Chapter 6
Case Studies
Irene Topor and Millie Smith
Table of Contents
Case Study 1: Tran
Collaborative Visual Skills Lesson Plan for instruction during regularly occurring activities
Activity: Breakfast Setting: Home, kitchen Instructor: Mom |
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Parent goal: Prepare, eat, and clean up in 20 minutes |
Task components related to visual efficiency: Pour milk into cereal bowl without spilling |
Visual efficiency IEP goal: Track vertical movement of object five out of five consecutive trials in six different tasks |
Present level of academic and functional performance: Responds quickly to movement peripherally, tracks to midline; loses fixation on moving target in central field |
Embedded visual efficiency short-term objective: Vertically track line of contrast between milk and bowl as it moves toward top of bowl |
Embedded visual efficiency accommodations: Heighten contrast (use a solid, dark color bowl) |
Strategies: Use quart-size milk jug (with screw-on hat)
Have slightly more than required amount of milk in the jug |
Activity: Arrival routine Setting: Pre-K class Instructor: Pre-K Teacher |
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General education skill: Organize and maintain personal possessions |
Task component related to visual efficiency: Use name tag to find locker for storage of backpack |
Visual efficiency IEP goal: Identify familiar words in hand-lettered, cursive, and different print fonts when used to label drawers, cabinets, and containers five out of five consecutive trials |
Present level of academic and functional performance: Identifies letters and familiar words in sans serif print fonts; has difficulty with hand-printed, cursive, and unfamiliar fonts |
Embedded visual efficiency short-term objective: Identify name in a variety of formats on name tag |
Embedded visual efficiency accommodations: Heighten contrast (Write the student’s name with wide-tip, black marker on light color paper. Use a light color name strip on dark seasonal cutouts or use light color cutouts for everyone.) |
Strategies: Write familiar words on labels in multiple formats; practice sorting cards on which words used on labels in the school environment are displayed in multiple formats |
Activity: Arrival routine Setting: Pre-K class Instructor: Pre-K Teacher |
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General education skill: Organize and maintain personal possessions |
Task component related to visual efficiency: Hang coat on hook on coat rack |
Visual efficiency IEP goal: Scan from left-to-right five out of five consecutive trials in four different arrays (coat rack, daily calendar, books, worksheets) |
Present level of academic and functional performance: Uses multiple fixations in random sequence to locate objects in arrays |
Embedded visual efficiency short-term objective: Scan from the beginning of the array on the left to the next coat in the row until an empty hook is found five out of five consecutive trials |
Embedded visual efficiency accommodations: Heighten contrast (Place black paper medallion around base of each silver metal hook.) |
Strategies: Initially, use direct lighting (penlight) to illuminate the transition from current to next coat in the sequence |
Activity: Puzzles Setting: Pre-K class Instructor: Pre-K Teacher |
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General education skill: Complete five-piece puzzle |
Task component related to visual efficiency: All |
Visual efficiency IEP goal: Assemble parts to complete whole |
Present level of academic and functional performance: Completes one-piece foam inset shape puzzles; refuses to work on multi-piece puzzles |
Embedded visual efficiency short-term objective: Given a two-part puzzle, hold one half steady with one hand while rotating the other half in a clockwise pattern until the image is complete |
Embedded visual efficiency accommodations: High contrast, solid color, single object pictures |
Strategies: Cut pictures of familiar objects in half; gradually increase complexity to objects with more colors and internal detail (Make dome magnifier available when pictures contain small internal details.) |
Direct Instruction Visual Skill Lesson Plan for vision-specific activities
Visual efficiency goal: Use top-to-bottom/left-to-right scanning patterns to examine projected materials visually |
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Visual efficiency short-term objective: Find the first picture in a vertical array of four and look at each picture sequentially from top to bottom |
Materials: 8”x10” (projected size) high contrast panels from Garfield® comic strip, colored pen light |
Instructor: TVI |
Location: Conference room |
Frequency: 3x weekly |
Procedure: Sit 12 feet from screen. Find panel at top of array with illumination. Follow penlight to next pictures in order. Find beginning and move through array without illumination. Repeat 20 feet from screen. |
Evaluation: Four errorless descriptions of panels in correct order in five consecutive trials |
Transition strategy: Play “I Spy” in the classroom. Find named pictures in projected arrays (supported by classroom teacher with role release). |
Visual efficiency goal: Identify letters and numbers presented in different graphic formats |
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Visual efficiency short-term objective: Identify four words used as labels in the classroom environment written in familiar fonts, unfamiliar fonts, cursive, and hand-lettering |
Materials: Word cards—four each of familiar font (18 point non-italic sans serif), unfamiliar font, cursive, hand-lettered; sorting tray |
Instructor: TVI |
Location: Classroom, in reading center |
Frequency: 3x weekly |
Procedure: Present four words printed in familiar fonts. Read each word while placing it in one of the four sections of the sorting tray. Present the “deck” of mixed word cards containing three examples of each word written in different graphic formats. Read each word and place it in the correct section of the tray with the word it matches. |
Evaluation: 12 out of 12 correct matches on five consecutive trials |
Transition strategy: Change some labels used in the classroom to different formats each week |
BVEE Intervention Guide
Priority Activities | Media/Objects affected by poor visual efficiency | Related visual developmental sequences (V) and/or Related perceptual skill deficits (P) |
Intervention Accommodation (A) Skill (S) Strategy (St) |
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Arrival time | Name tag on cubby | V: High contrast/low contrast P: Identification |
A: Enhance contrast with wide tip, black marker on white background St: Identify name written in cursive and manuscript on tag |
Hook on coat rack | V: Fixating/tracking/scanning | S: Scan from left to next hook in row until empty hook is located | |
Journal time | Notebook | V: High contrast/low contrast | A: Use bold line paper to enhance contrast |
Centers | Picture books | V: Simple/complex P: Closure and figure-ground |
S: Identify single element in scene St: Name partially obscured objects for student St: Use cutout window to isolate feature then find feature without cutout |
Centers | Puzzles | V: Part/Whole P: Constancy, Part/whole |
S: Assemble two halves of single-object pictures cut in half St: Teach clockwise rotation pattern |
Morning circle | Weather pictures | V: Outer edges/internal detail | A: Outline outer edges of salient feature |
Playground | Anything in bright sunlight | V: Fixating/tracking/scanning | A: Sunglasses |
Arts and Crafts | Lines for cutting | V: High contrast/low contrast | A: Used bold marker to enhance contrast |
Accommodations, Modifications, and Supports1 as determined by the FVA and BVEE
(List as appropriate)
Accommodations should be listed in two documents: 1) the accommodation section of the FVA and 2) the accommodation section of the IEP. This chart shows an example of what vision accommodation might look like in an IEP.
Accommodations and Modifications | Frequency | Location (name of school) | Instructional setting and person responsible | Duration (date to date) |
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Use 18-point, non-italic, sans serif type fonts | Daily | Bowie | Pre-K class: Bennet | 1/5/17 to 1/5/18 |
Use contrasting background colors for object location | Daily | Bowie | Pre-K class: Bennet | Same |
Use a cutout window to isolate single elements in multi-element pictures | Daily | Bowie | Specials: Spender, Cardenas, and Ponti | Same |
Name partially obscured elements in pictures | Daily | Bowie | Pre-K class: Bennet | Same |
Use bold lines for writing and cutting | Daily | Bowie | Pre-K class: Bennet | Same |
Use sunglasses outdoors as appropriate | Daily | Bowie | Pre-K class: Bennet Garden: Bennet | Same |
Supports: (Describe supports such as equipment, consultation, or training for school staff to meet the unique needs of the student.)
Reading stand, dome magnifier, variable beam flashlight with exchangeable colored lenses
1Source: Adapted from Virginia State Department of Education
Functional Vision Assessment
Student: Tran W.
DOB: March 9
Age: 4 years, 3 months
School: Centerville Elementary
Eye Condition: Ocular Albinism
Evaluator: Mary Johnson M.Ed., TVI
Date of Assessment: November 8-10
Date of Report: November 16
Purpose: Functional vision and learning media re-evaluation to provide current information about educational needs related to visual impairment.
Ophthalmological Summary
(Examiner: Lynde, pediatric ophthalmologist. Date of examination: 8/15)
Etiology: Retinopathy of Prematurity, four laser treatments bilaterally
Diagnosis: High Myopia
Fields: Peripheral fields restricted 20 degrees bilaterally due to laser treatments and corrective lenses
Acuity: Distance with correction 20/50 both eyes; distance without correction 20/200 both eyes
Color perception: Normal
Contrast sensitivity: Low normal
Accommodation: Normal
Fixation: Steady, maintained
Prognosis: Permanent
Recommendations
Glasses for correction at distance. Remove glasses or look over or under glasses for near. Try dome magnifier. Use high contrast materials when visual complexity is high.
Assessment procedure
Observations in three indoor and two outdoor environments were conducted over 3 days. An activity analysis method was used to assess distance and near function in tasks in each environment. Parent/Teacher interviews, picture books, weather cards, and pictures from the Diagnostic Assessment Protocol (out of print) were used for direct evaluation in addition to observation.
