The Basics of Blindness and Visual Impairment

Presented ByMarcia Wazeter, M.Ed.

Karen Walsh-Emma, MS, CRC

Office of Vocational Rehabilitation

BUREAU OF BLINDNESS AND VISUAL

SERVICES August 29, 2019

Eye Disorders and Intellectual Disabilities

• There is evidence that individuals with intellectual disabilities have a higher incidence of vision disorders in relationship to the general population.

• There are specific groups of individuals within the intellectually disabled population who are at particular risk for developing certain eye disorders.

• The Downs Syndrome Society reports in an article titled, “Vision and Downs Syndrome”, that “eye disease is reported in over half of patients with Downs Syndrome”.

• Others at risk are those diagnosed with: certain syndromes related to genetic anomalies, individuals with Cerebral Palsy, Rubella syndrome, and Autism.

Downs Syndrome and Eye Disorders

Individuals with Downs Syndrome often experience:

• Refractive errors (the general term for conditions that affect the ability of the eye to focus), including:

hyperopia (or farsightedness, difficulty seeing objects close up)

myopia (nearsightedness, difficulty seeing objects at a distance)

astigmatism (when the curve of the cornea or clear outer layer of the eye is not symmetrical)

Downs Syndrome and Eye Disorders

• Nystagmus-involuntary eye movements most commonly caused by a neurological problem present at birth

• Strabismus-condition in which the eyes are not both directed toward the same point simultaneously; occurs when eye muscles are not working together

• Cataracts-clouding of the lens of the eye

• Deficits with accommodation-ability of the lens to change shape in order for the eye to focus

• Blepharitis-inflammation, scaling, reddening or crusting of the eyelid caused by bacteria and inflammation from congested oil glands at the base of each eyelash

• Nasolacrimal duct problems- blocked tear ducts

• Keratoconus-condition where the cornea stretches causing the tissue to thin and the center to bulge

Identifying Vision Loss in Individuals with Intellectual Disabilities

• Vision is key to communication, learning and movement. It co-ordinates other senses and helps people to understand what they have heard, touched, tasted or smelled. Vision plays a major role in our ability to make sense of the environment.

• The timely diagnosis and treatment of visual pathology is essential to optimizing development in children and enhancing the quality of life in adults.

• The challenge in identification of vision problems can be compounded by those individuals who may have communication deficits.

• This information should be considered in identifying vision problems:

Family history of eye disease

Individual’s medical history

Age

Identifying Vision Loss in Individuals with Intellectual Disabilities (continued)

Potential Indicators of Eye Disease/Vision Loss

Physical Changes Behaviors

Discharge or tearing Redness or crustingEye lid droopEye turningInvoluntary eye movementsCloudiness of the lensBulging eyeMisshapen iris (colored part of the eye)

Rubbing or poking eyesHolding head/complains of headachesSensitivity to lightDifficulty when going from bright light to darkness or dark to lightUnusual head tiltClosing or covering one eyeHolding materials close to the face to viewOver/under reachingNot recognizing other individualsBumping into/tripping over objectsOverstepping drop-offsHesitation, shuffling or sliding feet“Freezing” or reluctance to move in an unfamiliar location

Diagnostic and Preventative Measures

• A baseline comprehensive and thorough screening exam should be obtained from an Ophthalmologist (medical doctor specializing in the diagnosis and treatment of diseases of the eye).

• Follow-up examination and treatment as recommended by the Ophthalmologist.

• The American Academy of Pediatrics and the Down Syndrome Medical Interest Group recommend screening at birth and the first eye exam at 6 months of age. After that, even if the child is without symptoms, they should see an Ophthalmologist every 1-2 years or more frequently, if eye problems are detected, and as recommended.

Defining Vision Loss

20/20 20/70 Legal Blindness

Total Blindness

We can illustrate vision loss by the use of a continuum. With 20/20 vision or normal vision on one end with varying degrees of loss, advancing at the other end of the continuum to total blindness.

Defining Vision Loss

Normal sight is usually considered 20/20 visual acuity or close to that standard, with binocular vision and a visual field in both eyes of approximately 155° horizontally and 135 vertically.

An individual may be myopic or near-sighted, hyperopic or far-sighted, or have astigmatism present based on the curvature of the eye, and may require glasses or corrective lenses to see clearly.

These conditions are common and are referred to as refractive errors. They can in most cases be corrected with glasses and contact lenses, but if left uncorrected, can limit the individual’s ability to learn and impact quality of life.

Defining Vision Loss: Blindness

• Blindness: a complete darkness or absence of any vision.

• In reality, less than 15% of all the people defined as legally blind have no usable remaining vision.

