Low Vision Curriculum



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Assisting low vision students in rural Nepal
Low Vision

Curriculum

Ophthalmology

IAPB Low Vision Work Group

International Agency for the Prevention of Blindness

November 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)

Outline of Low Vision Module for Ophthalmology Curriculum





Session No.

Session Title

Duration



Introduction to the Course and Low Vision

2 hours



Global, National, and Local Policies

2 hours



Epidemiology

2 hours



Anatomy and Function of the Eye

2 hours



Causes and Implications of Visual Impairment and Prevention

3 hours



Psychosocial Impact of Low Vision

3 hours



Clinical Low Vision Assessment

38 hours



Understanding Optical and Non-optical Low Vision Devices

15 hours



Paediatric Low Vision Care

26 hours



Accessibility and Environmental Modification

3 hours



Models of Low Vision Care

6 hours



Research in Low Vision

3 hours

Total Length of Course - 105 hours (3 weeks)





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

Material

Stage-1

Introduction of participants

Discussion 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: Introduction

Introduction of course leader

Prepare 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 Objectives

Share 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 expectations

Ask the participants about their expectations of this course and write these on a board or flip chart for the entirety of the course.


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 simulation

Provide 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.
Examples

Viewing 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



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

Material

Stage-1

Global programmes and policies

Discussion

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 policies

Share 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

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 applications

Case Study

Present a case study outlining a national or local situation where a teacher has gained support for a student with vision impairment.


Practical

Select 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.



REFERENCES

Universal 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.

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/





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 impairment

Session Plan :

Stage

Content

Method

Material

Stage-1

Describe and compare the ICD-10 and ICF

Instruction, 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
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 blindness

Refer 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 impairment

Share 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 impairment

Explain 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.
Exercise

Use 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

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



REFERENCES

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. 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.pdf

http://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


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

Material

Stage-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 functioning

Explain 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

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 Defects

Explain 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





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 impairment

Session Plan :

Stage

Content

Method

Material

Stage-1

Common causes of visual impairment in children

Discussion, 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

  • 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

Conduct this session in the form of group work.


Group work

Divide 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


Cataracts

Signs 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 ARMD

Signs 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


Diabetes

Signs 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


Glaucoma

Signs and Symptoms include:



  • loss of retinal nerve fibre layer

  • optic nerve head changes – notching, increased cupping, pallor

  • narrow anterior angle – partial/complete occlusion

  • visual field changes

  • reduced contrast acuity

  • possible glare sensitivity – haloes if cornea affected


Retinitis Pigmentosa

Signs 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/dystrophies

Signs and Symptoms include:



  • corneal haze, opacities, thickening, ectasias

  • decreased visual acuity

  • haloes

  • increased glare sensitivity


Trachoma

Corneal and lid scarring

Signs 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
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 BLINDNESS

Blindness due to malnutrition and its symptoms

Through 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 points

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


Teaching point 1

Rich 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 recommended

Ask 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.
Handouts

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


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

Material

Stage-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 vision

Describe 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, 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 disorders

Discuss 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.
Class discussion

Ask 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 disorders

Instruct 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?

  • are their interactions appropriate?


Standardized assessments

Teacher 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 competence

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


Teaching social skills

Children 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

  • 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 study

Give 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


REFERENCES

UCL 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=NBD43720160

http://www.cera.org.au/wp-content/uploads/2013/12/CERA_FocusLowVision.pdf




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

Material

Stage-1

Undertake a detailed case history

2 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


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:


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

  • Functional colour vision assessment


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

Demonstrate 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 interventions

Discuss 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 provider

Discuss 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 Practice

Participants 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

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;17:3-5

WHO 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


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 devices

Session plan :

Stage

Content

Time

Method

Material

Stage-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 training

Range 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




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 magnification

Describe 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.



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 devices

Describe the advantages and disadvantages of Galilean and Keplerian telescopes, and hand-held, spectacle and stand magnifiers.



Stage-5: Prescribing low vision devices

Discuss 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

  • hand held magnifiers

  • stand magnifiers

  • Prescription Verification


Stage-6: Train the patient in the correct use of the optical low vision devices

Explain 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 work

Ask 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 study

Assign 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/


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

Material

Stage-1

Normal visual development


2 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

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 assessment

Use 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

  • 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 children

List the 7 visual skills included in a functional assessment


Visual functions

Ask 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 exercise

Participants 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 children

Discuss 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:

  • 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 skills

Discuss 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


Brainstorm

Brainstorm 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

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 counselling

Participants 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 Practice

Participants 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

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


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 vision

Session Plan :

Stage

Content

Method

Material

Stage-1

Independence and low vision

Practical 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 demonstration

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


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 skills

Describe how to obtain information about the person’s independence / safety


Interviewing

Obtain 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 tasks

Observe areas of difficulty and safety precautions.



Stage-3: Teaching and Learning concepts

Describe 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

  • 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 demonstration

In 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 work

In 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
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



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

Material

Stage-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) programmes

Describe 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

  • 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 Program

For 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 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



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 objectives

Session Plan :

Stage

Content

Time

Method

Material

Stage-1

Baseline data for a low vision program

1 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 program

Participants 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 objectives

Participants 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

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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