Near Vision Function
Tran’s preferred viewing distance for objects and pictures is about 3 inches when he wants to see small details. He prefers leaving his glasses on and looking over the top. His recognition of objects was good although he did use touch for tactile confirmation of objects smaller than one inch. His recognition of pictured objects in drawings with inner detail and with and without color was good when items were displayed singly with high contrast, but he had difficulty when pictured objects were partially occluded by contiguous objects or displayed against complex backgrounds. Tran was able to identify pictured objects as small as one-half inch when they were displayed singly. He could describe the content of pictured scenes but could not find some elements in the scenes.
Distance Vision Function
Tran was able to identify outline drawings of objects on 2x2 cards at distances up to 10 feet. He did not identify scenes or complex photographs beyond 3 feet even when materials were as large as full-page illustrations in large picture books. He had difficulty locating medium sized and smaller objects (trashcan, basketball, pillow, etc.) outside his central field of vision. He had the most difficulty finding items in the 16-inch to 3-foot range. When looking for his favorite pillow, he moved away from the area where he expected to find it so he could view the area from a distance of about 8 feet. At this distance, he spotted his pillow and moved directly to it.
Ocular Motor Function
Tran loves to do puzzles and play with Legos®. He prefers to view his hands during manipulation of objects at face level while standing or lying. When he is aligning parts of small objects, his viewing distance is about 2 inches. His teacher reports that he resists visual-motor tasks such as coloring if he has to sit at a table.
Lighting
Tran preferred normal lighting. He did less well in dim lighting indoors and in bright sunlight outdoors. He consistently moved to shaded areas on the playground when possible even though the day he was observed was quite cool. His mother reports that he squints and sometimes covers his eyes when outdoors on sunny days.
Educational Recommendations
- An orientation and mobility evaluation is recommended.
- A clinical low vision evaluation is recommended before Tran’s next IEP so that optical devices for improving near vision function can be addressed as academic tasks become a larger part of his school experience.
Accommodations/Modifications/Supports
- Use 18 point, non-italic, sans serif type fonts for teacher made materials.
- Use contrasting background colors for location of medium to small objects at distance and for pictured objects.
- Use a cutout window to isolate single elements in multi-element pictured scenes.
- Name partially obscured elements in pictures.
- Use bold lines for coloring and cutting.
- Provide sunglasses for outdoors on sunny days.
- Use a reading stand to elevate materials used during table tasks.
- Provide a dome magnifier to increase viewing distance for small details.
- Allow Tran to move away from an area to a distance of 8 feet or so when he is searching for an object.
- Teach Tran a systematic scanning pattern for location of objects outside his central field in distance and near tasks.
Case Study 2: Ryan
Collaborative Visual Skill Lesson Plans for instruction of visual efficiency skills in regularly occurring activities
Activity: Getting ready for school Setting: Bedroom Instructor: Mom |
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Parent goal: To dress appropriately for school |
Task component related to visual efficiency: Locate shirt and pants and dress self before eating breakfast |
Visual efficiency IEP goal: Scan array of objects five out of five consecutive trials in six different tasks |
Present level of academic and functional performance: Scans complex presentations of objects if within 6-8 inches of stimuli; misses items that are partially hidden or very small |
Embedded visual efficiency short-term objective: To systematically horizontally scan from left to right the shirts and pants hung in the closet |
Embedded visual efficiency accommodations: Reset the clothes hangers so they are at eye level, use extra lighting in closet to make shirt colors and designs easier to see |
Strategies: Increase lighting in closet to heighten contrast; begin with six or fewer shirts and pants in the array; after considering one shirt and one pants choice, move outfit to the left to show which ones remain |
Activity: Language Arts Setting: 4th grade class Instructor: Teacher |
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General education skill: Complete daily journal |
Task component related to visual efficiency: Write cursive in journal about topic of the day |
Visual efficiency IEP goal: To write and read own handwriting in cursive for assignments in core general education curricula at least three times a day in two different subject areas |
Present level of academic and functional performance: Writes letters in manuscript, cursive, and in sans serif print fonts; sometimes has difficulty reading own handwriting or that of others if in cursive or an unfamiliar font |
Embedded visual efficiency short-term objective: To write and read own manuscript and cursive handwriting |
Embedded visual efficiency accommodations: Provide bold lined paper of color that provides contrast on request, give student choice for writing instrument, allow student to use stand or video magnifier to check work, provide a slant board if this accommodation has been successful for past writing activities |
Strategies: Have Ryan write several sentences and then have him read what is written before he finishes the journal entry. If there is more to write than time to write, allow Ryan to return to the journal at another time during the day and/or finish the journal entry by writing with a computer and printing the remaining sentences. |
Activity: Social Studies Setting: 4th grade class Instructor: Teacher |
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General education skill: Read and interpret maps |
Task component related to visual efficiency: Read states and capitals on map |
Visual efficiency IEP goal: To scan from left-to-right five out of five consecutive trials in four different arrays, e.g., real map, textbook display of partial map, globe of the US, puzzle representation of the US |
Present level of academic and functional performance: Uses multiple fixations in random sequence to locate state and capital names |
Embedded visual efficiency short-term objective: To scan from the left side of the map representation to the right until 10 states and their capitals are found five out of five consecutive trials |
Embedded visual efficiency accommodations: Outline two-dimensional maps in bold lines to show states, heighten contrast on textbooks by scanning and displaying on computer monitor where colors can be adjusted, enlarge state and capital names to at least a 20-point sans serif font, use a tablet so size (pinch close and spread open) is controlled by student |
Strategies: Use a cutout to show where to place eyes across array |
Activity: Tying Scout knots Setting: Scout Master Pike’s home Instructor: Scout Master Pike |
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General education skill: Tie knots |
Task component related to visual efficiency: All |
Visual efficiency IEP goal: To assemble parts to complete whole |
Present level of academic and functional performance: Completes overhand and square knots, needs assistance with two half-hitch and taut-line-hitch knots |
Embedded visual efficiency short-term objective: When given an animated movie of how to tie two half-hitch and taut-line-hitch knots, Ryan will copy three-dimensional representations of the knots for two consecutive times each for both knots. |
Embedded visual efficiency accommodations: Three-dimensional representations of the knots, short animated films of how to tie the knots that can be replayed as many times as necessary |
Strategies: Have Ryan demonstrate his mastery of overhand and square knots to show competence and build self-esteem. Demonstrate tying the two half-hitch and taut-line-hitch knots and allow three-dimensional knots to be model for end product. Provide movies (available online) of how to tie the two half-hitch and taut-line-hitch knots that Ryan can play at his convenience to learn the knot tying process. |
Activity: Miniature Golf Setting: Fantastics game center Instructor: Parents and siblings |
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General education skill: Participate in recreational activities with friends and family |
Task component related to visual efficiency: Visual alignment of ball, club, and hole |
Visual efficiency IEP goal: To strike a miniature golf ball with club and make a “hole” on the miniature golf course in five or fewer attempts |
Present level of academic and functional performance: Ryan can hit a target with a thrown object from a distance of 10 feet. |
Embedded visual efficiency short-term objective: Ryan will hit ball to intermediate targets at 10 foot intervals leading up to the golf hole. |
Embedded visual efficiency accommodations: Place yellow tape on green turf background at 10 foot intervals. |
Strategies: Have Ryan practice hitting the golf ball with the club without targets until alignment of ball and club is easy, then add targets. . |
Direct Instruction Visual Skill Lesson Plan
Visual efficiency goal: Use video magnifier to maintain place when reading passages in a science textbook |
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Visual efficiency short-term objective: Use video magnifier to read tongue twisters, limericks, and popular phrases |
Materials: Video magnifier with adjustable line markers for written phrases in standard print on 8½ x 11 inch pages; provide color cues: “green” dot on left side of margin to assist with finding beginning of the phrase and “red” dot on the right side to assist with finding the end of the phrase |
Instructor: TVI |
Location: General education classroom |
Frequency: 3x weekly |
Procedure: Sit in an ergonomically correct position (including distance from display) in front of the video magnifier. Focus the video magnifier. Find green color cue at the beginning of the phrase. Read limerick, riddle, or popular phrase. Read phrases (10 in all) sequentially. |
Evaluation: Nine errorless readings of captions in 10 trials |
Transition strategy: Take live science experiment and view it under the video monitor, read lab data information using the video magnifier (supported by classroom teacher with role release) |
Visual efficiency goal: To follow moving objects when playing a physical education game | ||||||||||
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Visual efficiency short-term objective: To track familiar objects when moving from near to distance in indoor and then outdoor environments | ||||||||||
Materials: Familiar soccer ball (add fluorescent orange tape if black and white not enough contrast), use ball with sound source if heightened color contrast is not enough to increase visual efficiency | ||||||||||
Instructor: TVI | ||||||||||
Location: Gymnasium and/or outdoors | ||||||||||
Frequency: 2x weekly | ||||||||||
Procedure:
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Evaluation: Four shifts to moving or stationary objects to moving object within 5 seconds in five consecutive trials | ||||||||||
Transition strategy: Role release procedure to instructional aide and P.E. teacher for daily practice. Attempt same procedure for visual efficiency for ball play outdoors. Provide alternate types of balls just in case the procedure can be enhanced in the outdoor environment with another modification. Wear sunglasses to reduce glare to see ball at varying distances. If telescope is prescribed, apply the same procedure for following moving ball as described above. |
BVEE Intervention Guide
Priority Activities | Media/Objects affected by poor visual efficiency | Related visual developmental sequences (V) and/or Related perceptual skill deficits (P) |
Intervention Accommodation (A) Skill (S) Strategy (St) |
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Language Arts | Pictures in textbooks, format of text in expository textbooks, writing paper | V: Simple/Complex, Large/Small, High/Low contrast P: Identification |
A: 20-point, sans serif font and bold line paper S: Match inner detail in figures of different sizes St: Provide sample picture to find match in textbook S: Write essay in cursive |
Mathematics | Worksheets and problems in textbooks | V: Simple/Complex, High/Low contrast P: Identification |
A: Use bold line paper S: Compute problems and write numerals on answer sheet St: Use cutout window to isolate and identify elements |
Social Studies Science | Reading and interpreting maps | V: High/Low contrast, Outer edges/Internal details P: Identification, Part/Whole |
A: Use bold lines to enhance contrast S: Identify specific pictorial elements of maps St: Provide sample picture to find match in textbook |
Physical Education | V: Hat Tracking and Scanning P: Identification, Figure-ground |
A: Balls with high contrast and/or a sound source S: Track the movement of a variety of balls in indoor and outdoor environments St: Practice tracking in uncluttered areas, gradually add more complex backgrounds |
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Computers | Access to some Internet sites difficult | V: Scanning, Familiar/Novel, High/Low contrast, Part/Whole, Simple/Complex P: Identification, Visual closure, Visual Memory, Part/Whole |
A: Enlarged numerals/letters on keyboard/ZoomText® S: Scan computer monitor display to identify pictorial elements St: Use cut-out window to isolate elements on screen |
Lunchtime | V: Localizing, Near/Far, Black & white/Colors P: Identification |
S: Sit at table next to friend St: Describe features of pictured person and same person seen in mirrors and at distance |
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Scout meetings and trips | Interpreting action in pictures | V: Large/Small, Outer edges/ Internal detail P: Visual memory |
A: Enlarge pictures, use magnification S: Identify objects and actions in simple pictures St: Describe actions associated with pictured action |
Accommodations, Modifications, and Supports1 as determined by the FVA and BVEE
(List as appropriate)
Accommodations should be listed in two documents: 1) the accommodation section of the FVA and 2) the accommodation section of the IEP. This chart shows an example of what vision accommodations might look like in an IEP.
