Low Vision Devices and Children with Visual Impairments

Cynthia Bachofer
Providing Access to the Visual Environment (PAVE)
Vanderbilt University, 691 Preston Building, Nashville, TN 37232-6838, USA
cynthia.bachofer@vanderbilt.edu

Karina was a kindergartener who kept me awake at night. Sometimes I found myself trying
to fall asleep and thinking about what activity I could come up with to keep her attention
and entice her to use her vision. Karina was an intelligent, curious five year old who had
retinitis pigmentosa, an estimated acuity of 20/400 and a prescribed 4x telescope.
Occasionally she was able to identify letters on a large sign in front of her school. Seeing
these letters was not important to her. I was struggling to convince her that she could gain
helpful information by using her eyes. Karina taught me valuable lessons about children and
use of optical devices. The following paragraphs focus on three primary points in
habilitation of children with low vision and the use of devices from my perspective as a
teacher of students with visual impairments (TVI). The three principles include: 1. Work
with a team of people to provide care; 2. Listen to the student’s messages and goals; and 3.
Integrate device use throughout daily routines. Giving attention to psychosocial issues is at
the center of each principle.

Introduction
Children who are born with a visual impairment have a very different response to their
condition than to adults who acquire a visual impairment later in life. Unlike adult
rehabilitation, learning to function with a visual impairment and development of the child
are taking place at the same time. Secondly, these adults have led a life of visual
independence, while children with visual impairment have no memory of typical vision use.
Rehabilitation is taking a person to a primary level of functioning. Habilitation is the process
of helping children to build a belief in the value of using the vision they have to complete
tasks and to acquire skills for maximizing their potential to use vision. These needs are
unique to the learning process.

Device use at a young age, even for children as young as three, is primarily about curiosity
and exploration. Learning materials are larger and lessons typically happen within arm’s
length where the item can be brought close to the child’s eyes and examined through both
vision and touch. Building early awareness of the tool that “helps me to see more by
making things bigger” is a critical lesson. By using a magnifier, the student can share in the
vivid descriptions of common items such as an insect held in a shallow dish, the color and
texture variations of the surface of many fruits and vegetables or the dials and gauges with
moving parts that indicate equipment is functioning. Using a telescope, the student can
mimic, along with classmates, the flowing movements of a brightly colored fish seen
through the side of a large glass container. From a safe distance, the student can study and
copy the facial expressions of animals. Taking turns with classmates, the student can
practice tracking skills by watching their movement in the distance and describing changes
in body position. Using devices in activities that take place within the classroom and

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beyond, the student is able to fully participate with peers and sometimes even add
additional details missed by impatient eyes.

Two influences have shaped my current understanding of this specialization. Having grown
up with low vision and having managed responsibilities in the competitive workplace, I am
aware of the necessity of visual efficiency and visual independence. As a teacher with the
project providing Access to the Visual Environment (PAVE) at the Vanderbilt Eye Institute,
Vanderbilt University Medical Center, I have benefitted from exposure to a multidisciplinary
model of comprehensive low vision care. This model supports follow-up instruction in the
use of optical devices for students in their education and community setting. To be
successful, professionals in low vision care must listen to the student as well as the multiple
voices that impact the student’s world.

What is success for my students? Success takes different shapes based on a student’s needs
and abilities. Cassidy, a 16 year old who uses eccentric fixation for near viewing, had
chosen to rarely read menus in a restaurant. Success is her willingness to explain to a
restaurant employee who questions how she performs her task, “I am visually impaired and
this is the best way for me to read.” Success for Carlos, a three year old, is willingness to
use wide head turns to scan the floor for a wanted toy rather than crying for help. Success
for Vincent, a 12 year old, is willingness to grab a telescope before heading to the school
assembly and sitting with friends in the gymnasium bleachers. These are examples of
personal confidence and visual independence from students who are finding their own style
of living with low vision.

Principles of Low Vision Care

Multidisciplinary Team
Low vision is personal, emotional and unpredictable. This disability is poorly understood by
the general public, including school systems, and frequently a family feels left on its own to
figure out how to raise a child whose vision is somewhere between blindness and typical
sight.

Low vision services entail problem solving. Problem solving is best accomplished with a
team approach. The members of a low vision team must understand the subtle and direct
influences of various professionals’ perspectives on the student. A parent or guardian
knows the child best while a doctor understands the effects of a condition and educators
can describe the impact of visual factors on learning. The meeting to review Karina’s report
from the low vision specialist established communication among her parents, classroom
teacher, school principal, TVI, orientation and mobility specialist and PAVE teacher. This
allowed us to determine common messages of visual efficiency for Karina. In response to
Karina’s questions such as “What is my teacher holding?” during classroom demonstration
time or “What is that noise?” with construction equipment operating in the neighborhood,
adults around her said, “Let’s grab your telescope and find out.”

