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Low Vision Curriculu Ophthalmology IAPB Low Vision Work Group International Agency for the Prevention of Blindness November 2016

low vision module FOR OPHTHALMOLOGY … · Web viewAlbinism Amblyopia Aphakia Cataract Corneal dystrophy High refractive errors Nystagmus Optic Atrophy Retinal dystrophy Retinopathy

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Low Vision CurriculumOphthalmology

IAPB Low Vision Work GroupInternational Agency for the Prevention of BlindnessNovember 2016

Low Vision Module for Ophthalmology Curriculum

Preface

The National Focal Persons Courses in Low Vision (held in Hong Kong, Durban, Cairo and Sao Paolo) were used as opportunities for consultation with participating ophthalmologists regarding curriculum needs for low vision in ophthalmology training programmes in order to make it relevant and practical to both developed and developing countries. Also, the International Council of Ophthalmology guidelines on low vision rehabilitation in the residency guidelines, the American Academy of Ophthalmology Preferred Practice Patterns for Vision Rehabilitation, VISION 2020 – the Right to Sight, WHO Global Action Plan for Universal Eye Health, and Sustainable Development Goals were used to provide a comprehensive global reference.

The curriculum guidelines as the name suggests are a guide that can be adapted according to local circumstances. It is envisaged that it shall have the following intended application and would be useful for:

Ophthalmology residency programme directors planning to update the low vision modules

Ophthalmology training centres already running or planning to conduct low vision training for qualified ophthalmologists in low vision

Ophthalmology training centres planning to offer accredited certificate level training of ophthalmologists in low vision

Multi-specialty training centres planning on offering distance learning courses in low vision for ophthalmologists with the practical component undertaken at the parent or nearby hospital with a well-established low vision clinic or low vision centre

The authorship for this curriculum was conceived primarily by the IAPB Low Vision Working Group. The development of the ophthalmology curriculum was led by:

Dr Haroon Awan (lead writer) Dr Pararajasegaram Dr Rosario Espinoza Carrillo Dr Filippo M. Amore. Contributions were provided by: Professor Jill Keeffe Mr Hasan Minto Mr Joseph Cho Ms Sumrana Yasmin.

Cover photo: Rajeev Karki, Nepal (from the #EyeCareForAll Photo Competition)

Low Vision Module for Ophthalmology Curriculum 2

Outline of Low Vision Module for Ophthalmology Curriculum

Session No. Session Title Duration

1. Introduction to the Course and Low Vision 2 hours

2. Global, National, and Local Policies 2 hours

3. Epidemiology 2 hours

4. Anatomy and Function of the Eye 2 hours

5. Causes and Implications of Visual Impairment and Prevention 3 hours

6. Psychosocial Impact of Low Vision 3 hours

7. Clinical Low Vision Assessment 38 hours

8. Understanding Optical and Non-optical Low Vision Devices 15 hours

9. Paediatric Low Vision Care 26 hours

10. Accessibility and Environmental Modification 3 hours

11. Models of Low Vision Care 6 hours

12. Research in Low Vision 3 hours

Total Length of Course - 105 hours (3 weeks)

Low Vision Module for Ophthalmology Curriculum 3

Session Plan 1

Introduction to the Course and Low Vision

Time : 2 hours

Outcomes : At the end of the session participants will know the overall objectives of this course, be familiar with one another and have an overview of the significance of low vision

Objectives : Understand the objectives of this course Understand the effects of low vision

Session Plan :

Stage Content Method MaterialStage-1 Introduction of

participantsDiscussion in pairs

Stage-2 Objectives of the course Discussion

Stage-3 Assess expectations Discussion

Stage-4 Develop an understanding of low vision through simulation

Practical Materials for low vision simulators

Process:Stage-1: IntroductionIntroduction of course leaderPrepare an orientation exercise to have participants work in pairs to get to know one another. Select participants to work in pairs. Give participants five minutes to introduce themselves to their partners. After the time is up, have them introduce their partner to the group.

Stage-2: Course ObjectivesShare the objectives of the course with the participants and follow this with a question and answer session about the overall course. Use the objectives of the curriculum as a guide.

Stage-3: Assess expectationsAsk the participants about their expectations of this course and write these on a board or flip chart for the entirety of the course.

Low Vision Module for Ophthalmology Curriculum 4

If there are any expectations that are relevant to the subject matter and have not been included as part of the training curriculum/schedule, consider adding them where appropriate.

The flip chart with the expectations should remain hanging on the wall during the entire course. At intervals during the course check that the listed expectations have been met.

Stage-4: Develop an understanding of low vision through simulationProvide instruction on the creation of low vision simulators and have the participants create their own simulators.

Once the participants have completed their low vision simulators provide them with exercises to complete while wearing the low vision simulators.

ExamplesViewing PowerPoint slides, reading notes, moving around the room in pairs.

REFERENCES

Focus on Low Vision http://trove.nla.gov.au/work/32458520?selectedversion=NBD43720160

Article for ophthalmologist to recognise and refer: Minto H, Gilbert C. Low Vision: We Can All Do More. Journal of Community Eye Health 2012;25:1. http://www.cehjournal.org/wp-content/uploads/low-vision-we-can-all-do-more.pdf

Low Vision Module for Ophthalmology Curriculum 5

Session Plan 2

Global, National and Local Policies

Title : Global, national and local policies

Time : 2 hours

Outcomes : At the end of the session participants will have a better understanding of global, national and local policies and statutory benefits for people with vision impairment

Objectives : To introduce major global programmes and policies relevant

to people with vision impairment To discuss regional and local programmes and their benefits

for people with vision impairment

Session Plan :

Stage Content Method MaterialStage-1 Global programmes and

policiesDiscussion Websites (see

references)

Stage-2 National and local policies

Discussion Websites (see references)

Stage-3 Preparing submissions and applications

Practical Sample forms

Process:Stage-1: Global programmes and policiesShare the global programmes and policies (that have relevance to low vision) with the participants and explain the rationale:

UN Universal Declaration of Human Rights 1948 UN Convention on the Rights of the Child 1989 UN Convention on the Rights of Persons with Disabilities 2006 UN Sustainable Development Goals 2015 VISION 2020 – IAPB & WHO Global Action Plan – Towards Universal Eye Health EFA –VI - ICEVI, WBU Discuss the current status of these agreements and their implementation in the context of the local country and implications for the country and region.

Stage-2: National and local policies

Low Vision Module for Ophthalmology Curriculum 6

Outline national welfare schemes, education support, employment opportunities, pensions, and other benefits provided for people with disabilities. Also discuss funding and benefits provided to non-government organizations working to support people with disabilities.

Discuss the roles, responsibilities and activities of disabled persons’ organizations.

Describe the responsibility and advocacy roles of a Teacher for a child with low vision and effective ways to advocate for their access to appropriate education.

Stage-3: Preparing submissions and applicationsCase StudyPresent a case study outlining a national or local situation where a teacher has gained support for a student with vision impairment.

PracticalSelect submission forms and applications from available sources of support and funding. Discuss the process of completing these forms and have the participants complete a sample form.

REFERENCESUniversal Declaration of Human Rights. http://www.un.org/en/documents/udhr/

UN Convention on the Rights of the Child. http://www.ohchr.org/en/professionalinterest/pages/crc.aspx

UN Convention on the Rights of Persons with Disabilities. http://www.un.org/disabilities/convention/conventionfull.shtml

Sustainable Development Goals. https://sustainabledevelopment.un.org/topics/sustainabledevelopmentgoals

Vision 2020 – The Right to Sight. http://www.iapb.org/vision-2020

WHO Global Action Plan – Towards Universal Eye Health 2014-2019. http://www.who.int/blindness/actionplan/en/index1.html

International Council for Education of People with Visual Impairment. http://www.icevi.org

Nordstrom, K. (2007). Convention on the rights of persons with disabilities. The Educator, 20 (2). http://www.icevi.org/january_07/educator_january-07.html

UNESCO. (1994). The Salamanca Statement and Framework for Action on Special Needs Education. Salamanca, Spain: UNESCO and Ministry of Education and Science Spain.