Accommodations and Modifications | Frequency | Location (name of school) | Instructional setting and person responsible | Duration (date to date) |
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Use 20-point, non-italic, sans serif type fonts; stand magnifier; and/or video magnifier (Determine by task and need.) | Daily | Eisenhower | All general education classes: TVI | 10/7/17-5/30/18 |
Preferential seating if desired—left side of room to optimize use of right eye | Daily | Eisenhower | All general education classes: TVI | 10/7/17-5/30/18 |
Use a cutout window to isolate and identify mathematical problems in textbooks and on worksheets and lines in other narrative or expository literature. Substitute video magnifier if available. | Daily | Eisenhower | All general education classes: TVI | 10/7/17-5/30/18 |
Name details of pictures in science and social studies textbooks | Daily | Eisenhower | All general education classes: TVI | 10/7/17-5/30/18 |
Provide a slant board to view two-dimensional objects and to read text in narrative and expository literature | Daily | Eisenhower | All general education classes: TVI | 10/7/17-5/30/18 |
Use contrasting background colors for object/image location on two-dimensional images for maps | Daily | Eisenhower | All general education classes: TVI | 10/7/17-5/30/18 |
Use sunglasses outdoors as appropriate for physical education activities, field trips, and other community events | Daily | Eisenhower | Outdoor physical education classes, field trips: TVI, Gerard | 10/7/17-5/30/18 |
Provide enlarged drawings | Daily | Eisenhower | All general education classes: TVI | 10/7/17-5/30/18 |
Supports: (Describe supports such as equipment, consultation, or training for school staff to meet the unique needs of the student.)
Provide dome and video magnifier, screen enlargement program (e.g., ZoomText® on PC or built-in zoom feature on Mac® to use in home, school, and community. Possible 4X – 6X telescope as prescribed by the clinical low vision optometrist to use as alternate equipment in community or home.
1Source: Adapted from Virginia State Department of Education
Functional Visual Assessments (FVA) will vary in style and content per the tool chosen by the TVI. The BVEP does not include a FVA. This example demonstrates the style and content used by the author.
Functional Vision Assessment
Student: Ryan M.
DOB: October 28
Age: 9 years, 11 months
School: Eisenhower Elementary School
Eye Condition: Ocular Albinism
Evaluator(s): Leanne Smith, M.Ed., TVI
Date of Assessment: September 13-26
Date of Report: October 4
Purpose: To provide current information about how effectively Ryan uses his vision, the extent to which reduced visual functioning affects his educational program, and specific needs for modification related to his visual impairment
Ocular History
Ryan’s most recent ophthalmologic report on file is dated August 29 of this year. In this eye report, Dr. Bryan Jones (pediatric ophthalmologist) states that Ryan has a diagnosis of ocular albinism, nystagmus, and esotropia. Ocular albinism is a congenital defect that causes lack of pigment in eyes, hair, and skin. Ocular albinism is a condition that is usually accompanied by poor vision, light sensitivity (photophobia), and involuntary eye movements (nystagmus). Nystagmus is involuntary, rhythmic side–to-side or up-and-down eye movements that are faster in one direction than the other. Esotropia is eye misalignment in which one eye deviates inward while the other fixates normally. The eye report also documents Ryan’s distance acuity as 20/200 in both eyes and near acuity as 20/70 in both eyes. At the time of this report, Dr. Jones noted Ryan’s ocular condition as stable. Additionally Dr. Jones noted in his report that Mrs. Moore (Ryan’s mother) has noticed Ryan’s eye alignment (esotropia) as looking better.
Ryan is prescribed glasses (corrective lenses) for near work.
RX: OU: +2.00
Assessment Procedures
- Parent interview
- Student interview
- Teacher interview
- Formal near and distance visual acuity assessment
- Functional visual acuity
- Functional (color, contrast, lighting)
- Visual field
- Oculomotor function
Parent Interview
Mrs. Moore stated that Ryan’s vision is better than his older sister who also has a diagnosis of ocular albinism. She noted that it is difficult for Ryan to interpret maps at school because of the detail and size of features on the maps. All of Ryan’s homework is completed weekly on the family computer (Mac®). To accommodate for his low vision, Ryan uses the “zoom” feature that comes with the computer. Mrs. Moore stated that Ryan completes his homework assignments independently. The only other devices that Ryan uses at home to complete work tasks are his dome magnifier and glasses for reading. Mrs. Moore added that Ryan picks up a lot about his environment when he travels in the car. He points out things that he sees. Additionally, she shared that Ryan is thought to be a candidate to drive when he is older.
Student Interview
Ryan is a 9-year-old boy who began fourth grade this fall. He is knowledgeable about his preferred vision and does not allow his visual impairment to prohibit him from activities or hobbies in which other 9-year-old boys are interested. When asked what he likes most about school, Ryan shared he likes “working on stuff”; he “loves math, computers, and PE”; and he added that he likes “reading and writing.” When asked what he likes least about school, Ryan shared that he dislikes Spanish and “hard things.” When asked if he has trouble copying things or seeing things on the board (whiteboard and use of projector), he simply stated “no.” Ryan shared that he sits close to the board in the classroom. When asked if his eyes get tired when he reads, he stated that his eyes don’t get tired, he just gets tired. Ryan noted that PE is one of his favorite things about school and shared that he does not have any trouble participating with his classmates and that the activities vary both indoor and outdoor. Ryan’s other interests are swimming, basketball, and baseball. His greatest interest, as noted by both him and his mother, is playing video games.
Teacher Interview
Ms. Pearce, fourth grade teacher, said that Ryan is a pleasure to have in class. She commented that he has many friends. Ryan initiates team projects, and class peers want to be on his “team.” He is always selected as a “team” member for small group activities in class and for teams in physical education. Ryan is often surrounded by a variety of peers at lunchtime. He knows how to use his equipment, including a computer that has ZoomText® (screen enlargement software) installed on it. Ms. Pearce noticed that Ryan does not finish his work as quickly as other peers, especially when the class is conducting a science experiment or reading a chapter in social studies. Ms. Pearce reported that last year’s teacher said Ryan couldn’t see the board and had great difficulty copying from the board. This year, Ryan is consistently using his Flipper™ for board work and/or moves to the front of the room to read board work. Ms. Pearce’s greatest concern is that Ryan be able to keep the pace of the fourth grade work for all literacy, math, science, and social studies assignments that will become more time intensive for all students as they move through the 4th grade school year.
Formal Near and Distance Visual Acuity Assessment
Setting: The assessments took place in Ryan’s fourth grade classroom, the school hallway, the playground, and the street in front of the school.
Acuity
Location: Indoors, Ryan’s fourth grade classroom
Lighting: Natural light from window
- Ryan’s near acuity was measured using the Lighthouse Continuous Text Card for Near Vision with correction.
- 3.2M at 16 inches with no additional light. Ryan stated this was the last line he could read at a distance of 16 inches. The Snellen equivalent for 3.2M is 20/160.