A collaborative approach is demanding of time initially but when members are able to
coordinate their roles, habilitation for the child with low vision is most effective. Prompting
from a parent in an unhurried moment for the child to read nutrition information on a food
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package using a magnifier or find a pedestrian’s bright colored outfit through the telescope
is a valuable lesson. Teachers can be supportive by helping parents to identify such
occasions in children’s daily routine.

Student Messages and Goals

Low vision defies explanation from a student’s developing vocabulary. Learning first to
understand how one sees differently than peers and then finding the words to explain the
condition are two unclear tasks. Learning to voice one’s own goals for using vision is a
further step in this continuum. Malcolm, a nine year old learning to use a 4x telescope,
fiercely stated, “I want to write my own spelling words from the white board.” Previously,
other students or the teacher had provided written lists to him. Hence had given his
declaration of independence.

Low vision devices are not a magic solution resulting in typical vision. Comments from
students give honest feedback of their frustrations. “But what if I can’t find the words on
the map during class tomorrow?” or “Don’t make me use that thing. I don’t want a
telescope!” Willingness by the teacher to explore these versions of “I don’t want to be a kid
with low vision” can be very instructive. For Kadeesha, this meant “It’s too hard to use my
vision when people are staring.” For Tobias this meant, “I can use the thing but I won’t take
the chance of being made fun of in front of my friends.” For Karina it meant “Your tool is
not giving me enough information that is valuable to make the struggle of using my
telescope worth it.” All of these messages are valid and are examples of growth toward
independence. Unfortunately, I may hear these messages in the closing moments of a
lesson. “Sometimes,” I tell a student, “my job is not to help you see, but to help you see
choices.”

Case Study: Bridgett

Bridgett wanted to see the batter at a baseball game and her sister on horseback at the
horse show. She was a 20 year old student with optic atrophy secondary to severe
cerebral palsy. She used a wheelchair and had involuntary, spastic reflexes and a
cognitive delay. A team of 12 people including family members, teachers and support
services staff came together to review her low vision report. Bridgett’s persistence in
wanting to see more pushed me to listen and to attempt an unconventional device
mounting system. After several months of experimenting with spectacle mounted and
head bourn systems, we settled on a telescoping rod from the back of her wheelchair
that placed a clip in front of her eye for telescope positioning. Her field through the
telescope is very restricted and requires adult assistance but Bridgett was able to spot
her batter and her sister on horseback.

Integration of Device Use

Using vision efficiently and use of low vision devices are not automatic skills to a student
who has low vision. Students who have gained proficiency in device use may not recognize
the instances in which the device can be helpful. They may even be disinterested in the
information that others acquire visually because access is out of their reach. Too often as
teachers, we focus so tightly on one environment that we neglect to extend visual reach
into active settings beyond a classroom. Successful low vision habilitation is truly found
when strategies and tools are integrated across environments and activities.
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 Case Study: Tadej
Tadej’s doctor described him as exhibiting “tremendous visual curiosity” in the report
following his low vision evaluation. He first came to clinic at age five with a diagnosis of
optic atrophy and an estimated visual acuity of 20/700. His family had recently moved
to the United States and Tadej’s first task was to learn English without a reading
medium. In his first years of school, the closed circuit television was his tool for learning
print letters; this was an inefficient medium for him. Tadej fiercely resisted Braille. Early
team meetings occurred, but communication among new team members was difficult
with his changing program. We started with a 2.8x telescope, with a final goal of his
using an 8x. By age 8, Tadej’s interest in finding distance information had increased.
Holding the 6x telescope, he motioned with his hand and said, “It’s not going far enough.
I want to push it out.” With youthful clarity, he illustrated his appreciation for range of
telescope power.
Today, at age ten, Tadej wants to see classmates’ facial expressions across the room and
identify what a speaker on Career Day is holding. He wants to find his buddies in the
parking lot after school and take the telescope to his brother’s soccer game. Tadej’s
success is an unfolding story.

Conclusion
Teachers must sometimes work as predictors of the future. They can help their students
anticipate life beyond the school setting and home. Can the student find travel information
such as bus numbers or building signs? Can the student check a grocery receipt or bank
statement for accuracy using high plus lenses or a magnifier? What visual tasks is a peer
three years older managing? We must remember, we’re not just helping a student use a
magnifier or a telescope, we’re helping this young person to gain independence with visual
tasks for life.

Pediatric low vision services are an evolving discipline in low vision care. The characteristics
of this population vary widely, yet some principles hold true for all students.
Communication among members of the team providing care is crucial. Listening to the
student’s messages and goals can inspire lesson plans that lead to motivating use of devices-
even in school. Finally, prompting integration of device use across environments
throughout instruction will support the development of self-reliance and independence.
Wondering if I’ve really listened to my student during today’s lesson comes to mind before I
sleep. Like rewinding a movie scene, I replay conversations in my head looking for clues to
understanding a student’s feelings about being visually impaired. Our most important goal
as members of a multidisciplinary team is preparing students for lifelong learning. Support
of device use is central to creating this reality.