Low Vision Module for Ophthalmology Curriculum 7

http://portal.unesco.org/education/en/ev.php-url_id=7939&url_do=do_topic&url_section=201.html

World Blind Union. http://www.worldblindunion.org/English/Pages/default.aspx

Marrakesh Treaty to Facilitate Access to Published Works for Persons Who Are Blind, Visually Impaired, or Otherwise Print Disabled (2013) www.wipo.int/ treaties /en/ip/ marrakesh

UNESCO. (2015) Education for All http://www.unesco.org/new/en/education/themes/leading-the-international-agenda/education-for-all/

Low Vision Module for Ophthalmology Curriculum 8

Session Plan 3

Epidemiology

Title : Epidemiology

Time : 2 hours

Outcome : Participants will have an understanding of the World Health Organization (WHO) terminology of visual impairment, and the prevalence and causes of visual impairment

Objectives : Understand the definitions and classification of visual

impairment, low vision and blindness Understand the sources of data and their limitations Able to present data on global epidemiology of visual

impairment Able to present data on national epidemiology of visual

impairmentSession Plan :

Stage Content Method MaterialStage-1 Describe and compare the

ICD-10 and ICFInstruction, Discussion

ICD-10, ICF handouts

Stage-2 Definitions and classification of visual impairment, low vision and blindness

Instruction, Discussion

WHO website

Stage-3 Global epidemiology of visual impairment

Instruction, Discussion

IAPB website

Stage-4 National epidemiology of visual impairment

Instruction, Discussion

Publications, National websites

Stage-5 Sources of epidemiological data and their limitations

Instruction, Discussion

Process: Stage-1: Describe and compare the ICD-10 and ICF

Low Vision Module for Ophthalmology Curriculum 9

Describe and explain the epidemiological and functional definitions of visual impairment as stated by the World Health Organization (WHO).

Describe the ICF and compare the implications of the medical and social models of health for the assessment and understanding of low vision.

Stage-2: Definitions and classification of visual impairment, low vision and blindnessRefer to the 2008 WHO definition of visual impairment. Highlight the importance of presenting compared to best corrected vision. Outline and discuss the critical differences between:

visual impairment low vision blindness

Explain the differences between none, mild, moderate, severe, and profound visual impairment categories.

Stage-3: Global epidemiology of visual impairmentShare information regarding the global prevalence and causes of visual impairment. Highlight the regional differences and their importance for planning of prevention, treatment, correction, and rehabilitation programmes.

Explain the differences between avoidable, preventable and treatable causes of visual impairment.

Discuss the following standard references:

WHO Global Data on Visual Impairment 2010 Global magnitude of visual impairment caused by uncorrected refractive errors in

2004 Global Burden of Disease Study 2010 – Blindness and Visual Impairment Global Vision Database Maps

Stage-4: National epidemiology of visual impairmentExplain how prevalence data can be applied to a country to establish the number of people with visual impairment and how this will vary across regions of a specific country.

Discuss the common problems related to lack of accurate and recent data on the causes of visual impairment. Discuss possible solutions, such as the use of regional data.

ExerciseUse the data on causes of vision impairment to plan the human resources needed for eye care within a country.

Stage-5: Sources of epidemiological data and their limitations

Low Vision Module for Ophthalmology Curriculum 10

Discuss the following:

Sources of data need to be critically reviewed to establish if the data is truly representative of a region or country

Differences in the methodology of data collection that affect its accuracy Categorization of vision Age and location of the population studied. The size of the sample studied The sources of the sample (particularly in children) Do the data give information on the disadvantaged and under-served populations

REFERENCESGilbert, C., & Foster, A. (2001). Childhood blindness in the context of VISION 2020 – The Right to Sight. Bulletin of the World Health Organization, 79(3), 227-232. http://www.who.int/bulletin/archives/79%283%29227.pdf

Global Burden of Disease Study.http://www.globalvisiondata.org/ http://www.iapb.org/sites/iapb.org/files/IAPB%20position%20on%20GBD%20data.pdfhttp://www.iapb.org/assembly/course-10-global-burden-disease-impact-vision-loss

Global Vision Database Maps. http://www.iapb.org/maps

World Health Organization. Refractive error and low vision. http://www.who.int/blindness/causes/priority/en/index4.html

World Health Organization. (1992). Management of low vision in children. WHO/PBL/93.27. http://apps.who.int/iris/bitstream/10665/61105/1/WHO_PBL_93.27.pdf

Bourne RRA, Stevens GA, White RA, Smith JL, Flaxman SR, Price H, Jonas JB, Keeffe J, Leasher J, Naidoo K, Pesudovs K, Resnikoff S, Taylor HR. Causes of Global Vision Loss: 1990-2010. The Lancet Global Health 2013. Open Access. http://www.thelancet.com/pdfs/journals/langlo/PIIS2214-109X(13)70113-X.pdf

Cama A, Keeffe J. Childhood visual impairment in Fiji. Arch Ophthalmol 2010;128:608-612. http://archopht.jamanetwork.com/article.aspx?articleid=425580

Gilbert CE, Ellwein L. Prevalence and causes of functional low vision in school-age children: results from standardized population surveys in Asia, Africa and Latin America. Invest Ophthalmol Vis Sci 2008;49:877-881. http://iovs.arvojournals.org/article.aspx?articleid=2184425

Understanding Low Vision. Gilbert C. Journal of Community Eye Health 2012;25:2. http://www.cehjournal.org/wp-content/uploads/low-vision-we-can-all-do-more.pdf

Low Vision Module for Ophthalmology Curriculum 11

Session Plan 4

Anatomy and Function of the Eye

Time : 1 hour

Outcome : At the end of this session the participants will able to describe the characteristics of the normal eye, and they will understand common visual defects.

Objectives : Understand what vision is and the importance of vision Understanding of at least six characteristics of the normal

eye Understanding of at least ten parts of the eye and their

functions Understanding of how the healthy eye functions Knowledge of common visual defects

Session Plan :Stage Content Method MaterialStage-1 Explanation of vision and

the importance of vision for learning and functioning

Instruction, Discussion

Diagrams

Stage-2 The parts of the eye and their functions

Instruction Model eye, Handout, Websites

Stage-3 Visual defects Demonstration, Discussion

Handout, Websites

Process: Stage-1: Explanation of vision and the importance of vision for learning and functioningExplain the visual system referring to the eye, brain and the environment. Discuss how the visual system receives and interprets information. i.e.visual mechanism, image forming mechanism

Outline the importance of vision in functioning particularly during early learning.

Stage-2: Parts of the eye and their function

Low Vision Module for Ophthalmology Curriculum 12

List the primary parts of the normal eye using the model eye. Use diagrams of the eye (external and internal components). Discuss the function of the anterior and posterior segments of the eye.

Discussion using simple questions such as: “How do you think the iris controls light?” or, “How does the lens help to see near and distant objects?”

Ask the participants to label a diagram of the eye, identifying the parts of the eye and describing the function.

Stage-3: Visual DefectsExplain examples of how abnormal functioning of the different parts of the visual system lead to specific visual defects.