- 2.5M at 10 inches with no additional light. Ryan was asked to read this line at a distance that was comfortable.
- 2.0M at 8 inches with no additional light with the dome magnifier.
Results: Ryan is able to read the sentences fluently on this card up to 3.2M, which is large print type (larger than 18 point). Upon observation, Ryan is able to read 20-point font at 6-8 inches away. He can read the same print size with a dome magnifier.
- Distance acuity was measured using the Logarithmic Visual Acuity Chart “2000” (10 feet) without correction. Ryan did not wear glasses for distance during our assessment.
Both eyes were tested together because Ryan has diagnosed nystagmus. When testing students with nystagmus, covering either eye may increase nystagmus.
- 10/100 (20/200) at 10 feet with no additional light.
Results: Ryan’s distance acuity is accurate with his last eye report of 20/200. When we tried 10/80 (20/160), Ryan was only able to read one letter with accuracy (this included guessing).
Recommended Accommodations: Use 20-point, non-italic, sans serif type fonts; stand magnifier; and/or video magnifier. Determine the use of each accommodation by task and need.
Functional Visual Acuity Assessment
Location: Outdoors on the school playground and in front of the school
Lighting: Bright, sunny day
Ryan was asked to visually track a remote controlled tractor (7 inches in height, 6 inches in width) as it traveled into a distance of about 20 feet while he stood in one location. He tracked the tractor easily as it moved in a straight path while in the bright sun.
Results: Ryan visually followed a motivating object as it moved away from him to a distance of 20 feet in an outdoor, sunny environment.
Functional Assessment
Location: Indoors, Ryan’s fourth grade classroom
Lighting: Overhead fluorescent light and natural light from a large window located north of where Ryan sat
Color
- Ryan was able to identify and match accurately 7/7 colors (red, blue, yellow, green, orange, black, and white) from the Disney® paint sample cards.
- Ryan used the same paint sample cards and was able to organize the colors from light to dark in a left-to-right sequence.
Contrast
- Using color contrast photo cards with black/white backgrounds, Ryan was able to accurately identify colored objects on 7/7 samples that progressed in difficulty.
- When presented with a cluttered and similar background, Ryan was able to locate three matching buttons of the same color (yellow on yellow) and varying sizes (small, large).
- Two books, Disney® Pixar Cars: Look and Find and I SPY™ Little Numbers, were used to determine if Ryan has trouble when the contrast of backgrounds becomes increasingly difficult. Ryan was able to identify hidden objects in both books easily.
Lighting
- For the majority of assessment, Ryan worked inside his fourth grade classroom with natural lighting coming from a window and overhead fluorescent lighting. He did not need additional lighting to perform any of the given tasks and did not have any functional interference with glare.
Results: Ryan appears to have normal color vision. Functionally he does not have any trouble with contrast or lighting.
Visual Field Assessment
A visual field is defined as the full extent of the area visible to an eye that is fixating straight ahead.
1. Preferred Visual Field
Location: Outdoors, school playground
Lighting: Bright, sunny day
To determine the potential “use” of his visual field, Ryan was asked to take a walk on the school playground moving his head and eyes as he normally would and indicate everything that he saw. In the top right circle, the horizontal line represents Ryan’s eye level and the vertical line represents his midline. The Xs in the circle correspond to where he indicated he saw objects when walking, moving his head and eyes as he normally would.
Results: While Ryan navigates seamlessly, there is a strong preference for things on his right side. He prefers to point out objects and items that are on his right. When asked to look toward the left, he overcorrects so that he uses his right visual field for identification. Ryan scans proficiently to find familiar objects and items on his right side.
2. Kinetic Visual Field at Near
Location: Indoors in Ryan’s fourth grade classroom
Lighting: Overhead fluorescent light and natural light from a window located about 10 feet from Ryan
To determine if Ryan has a blind area that may affect his ability to work at near, he was asked to fixate with both eyes on a mark in the center of the paper at the distance that he reads or does near task. Without moving his head or eyes, he indicated when he first saw the dot of a laser pointer that the evaluator was moving outside his visual field towards the center of the paper. The evaluator repeated the test from all meridians of his visual field.
Summary: Ryan’s usable visual field at 8 inches comprises an area represented in the diagram.
3. Static Visual Field
A visual field is defined as the full extent of the area visible to any eye that is fixating straight ahead. The diagram below illustrates normal visual fields.
Location: Indoor hallway
Lighting: Fluorescent light behind student
To determine his potential “area” of visual field, Ryan stood in the middle of a hallway that was 8 feet wide, 7.5 feet high, and 60 feet long. He was asked to look straight ahead with both eyes open. Without moving his head or eyes, he pointed to or described objects seen at his highest, lowest, and left and right peripheral boundaries. He indicated he saw objects on his right at about 90 degrees from his midline, on the left at about 75 degrees from his midline, up at about 45 degrees from his eye level, and down at about 65 degrees from his eye level.
Results: The picture on the left illustrates what a person with normal visual fields sees. The area within the Xs indicates what Ryan was able to see. This area represents his potential visual field.
Oculomotor Function
- Fixation: Ryan fixated on a target (orange pen) at about 10 inches and mainly used his right eye to view the target as it moved from left to right. Ryan fixated on the target, looked away briefly for a second, and then came back to the target.
- Accommodation: From a distance of 12 inches, Ryan noted that the magazine cover (large picture of a jaguar’s face) was blurry, and he looked away. As it was brought closer, within 6 inches, he noted that the image on the cover was clearer. As it moved even closer (closer than 6 inches), Ryan began to squint his eyes.
- Tracking: Ryan followed a remote controlled tractor as it traveled throughout the school playground in bright sun from distances of 1 foot to 16 feet without visually losing the tractor or saying that it was difficult to follow.
- Shift of gaze: Using two colored plastic cups positioned 6 inches apart and 12 inches from Ryan’s face, Ryan could shift his gaze between the two cups and he preferred to look at both cups with his right eye. He used eccentric viewing when he looked left so that his right eye was focused on the cup.
- Scanning: Ryan exhibited scanning behaviors as he explored two I SPY™ books. He moved his eyes back and forth across the page seamlessly to locate objects hidden in crowded backgrounds. Ryan scanned in a systematic search pattern and only used his vision to locate objects.
- Eye preference: While eye preference was not assessed formally, I conclude, based on observations, that Ryan has a preference for his right eye. In various assessments, I observed that he turned his head and used his right eye for most viewing.
Results: Ryan exhibits good oculomotor function when he uses both eyes together. He tends to look away for a second when images and/or objects are blurry or out of focus. He shows a preference for his right eye.
Summary of Results: Ryan has a stable condition of ocular albinism. He is able to move about seamlessly in the classroom and school environment. He shows a strong preference for using his right eye in most tasks and needs to be about 6-8 inches away from materials for optimal viewing. Ryan views enlarged video games and television at a distance of 12-16 inches if the print is 2.5M and the image is distinct. He can detect a moving object 7 inches x 3 inches at a distance of 20 feet away. His color vision appears to be within normal limits, and there is no need for extra lighting per this assessment.
Educational Recommendations
Referrals for other evaluations
- Clinical low vision evaluation (CLVE) to determine if there are optical devices that would increase Ryan’s visual efficiency
- A follow-up eye exam with Dr. Jones (pediatric ophthalmologist)
Accommodations
- Continue use of dome magnifier at school and home for reading and near work.
- Continue use of zoom feature on home computer (Mac®) for magnification of homework and assignments.
- Continue use of Flipper™ for optimal viewing of distance and near work.
- Allow additional time to complete assignments.
- Explore access to audible textbooks for assistance in completing assignments as the reading demands increase in upper elementary school.
- Provide preferential seating in close proximity to the board and/or projector. I recommend that Ryan sit on the left side of the classroom to optimize viewing out of his right eye.
- Use assistive technology (computer) when appropriate for writing and reports.
- Teach visual efficiency skills: scanning on left side to make sure that stimuli are seen.
- Use 20-point, non-italic, sans serif type fonts; stand magnifier; and/or video magnifier—determine by task and need.
- Use a cutout window to isolate and identify mathematical problems in textbooks and on worksheets and lines in other narrative or expository literature. Substitute video magnifier if available.
- Name details of pictures in science and social studies textbooks.
- Provide a slant board to view two-dimensional objects and to read text in narrative and expository literature.
- Use contrasting background colors for object/image location on two-dimensional images for maps.
- Use sunglasses outdoors as appropriate for physical education activities, field trips, and other community events.
- Provide enlarged drawings.
It was a pleasure to assess Ryan. I would be glad to review these results and discuss accommodations and materials for Ryan. You may reach me at Leanne.Smith@district.edu or by phone at 555-1234.
Sincerely,
Leanne Smith, M.Ed.
