least 80 of the time
• For 12 weeks.

Tips for Writing Goals Objectives. CO State
Dept. of Education
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Goals Objectives

• Panel Discussion

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• What barriers are there to conducting Functional
  Vision Assessments?

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How can these barriers be reduced or eliminated?
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QUESTIONS
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Darick.Wright_at_Perkins.org617-972-7355
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Kit Considerations
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Kit Considerations

• Age Group (population)
• What is the general age of the individuals?
• Sesame Street SpiderMan - Penlight
• Symbols Letters Numbers
• Additional disabilities?
• Motor/Cognitive requirement
• need for visual attention (auditory, visual)
• Sensitivity to multi-sensory stimulation

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Kit Considerations

• All FVA components addressed
• Supplement kit with familiar objects
• Real, familiar objects
• Textbooks, favorite toys

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Kit Considerations

• Multi-functional Objects
• Can each item be used for more than one
  component?
• Fixation Targets Tracking
• Color Screening Scanning

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Kit Considerations

• Portability of container
• Do all of the materials fit inside one container?
• Is it easily carried?
• Organization of materials
• Can items in the container be easily located?
• Is there space for files or forms?

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Additional Assessments

• Timed reading
• Threshold vs. Preferred
• Learning Media Assessment
• OM Assessment

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• Organize observation notes
• Primary Concerns
• Materials used Performance
• Recommendations
• what would increase performance?

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• Determine Report Format
• Reference other reports
• according to most recent reports available, Dr.
  ___ (3/06) states that
• Summarize observations by category
• Include specific recommendations

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Sample Kit
Can you find the object that should not be
included in this kit?
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Additional Assessments

• Timed reading
• Threshold vs. Preferred
• Learning Media Assessment
• OM Assessment

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Resources

• Precision Vision
• Various visual acuity charts (Patti Pics, HOTV),
  formal color tests
• http//www.precision-vision.com/
• Vision Associates
• LEA products
• http//www.visionkits.com/index.html

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Resources

• Lighthouse International
• General information about Low Vision
• http//www.lighthouse.org/default.htm
• Lighthouse Products by Optelec
• Various DN visual acuity charts, optical devices
• 800-665-3005 (Canada only)

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Resources

• Oriental Trading Company
• toys!
• http//www.orientaltrading.com/
• American Printing House for the Blind
• Project ISAVE
• www.APH.org