Examples Blurred vision – refractive system, ocular media, central retinal function Dark-Light adaptation – anterior segment (iris), retinal function Visual Fields – retinal function, cortical function, Central and para-central scotoma - retina Generalized loss such as peripheral - retina Hemianopia and quadrantanopia – cortical Colour Vision – retina, ocular media Eye movements – extra-ocular muscles, cortical, visual deprivation Contrast sensitivity – everything

EYE DISEASE SIMULATIONS

National Eye Institute https://nei.nih.gov/health/examples

CNIB http://www.cnib.ca/en/your-eyes/eye-conditions/eye-connect/Pages/EyeSimulator.aspx

Perkins http://www.perkinselearning.org/scout/simulation-vision-conditions

Low Vision Module for Ophthalmology Curriculum 13

Session Plan 5

Causes and Implications of Visual Impairment and Prevention

Time : 3 hours

Outcomes : Participants will be able to describe the causes, symptoms and implications of visual impairment and will have knowledge of prevention strategies

Objectives : Present the most common causes of visual impairment Explain parts of the eye and symptoms associated with the

causes of visual impairment Outline prevention and interventions for common causes of

vision impairmentSession Plan :

Stage Content Method MaterialStage-1 Common causes of visual

impairment in childrenDiscussion, Demonstration

WHO website, Model of the eye

Stage-2 Common causes of visual impairment in adults

Discussion, Demonstration

WHO website, Model of the eye

Stage-3 Signs and symptoms of common causes of visual impairment

Discussion ICEH and WHO posters, Model of the eye

Stage-4 Treatment and prevention Instruction, Discussion

Model of the eye

Process :Stage-1: Common causes of visual impairment in children Congenital Hereditary Later onset Trauma

List congenital, hereditary and acquired diseases and disorders of the eye that commonly cause low vision in children, including:

Congenital and traumatic cataracts

Low Vision Module for Ophthalmology Curriculum 14

Cornea degenerations/dystrophies Albinism Microphthalmos Aniridia Leber’s congenital amaurosis Optic atrophy Retinal disorders – retinoblastoma Amblyopia Retinopathy of prematurity Rubella Vitamin A deficiency – xerophthalmia Trachoma – eye lids and corneal changes

Intervention measures for all of the relevant diseases should be discussed in detail during this session. Emphasize the diseases that are a treatment priority.

List the diseases that cannot be treated or cured, but can be easily prevented.

Stage-2: Common causes of visual impairment in adults Hereditary Acquired Trauma

List hereditary and acquired diseases and disorders of the eye that commonly cause low vision in adults, including:

Cataracts – congenital and acquired Age related macular degeneration (ARMD) Diabetic retinopathy – vision loss from disease and consequent treatment

(laser photocoagulation) Glaucoma Retinitis pigmentosa Corneal degenerations/dystrophies Trachoma – eye lids and corneal changes Optic atrophy Multiple sclerosis Stroke and acquired brain injuries Macular dystrophies/degenerations – Best’s disease, Stargardt’s disease Myopic degeneration Ocular colobomas

Intervention measures for all of the relevant diseases should be discussed in detail during this session. Emphasize the diseases that are a treatment priority.

List the diseases that cannot be treated or cured, but can be easily prevented.

Stage-3: Signs and symptoms of common causes of visual impairment

Low Vision Module for Ophthalmology Curriculum 15

Conduct this session in the form of group work.

Group workDivide the participants into 4 or 5 small groups and ask each group to draw and label a diagram of the eye. Ask the participants to work in groups and point out which parts of the eye are affected by each disease and what are the likely symptoms. They can use simulators for this exercise. This task should take around 25 minutes.

Eyelid Cornea Lens Retina

CataractsSigns and Symptoms include:

Clouding of lens, opacities vision may seem cloudy and blurry; glare, where light sources appear too bright, and halos around lights double vision reduced contrast acuity poor night vision in the final stages, sight diminishes to the extent that the patient cannot see

Age Related Macular Degeneration (ARMD)Wet and dry ARMDSigns and Symptoms include:

choroidal neovascular net – bleeding, leakage of fluid, thickening of macula atrophic changes at the macula decreased visual acuity central scotoma – relative and absolute reduced contrast acuity possible glare sensitivity possible effects on colour vision

DiabetesSigns and Symptoms include:

retinal and vitreous haemorrhages retinal exudates and infarcts neovascular changes at the retina and iris decreased visual acuity scotomas associated with retinal bleeding and scarring from treatment with

laser photocoagulation reduced contrast acuity possible glare sensitivity possible effects on colour vision

GlaucomaSigns and Symptoms include:

loss of retinal nerve fibre layer optic nerve head changes – notching, increased cupping, pallor

Low Vision Module for Ophthalmology Curriculum 16

narrow anterior angle – partial/complete occlusion visual field changes reduced contrast acuity possible glare sensitivity – haloes if cornea affected

Retinitis PigmentosaSigns and Symptoms include:

peripheral retinal changes – typical bone spicule like pigmentary changes (there is a sine pigmento variant of the disease where pigmentary changes are absent)

attenuation of retinal blood vessels optic atrophy loss of peripheral visual field – bumping into objects, peripheral neglect decreased visual acuity at end stage of the disease reduced contrast acuity increased glare sensitivity deafness as part of syndrome – Usher’s syndrome

Corneal degenerations/dystrophiesSigns and Symptoms include:

corneal haze, opacities, thickening, ectasias decreased visual acuity haloes increased glare sensitivity

TrachomaCorneal and lid scarringSigns and Symptoms include:

corneal haze, opacities, thickening, ectasias trichiasis scarring of eyelid conjunctiva decreased visual acuity with cornea scarring increased glare sensitivity watery and sticky eyes

Implications of the common causes of visual impairment on parts of the eye

Relate low vision symptoms to the structures of the eye affected by the common causes of visual impairment described in Stages 1 and 2

Corneal disease – symptoms of decreased visual acuities, increased glare, haloes and decreased contrast

Iris disease – symptoms of increased glare

Lens opacities - symptoms of decreased visual acuities, increased glare, haloes and decreased contrast

Low Vision Module for Ophthalmology Curriculum 17

Central retinal disease - symptoms of decreased visual acuities, loss of central vision (relative and absolute), possibly increased glare, possible colour vision anomaly and decreased contrast

Peripheral retinal disease - symptoms of loss of peripheral visual field i.e. tunnel vision, bumping into objects

Optic nerve - symptoms of decreased visual acuities, loss of central vision (relative and absolute), loss of peripheral visual field, possible anomalous colour vision, possible increased glare and decreased contrast

Have each group present their findings and assist with any problems.

Distribute the handouts on the list of eye diseases and effects on visual function.

Stage-4: Treatment and Prevention

In the list of diseases and signs and symptoms identified in stages 1-3, ask the participants to indicate what is the most appropriate treatment for each and whether it is amenable to prevention.

Ask the participants if they have any questions.

MALNUTRITION AND BLINDNESSBlindness due to malnutrition and its symptomsThrough the discussion, cover the following points:

A person with blindness due to malnutrition will not see well after dusk or in dimly lit places, they may also stumble and fall, and have difficulty finding food on a plate

The eyes will gradually become dry The sclera gradually becomes frothy, as if it has a cover of soap bubbles The cornea will become scarred and damaged

Once a person experiences these symptoms and it leads to corneal damage, the damage is permanent and cannot be treated.

Causes and prevention of blindness due to malnutrition Vitamin A rich foods and Vitamin A supplements

Ask the participants if they know the causes of blindness due to malnutrition? Why does this problem arise at dusk? Teaching pointsThe principal cause of blindness due to malnutrition is lack of Vitamin A. Vitamin A deficiency leads to physical changes in the eye that can lead to visual impairment. The rod cells of the eye allow us to see in dim light and aid in the perception of motion. In the primary stage of the deficiency, the rod cells cease to function and as

Low Vision Module for Ophthalmology Curriculum 18

a result it becomes difficult to see in dim light. Gradually the deficiency leads to lesions that harm the cornea.

Teaching point 1Rich sources of vitamin A Green and coloured vegetables All kinds of coloured fruits and roots Milk and milk derivatives Animal livers Some fish (depending on local availability)

Teaching point 2 Treatment of night blindness and when vitamin A is recommendedAsk the participants if they know the treatment for night blindness due to vitamin A deficiency. Explain the recommended dosage information for vitamin A supplements.

Apart from the children identified with Vitamin A deficiency, any children that are recovering from measles or severe diarrhoea should also be given vitamin A supplements in the above dosage. Measles and severe diarrhoea can lead to being malnourished and a severe vitamin A deficiency if not treated.

In young children, vitamin A dosage should also not be exceeded as it can result in numerous side-effects such as sensitivity to sunlight, rough skin and rashes.

