Initial observations of Visual Functioning

The appearance of the eyes and surrounding structures Head Posture Responses to lighting Where objects are held to be examined

Initial observations of Visual Functioning

The range of distances and types of visual stimuli that

elicit visual responses

The general level of behavioral state and motivational

status
The general level of cognitive and motoric abilities The status of other sensory modalities

Preparation of the client

The assessment should be carried out at a time most

advantageous for the child.

If the time is not conducive to his needs, a second

observation may be warrented.

Identification of sleep and behaviour state cycles may

alleviate the need for a second observation

Readiness
The background lighting should be dimmed and the

use of very bright lights should be avoided.

Severe physical limitation The child in supine

position head raised @30 from supporting surface.

Stimuli to be introduced slowly, calmly and for a

short duration in appropriate intervals of time

Readiness
Be aware of
Your touch

Pacing of task presentation

Quality of voice when conducting the assessment

It is necessary to fluctuate between these ranges according to the student behaviour.

Behavior State
Re-assessment of state and range of behaviors

periodically as well as at the conclusion of the assessment

To note whether interaction altered the students

behavior state To determine optimal attending, endurance, and processing time To discern the factors responsible for eliciting optimal attending behavior

Other Considerations:
Ensuring Postural Stability Medications Seizure Disorder

Setting: Illumination
Adjustable lighting Minimal background lighting : Pupillary reactions,

alignment, binocular function, fixation and pursuit behaviour

Increased illumination: Contrast between the

foreground and background to highlight the visual stimuli

Setting:
Visual attentiveness decreases and visual distractibility

increases in an environment which is influenced by the other activities. Noise and ongoing activity will be important considerations when designing intervention strategies to facilitate functional visual behaviors. Material to be accessible, quickly located when the student is active. Several toys of different sizes placed randomly within the proximity of the student.

EVALUATION OF VISION

Deiva J
Frontline Eye Hospitals, Chennai

Evaluation of Vision
Process of observing of visual abilities and related components of visual behavior in children and adults who are traditionally perceived as Difficult to test.

Assessment Components
Oculomotor Skills
Visual Acuity Visual Field Ecological Observation Visual Perceptual skills

Oculomotor skills: Development of Fixation Abilities

Age
Birth 1 month 2 months 3 months 6 months

Fixation Level
Crude Monocular Monocular, alternates Monocular, early binocular

Partial binocular
Binocular established

Fixation Process:
Diffuse:

Fleeting fixation

Fixation: Glance briefly at an object presented Stuckness: Eyes remain fixed on an object even as he

attempts to turn his head away

Biphasic: To fix his attention on a specific stimulus and

then easily shift his attention ot other objects.

Observation of fixation:
Stimuli: Several sizes of quiet stimuli are preferable.
Toys with sparkling or oscillating lights Small, miniature musical toys with flashing lights Mechanical toys and sparklers Hand-held computer games with flash lights

Translucent finger puppets illuminated by penlights

Reflective postcards

Fixation is intact when:

The childs activity level quiets or diminishes Other facial features may relax Both eyes become stationary for three to four seconds or longer

and align with the stimulus

of the cornea

The image of the fixation target may be apparent on the surface Increased intensity of nystagmus upon efforts to fixate and a

head tilt or rotation may also manifest as the child attempts to locate the object

Assessment strategy: Fixation

Distance between 12 and 14 inches

The stimulus s/d be moved forward or backward

The stimulus s/d be positioned at or slightly below eye

level and slightly to the left or right of the midline.

Observations s/d include:

The smallest size of stimulus which elicits fixation
The quality of stimulus which elicits fixation The distance and positions in which fixation is elicited The speed and efficiency with which fixation is elicited and

shifted

Whether fixation is monocular or binocular The Stability of fixation

Recording Observations
Fixation may be considered achieved when the

direction of the pupils is aligned with the fixation target.

Oculomotor skills: Pursuit

New Borns: 30 to 60 of horizontal tracking. New

borns are capable of brief periods of smooth tracking when it is elicited by peripheral visual stimuli.
One month olds: Stimulus must be introduced into

the peripheral field to catch the infants attention and gaze may drift away if the motion is stopped when the stimulus moves into the foveal area.

Oculomotor skills: Pursuit

Two month olds: The child can attend to and follow

the stimulus when it is introduced in the central visual field. The child demonstrates social smile and emergence of visual memory for familiar events.
Three month olds: Develops the ability to move eyes

faster than the stimulus. Sequential scanning patterns also become evident between 3 and 6 months old.