Teacher of Students with Visual Impairments
Case Study 3: Charlene
Collaborative Visual Skills Lesson Plans
Activity: Getting on the school bus Setting: Neighborhood Instructor: Mom, orientation and mobility specialist, bus driver |
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Parent goal: To find bus door, walk up steps, and find seat without assistance from the bus driver |
Task components related to visual efficiency: Identify familiar objects on sight, locate open door and steps to get on bus, greet bus driver, walk down bus aisle, scan bus seats to select one that is unoccupied, locate numbers in outdoor areas. Match environmental sign of “bus stop” to one that TVI shows her in class. |
Visual efficiency IEP goal: To scan visually a complex array of three-dimensional objects efficiently and locate desired object or need, e.g., empty bus seat |
Present level of academic and functional performance: Locates bus and open door when school bus arrives |
Embedded visual efficiency short-term objective: Locate designated objects: parts of cars and uses; windows, doorways, stairs, exit signs, playground equipment, curbs, and railings |
Embedded visual efficiency accommodations: Bus driver gives verbal cue about where empty seats are located on the bus, “Third row on the right side"; or initially, the driver might reserve same seat for Charlene (third row, left side, on the aisle) for first 4 weeks. |
Strategies: Teach Charlene to take her time to look on both sides of the aisle systematically. If she determines that there is an empty seat by the window and the aisle seat is occupied, teach her to ask if someone is sitting in the open area, and, if available, ask if it is okay for her to occupy that seat. Once she can find that seat without asking for assistance, allow her to pick the first available one that she finds on her own. |
Activity: Game Center Setting: Kindergarten Instructor: Teacher |
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General education skill: Identifies and plays card or board games that can be played with at least one other student |
Task components related to visual efficiency: Match and identify colors, identify pictures by inner detail, locate numbers on objects |
Visual efficiency IEP goal: To identify specific elements in pictures and on three-dimensional representations in order to manipulate successfully a marker on a game board or match a shape/element on a card with another that looks the same |
Present level of academic and functional performance: Plays “Go Fish” with colors and numbers, occasionally mismatches colors; selects card on cue to see how many spaces to move marker |
Embedded visual efficiency short-term objective: Locate distinct features on spinner or die to move marker; match numbers on cards to numbers on objects |
Embedded visual efficiency accommodations: Provide a bigger die for board game, enhance the spinner so that it is distinctive in contrast and color is bright or number is enlarged |
Strategies: Give Charlene a chance to choose between the die and game spinner for board game. Allow her to practice throwing the die and “reading” the dots and/or spinning the spinner and reading where the arrow stops. Provide a small container for the die so that she can shake it and then roll it onto a dark background. Allow Charlene to bring the spinner or die as close to her face as necessary. |
Activity: Lunch in school cafeteria Setting: Summerhaven School cafeteria Instructor: Teacher |
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General education skill: Kindergartners will get their tray, tell cafeteria servers which entrée/veggie/fruit desired, and select their own milk—white or chocolate. |
Task component related to visual efficiency: Identify the tray storage area; remove one tray from the top of the stack and then push it on the frame in front of the food independently. Identify food choices or if needed, asked for assistance with identifying food choices. |
Visual efficiency IEP goal: To reach out and touch or point to food choices at 6-12 inches |
Present level of academic and functional performance: Charlene can find the tray and place it on the frame in front of the food choices. She does not always see the food choices and asks the instructional assistant or cafeteria server to tell her the choices. Charlene prefers chocolate milk and selects it 4 out of 5 days a week. |
Embedded visual efficiency short-term objective: Given pictures and words of lunch choices for the day, Charlene will select her entrée, veggie, and/or fruit by matching the word card to the picture with the same word five out of five attempts each day of the week. |
Embedded visual efficiency accommodations: Provide pictures accompanied by words of food entrees for the week. Charlene will have a folder marked “lunch choice foods” where the TVI and instructional aide have collected all the pictures and written words in 18-point sans serif font. |
Strategies: During circle time or other designated period, Charlene will learn what food choices for the day are offered for lunch as presented in pictures and words on cards. She will be able to select the pictures and words that match the day’s offering and put them on a magnetic board. Just before leaving for lunch, Charlene will review her choices and select what she will tell the cafeteria server when she is in line in the cafeteria. If needed, Charlene can audiotape choices for future reference and play back a recording of her choices. |
Activity: Field trip to Children’s Museum Setting: Community Children’s Museum Instructor: Teacher, TVI, and if available, O&M specialist |
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General education skill: Learn to match like artifacts into categories presented in museum exhibit |
Task component related to visual efficiency: Match and categorize objects |
Visual efficiency IEP goal: To match and categorize like objects, (e.g., insects, shells, and rocks) that have at least three of the same characteristics, (e.g., smooth rocks, big shells, dark insects) |
Present level of academic and functional performance: Matches characteristics of big/small, smooth/rough, dark/light colors |
Embedded visual efficiency short-term objective: Given two shells, insects, or rocks, Charlene will identify two or three characteristics of each artifact and match a shell with a similar one (based on size, texture, or color); an insect with a similar one (based on wings/no wings, legs/no legs, and color); and rock (based on smooth or rough, color, or big/small) in five of five trials for one artifact. |
Embedded visual efficiency accommodations: Display sample matches of shells, rocks, and insects for Charlene to refer to if she needs to see how one or more of the artifacts is categorized. Make available museum pictures that enlarge each of the artifacts for Charlene to view if she needs to have the detail of any artifact enlarged. Have available a portable video magnifier for Charlene to use—if needed—to inspect the artifacts more closely. |
Strategies: Encourage Charlene to pick two each of the shells, insects, and rocks to compare and contrast. Have her talk about the characteristics of each artifact that are similar or different. If she needs assistance to see some of the inner detail on any of the artifacts, allow her to use a portable video magnifier or handheld magnification device to enlarge the insect for better discrimination or inspect museum pictures of each that have been enlarged for everyone’s use. |
Activity: Gymnastics Setting: Gymboree® Instructor: Gymnastics teacher, parents |
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General education skill: Participate in recreational activities with peers |
Task component related to visual efficiency: Visually access information from visual modeling |
Visual efficiency IEP goal: Imitate movement after visual modeling |
Embedded visual efficiency short-term objective: Charlene will watch and imitate the teacher-demonstrated gymnastic movements for somersault and headstand. |
Embedded visual efficiency accommodations: Instructor stands in front of solid contrasting background. |
Strategies: Charlene watches the gymnastics teacher and four other students in class demonstrate somersaults. If Charlene does not know what to do with her body after she watches the other students, try tactile modeling—Charlene feels the movement of another student perform a slow somersault. If Charlene needs additional assistance, her mom or the teacher can use physical guidance—partnered with verbal instruction—to help Charlene move her head downward and touch the mat. With guidance, Charlene propels her body forward and gently rolls to complete a comfortable somersault. Follow the same procedure to teach a headstand—first against a wall as an anchor, then with some assistance if Charlene is able to move away from the wall and keep her legs high and straight. |
Direct Visual Skills Lesson Plans
Visual efficiency goal: To use eccentric viewing to spot/locate objects, events, and people at distance |
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Visual efficiency short-term objective: Charlene will learn how to position her eye to find her best visual field for eccentric viewing. |
Materials: Teacher made “clock” (without numbers) on white background with colored quadrants of red, yellow, green, and blue. Use the four LEA Symbols®, one at a time, as points of reference for Charlene in each colored quadrant. A picture of this teacher-made material can be seen in Hall-Lueck, A. (2004), Functional Vision: A Practitioner’s Guide to Evaluation and Intervention, AFB, pg. 365. |
Instructor: TVI |
Location: General education classroom, other quiet place in Summerhaven Elementary School |
Frequency: 3x weekly |
Procedure: Charlene reviews the components of the teacher-made “clock” on the easel. She identifies where the numeral “7” is in the middle of the chart and where the colored quadrants on the clock are located, i.e., yellow upper right, red lower right, blue lower left, green upper left. Place clock 1-3 feet from Charlene. Charlene will have the LEA Symbols® of house, square, circle, and apple in front of her. Ask Charlene to “find” the “7” located in the middle of the circle by turning her head to use her left eye to determine where she can best see the “7.” Then instruct Charlene to use this same eccentric viewing position to move head and eye to visually find the “house” on the clock in the yellow quadrant. Practice this eccentric viewing technique for all quadrants on the clock with different LEA Symbols® used in each color quadrant. When Charlene is 100% correct with her identification of the symbols at near to intermediate distance, move the clock to a farther distance and repeat the procedure to practice eccentric viewing. First, Charlene should just point toward the colored quadrant where she spots the LEA Symbol®. Then, instruct her to bring the monocular telescope to her eye and practice eccentric viewing through her telescope to identify each LEA Symbol® placed in different colored quadrants on the chart correctly. |
Evaluation: Charlene should identify correctly eight of the LEA Symbols® at near and four LEA Symbols® at distance. After Charlene identifies the symbols with 100% accuracy in the eccentric viewing position, require Charlene to repeat the procedure more quickly. |
Transition strategy: Ask Charlene to use eccentric viewing to find an item in a book or object on a shelf at near distance. Use the eccentric viewing procedure outdoors with the telescope to spot environmental signs, traffic lights, and other signage in familiar and unfamiliar environments. |
Visual efficiency goal: To localize and spot objects using a telescope |
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Visual efficiency short-term objective: Localize and spot objects in indoor and outdoor environments |