HandoutsUse slides/transparencies to show examples for different eye diseases from case studies. Distribute handouts on the causes, signs, prevention and interventions for eye diseases.

REFERENCES

Vitamin A Supplementation. http://www.who.int/vaccines/en/Vitamina.shtml

Gilbert, C., & Foster, A. (2001). Childhood blindness in the context of VISION 2020 – The Right to Sight. Bulletin of the World Health Organization, 79(3), 227-232.

WHO Prevention of Blindness and Visual Impairment. Causes of blindness and visual impairment. Global Data on Visual Impairment 2010. http://www.who.int/blindness/causes/en/

West, S. (2007). Epidemiology of Cataract: Accomplishments over 25 years and Future Directions, Ophthalmic Epidemiology, 14 (4). 173-178.

What is low vision. http://www.aao.org/eye-health/diseases/low-vision

Smart Sight. http://www.aao.org/smart-sight-low-vision

Low Vision Module for Ophthalmology Curriculum 19

Low Vision – essential guide for ophthalmologists. https://www.rcophth.ac.uk/wp-content/uploads/2014/08/2012_EXE_225_Low_Vision_BookD5-v4.pdf

Low Vision Module for Ophthalmology Curriculum 20

Session Plan 6

Psychosocial Impact of Low Vision

Time : 3 hours

Outcomes : Understanding of the psychosocial impact of low vision and strategies to manage coping difficulties

Objectives : Able to identify and describe potential psychosocial effects of

low vision at developmental stages Aware of the signs and symptoms of psychosocial problems

and disorders Aware of appropriate intervention and referral strategies to

promote healthy psychosocial development and coping

Session Plan :

Stage Content Method MaterialStage-1 Social and emotional

development and effects of low vision

Instruction, group work, class sharing

References on child development

Stage-2 Awareness of psychosocial problems and psychological disorders

Instruction DSM-IV (book, handout or internet site).Social skills assessments

Stage-3 Intervention strategies to promote healthy psychosocial development

Discussion and instruction

Intervention programmes or manuals. Local referral information

Stage-4 Case study Group work Case scenarios

Process :

Stage-1: Social and emotional development and effects of low visionDescribe the current knowledge regarding the psychosocial impact of low vision.

Highlight that differences exist between people with low vision; while many people function at high levels and demonstrate good social competence, develop strong,

Low Vision Module for Ophthalmology Curriculum 21

meaningful friendships and do not experience psychological problems, others can experience difficulties in coping.

Explain how low vision can lead to problems with the psychosocial well-being of students and adults with low vision. Describe these to the class, based on current literature.

Social impact of vision impairment It is more common for children with vision impairment to interact with adults in

classes rather than peers and spend less time interacting with peers. Sighted children more often choose sighted peers to interact with

Breakdown in communication with peers (particularly for younger children) is common

Isolation and or rejection by peers due to differences in appearance; stereotypical behaviours, social behaviours or specially adapted equipment

Potential for overprotection by peers and adults Difficulties learning social norms. Children with vision impairment often lack skills

to appropriately enter groups, hold conversation and negotiate conflicts Difficulties in locating peers for play

Potential psychosocial impact of low vision A feeling of difference to others Adjustment difficulties. Often children with low vision have greater difficulties than

those who are blind. Because their impairment is not obvious, adults often impose similar expectations for children with low vision as they do for sighted children. Unlike blind children, children with low vision are often not afforded modifications or support they require

Loneliness or isolation Adjusting to vision loss later in childhood, grief regarding the loss of vision Vision impairment is associated with depression amongst adult populations Often receive distorted and unreliable visual information, and as a result, may

grow up lacking confidence or develop a poor self-image or behavioural difficulties

Adolescents with vision impairments have significantly lower self-concept than their sighted peers. Feelings of inferiority and inadequacy caused by vision impairment could be a significant factor behind the problem of poor self-image (Beaty, 1991)

Adolescents who cannot conform to group norms are prone to peer rejection. Peer rejection and acceptance is a predictor of later academic success, social success and behaviour problems.

Stage-2: Awareness of psychosocial problems and psychological disordersDiscuss the range of normal emotions and difficulties faced in life and potential difficulties faced by students with low vision. Instruct the class on the difference between a typical or developmentally appropriate psychosocial problem / difficulty and a psychological disorder. Discuss psychological classifications for disorders (ICD-10, DSM-IV) compared to the range of normal experiences that people may face in their daily life.

Low Vision Module for Ophthalmology Curriculum 22

Class discussionAsk participants to name childhood / adolescent experiences and the spectrum which exists among these experiences. Provide cues and additional information regarding disorders. For example:

Sadness through to depression Periods of sadness are common aspects of life and should not be diagnosed as a

Major Depressive Episode unless criteria are met for severity (see ICD-10, DSM-IV)

Developmentally appropriate separation anxiety through to Separation Anxiety Disorder

Worry and anxiety through to generalized anxiety disorder Social shyness or embarrassment through to Social Anxiety Problem behaviours through to Conduct Disorder

Instruct the class about the signs and symptoms of disorders discussed above using the DSM-IV or ICD-10 classifications and diagnostic criteria. Provide a handout of the signs and symptoms.

Identification and assessment of psychosocial disordersInstruct the class regarding identification and assessment of psychosocial disorders:

Awareness of signs and symptoms allow the teacher to monitor a child’s well-being

If any concerns are raised, discuss with parents Assessment and diagnosis is required by a professional (psychologist,

psychiatrist or counsellor). Referral is important if signs are noticed; do not hesitate to refer them to a mental health professional for assessment

If immediate assessment is needed, contact parents and take the child to the hospital emergency room

Discuss the procedure for referring to health professionals in the local area Specialists may implement interventions such as counselling, medication and/or

cognitive behavioural therapy

Social skills deficits Discuss the signs of social skill deficits that are common among children with low vision. For example:

difficulties interacting with peers and adults inappropriate verbal or non-verbal communication skills inappropriate social behaviours overly assertive, aggressive or submissive behaviours.

Discuss ways to assess social skills Informal observation of social interaction. observe the frequency of interaction with peers, the nature of the interactions, does the child initiate interactions? does the child respond to other’s interactions?

Low Vision Module for Ophthalmology Curriculum 23

are their interactions appropriate?

Standardized assessmentsTeacher and parent questionnaires can be completed to measure the child’s social skills relative to the expected skills of the age range. Examples included:

Matson Evaluation of Social Skills with Youngsters (MESSY) Social Skills Rating System Vineland Adaptive Behaviour Scale

Demonstrate the procedures to administer, score, and interpret the assessments. Allow the participants to practice using the assessments.

Stage-3: Interventions to promote healthy psychosocial development

Building social competenceEarly exposure to social interaction is important. Encourage parents to mix the child with other children from an early age.

Teaching social skillsChildren with vision impairment may require explicit instruction regarding social norms, as well as suggestions for improving social competence. This may take the form of social skills groups (a good chance to put the social skills into practice) or one-on-one training.