Oculomotor skills: Pursuit

In older children: Gilligan et al(1981) in a study of 489

students from 3 11 years of age ocular pursuit skills continued to develop through seven years of age.

Until the age of six, the children showed a strong

tendency to incorporate head movements during tracking.

Pursuit: Stimuli
Maximum size of 3 4 inches. Preferably 1 2 inches. Mechanical sparklers and seasonal mechanical spinning toys Penlight covered with translucent finger puppets or pencil

toppers

Character flashlights Coloured and illuminated light sources, those with facial

features

Shiny or reflective surfaces

Developmental Progression of Pursuit Behaviors and Eliciting stimuli

Age & stimulus
Birth Brightly colored, moving,

Visual field / pursuit path

Central / Horizontal solid Central / horizontal 30 Central / Horizontal 20

2-3 form or face 1 month Brightly colored, object or pattern, 3-4, Oscillated/wiggled 2 months - Brightly colored object, 2-3 3 -4 months Brightly colored object, 2-3 6 months Brightly colored object, 1-2 8 12 months object which offers good contrast, to

nasally Central / horizontal / Vertical/diagnolly Physiological H pattern Central / horizontally at 10 feet

Recording Observations:
The point at which the eyes initially establish gaze

with the stimulus

Whether the eyes move together or separately The extent and quality of range of motion Whether both eyes move together throughout the full

range

Recording observations:Pursuit
The ease of regaining fixation, if lost
Whether the movement is jerky or smooth Any deviation of one or both eyes at any point The size and quality of the stimulus and the distance

which elicited optimal pursuit behaviors

Pursuit Diagrams:
Right to left and vertical pursuit patterns
Left to right and vertical pursuit patterns

The physiological H patterns

Mark X at any point along either the horizontal or vertical axis at which the student lost gaze or an eye deviated. If one eye deviates from alignment, beside the X, describe the direction of deviation.

Visual Acuity
Snellen equivalents to the Rolling Balls Test at 10 feet Sheridians Graded Balls(1973, P.31) Size Acuity 3.5 Inches 20/200 2 inches 20/100 1 inches 20/80 1 inch 20/60 inch 20/40 inch 20/30 3/8 inch 20/20

Visual acuity estimates based on common objects and toys:

Procedure size

Distance

Acuity

Sheridians Miniature Objects Knife Spoon Fork 3.25 inches 3.25 inches 3.25 inches 10 feet ,, ,, ,, ,, 20/30 ,, ,, 20/20 ,,

Knife Spoon Fork

2 inches 2 inches 2 inches

Visual Acuity estimates based on Common objects and toys:

Procedure
Jose (1983, P.89) Gross sizes (Observable)

size
3/8 inch inch 1 inch 1 inches 2 inches 2 inches 3 inches

Distance
20 feet

Acuity
20/20 20/30 20/60 20/80 20/120 20/160 20/200

Visual Acuity estimates based on Common objects and toys:

Procedure Size
4 inches 5 inches 6 inches 7 1/8 inches 10 inches 12 inches

Distance
20 feet

Acuity
20/225 20/300 20/350 20/400 20/600 20/700

Near Point Minimal Observable Acuity : Stimuli

The black felt backing on the visual display
Measuring tape and one half of the transparent grid card with cm ruler Template card for measuring object size Occluder Containers of cake decorations varying in size from @ 1 5

mm Candies, cereals, brightly colored items such as beads and character erasers from 1 5 cm (1/2 inch to 2 inches) Character pen, or flash lights

Recording observations:
Document the quality of each stimulus perceived by

the student, its approximate size, and the distance at which the student localized the object.
Note the abnormal or compensatory gaze behaviors

Near Visual acuity Assmt:

Attention to patterns and pictures

Picture Complexity and Contrast

Far Point Minimal Observable Acuity

Retrieval of Light at Far point
Stimuli:

Flashlights with colored filters or with character stencils that are placed over the face of the flash light and project an image Measuring strip An area which can be darkened and through which only minimal light can filter

Far Point Minimal Observable Acuity

Retrieval of objects at Far Point:
Stimuli: A variety of toys or other items which are readily mobile (roll easily), toys which can be easily propelled. Sizes should vary from inch to 5 inches
A strip of black cloth to provide contrast if necessary
Occluder

Far Point Minimal Observable Acuity

Object Detection: Stimuli:
A variety of objects of different sizes that are to the students needs

and interests. Objects S/d range from 1 6 - 9 inches.

