Clinical Assessment

Clinical assessment of a child with a suspected visual impairment always consists of a very detailed clinical evaluation by a pediatric ophthalmologist, with ancillary testing such as elec-trophysiology and ultrasonography when appropriate.

The measurement of visual function should be done with targets appropriately sized for both the age of the child and the level of vision suspected, moving the child closer to the testing targets both for near and for distance. The visual requirements for each child should also be assessed because the various therapeutic modalities are age and task appropriate.

The importance of early diagnosis of the child's visual disability cannot be overstated. The earlier the disability is diagnosed, the earlier treatment intervention can begin. Early treatment may produce a better outcome by allowing a stepwise approach to planning the use of aids, both visual and nonvisual, for the short and long term. For those children with an inherited process, early diagnosis makes it possible to provide expedient and appropriate counseling for the families involved. Innumerable low-vision aids of various types are available for enhancing both distance and near vision. The type of device that is appropriate will change as the child becomes older and their visual requirements change and increase. The low-vision devices that are useful for children bear no relationship to those used by most adults.

Because reading is the child's access to learning, a visual aid that makes this task possible is one of the most important devices for these children. The phakic school-age child has an enormous range of accommodation. These children find that reading can be a simple matter of bringing the print close enough to their faces to magnify the image. A fixed-stand low-power magnifier (Fig. 3-1) to enhance these images is probably the most useful low-vision aid for these young children. When the magnifier is placed directly on the page, its fixed focus keeps the

FIGURE 3-1. Low-power stand magnifier.

print clear at all times and lets the child run the device along the page. Even very young children learn to manipulate these devices, and they have been found more useful than many of the more technically sophisticated and costly aids available today.

The aphakic child has different needs. However, glasses or contact lenses with reading additions and the same fixed-focus stand magnifiers can be of great help to these children. The other aid that is exciting to young children with decreased vision is a monocular telescope (Fig. 3-2). It takes a little longer to master this device, but, once the child learns to use it, it opens up a whole new world. The small size of these telescopes makes

FIGURE 3-2. Monocular telescope.

them highly portable. A child can use this device anywhere and can share it with normally sighted friends, thus erasing the stigma associated with the use of a low-vision aid.

The social and academic success of a child with a visual disability depends largely on the expectations of the family and the understanding of the teachers and the school administrators; the focus should not be on the limitations that the visual disability creates but on the heights that these children can achieve. Teachers, classroom aides, and playground supervisors should be encouraged to treat these children no differently than they treat the others in the class. However, staff need to remain aware of the children's special needs and address these needs appropriately. Where these children are seated in the classroom, the distance between them and the blackboard, the size of the letters on the board, the color of the chalk used, and the angle of the glare from the windows are all as important as any optical or nonoptical visual aid being used.

Furnishing the family and the teachers with a detailed report of the size of print that the child can see for both near and distance work is most helpful. When there are problems with contrast on homework assignments (some copies are so poor that enlarging the print makes them impossible to read), a different type of copy for these children is important. For some children, a closed-circuit television (Fig. 3-3) facilitates reading when increased magnification is required, as the magnifying glass of increased power decreases the field of view. These devices are expensive, but an older child will find them very useful. Most schools with resource centers make them available, as do public libraries.

With increased awareness of and attention to those things that make schoolwork easier to handle, most children will adapt well to their less-than-normal vision, which will do more for their self-confidence than any expensive magnifier or complicated reading machine can possibly do. However, as the child becomes older and reading demands increase, these more sophisticated instruments will become appropriate and should be added to the armamentarium. Newer instruments include closed-circuit television cameras that can be used with computers and portable handheld devices that scan curved surfaces and have large-print readouts on the handles. There are many headborne devices, used for both distance and near reading, that are appropriate for adults who need them to maintain a career. These newer devices are not really necessary in the elementary

FIGURE 3-3. Closed-circuit television.

and high school classroom, but they may be more useful to college students who sit in large classrooms and who may find it necessary to copy notes from distant blackboards or screens.

There are some points to remember when evaluating a child for visual aids:

Amblyopia can occur in the presence of another visual abnormality and should be treated vigorously. The better the vision, the less magnifying power needed.

• It is acceptable for moderate to high myopes to remove their glasses for near work.

• The accommodative range will decrease as these children get older, and a change in vision does not necessarily mean a worsening of a previously stable condition.

• There is no limit to the amount of reading aid that can be prescribed so long as this aid improves near vision.

• Only those visual aids that are needed for the currently performed tasks should be prescribed. For the young child, this will probably mean a stand magnifier for near tasks and a telescope for distance tasks.

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