Provide an example of a social skills training program, manual or video. Topics may include:

Interpersonal communication skills Awareness of appropriate and inappropriate verbal and non-verbal behaviours Assertive communication Consideration of the perspective of others Joining groups Beginning and maintaining conversations Using trained peers or adults to reinforce social skills and provide feedback has

been shown to be effective for some children with vision impairment and other disabilities

Involve parents in teaching and reinforcing appropriate social skills Strategies to increase interaction between peers Balance of adult involvement in promoting interaction ‘Cooperative Learning Activities’ and group games in class Buddy systems Teaching peers and educators about vision impairment Adapt activities to increase participation in class and increase a sense of

belonging

Strategies to deal with stress

Low Vision Module for Ophthalmology Curriculum 24

Relaxation and meditation techniques Diversion techniques such as going for a walk Exercise Rational and non-rational thoughts. Teaching compensatory techniques for a realistic understanding of visual

problems

Strategies to increase confidence and self esteem Mastery of skills, achievement and having positive experiences Developing interests / hobbies, extracurricular activities Rewards and praise in class, setting achievable goals in class

Strategies to deal with bullying or isolation instruction regarding assertive, aggressive and submissive behaviour styles involvement in extra-curricular activities and groups developing interests

Family relationships and role of the family Discuss the importance of parent involvement, encouragement and positive,

healthy relationships with the child Family barriers (expectations, poor family relationships, sibling rivalry) Family facilitators (support, rewards and praise, listening and discussing

problems, stability and safety for the child) Referral to counsellors, psychologists, or psychiatrists. Who to refer to, when to

do so. Provide details of mental health specialists in the local area and how to find details

Stage-4: Case studyGive participants a case study regarding a student with low vision who is experiencing adjustment problems. Group members to examine and suggest:

Signs and symptoms the student is displaying How to identify the severity of the problem Suitable coping strategies Referral to specialists, local community organizations and groups

REFERENCESUCL Working Papers. Psychosocial implications of blindness and low-vision ISSN 1467-1298 https://www.bartlett.ucl.ac.uk/casa/pdf/paper114.pdf

Sharon Z Sacks Psychological and Social Implications of Low Vision in Foundations of Low Vision. Anne Corn and Jane Erin. ISBN: FOLV2, AFB Press, 2010

Focus on low vision. http://trove.nla.gov.au/work/32458520?selectedversion=NBD43720160http://www.cera.org.au/wp-content/uploads/2013/12/CERA_FocusLowVision.pdf

Low Vision Module for Ophthalmology Curriculum 25

Low Vision Module for Ophthalmology Curriculum 26

Session Plan 7

Clinical Low Vision Assessment

Time : 38 hours

Outcome : The participants will be able to undertake a comprehensive assessment of the visual functions of a client and suggest the most appropriate solutions

Objectives : Undertake a detailed case history Assess the residual visual function Collate the residual vision with the individual’s needs Suggest appropriate interventions Refer the client to the appropriate service provider

Session plan :

Stage Content Time Method MaterialStage-1 Undertake a detailed

case history2 hr. Instruction and

practical demonstration

Stage-2 Assess the residual visual function

10 hr. Instruction and practical demonstration

Functional low vision clinic

Stage-3 Collate the residual vision with the individual’s needs

2 hr. Instruction and practical demonstration

Stage-4 Suggest appropriate interventions

2 hr. Instruction and discussion

Stage-5 Referral to the appropriate service provider

2 hr. Instruction and discussion

Stage-6 Clinical Practice 20 hr. Clinical assessment with a client, class discussion & feedback

Assessment materials. Arrange field visits

Low Vision Module for Ophthalmology Curriculum 27

Process:

Stage-1: Undertake a detailed case history Discuss how participants can undertake a detailed history especially the ocular and general health history, family history, occupation and life style.

Teach the participants to determine the main complaints and challenges being faced by the client, and undertake a needs assessment. Discuss how the participants can assess the emotive state of the client.

Stage-2: Assess residual visual function Demonstrate the assessment of visual acuity using the following tests:

LogMar charts LVRC flip charts Feinbloom test Lea’s symbols etc

Demonstrate the assessment of near vision using the following tests:

LVRC near vision cards Lea symbols Lighthouse near vision test etc

Demonstrate the assessment of reading acuity using various materials e.g. newsprint, telephone directory, price tags etc. The participants should be able to assess the ability to read more congested type sets and note the speed and distance at which the individual clients can read.

Demonstrate the techniques for refraction of a low vision patient:

Bracketing Over-refraction Dynamic retinoscopy

Demonstrate the assessment of contrast sensitivity using the following tests:

Lea low contrast flip cards Bailey Lovie low contrast chart Contrast sensitivity assessment software etc

Demonstrate the assessment of visual fields using the following tests:

Disc perimetry Confrontation method Hand held perimetry Amsler grid

Demonstrate the assessment of colour vision using the following tests:

D-15 test Ishihara test

Low Vision Module for Ophthalmology Curriculum 28

Functional colour vision assessment

Stage-3: Collate the residual vision with the individual’s needsDemonstrate to the participants how the above assessments can be correlated with the client’s needs:

identifying the areas of strengths and weaknesses determining the most feasible interventions deciding on the appropriate referrals

Stage-4: Suggest appropriate interventionsDiscuss how the information obtained from the assessments can help in selection of the most suitable optical and non-optical low vision devices, environment modifications and independence and mobility.

Demonstrate to the participants how to calculate the magnification needs, selection and trial of devices and the training of the client in the use of the prescribed devices.

Demonstrate how to explain to the client on the use of adaptive devices and other assistive technology.

Stage-5: Referral to the appropriate service providerDiscuss how the participants can identify vertical and horizontal referral pathways in their settings.

Demonstrate how case report and referral letters are written.

Discuss how participants can advise clients to make best use of available statutory and legal provisions for people with disability.

Stage-6: Clinical PracticeParticipants to first observe a full clinical and functional vision assessment routine in at least 5 clients with various causes and severity of low vision; then to participate in supervised clinical and functional assessments of at least 5 clients with low vision, leading to skills to conduct and perform a low vision and functional assessment independently.

Where possible, participants should have the opportunity to observe and assess children with:

Age related macular degeneration Glaucoma Diabetic retinopathy Retinitis Pigmentosa Optic Atrophy Retinal dystrophy

Low Vision Module for Ophthalmology Curriculum 29

Participants to learn how to communicate the assessment findings and the plan for intervention to the clients and other professional colleagues. Following their assessments provide feedback to participants as a whole group. Correct any mistakes. Let participants check each other’s way of assessment, documentation and communication.

Participants shall also learn how to do the following:

Functional assessment of low vision and case studies Visual skills training Counselling techniques

Where feasible, arrange visits to the following:

A school for visually impaired and blind children A rehabilitation center for the blind and visually impaired

REFERENCES

Low Vision Online www.lowvisiononline.unimelb.edu.au/LVO.htm

Clinical low vision evaluation. http://www.teachingvisuallyimpaired.com/clinical-low-vision-evaluation.html

Specific assessment for students with low vision. http://www.afb.org/info/specific-assessments-for-students-with-low-vision/5

Jackson AJ, Wolffsohn JS. Low Vision Manual. New York: Butterworth-Heinemen/Elsevier; 2007.

Bailey I. Assessment of low vision and predicting vision functionality. American Academy of Optometry, 2014

Gilbert C, van Dijk K. When Someone Has Low Vision. Journal of Community Eye Health 2012;25:4-14. http://www.cehjournal.org/wp-content/uploads/low-vision-we-can-all-do-more.pdf

Keeffe J. Low Vision Assessment. Journal of Community Eye Health 2004;17:3-5WHO Low Vision Kit Book 2. http://apps.who.int/iris/bitstream/10665/58719/1/WHO_PBL_95.48_book2.pdf

Van Dijk K. Low Vision: The Patient’s Perspective. Journal of Community Eye Health 2012;25:3. http://www.cehjournal.org/wp-content/uploads/low-vision-we-can-all-do-more.pdf

Gilbert C. Making Life Easier for People with Low Vision. Low Vision. Journal of Community Eye Health 2012;25:12-13. http://www.cehjournal.org/wp-content/uploads/low-vision-we-can-all-do-more.pdf

Low Vision Module for Ophthalmology Curriculum 30

Low Vision Module for Ophthalmology Curriculum 31

Session Plan 8

Understanding Optical and Non-Optical Low Vision Devices

Time : 15 hours

Outcome : The participants will be able to determine the need for and teach people with low vision how to use appropriate optical low vision devices.