• That means approximately 85%of those who are considered legally blind do possess some remaining vision.

Defining Vision Loss (Continued)

Low Vision/Partially Sighted/Visually Impaired-

Those persons who have a severe enough impairment in the structure and functioning of their eyes that even with the best possible correction the impairment still interferes with their ability to learn and perform activities of daily living.

Visual Acuity/Legal Blindness

Visual Acuity measures what individual can see in a clinical setting, from a stationary position, seated 20 feet from this chart.

The individual with a corrected visual acuity of 20/70 will be able to see lines 1 through 3. This is the standard of eligibility used for BBVS services.

Legal Blindness-the best corrected visual acuity in better eye does not exceed 20/200, or the maximum diameter of the visual field does not exceed 20 degrees

Person seated 20 feet from Snellen chart can see at the most the big “E” or visual field is no bigger than that occupied by a 12” dinner plate at a distance of 34”

Functional Vision

VISUAL How person uses remaining vision they

FUNCTIONING have in performance of daily living activities

VISUAL Ability to understand and meaningfully

PERCEPTION interpret what is seen

Depending on the type of eye pathology an individual has and the part or structure of the eye effected, functional vision will manifest itself in different ways

Functional Vision

Depending on the eye pathology, what an individual sees can be affected in one of three ways:

• Central field loss

• Peripheral field loss

• Opacities or blurred vision

Central Field Loss

Functional Vision Implications: Central Field Loss

Eye pathologies causing central field loss:

• Stargardt's Disease

• Aged Related Macular Degeneration

• Macular Hypoplasia (associated with albinism)

• Optic nerve atrophy

• Diseases of the Macula-area in the center of the retina

Two types of photo receptor cells on retina: cones and rods

Cones: responsible for detailed, near vision and color discrimination

Higher density of distribution in macula

Visual Functioning Implications:

• Loss of central vision; blind spot called scotoma

• Will have difficulty with detailed vision for near tasks such as seeing features of a person's face, or print

• May have difficulty in identifying certain colors

• May see you better if they tilt head to side

• Will have useful vision to maintain orientation in environment

• Deficits with dark adaptation

Peripheral Field Loss

Functional Vision Implications:Peripheral Field Loss

Eye pathology causing peripheral field loss:

• Retinitis Pigmentosa

• Glaucoma

• Optic Nerve Hypoplasia (underdeveloped optic nerve)

• Diseases affecting rod cells

• Rod cells- alert us to motion in our periphery; not detail vision; needed to function in low light environments; more heavily distributed in periphery of retina

Visual Functioning Implications:

• Described as “tunnel vision”

• May have decreased night vision, or difficulty in seeing in low light environments

• May have difficulty with maintaining orientation in unfamiliar places

• May see more of an object by moving further away rather than closer to it

• May have difficulty with detecting drop-offs or changes underfoot

• May have impaired depth perception

Additional Types of Field Loss: Multiple Scotomas, Ring Scotomas

Loss of Half the Field of View-Hemianopsia

Opacities or Blurred Vision

Functional Vision Implications: Opacities and Blurred Vision

Eye pathologies causing blurred vision:

Cataracts, Nystagmus, Optic Nerve Hypoplasia, Degenerative Progressive High Myopia, Keratoconus

• Caused by opacities in any of structures of eye;

• Lens of the eye may have opacities (cataracts) or cornea (clear outer layer), may have scars/ abrasions which cause this; in the interior chamber of the eye, the vitreous, which is a clear gelatinous substance which keeps the shape of the eye, may also have opacities which affect the clarity of sight.

Visual Functioning Implications:

• Result is distortions and blurry vision and

• If cataracts are not surgically removed, vision loss cannot be corrected by glasses/contact lenses

• Loss of detail vision

• Sensitivity to bright light

• Will retain useful functional vision for identifying objects/ landmarks for orientation

• May have reduced depth perception

Enhancing Functional Vision

Regardless of the eye pathology and structural part of the eye effected, there are strategies we can use to optimize the use of remaining functional vision:

1. Low Vision Aids

2. Changing or Modifying The Environment

Low Vision Aids

• These are optical and non-optical aids prescribed by a Doctor of Optometry specializing in low vision.

• Aids are task specific and may include high powered glasses, magnifiers, telescopes, electronic magnification devices, special lighting and sun lenses.

Low Vision Aids

Optimizing Functional Vision: Changing and Modifying the Environment

Simple changes in the environment can enhance a person’s ability to complete a specific task.