Materials: APH ENVISION I and II kits (for near and distance activities for students 10 and younger) |
Instructor: TVI and orientation and mobility instructor |
Location: Classroom, hallways, at home, and/or outdoors |
Frequency: 2x weekly |
Procedure: Use a variety of motivating objects/two-dimensional representations of images that Charlene likes. For example, her princess and Barbie® dolls are her favorites, and she should be very motivated to look for them. Begin with the real doll and have her locate the doll in her home, classroom, and hallway of her school. Use stickers to represent the dolls and place the stickers in various places of the same environments throughout her home and classroom. If possible, travel to a toy store (that has been checked out first to locate the doll section) and have Charlene locate the dolls in the aisle, first without and then with the monocular. Charlene will practice the correct hand position of holding the monocular telescope (with rubber bands on the housing) and focusing the telescope in the classroom, hallways, or outdoor neighboring residential neighborhood. Encourage and reinforce correct positioning of her arm, hand, and monocular telescope for best viewing. When in a sitting position, Charlene will look at an enlarged picture of her princess or Barbie® doll at 10 feet with the telescope and determine which part of the doll is missing. TVI has systematically removed the eyes, ear, nose, one or two arms, etc., upon each presentation (with the help of computer imagery); Charlene must determine what is missing. Use ENVISION I for Distance Devices for children under 10 years as a reference for further indoor and outdoor spotting/localizing activities. Be sure to have some fun with Emmy the Emu in doing these activities! Incorporate her eccentric viewing techniques into the localizing/spotting activities for the telescope. |
Evaluation: Four correctly identified locations of favorite toys/two-dimensional representations in indoor and outdoor environments in five consecutive trials |
Transition strategy: Role release procedure to teacher and instructional aide. Attempt same procedure for visual efficiency for telescope use for classroom activities and other community outings. Avoid glare in lighting and decrease amount of clutter in the background to increase Charlene’s chances for success when she uses the telescope. Provide other familiar and motivating objects for Charlene to look for in unfamiliar environments just in case the procedure can be enhanced in the outdoor environment with another modification. |
BVEE Intervention Guide
Priority Activities | Media/Objects affected by poor visual efficiency | Related visual developmental sequences (V) and/or Related perceptual skill deficits (P) |
Intervention Accommodation (A) Skill (S) Strategy (St) |
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Circle Time | Calendar, temperature and job charts | V: Fixating/Tracking/Scanning | A: Sample calendar and charts with outlined salient features in book for Charlene, own carpet square S: Scan from left to right across the week until “today” is located S: Identify likenesses and differences in words, match word card to picture |
Teacher’s book when read aloud | V: Simple/Complex P: Closure and figure-ground |
A: Own books to adjust working distance S: Match inner detail in figures of different sizes, shapes, and colors St: Use cutout window to isolate figure then find figure without cutout |
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Centers Activities Math/Science Table games |
Puzzles | V: Part/Whole P: Constancy, Part/whole |
A: Paint puzzle background to heighten contrast of shape to form; outline edges of salient features S: Assemble two halves of single object pictures St: Teach clockwise rotation pattern |
Drawing and coloring books | V: Black and white/Color, Simple/Complex P: Identification |
A: Organize materials into containers for easy access; slant board; additional light; use bold marker to enhance contrast S: Trace, draw, and cut shapes; select like and different pictures of objects; observe the picture and position like object to match; match and identify primary and secondary colors St: Identify shapes in coloring book and crayon colors |
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Centers Activities Math/Science Table games |
Books | V: Simple/Complex P: Closure and figure-ground |
S: Identify single element in scene in I SPY™ books, Weekly Reader®, and APH reading and coloring books St: Use cutout window to isolate feature then find feature without cutout |
3-D objects under the microscope | P: Fixating, Peripheral/Central | A: Use an Invisiboard around workspace to block out peripheral clutter; use scientific microscope to view bugs, plants, and human body parts such as fingernails | |
Lunchtime | Peers’ faces | V: Localizing, Scanning, Simple/Complex P: Figure-ground |
A: Buddy system for socializing at lunch S: Select peer from class photo to sit with by using a cutout window to isolate faces |
Small group work; independent work | Worksheets | V: High contrast/Low contrast | A: Format worksheets in 18-point print with less information on each page; use bold marker to enhance contrast S: Draw shapes from models; cut out solid and outline shapes |
Recess/Outdoor play | Balls, weather conditions (cloudy, bright sunlight) | V: Fixating/Tracking/Scanning | A: Balls with high contrast and/or a sound source S: Track the movement of a variety of balls in indoor and outdoor environments; find friends to play with on jungle gym |
Library (school or community) | Books of interest | V: Simple/Complex P: Closure and figure-ground |
A: Use magnification devices for picture enlargement S: Identify objects and actions in simple pictures, recognize specific objects in pictures, interpret actions in pictures of books or DVDs St: Use cutout window to isolate feature then find feature without cutout |
Community Children’s Museum | Interpreting actions in pictures at science stations, observing adult models of what to do at each exhibit | V: Near/Far, Part/Whole P: Part/whole |
A: Magnification, eccentric viewing, getting closer to see live demonstration or picture in book S: Fit objects together (e.g., lids to jars, nested items), trace and copy lines for diagrams, discriminate missing parts, match identical objects, identify position of objects |
Accommodations, Modifications, and Supports1 as determined by the FVA and BVEE
(List as appropriate)
Accommodations should be listed in two documents: 1) the accommodation section of the FVA and 2) the accommodation section of the IEP. This chart shows an example of what vision accommodations might look like in an IEP.
Accommodations and Modifications | Frequency | Location (name of school) |
Instructional setting and person responsible | Duration (date to date) |
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18-point, non-italic, sans serif type fonts; stand magnifier (Depends on task and need) | Daily | Summerhaven | Kindergarten class: Teacher and TVI | 1/3/18 – 6/12/18 |
Preferential seating if desired; right side of room to optimize use of left eye | Daily | Summerhaven | Kindergarten class: Teacher and TVI | 1/3/18 – 6/12/18 |
Slant board for viewing twodimensional objects, e.g., pictures in books, APH SQUID activities | Daily | Summerhaven | Kindergarten class: Teacher and TVI | 1/3/18 – 6/12/18 |
(Subject to change per more extensive lighting assessment) Dim-to-natural lighting indoors, reduce glare by sitting with back to windows or direct light away from Charlene | Daily | Summerhaven | Kindergarten class: Teacher and TVI | 1/3/18 – 6/12/18 |
Place a colorful tactile marker on cubbyhole and desk (bottom of cubbyhole, left side of desk) for easier location. | Daily | Summerhaven | Kindergarten class: Teacher and TVI | 1/3/18 – 6/12/18 |
Let Charlene select the color carpet square she can see best to identify her place at circle time. | Daily | Summerhaven | Kindergarten class: Teacher and TVI | 1/3/18 – 6/12/18 |
A personal copy of calendar, temperature chart, student job chart, etc., that Charlene can use to go along with teacher demonstration during circle time | Daily | Summerhaven | Kindergarten class: Teacher and TVI | 1/3/18 – 6/12/18 |
A crayon holder that allows Charlene to match color crayon with the color presented around the hole and color word | Daily | Summerhaven | Kindergarten class: Teacher and TVI | 1/3/18 – 6/12/18 |
Supports: (Describe supports such as equipment, consultation, or training for school staff to meet the unique needs of the student.)
Training for video magnifier (in classroom) and telescope (in classroom, home, and community) with assistance of O&M specialist; eccentric viewing training to develop efficiency for reading at near and spotting at a distance (necessary for best efficiency with telescope).
1Source: Adapted from Virginia State Department of Education
Functional Visual Assessments (FVA) will vary in style and content per the tool chosen by the TVI. The BVEP does not include a FVA. This example demonstrates the style and content used by the author.
Functional Vision Assessment
Student: Charlene U.
Age: 5 years
School: Summerhaven Elementary
Eye Condition: Retinopathy of prematurity (ROP), horizontal nystagmus
Evaluator: Terry Hasken, TVI
Mr. and Mrs. Underwood, parents
Connie Ruskie, kindergarten teacher
FVA Dates: September - November of kindergarten school year
Date of Report: December
Purpose: A functional visual assessment (FVA) was conducted to provide current information about how effectively Charlene uses her vision, the extent to which reduced visual functioning affects her educational program, and specific needs for adaptations and instructional strategies related to her visual impairment.
Assessment Procedures
- Background Information
- Informal Observations
- Formal Visual Acuity (near and distance)
- Functional Visual Acuity
- Functional (color, contrast, lighting)
- Visual Field
- Oculomotor Function
Background Information
Charlene is an energetic kindergarten student who loves to engage peers and adults in conversation. She is an active girl who prefers to be outside for recess—hanging from the jungle gym—than doing work at her desk. Her mother and father report that she loves to find bugs and insects by getting very close to the ground and visually picking them out by movement or color. Her favorites are orange ladybugs and black beetles. Charlene loves to play games on her iPad® but only for 5–10 minutes at one sitting. Charlene has a loving relationship with her older brother, Geoffrey, and younger sister Gracie. Charlene will select a book and “pretend” to read it to Gracie as she turns the pages, but rarely points to pictures or details on any of the pages. Ms. Connie Ruskie, Charlene’s kindergarten teacher, is optimistic to have Charlene in class and reports that she demonstrates emerging literacy skills, including listening and enjoying books that are read to her, noting differences and likenesses in sounds or spoken words, telling stories about a recent personal event, completing sentences in books with repeated patterns, and relating personal experiences to characters or events in stories. Charlene does not show much interest in pictures, though she will manipulate objects associated with pictures in stories or books. For example, when reading If You Give a Mouse a Cookie, Charlene will take a drink of milk and then pretend to have a stuffed animal mouse take a drink of milk from a small cup. She scribbles, but when asked to read or write letters or complete puzzles, she often finds other things to do. She attempts to write her name but works 3 inches from the paper to write. Charlene enjoys math, especially simple counting and touching one toy for each number named. Again, doing any sort of writing of numbers is less enjoyable for Charlene.