Objectives : Classify the types of optical and non-optical devices

available for people with low vision Understand the principles of and formulae for magnification Comprehend the optics of low vision devices Understand the advantages and disadvantages of these

devices Determine the required and the actual magnification and

prescribe the appropriate devicesSession plan :

Stage Content Time Method MaterialStage-1 Types and classification

of optical and non-optical low vision devices

2 hr Instruction and demonstration

Range of optical low vision devices including spectacle hand-held, stand magnifiers with and without internal illumination, telescopes, field expanders, near vision and reading vision charts, training software for telescope trainingRange of non-optical devices

Stage-2 Types of magnification 2 hr Instruction

Stage-3 Optics of low vision devices

4 hr Practical exercise

Stage-4 Advantages and disadvantages of different devices

1 hr Instruction

Low Vision Module for Ophthalmology Curriculum 32

Stage-5 Prescription of low vision devices and verification

4 hr Instruction and practical exercise

Stage-6 Training in the correct use of optical low vision devices

2 hr

Process:Stage-1: Classify the types of optical and non-optical devices available for people with low vision Describe the types of optical and non-optical low vision devices and discuss the difference between optical and non-optical materials. Explain how these devices are used to magnify the objects. Group them as:

Devices for near vision Devices for distance vision

Describe the commonly used optical devices and give examples of the following three types:

Magnifiers Telescopes Field Expanders

Describe the aids available for peripheral field loss. Explain the theory behind these aids and describe and demonstrate their operation.

Describe the commonly used optical devices and give examples of the following: lamps reading stands typoscopes felt-tip pens

Stage-2: understand the principles of and formulae for magnificationDescribe the various types of magnification and the rationale. Discuss the different formulae used to calculate magnification. Illustrate with examples using the types of magnification below:

Relative Size Magnification Relative Distance Magnification Angular or Optical Magnification Electronic Magnification

Explain how the magnification of hand-held, stand, spectacle magnifiers and telescopes is calculated. Demonstrate and explain how magnification from various sources is calculated.

Low Vision Module for Ophthalmology Curriculum 33

Stage-3: Optics of low vision devices Describe the optics of a convex lens. Discuss the optics of stand, hand-held, spectacle magnifiers and telescopes.

Explain how the optics of the device affects its functions. Discuss how the placement of the following affect the magnification and the field of view:

Eye to device Device to the target

Describe the factors which influence the field of view and the image brightness in a telescope.

Stage-4: Advantages and disadvantages of different devicesDescribe the advantages and disadvantages of Galilean and Keplerian telescopes, and hand-held, spectacle and stand magnifiers.

Stage-5: Prescribing low vision devicesDiscuss how the needs for vision enhancement through optical systems are determined. Explain how this may be done using the following principles of prescribing low vision devices:

Determine the resolution ability for near and distance tasks Predict the distance required to meet the resolution goal Verify that the predicted EVD allows the resolution goal Consider other optical systems to provide the same EVD

Discuss how the following options can address the needs:

Spectacles with reading addition Hand held magnifier Stand magnifier Near vision telescope Video magnifier or other projection system

In all these cases, explain what the magnifying systems are doing and how they provide the required Equivalent Viewing Distance (EVD).

Describe the method for determining the power of a distance viewing telescope.

Explain to the participants how to measure the magnification of optical devices:

Checking the dioptric power In-office measurement of equivalent power In-office determination of image loc. Finding the enlargement ratio for a stand magnifier Measuring lens power Measuring equivalent power for: spectacles

Low Vision Module for Ophthalmology Curriculum 34

hand held magnifiers stand magnifiers Prescription Verification

Stage-6: Train the patient in the correct use of the optical low vision devicesExplain how various devices function and the best way of using them to enhance vision. Demonstrate to the participants the correct method of handling low vision devices for obtaining the desired outcome:

Hand held magnifiers Spectacle magnifiers Stand magnifiers CCTVs Telescopes

Demonstrate where the object needs to be placed with regards to the magnifier and the eye. Discuss and demonstrate how optical and non-optical devices can be sued together to achieve the best possible visual function.

Develop a training program for the appropriate use of the appropriate devices for distance, near and for peripheral awareness.

Advise the clients on the correct posture and positioning of the client and advise on the ergonomics.

Demonstrate on how the clients may care and maintain their prescribed devices.

Practical workAsk participants to split into pairs (one to act as clinician, the other as person with low vision). Participants to teach each other how to use the near and distance optical and non-optical devices.

Case studyAssign the participants cases studies of clients with different visual problems, age and physical function who participate in different occupations or activities. Ask participants to prescribe suitable low vision devices for the individuals.

REFERENCES

Low Vision Online. http://www.lowvisiononline.unimelb.edu.au/index.htm

All about low vision. http://www.lighthouse.org/about-low-vision-blindness/all-about-low-vision/

All about vision. http://www.allaboutvision.com/lowvision/

Low Vision Module for Ophthalmology Curriculum 35

Low Vision Module for Ophthalmology Curriculum 36

Session Plan 9

Paediatric Low Vision Care

Time : 26 hours

Outcome : Participants will have a broader understanding of the various needs of a child with vision impairment and the clinical expertise to perform a low vision assessment and recommend visual aids and other appropriate management including referrals.

Objectives : Describe visual development and how it relates to the overall

growth of a child List sequence of activities as appropriate to develop each of

the seven visual skills Assess the visual functions of pre-verbal, verbal and school

aged children using appropriate assessment techniques and tools

Prescribe and train in the use of optical, non-optical low vision and simple adaptive devices according to the child’s needs

Orient and familiarize students with principles of early intervention, and what types of material can be developed locally for training

Advise the parents, teachers and caretakers on prognosis of the disease and its impact on the child’s visual performance

Provide appropriate referral for support services in education, rehabilitation, social and other areas for the child and his/her family

Session Plan :

Stage Content Time Method MaterialStage-1 Normal visual

development2 hr. Brainstorm, individual

exercise, instruction, discussion

Audio-visual materials

Stage-2 Clinical assessment of low vision in children

4 hr. Instruction and practical demonstration

Access to a low vision clinic

Stage-3 Prescription 2 hr. Instruction and practical demonstration

Access to a low vision clinic

Low Vision Module for Ophthalmology Curriculum 37

Stage-4 Early intervention and training of visual skills

2 hr. Discussion, instruction, brainstorm, small group work

Access to an early intervention facility

Stage-5 Advice and counselling

2 hr. Discussion, instruction, brainstorm, small group work

Stage-6 Clinical Practice 14 hr. Clinical assessment of children, class discussion & feedback

Assessment materials. Arrange class visits

Process: Stage-1: Normal visual development and functional vision assessmentUse visual development exercise. Ask participants to fill match visual responses and skills to age groups using their own experiences and observations. E.g. Name the age at which you would typically expect a child to start to:

Follow moving objects and lights Watch movements and scribbling Match geometric forms Fit objects together Reach towards objects Play looking games Imitate facial expressions

Provide participants with a handout of normal visual development skills and ages adapted from Barraga “Development of efficiency in visual functioning: Rationale for a comprehensive program” (available Low Vision Online). Participants to compare their responses to the handout.

Describe that functional vision assessment and training is based on a comparison of normal visual functioning to the functional level of a person with visual impairment. Teach participant to perform a functional assessment.

The participants relate the normal visual skills to the visual skills assessed in the functional assessment:

Near and distance visual acuity: Fixation 1-2 Follows slow moving objects: Tracking 0-1 Awareness of outlines of familiar objects, simple pictures: Awareness 2-4 Fixates on mother’s face: Fixation 0-1 Walks around freely in own environment and similar places: Mobility 2-4 Inspects objects with eyes only: Fixation / focus 1-2 Moves eyes to search and explore visually: Scanning 0-1 Response to light: Awareness 0-1 Identifies actions, objects in complex pictures: Awareness 5-7 Glances at small objects of 2 cm: Attention 0-1 Copies symbols, starts writing; Attention 5-7

Low Vision Module for Ophthalmology Curriculum 38

Follows rapidly moving objects in all directions: Tracking 1-2

Brainstorm problems of a blind/low vision young child. Highlight main areas, e.g.: no imitation, eating, concepts, body image, movement, dressing, washing, latrine, playing, use of senses like hearing, smell, and taste, use of residual vision, communication, language, and social skills.

Stage-2: Clinical assessment in childrenList the 7 visual skills included in a functional assessment

Visual functionsAsk the class what can you assess? Discuss the relevance of these visual skills to children and come to a consensus of whether they are applicable at each age range: near, distance, field, colour, contrast, fixation, tracking, scanning, mobility etc.