There are five variables to consider when creating an environment that optimizes the individual’s use of their vision:

1. Illumination-

a. Type of light source

b. Amount of Light

c. Position of light

d. Glare

2. Color and Contrast

3. Size and Distance

4. Organization

5. Time

Illumination: 1. a. Type of Light Source

Consider full spectrum bulbs, or natural light bulbs. These are similarto natural sunlight. Advantages:• Produce high brightness with even cool illumination• Reduce eye strain• Colors appear balanced and true to life

Illumination 1. b. Amount of Lightand c. Position of Light

Changing the amount or position of light:

• You may think that more or brighter light is always better; with certain eye conditions more light can cause glare that interferes with what the individual can see.

• Try bringing the light source closer to the task or work site for maximum illumination rather than relying solely on diffuse overhead light.

• Moving a 60 watt lamp ½ the distance closer doubles the intensity of the light.

• Some tasks such as craft work may require a light source shining directly on the persons hands.

Illumination: 1. d. Glare

• Glare is light scatter.

• It can cause physical discomfort and loss of clarity of vision.

• Caused by light reflected off of glossy paper, ceilings, walls, objects, floors, or anything with a glossy finish such as paint, wax, polished or lacquered surfaces, metals, and some bright colors.

• Modifications for reducing glare:

Wearing sun lenses, hats with brims,

and visors can reduce glare.

Optimizing Functional Vision: 2. Color and Contrast

• Contrast is the visibility of a target against it’s background.

• Adding contrast enhances visibility.

• Contrasting colors, such as black and white, help objects or shapes to stand out (e.g. use a dark placemat under a light –colored plate; or a dark colored mat or tray under a work activity).

• Complexity of the background surface can be confusing; solid colors work best; patterns, stripes or checks can be confusing

Examples of How Contrast Can Be Used to Enhance Vision

The use of a black colored switch plate enhances the contrast of the white light switch

The use of black tape on the edge of the white stair tread enhances the visibility of the edge of each stair.

Illustrations of Changing and Modifying the Environment-3. Size and Distance

• Use of bold line paper and bold line pen and larger print. In general, enlarging the image on the retina enables us to see it better.

• Moving closer to something makes it appear bigger and sometimes easier to see.

• When using printed materials font size and style should be considered. Use “clean” fonts such as Tahoma, Arial, or

Verdana. Large print

(18pt.) is more visible.

Optimizing Functional Vision: 4. and 5. Organization/Time

• Analyze a task, break it down into its sequential components

• Organizing the task in sequence makes it easier to perform

• Use trays, bins, or containers with sides helps to contain items and keep them within arms length

• Reduce “Visual Clutter”

• Incorporate the use of color, contrast, and illumination

• Time-how long does it take to do the task

Use of Trays to Organize Tasks

Trays contain items and keep them within arms length

They help in sequencing the task to be completed.

Modifying the Environment: OrganizationReduce Visual Clutter

Visual Clutter causes over stimulation of our visual sense impeding our ability to focus and complete tasks.

The two pictures below illustrate two different classrooms. Which one provides the more focused learning environment?

Modifying the Environment: OrganizationReduce Visual Clutter

Visual clutter impairs the individual’s ability to efficiently complete activities

How can these environments be modified to enhance functional vision

Tips for Assisting the Individual Who is Visually Impaired

• Identify yourself; don’t make it a guessing game by asking, “Do you know me?” or “Remember me?” Although your voice might be familiar, identifying you may be difficult in a new location with distracting background noises.

• Give directions according to the way the individual is facing; e.g. to your left, right, in front of you, etc., pointing to something or saying “It’s over there.” won’t work.

• Using the face of a clock as a reference system may be useful; e.g. the salt and pepper is in front of you at 11:00 on the table.

• If you need to provide instruction in a physical activity, use the “hand under hand” method.

• Always ask permission first before contacting the person.

• When you are in the work space of a person, order is important; if you need to pick something up, put it back where it was, if you need to leave something with them, tell them where.

• Don’t leave doors or cabinets ajar; push chairs back in.

Overview: Agency Organization

Commonwealth of Pennsylvania (CWOPA)

Department of Labor and Industry (L&I)

Office of Vocational Rehabilitation (OVR)

Bureau of Vocational Rehabilitation Services

(BVRS)

15 District Offices

Bureau of Blindness and Visual Services

(BBVS)

6 District Offices

(Located with BVRS)

Hiram G. Andrews Center (HGAC)

Johnstown, PA

Bureau of Central Operations

Harrisburg, PA

OVR District Offices (Map)

Services Available Through BBVS

• BBVS provides rehabilitation services through the following programs:

• Vocational Rehabilitation Program (VR)

• Special Services for Children's Program

• Specialized Services for Adults Program

• Independent Living Older Blind Program (ILOB)

• Vision Rehabilitation Therapy

• Orientation and Mobility

* VRT and OM Services are available in all four programs

Mission of BBVS

The mission of BBVS is to assist Pennsylvanians who are blind or visually

impaired to work and maintain independent lives.