Medical History
Charlene was born at 24 weeks gestation and hospitalized for 6 months following her birth. She required life support throughout the duration of her hospital stay, as well as at home for a short period following her release. In the hospital, Dr. Jared Metler, pediatric ophthalmologist, diagnosed Charlene with retinopathy of prematurity (ROP). This is the result of a series of destructive retinal changes that can develop after prolonged life-sustaining oxygen therapy is given to premature infants. In Charlene’s case, ROP has caused “total retinal detachment of her right eye,” leaving her with “no usable vision.” In addition to ROP, Charlene has horizontal nystagmus, or involuntary jerky movements of the eyes. Her right eyeball is shrinking over time, a condition called phthisis bulbi. This condition is associated with low intraocular pressure and results in vision loss. A macular fold in Charlene’s left eye has also left her with reduced ability to see detail. She has undergone laser retinal surgery, but the surgery did not appear to increase Charlene’s ability to see. She wears corrective lenses—recorded 9 months ago—with a prescription of OD (right eye): Plano lens (no correction) and OS (left eye): -1.00.
Dr. Robert Tucker, clinical low vision optometrist, tested Charlene 5 months ago. He reported her near acuity as OU (both eyes): 2.5 M (20/125) at 3 inches with a slight field restriction in the left eye. Her distance visual acuity was OU (both eyes): 10/200; OS (left eye): 10/200; OD (right eye): not tested. Dr. Tucker prescribed a 6X monocular for distance viewing with the added comment that she would need training from a teacher of students who have visual impairments to use it at school, home, and in the community. A video magnifier with auto focus and a color monitor was recommended for Charlene to use for any task in which she needs assistance to see more detail.
Charlene was tested for hearing loss, and because of her “active behavior,” results were inconclusive. Charlene’s family will follow up with her primary care physician and be sure that her hearing acuity be retested prior to the beginning of the next school year.
Informal Observations
Charlene was observed specifically for 3 days in a variety of environments, including her general education classroom with Ms. Connie Ruskie, during an orientation and mobility lesson, and throughout the routine day.
Classroom
Environmental attributes: The kindergarten classroom was well organized, with tables and chairs clustered and neatly arranged for three students to a group. Centers, bookshelves, teacher’s desk, and cubbies are all set against walls on the north, east, and west side of the room. The door entrance is on the south side of the room. Overhead full spectrum fluorescent and natural lighting from windows on the east and north walls provide light in the room. All windows have blinds to control the amount of light that enters the classroom.
During the classroom activities, Charlene wore her prescription lenses, but removed them claiming they were “too big.” In the classroom, Charlene located colored cotton balls on black felt at 18 inches. Charlene had no difficulty matching colors. Charlene matched yellow, orange, blue, and red felt consistently. When asked to locate these colored cotton balls again on a floral patterned background, Charlene was able to do it with ease. She experienced a delayed response when she worked with white on yellow. Charlene dropped a blue crayon on grayish blue carpet and located it visually with no difficulty. When given a choice between blue and yellow colors, Charlene picked yellow.
Orientation and Mobility
Environmental attributes: Outdoors, the weather was overcast with patches of sun peeking through the clouds.
Charlene was observed traveling around the Summerhaven Elementary School campus with her O&M specialist Ms. Laurie Sailor. Charlene used her cane as she traveled in familiar and unfamiliar places. During the lesson, Ms. Sailor took Charlene on her second trip to use the elevator to get to the cafeteria, which is in the basement. Charlene was able to locate the elevator without difficulty, and immediately walked to the black button to activate the down arrow. (She focused on the button at 5 feet away). Upon arriving at the cafeteria in the basement, Charlene commented that the lighting inside the cafeteria was dim. While inside the basement, Charlene located the light switch panel in the cafeteria while getting a drink from the fountain.
On her return to the classroom, Charlene was asked what cars she saw in the visitor parking lot near the school office building. Charlene stated that she saw two white jeeps; however, the white jeeps were not there (although typically they are). Charlene also stated that she saw a white van, which was approximately 50 feet away on her right side. When asked to point to the red Toyota Tacoma® truck parked perpendicular to the white van, Charlene could not identify it. Charlene did not identify the truck until she was approximately 5 feet away from it. Charlene did not know the truck was red until standing next to it.
Classroom Hallway
Environmental attributes: The hallway outside the classroom has full spectrum lighting, gray carpet, and blue walls.
Charlene was observed in the hallway during regular classroom time. She did not wear her prescription lenses. A green basket was placed at one end of the hallway, and Charlene was asked to identify where the basket was located while she stood at the opposite end of the hallway. Charlene tilted her head consistently to use vision in her left eye. Her “eccentric viewing” was noted throughout the activity. At 18 feet, Charlene pointed in the general direction of the basket; but it is not known if she saw the detail at this distance.
Charlene was taken to a busy hallway at the opposite end from her classroom and asked to identify objects on the wall. She did not wear her prescription lenses. Charlene identified a pink circle on the wall to her left at 2 feet, and called both the yellow and orange circles “orange” (approximately 4 to 6 feet away). At 20 feet, Charlene could not identify a large yellow smiley face and a bright red stop sign, nor could she name the colors. From a few feet away, Charlene identified the yellow smiley face and the stop sign, but still misnamed the color red as blue. Charlene does not name colors consistently. She does not always call red “blue” or any other color for that matter. Her color choices are random.
Informal visual field moving through the environment—Charlene did not identify any objects on her right side, above her head, or on the ground. All objects were seen on her left field of view, at eye level.
Formal Visual Acuity (near and distance)
Acuity
- Near Visual Acuity: Charlene was tested using the LEA Symbols® Logarithmic Near Acuity Test. Using both eyes together, Charlene read accurately the LEA Symbols® at 8.0M held 2 inches from her face. She lost her prescription glasses recently, so she wears glasses with no prescription strictly for protection. The glasses on and off did not show a change in test results. The use of supplemental light showed no difference in test results. Charlene stated that she preferred to have no extra light.
Informally, Charlene locates objects within 3-6 inches of her face with relative ease.
Results: Charlene’s distance for recognizing detail at near is 2–6 inches from her face. Optimal letter size is 8.0M at 2 inches. These acuity results should be considered minimal estimates of how well Charlene discriminates detail because she was not wearing her prescriptive glasses.
- Distance Visual Acuity: Charlene was tested using the LEA Symbols® Logarithmic Distance Acuity Test. She identified the LEA Symbols® when standing at 10 feet. At 8 feet, Charlene identified the top row of symbols inconsistently. At 5 feet from the chart, Charlene identified the symbols by pointing to the same ones that she believed her teacher had just indicated. Charlene was unable to name the symbols correctly, but she did match them with 90% accuracy. Charlene’s visual acuity measured OU (both eyes) without correction: 5/100.
Informally, Charlene identified objects at a 3-foot distance that are present on campus permanently, e.g., cars, buildings, doors, etc. Charlene often saw things in the distance that were not there and rarely identified the color of the objects she claimed to locate. It is uncertain if Charlene saw these objects in the distance, or if she identified them from memory.
Results: Informally, Charlene discriminates detail up to a 5-foot distance. Using two-dimensional optotype shapes, her uncorrected vision was 5/100 for matching LEA Symbols® at 5 feet. These results should be considered a minimal estimate of Charlene’s ability to see detail at a distance because she was not wearing her prescriptive glasses.
Functional Assessment
Location: Indoors
Lighting: Classroom with fluorescent overhead lighting
Color
- Color Vision: Color vision was tested using paint color swatches (yellow, orange, green, blue, purple, pink, and red). Charlene was unable to name colors consistently and tended to name a color as that of its
- closest hue, i.e., pink for red, yellow for orange, etc. Charlene called any dark color black if she was unable to assign it a color name.
- Contrast: Although only briefly tested, Charlene was able to identify a red cotton ball on a red piece of felt. She also was able to identify a blue cotton ball on a cluttered blue floral background. Charlene’s ability to detect objects in a low contrast and cluttered environment seems to be adequate in this controlled setting.
Lighting
- Sensitivity to Light: Observations in her classroom and on walks outside indicate that Charlene does not have any sensitivity to light. No observable squinting or discomfort was noted between inside/outside or dark/light environments. Charlene does not request extra light when doing tasks in the classroom.
Visual Field Assessment
1. Static Visual Field
Location: Summerhaven Elementary Hallway
Lighting: dim, fluorescent lighting
To determine Charlene’s potential “area” of visual field, she stood in the middle of a hallway that was 7 feet wide, 8 feet high, and 20 feet long in the kindergarten-first grade wing of Summerhaven Elementary. Charlene was asked to look straight ahead with both eyes open. Without moving her head or eyes, she pointed to or described objects seen at her highest, lowest, left, and right peripheral boundaries.