Small group exerciseParticipants to work in small groups. Review normal visual skills for age. Groups to write on flipchart practical ways of assessing the following for a child (1 to 6 years old):

Visual acuity – preverbal using preferential looking test, verbal using matching and pointing tests, and school aged using LogMAR charts, near vision and reading vision charts

Specialized techniques for refracting children with low vision Visual field – including confrontation, perimetry using visual fields testing

software, hand held perimeter Colour perception – using D-15 and matching colour Contrast sensitivity – using Hiding Heidi, contrast sensitivity function software Binocular vision – using Lang stereo test and other standard stereo tests Light adaptation – using Cone adaptation test Provide feedback to whole class. Describe suggestions of activities to assess vision in children (see "Assessment

of Low Vision in Developing Countries" in the Low Vision Kit).

Emphasize: The use of every day materials Choosing good assessment materials and backgrounds Age-relevant activities

Stage-3: Prescription for childrenDiscuss the purpose of prescribing optical and non-optical devices and interventions for children. Ask participants to name and correctly identify a variety of optical and non-optical low vision devices and their uses.

Describe the prescription process and applications, and train in the use of various low vision devices, ergonomics and adaptive technology:

Low Vision Module for Ophthalmology Curriculum 39

Magnifiers – stand and hand-held Telescopes Electronic devices including CCTVs Adaptive devices - including reading stands, typoscopes, writing guides Ergonomics – lighting, colour and contrast

Demonstrate the use and limitations of the various low vision and adaptive devices mentioned above in a child’s education, recreation and daily living skills.

Develop a training and follow-up program for children with low vision for developing their skills in using the above mentioned low vision and adaptive devices.

Stage-4: Early intervention and training of visual skillsDiscuss the purpose of visual skills training – write a list of aspects on the board (e.g. attention, visual acuity, visual field, scanning etc.). Ask participants to correctly identify aspects which can be modified and to take into consideration the plasticity of vision during early age of development.

Identify the three aspects of vision training: Encouraging use of vision (early intervention) Visual efficiency – how vision is used, interpreting meaning of shapes, using

vision in combination with other senses Changing the environment

Provide an overview for developing a visual training program based on the functional assessment. Look at the results of the functional vision assessment:

Identify areas – 7 areas of visual skills Set objectives Select activities Training Evaluation

Provide an overview of intervention for training visual skills:

General principles (e.g. simple to complex) Four stages of training (touch, touch and vision, vision confirmed by touch, vision

only) Activity and environmental hints for increasing attention and motivation

BrainstormBrainstorm with the class a sequence of simple activities for one of the skill areas (e.g. attention and awareness), using the sequence outlined (four stages).

Group work

Low Vision Module for Ophthalmology Curriculum 40

In small groups, discuss the functional assessment results of 2 children or case studies with low vision. Provide the group with completed functional assessment forms. Provide each group a selection of primary school books and/or other relevant materials to assist in identifying useful training activities.

Provide a list of activities for young children to practice to encourage the use of vision.

Demonstrate early intervention care using available audio-visual training videos.

Stage-5: Advice and counsellingParticipants to learn to advise and counsel parents, teachers, children and other professional colleagues on the prognosis, treatment options, low vision management, referrals to other service providers and consumer/support groups.

Participants should also be able to advise on the possible opportunities on educational supports, learning medium e.g. visual, tactile or mixed, orientation and mobility training, psycho-social counselling, access to social welfare and other statutory bodies, participate in a multi-disciplinary team to develop a plan for rehabilitation, and write referral letters.

Demonstrate advice and counselling using available audio-visual training videos.

Stage-6: Clinical PracticeParticipants to first observe the full clinical and functional vision assessment routine in at least 5 pre-verbal, verbal and school aged children with various causes and severity of low vision; then to participate in supervised clinical and functional assessments of at least 5 children with low vision, leading to skills to conduct and perform a low vision and functional assessment independently.

Where possible, participants should have the opportunity to observe and assess children with:

Albinism Amblyopia Aphakia Cataract Corneal dystrophy High refractive errors Nystagmus Optic Atrophy Retinal dystrophy Retinopathy of prematurity

Participants to learn how to communicate the assessment findings and the plan for intervention to the parents, teachers, children and other professional colleagues.

Following their assessments provide feedback to participants as a whole group

Low Vision Module for Ophthalmology Curriculum 41

Correct any mistakes. Let participants check each other’s way of assessment, documentation and communication.

REFERENCES

Van Dijk, K., Keeffe, J., & Nottle, H. Low Vision Training Manual: for use in developing countries. Melbourne: Centre for Eye Research Australia

Low Vision Online. http://www.lowvisiononline.unimelb.edu.au/index.htm

Pediatric low vision. http://www.aapos.org/terms/conditions/134

Low vision examination of children. http://www.lighthouse.org/for-professionals/practice-management/patient-management-pediatrics/low-vision-examination-children/

Audio-visual learning videos

Low Vision Module for Ophthalmology Curriculum 42

Session Plan 10

Accessibility and Environmental Modification

Time : 3 hours

Outcomes : Understanding of adaptive daily living skills and practical techniques for training people with low vision. Knowledge on how to adapt an environment to promote independence.

Objectives : Aware of the impact of low vision on activities of daily living Able to train a person with low vision in adaptive daily living

skill techniques Aware of modifications that can be made to the environment

and building design to assist people with low visionSession Plan :

Stage Content Method MaterialStage-1 Independence and low

visionPractical exercise, discussion

Low vision folds, bowls, cups, food, drink, utensils

Stage-2 Evaluating independence / ADL skills

Practical exercise, discussion,

Stage-3 Teaching and learning strategies

Instruction, practical exercise

Stage-4 Training techniques in adaptive living

Instruction, demonstration, practical exercise

Clothes, coins, food,

Stage-5 Physical access and environmental modifications

Instruction, group work

Photographs or community visit

Process:Stage-1: Independence / activities of daily living and low vision:Discuss the concept of independence taking into the consideration of “Culture for All” and activities of daily life.

Practical demonstrationHave participants attempt to complete some daily living tasks using low vision goggles. For example: eating a meal, pouring a drink.

Low Vision Module for Ophthalmology Curriculum 43

Discuss the activity with the group. Ask the participants questions about:

Was the task difficult? What effect can low vision have on independence? What difficulties may exist with different eye conditions and types of vision loss

(e.g. peripheral, central vision loss, glare)? What other factors may impact upon performance? For example age, habit,

motivation, co-existing disabilities, cognitive impairment/ memory.

Stage-2: Evaluating independence / adaptive skillsDescribe how to obtain information about the person’s independence / safety

InterviewingObtain a client history – find out about the client’s meaningful activities, social support, financial situation, access to services, age/developmental stage.

Determine activities where they currently experience difficulty or cannot participate in, but want to. Discuss different attitudes (e.g. some people may be satisfied with receiving assistance from other people, whilst others may want to do most things for themselves).

Observation of tasksObserve areas of difficulty and safety precautions.

Stage-3: Teaching and Learning conceptsDescribe concepts of learning and training skills

Task analysis – breaking the skill down into small steps Chaining – forward chaining: teaching the skill from beginning to end; and

backward chaining: teaching the skill from the last step to the first step Removing assistance when the client is learning – reducing the physical or verbal

assistance, reducing visual, verbal or situational cues, increasing the complexity of the task (e.g. reduce the size of the objects)

Motivating the client to continue practice – reinforcement (what is motivating to the client e.g. colour, sound, reward, completion of the task), meaningful activity, learning in context, practicing in the environment.