BBVS provides services to Pennsylvanians of all ages experiencing vision loss

Eligibility Requirements

All programs have eligibility requirements. In order for an individual to receive any services in either program, they must meet one of these requirements.

Eligibility Requirements Are:

• A corrected visual acuity of 20/70 or greater loss in the better eye

• A visual field loss of 20 degrees or greater

• A diagnosis of a progressive sight threatening disease

• A significant functional limitation from vision loss (threatens health & safety)

Who can refer to BBVS?

• Anyone!

• Self referral

• Parents/guardians

• Doctors

• Education Professionals

• Employers

• County/government case workers

• Provides instruction in adaptive equipment and techniques to ensurean individual can safely and efficiently perform their daily living activities at home, on the job and in the community.

• A comprehensive evaluation is completed by a trained teacher and a plan is developed with the customer

Vision Rehabilitation Therapy

Orientation and Mobility Instruction (O&M)

O&M training teaches individuals how to travel independently and safely within their homes, workplaces and the community.A BBVS professional instructor provides individualized training. After evaluation is completed by the instructor, an instructional services plan is developed with customer to meet their specific needs.

Specialized Services Program (SS)

Specialized Services Programs assists individuals to become more self-sufficient and independent in their homes and communities without a goal of work.

Two components to this program:• SS-Children: serves children from birth to age

21 years old• SS-Adult: serves adults from 18 to 54 years

of age who are not candidates for VR Program.

Services Available In the SS-C Program

• Adaptive equipment

• Advocacy for educational services

• Low Vision Evaluations

• Vision Rehabilitation Therapy

• Counseling and Guidance

• Community Orientation and Mobility instruction

• Access to Children’s summer programs

• Transition Services

Services Available In the SS-Adult Program

In order to be eligible for the SS-A program the individual must provide a letter from their Doctor stating that they are unable to pursue employment.

Services can include:

• Vision Rehabilitation Therapy

• Orientation and Mobility instruction

• Counseling and Guidance

• Information and Referral

Independent Living Older Blind Program (ILOB) Age 55+

Purpose of program: to provide rehabilitation services to enable individuals who are not working to regain or maintain maximum independence in their homes and communities.

• After receiving a referral, a BBVS Social Worker contacts the customer, establishes eligibility, assesses their needs and develops a Service Plan with them which identifies the services to be provided.

ILOB Continued

Services can include

▪Information and Referral

▪Counseling and Guidance

▪Diagnostic Services

•Low Vision Services

•Vision Rehabilitation Therapy

•Orientation and Mobility Instruction

Services to Residents of Assisted Living, Personal Care Homes and Group Homes

• Comprehensive BBVS services can be provided to those residents who are blind or experiencing vision loss to maximize their independence.

• It should be noted that comprehensive services can be provided to a resident of a nursing home if the facility is providing temporary rehabilitative services prior to the resident being discharged into a community setting.

Vocational Rehabilitation Program

• The goal of the Vocational Rehabilitation Program is to assist an individual in gaining or maintaining employment

• A Vocational Rehabilitation Counselor (VRC) meets with the customer’s individually to provide vocational counseling and guidance.

• Through vocational counseling and guidance, the VRC can assist the customer with identifying their interests and related potential job goals.

• After a job goal is identified by the customer and VRC, the VRC then identifies the different services that will be needed for the customer to be successful in achieving their goal.

• The VRC will then coordinate the needed services and will continue to meet with the customer regularly until they have achieved their employment goal.

Services Available in VR Program

• Some of these services include:1. Vocational Counseling and Guidance

2. Diagnostic Evaluations

3. Counseling on Post-Secondary Training Opportunities

4. Work site evaluations and accommodations

5. Information and Referral

6. Low Vision Evaluation

7. Orientation and Mobility Instruction

8. Vision Rehabilitation Therapy

9. Assistive Technology Evaluation and Training

VR Services for Transition Age

• Additional VR services for Transition age 14 –21 years old:

1. Attend IEP Meetings and collaborate with the students Educational Team

2. Funding for Summer Transition Programs for youth

3. Work-Based Learning Experiences

4. Job Shadowing

5. Instruction in Self-Advocacy

Attached Documents

• Blindness and Visual Services Brochure

• Referral Form

• Case Study

• Environmental Factors Overview

QUESTIONS????

kwalshemma@pa.gov