acceptable)

Several duplicate items of each size object ( color differences are

A 10 foot measuring strip, marked at intervals of 30 inches, three,

five and seven feet

Occluder

Far Point Minimal Observable Acuity

Detection of Pictures at Far Point
Stimuli: Simple picture books should be purchased in duplicate. Each page should contain only one object and pictures as well as photographs and line drawing should be available. Sizes @ 5x5, 7x7 inches Template card for measuring picture sizes Measuring tape Occluder

Far Point Minimal Observable Acuity

Acuity / Estimation Card:
Stimuli: Acuity card Duplicate sets of stickers that are very similar in configuration, size, and color (1/2 inch to 1 inch) Measuring strip Occluder

Far Point Minimal Observable Acuity

Detection of colors at Far Point:
Stimuli: Duplicates of primary-colored items approximating 1 inch in size Matching colored paper or plastic plates or disks @ 6 inches or larger in circumference Measuring strip Occluder (If the student cannot match reliably, this strategy in not appropriate)

Visual Field:
When there is a peripheral field loss,
awareness of obstacles motivation to explore the surroundings

ability to function efficiently both visually or adaptively

may be significantly diminished.

Visual Field:
Stimuli: Various sizes and colors balls, linking stars, slinkies 8 10 inches extensions topped with attachments such as character finger puppets, streamers etc Toys with sharp angles suspended from a 10 12 inch string Sources of illumination such as character penlights Several brightly colored small wind-up toys with unpredictable movement patterns

Visual field: Observations

Eyes orient /localise the peripheral stimuli in Lateral

fields, Upper fields, lower fields.

Gaze stuck on one of two stimuli Shifts gaze to competing target

Systematic Documentation of Visual Fields:

Shifts Clock Position - Peripheral Fields:
Tw0 stimuli are needed, equal in interest level or one slightly

more appealing than the other.

The image of a circular clock (on a transparent grid), @ 24

inches horizontal axis, 18 inches vertical axis shd be used to localise different quadrants of the field.
Attract with less appealing stimulus near the midline, 12 14

inches from the face. Move the second more motivating stimulus around the clock positions.

Systematic Documentation of Visual Fields:

Activate the first stimulus , if it aligns with the first

stimulus, activate the second stimulus- 120 clock on the clock face.

As the second stimulus moves around the clock positions,

attract attention to the first stimulus and then to the second one, moving thro the clock positions. direction.

Move the stimulus in clockwise and anti-clockwise A single stimulus presented at random positions if the gaze

shift between two stimuli is difficult.

Systematic Documentation of Visual Fields:

Recording Observations:

Indicate directly on the clock grid the positions of gaze shift. If gaze is not achieved in a position, do not mark in that quadrant. * An attractive stimulus should be presented at the midline to assess the central field

Ecological Observation
Orientation & Mobility: Movement into areas familiar & Unfamiliar Movement across different surface textures and heights and through areas of various widths Movement toward obstacle such as a toy basket, furniture, planters, low lying shelves, etc Movement into different illumination, contrasts Movement in quite areas and in areas in which there is some back ground noise

Ecological Observation:
Functional Application: What the student appears to see How vision is used in different context The distance at which environmental stimuli is noticed The smallest item noticed The conditions surrounding the visual context Visual and Postural compensations Whether optical devices are used effectively and appear appropriate

Ecological Observation
Functional application of Optical devices
Visual Reaction to people Visual behavior during play Visual behavior during mealtime Behaviors suggesting vision Mannerism or stimulatory behaviors suggest the

presence of vision

Visual Perceptual Skills:

Perceptual skill
Figure ground discrimination Visual closure Visual association

Task
Localisation of pacifier

among toys Recognition of shoe extending from under the bed Opens mouth at approach of spoon
Dialing phone number ,

Figure ground/depth/

iscrimination

localisation of key ad insertion in lock

Visual perceptual skill

Perceptual skill
Visual motor

Task
Bowling, throwing ball into

integration/depth
Size / form description

hoop, placing coins in a bank

Selection of appropriate

shape and size of lid to place on containers

Results: Vision Evaluation

Optical Devices Non-Optical Devices Illumination Contrast Seating posture Environmental modifications Learning Media Large print, Braille, audio tapes, softwares or combinations Learning Mode: Special school, integrated school or inclusive education mode

Ref:
ISAVE Individualised Systemmatic Assessment of

Visual Efficiency
Articles by Dr. LEA H

Thank you