Stage-4: Adaptive living techniques:To promote independent living in people with low vision some basic factors should be considered and implemented. Describe and demonstrate key strategies and techniques to facilitate independence:

Routine activities: e.g. eating, identifying and accessing money, signing name, using telephone, accessing and recoding information

Educational activities: e.g. learning concepts, recording work Employment activities: e.g. needlework, farm work, desk work

Low Vision Module for Ophthalmology Curriculum 44

Domestic activities: e.g. laundering clothes, cooking, cutting, serving, organizing cupboards, using appliances

Recreational activities: e.g. modifying rules games, sports, watching TV Self and health care activities: e.g. choosing clothes, applying makeup, shaving,

identifying medicines Outdoor activities: e.g. gardening, transport or mobility

Practical demonstrationIn pairs, participants practice implementing the adaptive daily living training techniques by teaching each other e.g. folding clothes, serving rice, selecting the correct money for payment, selecting a particular object from several objects.

Stage-5: Physical access and environmental modifications Discuss the essential elements of physical access. It is pleasant and easy to move around in an accessible environment. Physical access means accessible parking spots, level passageways, large

enough elevators and toilets and comfortable rest places. Works of art and other objects, as well as texts, are placed so they can be looked

at from different heights. There are places for wheelchairs in halls with audience seating, and chairs are

available in exhibition halls. Emergency plans take account of visually impaired, wheelchair users and others. Small changes that make a big difference: minor improvements can be done

without delay: remove thresholds; add seats, handrails and mini ramps, high contrast signs, etc.

Review the concepts of environmental facilitators for low vision:

Bigger (e.g. large print signs) Brighter or reduce glare (use of general lighting or daylight and task lighting) Bolder and contrast (e.g. contrasted coloured door frames to identify where the

door is) Simplified layout (e.g. uncluttered environment, clear pathways) Use of tactile or audio features (e.g. door mat at front door, personal assistance).

Group workIn groups, have participants to describe and assess the following of a building:

The facilitators that are present in the building (interior and exterior) for people with low vision considering the five factors above.

Environmental barriers of the building that reduce access for people with low vision

Make recommendations for improving the design, layout or features of the building.

REFERENCES

Low Vision Module for Ophthalmology Curriculum 45

Creating a comfortable environment for people with low vision. http://www.afb.org/info/low-vision/living-with-low-vision/creating-a-comfortable-environment-for-people-with-low-vision/235

Organizing and modifying your home. http://www.visionaware.org/info/everyday-living/home-modification-/12

Making life easier for people with low vision. http://www.cehjournal.org/article/making-life-easier-for-people-with-low-vision/

Tips for Modifying the Learning Environment for Children with Visual Impairments and Additional Disabilities. http://www.perkinselearning.org/activity-bank/tips-modifying-learning-environment-children-visual-impairments-and-additional

Household tips for people with low vision. http://www.environmentalgeriatrics.com/pdf/handouts/household_tips_low_vision.pdf

Low Vision Module for Ophthalmology Curriculum 46

Session Plan 11

Models of Low Vision Care

Time : 6 hours

Outcomes : An understanding of different models of low vision care

Objectives : Aware of the elements and objectives of a low vision

program Know effective resource and human resource strategies

required to implement a low vision service Be able to develop a model for a low vision service and

recommend short and long term actions

Session Plan :

Stage Content Method MaterialStage-1 Inclusion/ exclusion of low

vision in Community Based Rehabilitation programmes

Instruction Journal articles/ reference books

Stage-2 Essential elements of a low vision program

Brainstorm

Stage-3 Models of Low Vision Service

Community consultation & group assignment

Process:Stage-1: Inclusion / exclusion of low vision in Community Based Rehabilitation (CBR) programmesDescribe the disadvantages of non-inclusion of low vision in traditional CBR programmes:

Techniques used by CBR workers are geared towards non-sighted methods Training in low vision is inadequate to offer effective services to low vision clients

Low Vision Module for Ophthalmology Curriculum 47

Children with visual impairment usually do not fall under the responsibility of CBR workers and their education is primarily seen as the responsibility of specialist or itinerant teachers

Describe the potential effects of adding low vision services (refer to Yasmin & Minto, 2007):

Children with low vision could re-enter mainstream education Interventions to create an enabling environment and motivate the teachers and

the families for the education of these children Provision of basic materials CBR workers can play an effective role in

rehabilitation of persons with low vision in general and children in particular

Stage-2: Essential Elements of a Low Vision ProgramFor tertiary, secondary, primary levels of low vision care and community rehabilitation, brainstorm with the class:

Objectives of a low vision program Personnel involved Roles and functions of personnel (including teachers) For example, case finding and referral, assessment, advocacy, provision of basic

needs, skills training, medical services, equipment provision, monitoring, eye health education, health promotion, early intervention and visual stimulation, employment, welfare

Equipment required Personnel training/ human resource requirements

Stage-3: Models of low vision service Participants to visit a field site (e.g. local community, city center etc) to determine the needs of the local community and assess how people with low vision could be identified, assessed and provided with intervention or training in the local area. Participants are to propose the implementation of a low vision model in their local area, identifying the roles of personnel, training, referral procedures and services provided to people with low vision.

Participants to make recommendations for a plan of action:

Short term Medium Term Long Term

REFERENCES Guidelines for setting up a low vision programme for children. http://www.cehjournal.org/article/guidelines-for-setting-up-a-low-vision-programme-for-children/

Establishing low vision services at secondary level. http://www.cehjournal.org/article/establishing-low-vision-services-at-secondary-level/

Low Vision Module for Ophthalmology Curriculum 48

Low vision and rehabilitation for older people. http://www.cehjournal.org/article/low-vision-and-rehabilitation-for-older-people-integrating-services-into-the-health-care-system/

Asia Pacific Regional Low Vision Workshop, Hong Kong 2001. http://apps.who.int/iris/bitstream/10665/67744/1/WHO_PBL_02.87.pdf

Yasmin, S. & Minto, H. (2007). Development of CBR Services for Children with Low Vision. The Educator, 20 (1), 34-41. http://icevi.org/pdf/educator_july_2007.pdf

Pizzimenti JJ. The Low Vision Rehabilitative Service Part One: Understanding Low Vision. The Internet Journal of Allied Health Sciences and Practice. July 2003. Volume 1, Number 2. http://ijahsp.nova.edu/articles/1vol2/pizzimenti-Low_Vision.pdf

Inclusion made easy in eye health programmes. Disability inclusive practices for strengthening comprehensive eye care. CBM, 2013. www.worldblindunion.org/English/resources/Documents/CBM%20Inclusion_Made_Easy_in_Eye_Health_Programs.pdf

Low Vision Module for Ophthalmology Curriculum 49

Session Plan 12

Research in Low Vision

Time : 3 hours

Outcome : At the end of the session participants will have a better understanding of the research needs for a low vision program

Objectives : Be aware of the need for baseline data for a low vision

program Be aware of research to determine whether the program is

achieving its objectivesSession Plan :

Stage Content Time Method MaterialStage-1 Baseline data for a low

vision program1 hr. Instruction and

group discussion

Stage-2 Research to determine whether the program is achieving its objectives

1 hr. Brainstorm and instruction

Stage-3 Need for an evidence base to inform interventions

1 hr. Instruction

Process:Stage-1: Baseline data for a low vision programParticipants learn to interpret situation analysis data and to establish a baseline of low vision statistics that would be used for a low vision program. Practical examples of use of baseline data at a hospital, district and national levels to be used for explaining importance of baselines. Examples of research options can include surveys, quantitative and qualitative data, clinical research etc.

Stage-2: Research to determine whether the program is achieving its objectivesParticipants should be aware that research can also be undertaken to determine the overall progress of a low vision program e.g. if there is a program being run at national level or even at district level. Use examples of action research, operational research to help participants understand research implications for programmes.

Stage-3: Need for an evidence base to inform interventions

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A sound evidence base is required to convince professionals and policy makers and in advocacy work. Explain to the participants how building an evidence base will help in maintaining the quality of services, determining the impact of interventions and the changes in quality of life of the affected individuals. Institutional collaboration for research can be achieved through clinical eye departments, special education departments, universities, field studies etc.

REFERENCES

Health Research Methodology - A Guide for Training in Research Methods. http://www.wpro.who.int/publications/docs/Health_research_edited.pdf

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