During the assessment, Charlene detected objects in her upper, lower, and left visual fields. Charlene did not detect objects in her right visual field. Charlene identified pink and yellow construction paper on the left side of the hallway approximately 4 to 6 feet away at eye level. Charlene also pointed to a red stop sign on the door at the end of the hallway at 20 feet, but called it a yellow pumpkin. Ms. Molly McCabe, speech and language therapist, stood 12 feet away, and Charlene identified the color of her pants. Charlene saw the color white on her right side where the letters F, E, J, and Y were stapled to the wall, and she noticed the light on the ceiling.
Results: Charlene is able to detect objects in her upper, lower, and left visual fields. Charlene claimed to see objects in her right field. Because of “active behavior,” it was difficult to keep Charlene still. Results may be skewed because she moved her head throughout the exercise.
2. Peripheral Constriction (using linear measurement)
Location: Connie Ruskie’s kindergarten room
Lighting: Full spectrum fluorescent and natural
To determine if Charlene has a blind area that may affect functionally her early detection of objects or people, she was asked to look straight ahead with both eyes open. Without moving her head or eyes, she indicated when she first noticed a person passing on her left and right sides. The person walked from behind Charlene (2 feet to the left or right of her midline) and continued to walk forward, parallel to Charlene’s line of sight. Charlene indicated that she detected the person walking on her left when the person was about 6 inches away. The linear measurement corresponds to about a 10-degree field loss. Charlene indicated she was first able to detect the person walking on her right when the person was about 15 feet away. This linear measurement corresponds to about an 85-degree field loss.
Results: Charlene has severe field restrictions on her right side per the results of the early warning of visual field test. The unshaded portion of the diagram on page I-96 reflects an approximation of Charlene’s peripheral visual field measured in degrees. Normal fields are around 85-90 degrees from midline.
3. Kinetic Visual Field at Near
Location: Kindergarten classroom not familiar to Charlene
Lighting: Overhead fluorescent lights, illumination filtered into the room from a window on Charlene’s right side
To determine if Charlene has a blind area that may functionally affect her ability to work at near, she was asked to fixate with both eyes open on a mark in the center of the paper at the distance that she reads or does near tasks. Without moving her head or eyes, she indicated when she first saw the dot of a laser pointer that the evaluator was moving outside her visual field toward the center of the paper. The evaluator repeated the test from all meridians of Charlene’s visual field.
Summary: Charlene’s usable visual field at 3 inches comprises an area represented in the diagram.
4. Oculomotor Function
- Fixation: Charlene fixated on a target (4-inch orange car) from about 12 inches with her left eye. Her left eye turned inward. She also turned her head slightly to the left. Her left eye moved constantly because of nystagmus.
- Accommodation: Charlene read 1-inch letters at 3 inches. Her right eye consistently turned inward.
- Tracking: Charlene followed the orange car as it rolled across her desk. She visually tracked the car left to right at a near distance of about 1 foot and at 3 feet. Charlene turned her head slightly to the right to cross midline. The left eye tracked the car while her right eye turned inward. Charlene engaged in similar tracking behavior when she watched a person walk in front of her at 10 feet.
- Shift of gaze: Charlene demonstrated her ability to shift gaze between looking at a toy car and a toy bus at a distance of 1 foot and 3 feet. She had more difficulty shifting to the right side and paid more attention to whatever was on her left.
- Scanning: When asked to locate pictures in a book, Charlene moved her head and eyes at 3 inches from the page in a random search pattern. She is able to locate specific items on her desk.
- Eye preference: Charlene prefers her left eye.
Summary of Results: Charlene uses her vision to notice detail at near (3 inches) with a tested acuity of 2.5M and distance of 10/200. Charlene prefers her left eye for discriminating detail at near, and for viewing at a distance (within 3-5 feet) as demonstrated by her close proximity to see objects, people, and events in familiar and unfamiliar environments. Her formal and informal acuity test results indicate that her ability to detect detail is compromised and dependent upon environmental variables, e.g., indoor/outdoor lighting. For example, in a bright outdoor environment, Charlene is unable to detect the presence and color of vehicles in a familiar place. Charlene has significant visual field restrictions for viewing objects, events, and people at near and distance (see diagrams). She matches colors—sometimes misnaming them—and picks out items of high contrast and in controlled conditions. These same visual efficiency behaviors are not seen as often in uncontrolled, familiar environments where the light or contrast is not adapted. Interestingly, Charlene didn’t use her video magnifier or her telescope throughout the assessment.
Educational Recommendations
Referrals for other evaluations
- Return to the ophthalmologist per his recommendations for a follow-up to ensure that Charlene’s ocular health remains stable.
- Conduct a follow-up clinical low vision evaluation per Dr. Tucker’s notes to ensure that current prescribed optical devices continue to be useful to Charlene.
- Charlene needs an occupational therapy evaluation to determine if services by a specialist will enhance her ability to do near fine motor tasks. It still needs to be determined if the motor component of Charlene’s work at near has anything to do with her less than enthusiastic attitude toward doing puzzles, writing, and picking out details in two dimensions.
- Charlene needs a routine audiological evaluation to rule out a mild hearing loss. This is recommended because of the cause of her vision loss (ROP) and for learning other literacy skills where hearing the sounds of letters will be important.
- Conduct a night orientation and mobility evaluation to determine if dim or no illumination affects Charlene’s ability to visually function in familiar and unfamiliar environments.
- Conduct a sun lens evaluation to determine if inhibiting glare and light transmission affects her ability to use vision in indoor and outdoor environments.
- Conduct a formal lighting assessment to determine if Charlene will benefit from extra lighting by providing different types of lighting, e.g., full spectrum, LED, incandescent. The results of such an evaluation will lead to a better understanding of Charlene’s lighting needs in indoor environments and should be done in concert with the sun lens evaluation.
- Conduct a learning media assessment to determine if print/braille or a combination of the two learning media will benefit Charlene’s long-term literacy skills best.
Accommodations
- Offer Charlene preferential seating if desired; right side of room to optimize use of left eye.
- Ask Charlene her seat location preferences in class for small group and whiteboard presentations. If Ms. Ruskie agrees, Charlene should move closer to see pictures in a book, or other demonstrations. It appears that Charlene’s left visual field is her preferred field, and though compromised, the placement of items on this side might be desired. However, the TVI will begin visual scanning strategies so that Charlene will learn to scan into her visual field of view that is more compromised.
- Provide 18-point, non-italic, sans serif type fonts; stand magnifier. (Depends on task and need)
- A slant board will bring two-dimensional representations, e.g., pictures in books, magazines, APH SQUID workbook activities closer to Charlene’s face; provide one as a choice if she expresses the desire or need to use one.
- Provide more or less lighting as recommended by the pending illumination assessment.
- Other accommodations will be recommended per the results of future assessments.
- Charlene may prefer to place a colored acetate sheet over reading material. This will provide greater contrast between the print and the background. Allow Charlene to choose the color acetate sheet she prefers to enhance contrast and to improve contrast sensitivity.
- Teach Charlene to find her “null point” (where her nystagmus slows) and she will have better fixation. If unsure about how to determine Charlene’s null point, Dr. Tucker will instruct the procedure.
- Teach Charlene to become efficient with eccentric viewing. This instruction is important before she can be an efficient user of her 6X telescope. Prepare a modified eccentric viewing clock for Charlene. The TVI will work with Charlene to develop strategies to increase her eccentric viewing technique. See page 365, Functional Vision: A Practitioner’s Guide to Evaluation and Intervention, Amanda Hall-Lueck, editor, AFB Press. Colors and shapes are used on the clock instead of numbers.
- Charlene will benefit by being taught to scan systematically with both eyes for near, mid, and distance viewing. Again, these skills will be very useful for her prior to using her video magnifier and telescope so that she knows the concept of what it means to scan and to be more visually efficient. Provide high contrast, colorful three-dimensional objects to scan and reach for initially to provide successful practice at near.
- A systematic approach to teaching Charlene to use her video magnifier will produce independent behavior for using the equipment. There are several resources for this, including Chapter 2 in Assistive Technology for Students Who are Blind or Visually Impaired by Ike Presley and Frances Mary D’Andrea, AFB Press. This chapter also lists the advantages of different types of video magnifier systems.
- Charlene needs systematic instruction to use her telescope and embrace it for school, community, home, and future workplace functions. Appendix 9.2 in the Hall-Lueck book outlines the areas/ steps to teach systematic use of a telescope.
- (Subject to change per more extensive lighting assessment) Dim-to-natural lighting indoors, reduce glare by sitting with back to windows or direct light away from Charlene
- Charlene selects her own cubbyhole and desk; place a colorful tactile marker on them (bottom of cubbyhole, left side of desk) so she can easily locate it among other cubbies/desks.
- Use carpet squares to designate student placement for circle time; let Charlene select the color carpet square she can see best to identify her place in the circle.
- Provide a personal copy of calendar, temperature chart, student job chart, etc., that Charlene can use to go along with teacher demonstration during circle time.
- Provide a crayon holder that allows Charlene to match color crayon with the color presented around the hole and color word.
It was a pleasure to conduct this assessment with the team members to discover how Charlene uses vision in a variety of environments. It will be an exciting year to instruct her to become more efficient visually through a variety of instructional approaches.
Terry Hasken, TVI
Summerhaven Elementary School
Adventure School District